BVA9502674 DOCKET NO. 93-02 786 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for intracerebral lesions. 2. Entitlement to service connection for hypertension. 3. Entitlement to an increased evaluation for post-traumatic stress disorder, evaluated as 50 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD James A. Frost, Associate Counsel REMAND The veteran served on active duty from June 1966 to July 1969. This appeal arises from rating decisions in October 1989, October 1990 and March 1992 by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Board of Veterans' Appeals (the Board) notes that the RO adjudicated claims of entitlement to VA compensation for eye injuries under the provisions of 38 U.S.C.A. § 1151 and 38 C.F.R. § 3.358, but suspended action on those claims and did not certify those issues as part of the veteran's current appeal. Those issues will thus not be considered by the Board at this time. With reference to hypertension, in October 1988, the Board denied entitlement to service connection for that disability, finding as a fact that, "The veteran had elevated blood pressure readings in service, but a finding of essential hypertension in service or thereafter has not been shown in the evidence." In December 1991, the veteran attempted to reopen the claim of entitlement to service connection for hypertension and submitted additional evidence, consisting of a report of a visit to a VA medical clinic in February 1991. He had been referred to the medical clinic from a VA eye clinic, with elevated blood pressure readings. When first seen at the medical clinic, his blood pressure was 172/112. On further examination, blood pressure readings were 140/98 and 142/102. The assessment was hypertension. Antihypertensive medication was prescribed. The Board finds that the additional evidence concerning hypertension is new and material; the veteran's claim of entitlement to service connection for hypertension is thus reopened and will be considered on a de novo basis. The Board believes that additional medical information on this issue is necessary prior to a final disposition of the appeal to either confirm a diagnosis of hypertension or to rule out the presence of essential hypertension as that disorder is currently understood by medical science. The Board also thinks that a medical opinion by a specialist in cardiovascular medicine as to whether elevated blood pressure readings in service were early signs and symptoms of essential hypertension should be obtained. With reference to post-traumatic stress disorder (PTSD), the Board finds that additional medical information is likewise necessary prior to a final disposition of the appeal. In this connection, the Board is mindful of the recent finding by the United States Court of Veterans Appeals (the Court) that the diagnostic codes under 38 C.F.R. § 4.132 of VA's schedule for rating disabilities do not present a clear basis for describing the degree of impairment imposed by psychoneurotic disorders. Massey v. Brown, No. 93-135 (U.S. Vet. App. Dec. 6, 1994). The Court in Massey directed VA's attention in such cases to the rating schedule's focus on the ability to establish and maintain effective and wholesome relationships with people and the reduction by psychoneurotic symptoms of initiative, flexibility, efficiency and reliability levels such as to produce industrial impairment. In this connection, the Board notes that the multiaxial diagnostic system of The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders- Third Edition, Revised includes on Axis V a score for "Global Assessment of Functioning" (GAF), which allows a psychiatric practitioner to convey a medical assessment which is highly relevant to VA's assignment of a disability rating under the criteria set forth in 38 C.F.R. § 4.132. The record reveals that during VA hospitalization for psychiatric treatment in August to October 1982, the Axis V diagnosis was that the veteran's level of functioning was "fair." During VA hospitalization in October 1983, after a suicide attempt by means of an overdose of prescription medicine, a GAF score of 5 was assigned. During VA hospitalization in January to March 1986, the Axis V diagnosis was a "poor to fair" level of functioning. At a VA psychiatric examination in April 1992, the veteran reported the persistence of sleep disturbance, nightmares, social withdrawal and flashbacks of Vietnam experiences. He was taking psychoactive medication. He last worked in 1984. The examiner rendered an Axis I diagnosis of PTSD, chronic, severe, but did not provide an Axis V diagnosis or a GAF score. Furthermore, the record contains a certification by the Social Security Administration (SSA) that the veteran was awarded disability benefits by that agency in December 1984. The record also contains medical evidence from the SSA file. However, the veteran's claims folder does not contain a copy of the SSA decision awarding him disability benefits. A copy of the SSA decision should be obtained prior to a final disposition of the appeal. Martin v. Brown, 4 Vet.App. 136 (1993). In order that VA may fulfill its duty to assist the veteran in the development of facts pertinent to his claim, under 38 U.S.C.A. § 5107(a), this case is REMANDED to the RO for the following: 1. The RO should request that the veteran identify all health care providers and facilities, VA or non-VA, which have treated him for hypertension since February 1991 and for PTSD since April 1992. The RO should attempt to obtain copies of all such clinical records. 2. The RO should request that SSA provide a copy of its decision awarding the veteran disability benefits. 3. The RO should schedule the veteran for an examination by a physician who is a specialist in cardiovascular medicine. It is imperative that the veteran's claims folder be made available to the examiner for review prior to the examination. The physician's attention should be directed, in particular, to the account of the veteran's blood pressure readings in the Board of Veterans' Appeals October 1988 decision and to the report of a visit by the veteran to a VA medical clinic in February 1991, at which time several blood pressure readings were taken. The examiner should take the veteran's blood pressure a sufficient number of times, on separate days, if necessary, to determine whether he does or does not have essential hypertension as that disorder is currently understood by medical science. In the event that the veteran presently has hypertension, the examiner should express an opinion as to whether elevated blood pressure readings during the veteran's period of active service were early signs or symptoms of essential hypertension. 4. The RO should schedule the veteran for a psychiatric examination. It is imperative that the claims folder be made available to the psychiatric examiner prior to the examination. The examiner's attention should be directed, in particular, to the numerous summaries of the veteran's hospitalizations at VA facilities for psychiatric treatment and to the report of the VA psychiatric examination in April 1992. The examiner should comment on the extent to which PTSD impairs the veteran's ability to establish and maintain effective and wholesome relationships with people and on the extent to which PTSD reduces his initiative, flexibility, efficiency and reliability levels and thus causes industrial impairment. The examiner should render complete diagnoses using The American Psychiatric Association's multiaxial system, with particular emphasis on the Axis V diagnosis and the Global Assessment of Functioning Score. The examiner should be requested to explain in detail how and why he or she assigned the GAF score. Following completion of these actions, the RO should review the evidence and determine whether the veteran's claims of entitlement to service connection for hypertension and to an increased evaluation for PTSD may now be granted. If the decision remains adverse to the veteran on either issue, he and his representative should be provided with an appropriate supplemental statement of the case an opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration. The purposes of this REMAND are to assist the veteran in the development of his claim and to procure clarifying medical information. Appellate review of the issue of entitlement to service connection for intracerebral lesions is deferred, pending completion of this REMAND. No action is required of the veteran until he receives further notice. ALBERT D. TUTERA Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).