Citation Nr: 0007149 Decision Date: 03/16/00 Archive Date: 03/23/00 DOCKET NO. 98-14 026 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts THE ISSUES 1. Entitlement to service connection for unspecified symptoms as a chronic disability resulting from an undiagnosed illness. 2. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Dennis F. Chiappetta, Associate Counsel INTRODUCTION The veteran served on active duty with the United States Army from May 1990 through April 1993. The veteran's DD-214 indicates that decorations awarded included, in part, a Southwest Asia Service Medal with 3 Bronze Stars and a Kuwait Liberation Medal. In July 1994, the RO denied the veteran's claims for service connection for numerous disorders. In pertinent part, the RO denied the veteran's claim for service connection for a psychiatric disorder, to include PTSD. The RO indicated that the denial was based on the fact that the veteran's psychiatric symptoms were not shown to be due to service, and the fact that the veteran was never diagnosed with PTSD. While the veteran submitted a Notice of Disagreement (NOD) and was sent a Statement of the Case (SOC), she failed to file a substantive appeal, and that decision became final. In an April 1998 decision, the RO apparently determined that new and material evidence had been submitted that was sufficient to reopen the veteran's claim for service connection for PTSD. The Board agrees, noting that the July 1997 VA outpatient treatment examination included a diagnosis of PTSD. By the April 1998 decision, the RO reopened and then denied the veteran's claim with respect to service connection for PTSD, on the basis that the claim was not well-grounded. The veteran timely appealed this decision, and the issue of entitlement to service connection for PTSD is now before the Board of Veterans' Appeals (Board), for appellate review. This case is also now before the Board on appeal from the April 1998 RO rating decision which, in pertinent part, denied the veteran's claim seeking service connection for what the veteran claimed was "Persian Gulf War syndrome." While the RO denied service connection for "Persian Gulf War syndrome," the Board has seen fit to recharacterize the issue, as stated above, to comport with 38 C.F.R. § 3.317, which pertains to compensation for undiagnosed illnesses. Additionally, the Board notes that the veteran has attempted to appeal an issue that was never actually decided by the RO. Adjudication of the issue regarding entitlement to service connection for a left wrist disorder was deferred by the RO in April 1998. Such was noted in the statement of the case. As this issue has not yet been decided by the agency of original jurisdiction, and has not otherwise been developed for appellate review, the Board cannot review it on appeal. The RO should proceed with action deemed appropriate and address this issue when adequately developed. The representative has raised a claim for service connection for a psychiatric disorder on a secondary basis, under 38 C.F.R. § 3.310 (1999), as being proximately due to the veteran's service-connected back disorder. This matter also has not been developed for appellate review and is referred to the attention of the RO for appropriate action. The issue of service connection for PTSD, is addressed in the Remand portion of this decision. FINDINGS OF FACT 1. In July 1994, the RO denied the appellant's claim for service connection for a psychiatric disorder, to include PTSD. The veteran did not perfect an appeal and the decision was final. 2. Since the July 1994 decision, the Board finds that new and material evidence has been associated with the claims folder which, by itself or in connection with evidence previously assembled, is so significant that it must be considered in order to fairly decide the merits of the veteran's claim for entitlement to service connection for PTSD. 3. The claim for service connection for PTSD is plausible. 4. The appellant had active military service in the Southwest Asia theater of operations during the Gulf War; the veteran's allegation that she currently has unspecified symptoms, which are related to an undiagnosed illness, is not supported by any medical evidence that would render the claim plausible. CONCLUSIONS OF LAW 1. The evidence submitted since the July 1994 RO denial of service connection for PTSD is new and material; thus, the claim for service connection is reopened. 38 U.S.C.A. §§ 5108, 7105(c) (West 1991); 38 C.F.R. §§ 3.104(a), 3.156, 20.1103 (1999). 2. The claim of service connection for PTSD is well grounded. 38 U.S.C.A. § 5107 (West 1991). 3. The claim of entitlement to service connection for unspecified symptoms, as a chronic disability resulting from an undiagnosed illness, is not well grounded. 38 U.S.C.A. §§ 1117(a), 5107(a) (West 1991 & Supp. 1999); 38 C.F.R. § 3.317 (1999); VAOPGCPREC 4-99 (May 3, 1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Undiagnosed Illness Claim I. Facts The file contains no examination performed prior to entrance into active duty. Review of the veteran's service medical records reveals that the veteran was treated during service for numerous complaints resulting in various diagnoses. On a May 1992 periodic examination, the veteran was evaluated as normal except for findings of tenderness around the insertion of the plantar fascia and right ankle mild laxity to stress testing. On her report of medical history, the veteran checked "yes" for prior problems with ear/nose/throat trouble, adverse reaction to serum, drug, or medication, VD, and foot trouble. A physician's notes indicated that the veteran had recurrent streptococcal tonsillitis; adverse reactions to certain vaccines; VD; and foot trouble including chronic pain in the area of the arches. No service medical records on file indicates that the veteran had ever suffered from symptoms of an undiagnosed illness. The file contains no examination prior to separation from service. An April 1993 memorandum regarding the veteran's medical examination for transition/retirement indicated that the veteran had elected not to undergo medical examination before the transition date. A service physician indicated that the veteran's records were reviewed and that a medical examination for transition was not required. In May 1993, the veteran submitted a claim for service connection for various disorders including: neck, shoulder, lumbar scoliosis, and back pain secondary to an inservice motor vehicle accident; chronic recurrent pain; recurrent bronchitis; bilateral shin splints; scar to the left lower lip; chronic recurrent UTI's /vaginitis; irregular menses; a history of syphilis with recurrence; and PTSD. On VA examination in June 1994, diagnoses included whiplash neck injury, lumbosacral strain, and right shoulder sprain secondary to a 1992 motor vehicle accident; plastic surgery to correct electrical burn scar resulting from a childhood accident; and history of latent syphilis, status post penicillin treatment. In a July 1994 decision, the RO denied each of the veteran's claims for entitlement to service connection. The veteran did not appeal, and the decision with regard to these issues became final. In March 1995, medical treatment records were submitted from the VA facility at Oakland Park, Florida. Aside from gynecological (GYN) problems identified as "healthcare maintenance," VA outpatient treatment records from the Oakland Park facility indicate that the veteran had treatment for the following: venereal warts (October 1993); microscopic hematuria (October 1993); yeast infection (November 1993); osteoarthritis and degenerative joint disease of the spine (January 1994); inflammatory atypia (January 1994); acute abdomen (February 1994); kidney infection (February 1994); tubal pregnancy (February 1994); acute tonsillitis (May 1994); chronic endocervicitis (July 1994); mild UTI (urinary tract infection) (July 1994); degenerative joint disease lumbar spine (July 1994); vaginal gardenilla, yeast (October 1994); right shoulder pain (October 1994); degenerative joint disease low back (January 1995); acne vulgaris (January 1995); complaints of headaches since Gulf War (February 1995); adjustment disorder with depressed mood/depression (March 1995); adjustment reaction (March 1995); and dysthymic disorder (March 1995). On VA examination in May 1995, it was noted that the veteran had a history of GYN problems and kidney problems during service. A history of lumbar strain and right shoulder complaints due to a 1992 motor vehicle accident was also noted. Records from St. Mary's Hospital showed treatment for nausea and vomiting in May 1995. Records from Plantation General Hospital indicate that the veteran was treated for complaints of abdominal pain diagnosed as gastroenteritis in May 1996. Additional records from St. Mary's Hospital diagnose acute pelvic pain of unknown etiology in May 1996. Medical records from the West Boca Raton Medical Center show that the veteran had treatment for gastroenteritis in April 1996 and for acute bronchitis, nausea, and vomiting in November 1996. The November 1996 record also indicated that the veteran had a history of a ruptured ovarian cyst. In June 1997, the veteran submitted a claim for service connection for Gulf War Syndrome. With that claim she also asserted claims for service connection for a left wrist disorder, a cervical spine disorder, low back/lumbar spine disorder, and PTSD. In July 1997, the VA sent the veteran a letter asking, among other things, that she specify the symptoms or disabilities that she is claiming as undiagnosed illness or as a result of environmental hazard. On mental health examination performed by the VA in July 1997, it was noted that the veteran reported that she had been suffering multiple health problems since the Gulf War. It was noted that since 1992 the veteran had reported problems including: resistant yeast infections, irregular menses, headaches, vomiting, flu-like symptoms, kidney problems, muscle spasms, ruptured ovarian cyst, exhaustion, and a (gastrointestinal) GI problem that has caused her to lose 15 pounds. The diagnosis included PTSD, status post motor vehicle accident with associated pain, a ruptured ovarian cyst, GI problems, and a possible thyroid problem. On a December 1997 VA examination of the joints it was noted that the veteran had back and neck pain secondary to a motor vehicle accident, and that she had left wrist pain ever since the summer of 1996. The diagnoses included chronic neck pain, chronic back pain, and chronic left wrist pain without clinical evidence of tendinitis or carpal tunnel syndrome. In April 1998, the RO denied the veteran's claim for service connection for Gulf War Syndrome. By this decision, the RO also granted service connection for a low back disorder and a disorder of the cervical spine. In a September 1998 statement, the veteran's service representative asserted that post-service medical records concerning Gulf War syndrome included: a May 1995 record from St. Mary's Hospital indicating that the veteran was admitted with complaints of nausea, diagnosed as a viral type illness; a May 1996 hospital report from St. Mary's indicating that the veteran was diagnosed with pelvic pain of unknown etiology; and hospitalization reports from April and November 1996 which disclose that the veteran was admitted with complaints of nausea, vomiting, headaches, and chest pain. II. Analysis Initially, the Board notes that the veteran has claimed that she is entitled to service connection for "Persian Gulf War syndrome". As stated in the introduction, and for reasons explained below, the Board has recharacterized the issue as entitlement to service connection for unspecified symptoms as a chronic disability resulting from an undiagnosed illness. While the veteran failed to respond to a letter from the VA that specifically requested she specify the symptoms or disabilities she is claiming as undiagnosed illness, it is not prejudicial to the veteran for the Board to broadly infer that she is asserting a claim for any symptoms that could be manifestations of a chronic disability due to an undiagnosed illness. Upon enactment of the Persian Gulf War Veterans' Benefits Act, title I of Public Law No. 103-446 (Nov. 2, 1994), a new section 1117 was added to title 38, United States Code. 38 U.S.C.A. § 1117 authorizes VA to compensate any Persian Gulf War veteran suffering from a chronic disability resulting from an undiagnosed illness or combination of undiagnosed illnesses which became manifest either during active duty in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more within a specified presumptive period following service in the Southwest Asia theater of operations during the Persian Gulf War. To implement the Persian Gulf War Veterans' Benefits Act, VA added a regulation, entitled "Compensation for certain disabilities due to undiagnosed illnesses," which provides as follows- (a) (1) Except as provided in paragraph (c) of this section, VA shall pay compensation in accordance with chapter 11 of title 38, United States Code, to a Persian Gulf veteran who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of this section, provided that such disability: (i) became manifest either during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2001; and (ii) by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. (2) For purposes of this section, "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non- medical indicators that are capable of independent verification. (3) For purposes of this section, disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. (4) A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. (5) A disability referred to in this section shall be considered service connected for purposes of all laws of the United States. (b) For the purposes of paragraph (a)(1) of this section, signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: (1) fatigue (2) signs or symptoms involving skin (3) headache (4) muscle pain (5) joint pain (6) neurologic signs or symptoms (7) neuropsychological signs or symptoms (8) signs or symptoms involving the respiratory system (upper or lower) (9) sleep disturbances (10) gastrointestinal signs or symptoms (11) cardiovascular signs or symptoms (12) abnormal weight loss (13) menstrual disorders. (c) Compensation shall not be paid under this section: (1) if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or (2) if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or (3) if there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. (d) For purposes of this section: (1) the term "Persian Gulf veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. (2) the Southwest Asia theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317 (1999). The United States Court of Appeals for Veterans Claims (formerly known as the Court of Veterans Appeals, prior to March 1, 1999) (herinafter "the Court") has held that any claimant for benefits administered by VA has the burden of submitting evidence sufficient to justify a belief that the claim is well grounded. If that burden is met, then the Secretary of Veterans Affairs has the duty to assist the claimant in developing additional evidence pertaining to the claim. 38 U.S.C. § 5107(a); see Murphy v. Derwinski, 1 Vet. App. 78, 81-82 (1990); Lathan v. Brown, 7 Vet. App. 359, 365 (1995). If that burden is not met, the statutory duty to assist does not attach. Anderson v. Brown, 9 Vet. App. 542, 546 (1996). Indeed, if the claim is not well grounded, the Board is without jurisdiction to adjudicate it. Boeck v. Brown, 6 Vet. App. 14, 17 (1993). Further, the Court has made it clear that it is error for the Board to address the merits of a claim that is not well grounded. Epps v. Brown, 9 Vet. App. 341, 344 (1996), aff'd sub nom. Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 118 S. Ct. 2348 (1998). More recently, the Court issued a decision holding that VA cannot assist a claimant in developing a claim which is not well grounded. Morton v. West, 12 Vet. App. 477 (July 14, 1999), req. for en banc consideration by a judge denied, No. 96-1517 (U.S. Vet. App. July 28, 1999) (per curiam). Thus, the threshold question in any case is whether the claimant has presented a claim which is well grounded. Well-established judicial caselaw mandates that, for a service-connection claim to be well grounded, there must be medical evidence of current disability, lay or medical evidence of incurrence or aggravation of a disease or injury in service, and medical evidence of a nexus (i.e., a link or a connection) between the injury or disease in service and the current disability. See Winters v. West, 12 Vet. App. 203, 207-209 (1999) (en banc); Epps, supra; Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Once a claimant has submitted evidence sufficient to justify a belief by a fair and impartial individual that a claim is well grounded, the claimant's initial burden has been met, and VA is obligated under 38 U.S.C. § 5107(a) to assist the claimant in developing the facts pertinent to the claim. A well grounded claim for compensation under 38 U.S.C. § 1117(a) and 38 C.F.R. § 3.317 for disability due to undiagnosed illness generally requires the submission of some evidence of: (1) active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) the manifestation of one or more signs or symptoms of undiagnosed illness; (3) objective indications of chronic disability during the relevant period of service or to a degree of disability of 10 percent or more within the specified presumptive period; and (4) a nexus between the chronic disability and the undiagnosed illness. VAOPGCPREC 4-99. With respect to the second and fourth elements, evidence that the illness is "undiagnosed" may consist of evidence that the illness cannot be attributed to any known diagnosis or, at minimum, evidence that the illness has not been attributed to a known diagnosis by physicians providing treatment or examination. The type of evidence necessary to establish a well-grounded claim as to each of these elements may depend upon the nature and circumstances of the particular claim. Medical evidence would ordinarily be required to satisfy the fourth element, although lay evidence may be sufficient in cases where the nexus between the chronic disability and the undiagnosed illness is capable of lay observation. For purposes of the second and third elements, the manifestation of one or more signs or symptoms of undiagnosed illness or objective indications of chronic disability may be established by lay evidence if the claimed signs or symptoms, or the claimed indications, respectively, are of a type which would ordinarily be susceptible to identification by lay persons. If the claimed signs or symptoms of undiagnosed illness or the claimed indications of chronic disability are of a type which would ordinarily require the exercise of medical expertise for their identification, then medical evidence would be required to establish a well-grounded claim. With respect to the third element, a veteran's own testimony may be considered sufficient evidence of objective indications of chronic disability, for purposes of a well grounded claim, if the testimony relates to non-medical indicators of disability within the veteran's competence and the indicators are capable of verification from independent sources. As an initial matter, the Board notes that the DD Form 214 reflects that the veteran received the Southwest Asia Service Medal and the Kuwait Liberation Medal. It also reflects that the veteran had over one year of foreign active duty. Based on this evidence and for purposes of analysis under 38 C.F.R. § 3.317 (1999), the Board finds that the veteran had active military service in the Southwest Asia theater of operations during the Gulf War. While the veteran has met the first element by nature of her active service in the Gulf, under the above legal criteria, it does not appear that her claim for service connection with regard to any unspecified symptom can meet all three of the other elements to be considered well grounded, pursuant to 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317, and VAOPGCPREC 4- 99. Specifically, the veteran has submitted very little in the way of evidence which indicates she has manifestations of an undiagnosed illness. The Board notes that upon the definitive diagnosis of a concrete disability, the applicability of the special provisions for Persian Gulf War benefits ceases. The General Counsel has stated that "evidence of a nexus between the chronic disability and the undiagnosed illness is an essential element of a well- grounded claim under section 1117." See VAOPGCPREC 4-99, supra, at para. 12. Moreover, the governing regulation clearly provides that compensation is payable only for chronic disability which, "by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis." 38 C.F.R. § 3.317(a)(1)(ii) (1998). Here, nearly all of the symptoms that were noted in medical records over the years, found by objective examination in 1997, or listed by the veteran's representative in the September 1998 statement are attributable to an identifiable disability. Back and neck pains were service-connected after they were linked to an inservice motor vehicle accident in 1992. The veteran herself related her left wrist pain to an incident in 1996, and not to service in the Persian Gulf. Additionally, flu-like symptoms including nausea and vomiting have been tied to various identifiable causes including gastroenteritis and viral type illness. GYN symptoms have also been specifically diagnosed over the years as the result of venereal warts, yeast infections, endocervicitis, tubal pregnancy, etc. Medical records on file show that most of the veteran's symptoms were attributed to one of these disorders or to other such diagnosed disorders listed in the facts reported above. The Board notes that even if these infrequently noted symptoms were evidence of a chronic disability, there has been no evidence submitted of a nexus between these reported symptoms and any chronic undiagnosed illness. After careful review of the file, the Board finds only two cases where symptoms were reported that were not linked to a specific disorder. In February 1995, the veteran reported headaches since service, and in May 1996, the veteran was diagnosed with "acute pelvic pain of unknown etiology". While these may be manifestations of an illness that was not diagnosed in 1995 or 1996, the record does not show that either symptom is an objective indication of chronic disability. The Board notes that the pelvic pain was specifically described as acute and not chronic. Furthermore, while the pelvic pain was found to be of unknown etiology, it was not seen again on any subsequent medical record. As such, it does not appear to be chronic. Similarly, while headaches were noted in February 1995, they were not shown by objective medical evidence in any subsequent examination. The Board notes that even if the headaches were evidence of a chronic disability, there has been no evidence submitted of a nexus between subjective symptoms of headaches and any chronic undiagnosed illness Therefore, since the veteran's unspecified symptoms have not been shown to be both manifestations of one or more signs or symptoms of undiagnosed illness, and objective indications of chronic disability, the veteran's claim concerning service connection for unspecified symptoms, as manifestations of an undiagnosed illness, is not well grounded. Although the General Counsel has noted that in some circumstances the relationship between symptoms and a current disability is capable of proof by lay evidence alone, this is not such a circumstance. The Board does not find anything in the claims file which would indicate that the veteran, who is not a medical professional, is capable of providing a nexus opinion relating her reported symptoms to an undiagnosed illness, as opposed to a clinically diagnosed condition. Thus, the veteran's claim concerning service connection unspecified symptoms as a chronic disability resulting from an undiagnosed illness, is not well grounded. PTSD As noted in the introduction, and in the finding of facts and conclusion of law, the veteran's initial claim for service connection for PTSD was denied in July 1994. Finding a July 1997 VA diagnosis of PTSD to be new and material evidence, the veteran's claim was reopened and denied in April 1998. This appeal ensued. The Board concurs with the finding that the newly submitted evidence is new and material, because the diagnosis of PTSD is so significant that it must be considered. New and material evidence means evidence not previously submitted to agency decisionmakers which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156 (1999). As the veteran's claim has been reopened, the Board must now determine whether, based upon all the evidence of record in support of the claim, presuming its credibility, the reopened claim is well grounded pursuant to 38 U.S.C.A. § 5107(a). Elkins v. West, 12 Vet. App. 209 (1999). The Board notes that the veteran's service medical records reveal no complaints or findings indicative of chronic psychiatric problems during service. The Board does note that the veteran was diagnosed with "other life circumstance problem" after being seen in psychiatry in August 1992 for feeling very "stressed out". The file contains no other service medical records indicating the presence of an ongoing disorder. The Board observes that, since separation from service, the veteran has been diagnosed with numerous disorders, including depression, dysthymic disorder, adjustment reaction and, since the last final decision, PTSD. It is noteworthy, however, that the impression of PTSD, made at the time of outpatient evaluation in July 1997, was made by a "psychology intern," whose medical training and qualifications to render such an opinion are unknown. Nonetheless, the claim for service connection for PTSD is a plausible claim, and it is considered to be well grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, she has presented a claim which is not inherently implausible. See Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). ORDER A well-grounded claim not having been submitted, entitlement to service connection for unspecified symptoms, as a chronic disability resulting from an undiagnosed illness, is denied. New and material evidence having been submitted, the claim for service connection is reopened and found to be well grounded. To this extent, the appeal is allowed. REMAND VA has a duty to assist in the development of a well grounded claim. 38 U.S.C.A. § 5107(a). In June 1997, when the veteran filed her reopened claim for service connection for PTSD, 38 C.F.R. § 3.304(f), the applicable regulation, provided, in pertinent part, as follows: Service connection for post-traumatic stress disorder requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. If the claimed stressor is related to combat, service department evidence that the veteran engaged in combat or that the veteran was awarded the Purple Heart, Combat Infantryman Badge, or similar combat citation will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed inservice stressor. That regulation was recently amended and now provides, in pertinent part: Service connection for post-traumatic stress disorder requires medical evidence diagnosing the condition in accordance with Sec. 4.125(a) of this chapter; a link, established by medical evidence, between current symptoms and an in- service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 64 Fed. Reg. 32,807 (Jun. 18, 1999). The amendment implements a decision by the Court, Cohen v. Brown, 10 Vet. App. 128 (1997), which held that 38 C.F.R. § 3.304(f) did not accurately reflect the law of the governing statute. The effective date of the amendment is March 7, 1997, the date the Cohen decision was issued by the Court. When regulations are changed during the pendency of an appeal, the veteran is entitled to a decision on the claim under the regulation most favorable thereto. See Fischer v. West, 11 Vet. App. 121, 123 (1998), quoting from Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991). A significant difference between the old and new versions of the regulation applicable to this case is the reference, in the new version, to 38 C.F.R. § 4.125(a). That related section provides that diagnoses of mental disorders must conform to the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed. 1994), published by the American Psychiatric Association, and known as "DSM-IV." In June 1997, when the veteran filed her claim, the revised third edition of the Manual, published in 1987 and known as "DSM-III-R," was applicable. See 38 C.F.R. § 4.125 (1996). The traumatic event that will justify the diagnosis of PTSD is described differently in each Manual. The previous description was: The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone, e.g., serious threat to one's life or physical integrity; serious threat or harm to one's children, spouse , or other close relatives and friends; sudden destruction of one's home or community; or seeing another person who has recently been, or is being, seriously injured or killed as the result of an accident or physical violence. DSM-III-R, at 250. The current description of a stressor event is: The person has been exposed to a traumatic event in which he experienced, witnessed, or was confronted with actual or threatened death or serious injury, or a threat to the physical integrity of self or others and his response to the event involved intense fear, horror, or helplessness. DSM-IV, at 424. In this case, it is not entirely clear which events were relied upon by health care providers to diagnose PTSD. Mental health professionals who have diagnosed PTSD should specify the events they believe the veteran experienced that meet the criteria for the diagnosis under either DSM-III-R or DSM-IV. Once those health care providers identify the traumatic events upon which they have relied to make the PTSD diagnosis, the RO must determine, in its adjudication of the claim, which of those events relate to combat. If the diagnosis is based upon events related to combat (as described by the veteran), then the RO must determine whether the veteran engaged in combat with the enemy. 38 C.F.R. § 3.304(f). Another significant difference between the old and new regulations is the nature of the evidence needed to prove that the veteran engaged in combat with the enemy. The old regulation referred to awards and decorations indicative of combat, while the new regulation does not contain that reference. The new, seemingly less restrictive, regulation is consistent with judicial caselaw and, pursuant thereto, the determination as to whether the veteran engaged in combat with the enemy must be based on all the evidence of record and not just service department evidence regarding awards and decorations. Dizoglio v. Brown, 9 Vet. App. 163(1996); Cohen, supra. In this case, if the PTSD diagnosis is based upon events related to combat, then the RO must determine, based upon all the evidence of record, whether the veteran engaged in combat with the enemy. Finally, if the stressor events described by the veteran, upon which the PTSD diagnosis is based, are not related to combat, or if they are related to combat but it is determined that the veteran did not engage in combat with the enemy, then the events upon which the PTSD diagnosis is based must be verified by credible supporting evidence. 38 C.F.R. § 3.304(f). In other words, if the claimant did not engage in combat with the enemy, or claimed stressors are not related to combat, then the claimant's testimony alone is not sufficient to establish the occurrence of the claimed stressors, and his testimony must be corroborated. Cohen, supra; Moreau v. Brown, 9 Vet. App. 389 (1996); Dizoglio, supra. Service department records must support, and not contradict, the claimant's testimony regarding noncombat stressors. Doran v. Brown, 6 Vet. App. 283 (1994). The question of whether the veteran was exposed to a stressor in service is a factual one, and VA adjudicators are not bound to accept uncorroborated accounts of stressors or medical opinions based upon such accounts. Wood v. Derwinski, 1 Vet. App. 190 (1991), aff'd on reconsideration, 1 Vet. App. 406 (1991); Wilson v. Derwinski, 2 Vet. App. 614 (1992). In sum, whether the evidence establishes the occurrence of stressors is a question of fact for adjudicators, and whether any stressors that occurred were of sufficient gravity to cause or to support a diagnosis of PTSD is a question of fact for medical professionals. In the instant case, the veteran has been diagnosed with PTSD on a VA outpatient treatment mental health examination in July 1997. The Board is well aware of the fact that this single PTSD diagnosis has been complicated by other psychiatric diagnoses and, as noted above, was made by a psychology intern with unknown qualifications, who did not articulate the stressors on which such diagnosis was based. While the veteran has asserted that she has had combat related experiences in the Persian Gulf, the Board notes that the objective evidence of record does not verify that she was involved in combat. Review of the veteran's DD Form 214 reveals that she served in the Persian Gulf. Her listed awards and decorations are an Army Service Ribbon, an Army Lapel Button, a National Defense Service Medal, an Overseas Service Ribbon, a Southwest Asia Service Medal with 3 Bronze Stars, a Kuwait Liberation Medal, a marksman badge for riflery. Her record of assignments indicates that she served two years and eight months as a food service specialist. Stressful incidents during service reportedly included being near bombing the on enemy line, partaking in gas drills, working 13 hours of guard duty, seeing dead bodies, and other stresses of war. The Board notes, however, that none of these events has not been verified. Prior to determining whether the veteran has PTSD related to service, it is necessary to verify her claimed in-service stressors. The record reflects that the RO has not referred this claim for verification of the stressful incidents related by the veteran, to the U.S. Armed Services Center for Research of Unit Records (USASCRUR) (formerly the Environmental Support Group). Accordingly, the Board finds that the RO should forward to the USASCRUR comprehensive and detailed information regarding the stressful events claimed to have been experienced by the veteran during service. Although the veteran has provided some information regarding the claimed stressors, the RO should make an additional request to the veteran for more details prior to forwarding this information to USASCRUR. In so doing, the RO should once again request from the veteran a statement containing as much detail as possible regarding the stressors to which she was exposed during service. The veteran should be asked to provide specific details of the claimed stressful events during service, such as dates, locations, detailed descriptions of the events, her service units at the time of the stressors, and the duty assignments, names and any other identifying information concerning other individuals involved in the stressor events. The veteran should be notified that this information is critical to the attempted verification of her claimed stressors. The RO should then specifically summarize any information obtained from the veteran pursuant to this remand and also all information previously obtained, and this information, as well as copies of the veteran's DD Form 214s and DA Form 20s, should be forwarded to the USASCRUR for verification of her claimed stressors. Specifically requested should be unit histories regarding the veteran's assigned units during her service in the Persian Gulf. It should be requested whether it can be verified that the veteran ever dealt with dead bodies or was in the proximity of bombing on enemy lines. In West v. Brown, 7 Vet. App. 70 (1994), the Court elaborated on the analysis in its decision in Zarycki v. Brown, 6 Vet. App. 91 (1993). In Zarycki, the Court had held that, in addition to demonstrating the existence of one or more stressors, the facts must also establish that any such stressful event was sufficient to give rise to PTSD. In West, the Court held that the sufficiency of the stressor is a medical determination, and therefore adjudicators may not render a determination on this point in the absence of independent medical evidence. The Court also held, in West, that a psychiatric examination for the purpose of establishing the existence of PTSD was inadequate for rating purposes where the examiners had relied, in pertinent part, upon events whose existence had been rejected by VA adjudication personnel. Based upon the holdings in Zarycki and West, it appears that, consistent with our discussion above, in approaching a claim for service connection for PTSD, the question of the existence of an event claimed as a recognizable stressor must be resolved by adjudication personnel. If the adjudicators conclude that the record establishes the existence of such a stressor or stressors, then, and only then, the case should be referred for a medical examination to determine the sufficiency of the stressor(s) and whether the remaining elements required to support the diagnosis of PTSD have been met. In such a referral, the adjudicators should specify to the examiner precisely what stressors have been accepted as established by the record, and the medical examiner must be instructed that only those events may be considered in determining whether stressors to which the veteran was exposed during service were of sufficient severity as to have resulted in current psychiatric symptoms. In other words, if the adjudicators determine that the existence of an alleged stressor or stressors in service is not established by the record, a medical examination to determine whether there is a diagnosis of PTSD due to service would be pointless. Likewise, if the examiner renders a diagnosis of PTSD that is not clearly based upon stressors in service whose existence the adjudicators have accepted, the examination would be inadequate for rating purposes. See Cohen, supra, 10 Vet. App. at 145 (holding that "[a]n opinion by a mental health professional based on a post- service examination of the veteran cannot be used to establish the occurrence of the stressor"). In view of the foregoing, it is the Board's judgment that the RO should obtain additional information from the veteran regarding her alleged in-service stressors. The RO should then forward all available information to the USASCRUR for an attempt at verification of the stressors. If indicated, i.e., in the event that the USASCRUR response documents one or more verified stressors, the RO should specifically request that the examiner performing the VA psychiatric examination either confirm or reject the PTSD diagnosis in light of such stressor evidence. The record also reflects that the veteran may be receiving ongoing psychiatric treatment, and that copies of clinical records of recent treatment have not been associated with the claims file. Specifically noted in this regard is the lack of any records of psychiatric treatment since 1997. These records and any ongoing treatment records should be obtained. See Murincsak v. Derwinski, 2 Vet. App. 363 (1992). We wish to emphasize that, "[t]he duty to assist in the development and adjudication of a claim is not a one way street." Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996). "If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). See also Olson v. Principi, 3 Vet. App. 480, 483 (1992). Clearly, therefore, it is incumbent upon the veteran to cooperate in any way that would facilitate the RO's efforts in developing this claim, to include providing specific stressor information, and reporting for an examination if the RO determines it is necessary. In light of the foregoing, and in order to fairly and fully adjudicate the veteran's claim, the issue of service connection for PTSD is remanded to the RO for the following action: 1. The RO should take appropriate action to contact the veteran and determine whether she has any additional information or evidence to present in support of her claim of service connection for PTSD. The veteran should also be requested to submit the names, addresses, and approximate dates of treatment of all health care providers, VA and non-VA, who have treated her for symptoms of her psychiatric disorder since service. When the veteran responds, and provides any necessary authorizations, the named health care providers should be contacted and asked to provide copies of all clinical records documenting their treatment, which are not already in the claims folder. Specifically noted in this regard are records of psychiatric treatment since 1997. 2. The RO should request from the veteran a comprehensive statement, containing as much detail as possible, regarding the stressors to which she alleges she was exposed in service, to include the events surrounding the reported incidents involving dead bodies, bombing, and stressful guard duty. The veteran should be asked to provide specific details of the claimed stressful events during service, such as dates, places, detailed descriptions of events, and identifying information concerning any other individuals involved in the events, including their names, ranks, units of assignment, etc. The veteran is advised that this information is vitally necessary to obtain supportive evidence of the stressful events, and that she must be as specific as possible because, without such details, an adequate search for verifying information cannot be conducted. 3. Regardless of the veteran's response, the RO should then review the entire file, including the veteran's previous statements of stressors and any additional information submitted by her or otherwise obtained pursuant to this remand, and prepare a summary of all the claimed stressors. This summary, together with a copy of the veteran's DD Form 214 and DA Form 20, or equivalent, and all associated documents, should be sent to the United States Armed Services Center for Research of Unit Records, 7798 Cissna Road, Springfield, Virginia 22150. USASCRUR should be requested to provide any information that might corroborate the veteran's alleged stressors. 4. The RO should then schedule the veteran for a VA psychiatric examination in order to determine her current neuropsychiatric diagnosis or diagnoses, if any. All necessary special studies or tests, to include psychological testing and evaluation, such as the Mississippi Scale for Combat-Related Post-Traumatic Stress Disorders, should be accomplished. The claims folder must be made available to the examiner for review in connection with the examination. In determining whether the veteran experienced an inservice stressor that may be related to any diagnosed disorder, the examiner is hereby notified that only the verified history detailed in the reports provided by USASCRUR and/or the RO may be relied upon. Based on his/her review of the case, the examiner should express an opinion, if possible, as to the medical probability that any currently demonstrated disorder is etiologically related to the veteran's service or her service-connected disorders. If PTSD is diagnosed, then the examiner should specify which verified incident(s) led to the development or aggravation of this disorder. At the conclusion of the evaluation, the examiner should enter a full multiaxial evaluation, including a score on the Global Assessment of Functioning (GAF) Scale on Axis V, with an explanation of the import of that score. 5. After the development requested above has been completed to the extent possible and any other development deemed necessary has been completed, the RO should again review the veteran's claim, considering the issue of whether service connection is warranted for PTSD on the basis of all the evidence, both old and new. If the benefit sought on appeal remains denied, the appellant and representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The veteran need take no further action until she is informed, but she has the right to submit additional evidence and argument on the matter or matters that the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992); This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. N. R. ROBIN Member, Board of Veterans' Appeals