BVA9500267 DOCKET NO. 93-07 291 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Daniel J. McTavish, Associate Counsel INTRODUCTION The veteran had active, honorable service from April 1968 to February 1970, which included service in Vietnam from February 1969 to February 1970. The veteran also had active service from April 1970 to September 1970, which was determined by administrative decision of the Department of Veterans Affairs (VA) to have been under other than honorable conditions and the veteran was not entitled to service connection for any injury incurred in or aggravated during this period. This matter came before the Board of Veterans' Appeals (Board) on appeal of a January 1992 rating decision by the Montgomery, Alabama Regional Office (RO), which denied service connection for PTSD. REMAND The veteran contends, in substance, that he is entitled to service connection for PTSD. He served in Vietnam and was awarded the Vietnam Service Medal and Vietnam Campaign Medal. His military occupation was that of a baker. No evidence of combat service was shown. Service medical records show no complaints, diagnoses or treatment of a psychiatric disorder and psychiatric evaluation was normal on his separation examination in February 1970. However, on the preinduction examination, the veteran admitted that he had nervous trouble. Post service treatment records show that he was hospitalized at the Birmingham, Alabama, VA Medical Center in January 1980 for evaluation of suspected alcohol withdrawal accompanied by agitation, insomnia, paranoid ideations and visual hallucinations. He was employed at a local bake shop at this time. It was indicated in the hospital summary report that he had a history of a diagnosis of paranoid schizophrenia versus alcoholic hallucinosis and had been followed in Smolian Clinic since 1977 through November 1978. Records from Smolian Clinic are not in the veteran's claims file. During his January 1980 hospitalization, it was stated by the examiner that the veteran did not need antipsychotic medication but did need to remain off alcohol. It was also stated that the veteran had had the symptoms of paranoid ideations, visual hallucinations, agitation, and insomnia, while under the influence of alcohol, since the late 1960's, after his discharge from military service. In August 1981, he was hospitalized at the Tuscaloosa, Alabama, VA Medical Center where he was placed on suicidal precautions. He had a history of two suicide attempts, first by slashing both wrists and second by jumping from a third floor window sustaining a severe comminuted subtrochanteric fracture of the left femur. He also sustained a head injury from the jump. Mental status examination revealed the following diagnoses: Probable alcohol hallucinosis; possible toxic organic brain syndrome; possible traumatic organic brain syndrome; and history of alcohol dependence. Schizophrenia was ruled out. Upon discharge, he appeared in good reality contact and his mood was within normal limits. He was pleasant and participated actively and appropriately in group therapy. He acknowledged alcohol as a problem and verbalized intention of abstaining from its use. On June 7, 1991, approximately 20 years subsequent to his discharge from military service, the veteran was admitted at the Tuscaloosa, Alabama, VA Medical Center with complaints of seeing things. He indicated that he had been drinking 24 cans of beer per day for the past year prior to this admission. He stated that he consumed alcohol for relief from his hallucinations, flashbacks and nightmares associated with Vietnam. He stated specifically that he had lost a friend named George who was blown apart. He also reported seeing a Green Beret wearing a necklace made of human fingers. He successfully completed the PTSD program and was scheduled to receive psychiatric follow-up for PTSD upon his discharge on July 19, 1991. Pertinent diagnoses were PTSD, chronic, severe, and alcohol dependence, continuous. Subsequent to this hospitalization, he received VA outpatient treatment in the mental hygiene clinic. Treatment records from September 1991 to March 1992 reveal that he was treated for hallucinations, delusions, increased depression, increased nightmares, violence, and decreased appetite. He stated that he felt people were pointing fingers at him and talking about him. He claimed to have visions of "fingers" as a result of seeing Green Berets wearing fingers around their neck during service. Psychological evaluation in November 1991 showed that his current Minnesota Multiphasic Personality Inventory (MMPI), a psychological test, suggested considerably more exaggerated depression and suspiciousness over the past six months. Diagnostic impressions included, in pertinent part, PTSD; psychotic disorder not otherwise specified, depressive and paranoid features; organic mental disorder, not otherwise specified. The severity of his psychological stressors was said to be moderate. Although the veteran received psychological evaluation during this period of outpatient treatment at the VA, he was never afforded a VA psychological examination. In June 1992, a Notice of Award letter was received from the Social Security Administration (SSA) which showed the veteran was entitled to monthly disability benefits beginning March 1992. It does not appear, however, that the RO has attempted to obtain the records pertaining to the SSA's decision to grant benefits. In support of his claim for service connection for PTSD, the veteran repeated his claimed stressors that he saw his friend, George Harvel, die and saw strings of human fingers hanging around a soldier's neck. Reply dated October 1992 from the United States Army and Joint Services Environmental Support Group reported that United States Army casualty files do not list a George Harvel as wounded or killed in action in Vietnam. It was also noted that the veteran's other claimed stressor could not be verified and that an incident such as this was seldom found in combat records. Since the veteran has not been afforded a VA compensation examination and the SSA records are not in the claims file, the Board finds that the veteran is entitled to further assistance from the VA. The United States Court of Veterans Appeals (Court) has held that the duty to assist the veteran in obtaining and developing available facts and evidence to support his claim includes obtaining evidence from any source, and obtaining adequate VA examinations. Littke v. Derwinski, 1 Vet.App. 90 (1990). This duty also includes obtaining available evidence to support the claim. Murphy v. Derwinski, 1 Vet.App. 78 (1990). The Board also finds that it may be helpful to fully develop the medical record, prior to conducting a VA examination, so that the examiner(s) have full information available, prior to offering a diagnosis. In view of the foregoing, the Board finds that further development is in order to assist the veteran in the development of his claim. Therefore, the case is REMANDED to the RO for the following action: 1. The RO should contact the veteran and ask him to identify any and all sources of medical treatment for his psychiatric disorder or alcohol abuse, whether from VA or private care providers, both prior and subsequent to military service. The RO should then obtain and incorporate records of this treatment into the claims file. All records should be obtained in compliance with appropriate procedure. Specifically, the RO should attempt to obtain any treatment records for the veteran at the Smolian Clinic from 1977 to the present. 2. The RO should request the veteran's local SSA District Office to furnish a copy of the administrative decision granting the veteran's Social Security benefits, as well as any supporting medical records not already on file, including all exhibits, which were considered when he was granted benefits and all records of re-examination since that time. All records obtained should be associated with the claims file. 3. If any of the clinical records of psychiatric treatment record a history of verifiable stressors while the veteran was in Vietnam, those stressors should be verified by the RO. 4. The veteran should then be afforded a VA social and industrial survey in order to obtain a history of his functioning since military service. A written copy of the report should be inserted into his records. 5. The veteran should also be afforded full psychological testing by the VA, preferably by clinicians who have not previously seen him. The report should be entered into the record. 6. After the above development has been undertaken, the veteran should be examined by a panel of two VA psychiatrists who have not previously examined him to determine the exact nature of any psychiatric disorder currently present. Each psychiatrist should conduct a thorough review of the claims folder, to include the report from the Environmental Support Group, and conduct a separate examination with consideration of the criteria for PTSD. The examination report should include a detailed account of all pathology found to be present. If there are different psychiatric disorders than PTSD, the Board should reconcile the diagnoses and should specify which symptoms are associated with each of the disorder(s). If certain symptomatology cannot be disassociated from one disorder or another, it should be specified. If a diagnosis of PTSD is appropriate, the examiners should specify the credible "stressors" that caused the disorder and the evidence upon which they relied to establish the existence of the stressor(s). They should also describe which stressor(s) the veteran reexperiences and how he reexperiences them. The psychiatrists should describe how the symptoms of PTSD affect his social and industrial capacity. The report of examination should include a complete rationale for all opinions expressed. The diagnosis should be made in accordance with DSM-III-R. The entire claims folder should be made available to the examiners for review prior to the examinations. When the above development is completed, the case should be reviewed by the RO. If the decision remains adverse to the veteran, the RO should issue a supplemental statement of the case summarizing the evidence, law and regulations, and explaining how the law and regulations apply to the evidence. The RO should afford the veteran and his representative 60 days to respond to the supplemental statement of the case before the matter is returned to the Board for final adjudication, if otherwise in order. 38 C.F.R. § 20.302(c) (1993). The purpose of this REMAND is to procure clarifying data. No action is required of the veteran until further notice. N. R. ROBIN 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).