BVA9506287 DOCKET NO. 93-10 461 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUE Whether new and material evidence has been received to reopen a claim of entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Nadine W. Benjamin, Counsel INTRODUCTION The veteran served on active duty from July 1966 to July 1969. This appeal comes to the Board of Veterans' Appeals (Board) on appeal from a June 1992 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. In May 1990, the Board denied service connection for a psychiatric disorder, to include post-traumatic stress disorder (PTSD). The veteran seeks to reopen his claim, and this appeal ensued after the RO determined that no new and material evidence had been received. REMAND The veteran is attempting to reopen his claim of entitlement to service connection for PTSD. The record shows that he has submitted evidence concerning stressful experiences in Vietnam in the form of a statement from a comrade who also served in Vietnam and who related the death of a comrade of both himself and the veteran. The veteran also testified at a hearing before the Board concerning missions in which he was involved as a helicopter gunner. He also reported that he had been put in for a Bronze Star, but had never received it. He further testified concerning other incidents in Vietnam, including a friendly fire attack where 6 were killed and 43 were wounded and the decapitation of a young boy. The record contains other incidents related by the veteran concerning stressful situations in Vietnam. The Board is of the opinion that additional inquiry regarding incidents in Vietnam is warranted. The Board notes that the record contains several diagnoses of PTSD, and that a VA examiner reported in May 1988 that after reviewing the veteran's extensive file and interviewing him for over an hour that the veteran' symptoms, especially his rage, were more suggestive of an underlying personality disorder rather than PTSD. He also stated that to attribute all of the veteran's distress to his Vietnam experiences would be in error. The Board believes that further examination of the veteran would be helpful in this case. The Board notes that the veteran has had ongoing treatment for his psychiatric disorder by the VA and at the Vet Center in Martinsburg, West Virginia, and that he was found to be disabled by the Social Security Administration (SSA) due to PTSD. The most recent VA treatment records are dated in 1991, the most recent records from the Vet Center are dated in 1989, and records were not obtained from SSA. At the veteran's hearing in July 1993, he stated that he wished to amend his claim to include entitlement to increased ratings for his service-connected hypertension and headaches. These matters have not been addressed by the RO. In view of the foregoing, the case is hereby REMANDED to the RO for the following development: 1. The RO should contact the veteran and request that he provide the names, addresses and approximate dates of treatment for all VA and non-VA health care providers who have treated him since service for any psychiatric disability and in recent years for headaches or hypertension. With any necessary authorization from the veteran, the RO should attempt to obtain copies of pertinent treatment records identified by the veteran which are not currently of record. Of special interest are any records from the Vet Center in Martinsburg, West Virginia since 1989. 2. The RO should obtain a copy of the SSA decision granting disability benefits to the veteran, together with all supporting medical documents. Once received, they should be added to the claims folder. 3. The RO should request that the veteran give complete information concerning his claimed stressors, including complete information concerning the related circumstances, such as approximate dates and locations of the stressful events, as well as his unit assignment at the time of each claimed stressor. With respect to any of the veteran's service comrades asserted to have been killed or wounded, the veteran should provide the full name and approximate date of injury or death for each such person. The importance of this information to his PTSD claim should be explained and stressed to the veteran. 4. Any information obtained should be sent to the U.S. Army and Joint Services Environmental Support Group, 7798 Cissna Road, Suite 101, Springfield, Virginia, 22150-3197, so that an attempt may be made to confirm any incidents reported by the veteran, including information relating to combat action. 5. The RO should contact the National Archives and Records Administration, 9700 Page Boulevard, St. Louis, Missouri 63132, and obtain copies a of records contained in the veteran's OMPF file. Any records so obtained should be associated with the veteran's claims folder. 6. Thereafter, the veteran should be afforded a VA examination by a board of 2 board certified psychiatrists, if available, to determine the nature and extent of the veteran's psychiatric disability. All indicated studies should be performed. The examiners should also be requested to review the material in the claims file. The examiners should assign a Global Assessment of Functioning Score consistent with the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (3d ed. rev; 1987), and explain what the assigned score represents. The examiners are requested to give an opinion on the degree of social and industrial impairment that the veteran experiences. If the examiners find that a diagnosis of PTSD is warranted, the examiners should specify the diagnostic criteria utilized to support such a diagnosis including enumeration of the specific stressor(s) relied on. A complete rationale should be given for all opinions and conclusions expressed. 7. The RO should also schedule the veteran for a cardiology examination to be performed by a board certified cardiologist, and for a neurology examination to be performed by a board certified neurologist, if these specialists are available, to evaluate the severity of the veteran's service-connected hypertension and his service-connected headaches, respectively. Thorough histories should be taken, and all indicated tests should be performed. All current manifestations should be described in detail. A complete rationale should be provided for all conclusions or opinions expressed. 8. Thereafter, the RO should review the claims file to ensure that the actions taken, including the examinations, comply with the directives of this remand. If they do not, corrective action should be taken. Then, the RO should undertake any other indicated development, readjudicate the issue on appeal, and adjudicate the issues of entitlement to increased evaluations for hypertension and headaches. If the benefit sought on appeal is not granted to the satisfaction of the veteran, or if a timely Notice of Disagreement is received as to any other matter, a Supplemental Statement of the Case on all issues in appellate status should be issued, and the veteran and his representative provided an opportunity to respond. Thereafter, the case should be returned to the Board for further consideration, if otherwise in order. By this REMAND, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is otherwise notified by the RO. ROBERT E. SULLIVAN 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) (1994).