BVA9500872 DOCKET NO. 89-23 679 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Fort Harrison, Montana THE ISSUE Entitlement to an increased evaluation for post-traumatic stress disorder, currently evaluated as 70 percent disabling. REPRESENTATION Appellant represented by: Montana Veterans Affairs Division WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD John J. Crowley, Associate Counsel INTRODUCTION The appellant served on active duty from September 1966 to September 1968. This matter is currently before the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In an October 1990 decision, the Board upheld the RO's denial of the appellant's claims for an increased rating for post-traumatic stress disorder (PTSD), evaluated at that time as 50 percent disabling, and denying entitlement to a total evaluation under 38 C.F.R. § 4.29 (1993) for a service-connected disability requiring hospital treatment or observation subsequent to July 31, 1988. The appellant filed a timely appeal to the United States Court of Veteran's Appeals (Court) on only the denial of the increased PTSD rating claim. In [citation redacted], a panel of the Court held that jurisdiction rested with the Court to consider the appellant's appeal regarding an increased rating for PTSD. Pursuant to that holding, the case was reverted to a single-judge determination on the merits. Id. In [citation redacted], the Court held that the Board had committed clear error in the decision denying the appellant an increased PTSD disability rating higher than 50 percent. The Court reversed that decision and remanded the matter to the Board for the prompt assignment of a 70 percent rating effective March 10, 1988. The Court also remanded this matter to the Board for further development and readjudication of the appellant's entitlement to a 100 percent schedular rating under 38 C.F.R. § 4.132, Diagnostic Code 9411, and the appellant's entitlement to a 100 percent imputed rating under 38 C.F.R. § 4.16(c) (1993). Pursuant to the VA's General Counsel's August 1994 Motion to Modify, the Court, on August 30, 1994, amended the order of the single-judge decision in [citation redacted], nullifying the assignment of an effective date of March 10, 1988, and remanding to the Board for the prompt assignment of an effective date. The case was received at the Board from the Office of General Counsel on September 23, 1994. On October 12, 1994, the Office of the Counsel to the Chairman sent a letter to the veteran's representative before the Court to clarify whether this representative intended to represent the appellant before the VA. On October 14, 1994, the representative of the appellant before the Court responded that she was not representing the appellant before the VA. The Office of the Counsel to the Chairman then sent a letter to the representative who had previously represented the veteran before the VA on October 28 providing the representative 30 days in which to submit any further argument. On December 2, 1994, the Board received an additional communication from the appellant's representative, with an enclosed copy of the brief submitted before the Court. Between December 9 and December 29, 1994, the Board made several inquiries based upon the information in the claims folder to determine whether the Court's order to award a 70 percent evaluation had been implemented by the RO. The record contained a document appearing to indicate that the RO had been directed to make the award on August 9, 1994, based on a directive from the Compensation and Pension Service, Veterans Benefits Administration. The record also contained documents that appeared to indicate that a copy of the rating action implementing the Court's decision had been sent from the RO to the Office of the General Counsel. However, a copy of this rating action was not in the material forwarded to Board. From these inquiries it was ultimately determined that: (a) the Court's order had not been implemented; and (b) that the litigation file maintained at the Office of the General Counsel, into which the copy of the rating action should have been filed, could not be located, and that it could not be determined whether the litigation file may have contained other evidence submitted by the appellant during the course of the proceedings before the Court. In view of these matters, as noted below, the RO must immediately implement the order of the Court. Further, the appellant is advised that any evidence he may have sent to the Office of the General Counsel may not have been placed in the claim file, and may not now be of record. Therefore, he should submit copies of such evidence directly to the RO, if he has not already done so. The Board further points out that the effective date of the appellant's rating had not been appealed by the appellant to the Board and was not before the Board at the time of it's October 1990 determination. Accordingly the issue is referred to the RO for appropriate and prompt action in conjunction with the implementation of the award of the 70 percent schedular evaluation. The undersigned must also note that in January 1992 the appellant requested to reopen his Agent Orange claim. His claims for multiple disabilities as the results of exposure to Agent Orange have never been fully adjudicated by the RO. In June 1989, the appellant requested service connection as a result of exposure to Agent Orange for the following: chloracne, weakness of extremities, loss of strength, easy fatigability, fatigue, headaches, loss of sensation, loss of hearing, weight gain, sleep disturbances, hypertension, abdominal pain, nausea, diarrhea, rectal bleeding, gastrointestinal disorders, depression, violent behavior, uncontrolled behavior, skin rash, feet and arm disability, "other" organ damage, aching muscles and lower back disability. In Nehmer v. United States Veterans Administration, 712 F. Supp. 1404 (N.D. Cal., May 2, 1989), a United States District Court (District Court) voided all benefit denials under 38 C.F.R. § 3.311a, the "dioxin" (Agent Orange) regulation, which was promulgated under the "Dioxin and Radiation Exposure Compensation Standards Act," 38 U.S.C.A. § 1154(a) (West 1991), and remanded the case to the VA for revision of the regulation in accordance with the ruling of the District Court. In a February 1990 rating determination, the RO had deferred the appellant's Agent Orange claims pending revised regulations. The new regulations pertaining to Agent Orange, now expanded to include all herbicides used in the Republic of South Vietnam, provide for a presumption of exposure to herbicide agents for veterans who served on active duty in Vietnam during the Vietnam era. 59 Fed. Reg. 5106 (1994) (to be codified at 38 C.F.R. § 3.307(a)(6)). The regulations also stipulate the diseases for which service connection may be presumed due to an association with exposure to herbicide agents. 59 Fed. Reg. 5107 and 29724 (1994) (to be codified at 38 C.F.R. § 3.309(e)). The specified diseases are chloracne or other acneform diseases consistent with chloracne, Hodgkin's disease, non-Hodgkin's lymphoma, porphyria cutanea tarda, soft-tissue sarcoma, multiple myeloma and respiratory cancers. Id. Further, the Secretary of Veterans Affairs formally announced in the Federal Register on January 4, 1994, that a presumption of service connection based on exposure to herbicides used in Vietnam was not warranted for certain conditions, to specifically include circulatory disorders or for "any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted." 59 Fed. Reg. 341 (1994). Notwithstanding the foregoing, the United States Court of Appeals for the Federal Circuit (Federal Circuit) recently determined that the Veteran's Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984) does not preclude a veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed.Cir.1994). However, the United States Court of Veterans Appeals has held that where the issue involves medical causation, competent medical evidence which indicates that the claim is plausible or possible is required to set forth a well-grounded claim. Grottveit v. Brown, 5 Vet.App. 91, 93 (1993). In a June 1992 statement, the appellant requested reopening of his claims of entitlement to service connection for a stomach ulcer and hypertension secondary to his PTSD. The appellant also sought service connection for hearing loss on a direct basis. Entitlement to service connection for peptic ulcer disease and hypertensive vascular disease were denied by the Board in October 1989. Review of recent evidence received by the Board indicates that in a March 1993 VA hospital discharge summary the veteran's blood pressure of 140/96 was noted to be secondary to PTSD stress. These applications to reopen his claims have not been adjudicated by the RO and are not before the Board at this time. They are referred to the RO for appropriate action. REMAND The appellant claims entitlement to a 100 percent evaluation for his PTSD under 38 C.F.R. § 4.132, Diagnostic Code 9411 (1993). In the alternative, the appellant's representative claims that he meets the requirements of a total disability rating based on unemployability under 38 C.F.R. § 4.16(c) (1993). A 100 percent evaluation is warranted for PTSD where the attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community. The 100 percent rating requires total incapacitating psychoneurotic symptoms bordering on gross repudiation of reality and disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior. The appellant must be demonstrably unable to obtain or retain employment. A 70 percent evaluation for PTSD is warranted where the ability to establish and maintain effective or favorable relationships with people are severely impaired, and the psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. 38 C.F.R. § 4.132, Diagnostic Code 9411. Under 38 C.F.R. § 4.16(c), where, as in the appellant's case, the only compensable service-connected disability is a mental disorder assigned a 70 percent evaluation, and such mental disorder precludes the appellant from securing or following a substantially gainful occupation, the mental disorder shall be assigned a 100 percent schedular evaluation under the appropriate diagnostic code. I. Background Preliminary review of the record now before the Board discloses material conflicts concerning the appellant's employment history, and the reasons for the difficulties he has experienced in employment. These conflicts are significant in evaluating the medical opinions of record with respect to the industrial impairment attributable to his service-connected disorder, and thus must be resolved prior to adjudicating the issue now before the Board. Further, such development will permit the formulation of medical opinions based upon an accurate picture of the appellant's employment history. The appellant has undergone treatment for his PTSD condition for a number of years. He has submitted statements from his therapist, Lee Tonner, A.C.S.W., providing descriptions of his flashbacks and nightmares, indicating that they were quite severe and graphic. In an April 1986 statement, Mr. Tonner related that he had treated the appellant since July 1983. With respect to the appellant's work history, it was noted that the appellant had been laid off from a forest service job due to a back injury. It was indicated that the appellant had "no problem on the job." The report further described how the appellant's application for a job with a municipal government was rejected, but that thereafter the appellant prevailed in a damage suit for failure to accord him veteran's preference. The appellant next was employed with the county in weed control and as a "flagman," but reportedly lost this employment when the county was warned that if he was injured on the job, he would sue them. He then reportedly secured a franchise custodial job, two hours per night, which was terminated when he refused to work three hours nightly for no additional salary. Mr. Tonner also stated that jobs were scarce in the area and the appellant's employer fired him because it was easy to find someone who would work three hours each night for the same amount of money. Mr. Tonner also noted that the appellant had been discriminated against because of a back injury stemming from Vietnam, and in a further statement in April 1986, referred to the appellant's ulcer disease as a factor that would preclude employment in the forest service. A series of statements from Mr. Tonner in 1987 indicate, in combination, that the appellant experienced troubling recollections of Vietnam events that produced symptoms that would interfere periodically with employment, but Mr. Tonner linked the appellant's major employment difficulties more closely to physical problems and the veteran's reputation in the community for suing over his physical disabilities. At his most recent VA examination of record in October 1986, the appellant reported he had held 60 jobs since service and that he had left the jobs due to "people" and "stress." He complained of flashbacks, nightmares, sleep difficulties, feeling of survivor guilt, nervousness and difficulties interacting with people. He spoke of periods of depression and difficulties trusting anyone. Examination resulted in a diagnosis of PTSD, chronic, delayed. The examiner concluded that this condition caused the appellant severe social and industrial impairment. The record contains a May 1987 statement from the Social Security Administration, indicating that, after an independent review by a physician and a disability examiner, his claim for Social Security benefits had been denied. In a February 1988 statement, T. Gary Curtis, the Administrator of the Department of Labor and Industry of the Job Service Division of the State of Montana, cited several factors contributing to the appellant's apparent inability to secure permanent full-time employment. These included an inability to lift heavy objects, a lack of education or experience for most "white collar" jobs, the general state of the economy where the appellant was located, and the fact that he had filed suit against his local employers. For these reasons, Mr. Curtis did not believe his organization would be of assistance to the appellant. In a March 1988 statement, Mr. Curtis referred to the veteran's concerns about his dealings with the Libby Job Service office. Mr. Curtis indicated that the staff members had no "personal hard feelings" about the appellant, but were concerned about referring the appellant to employers due to his "interpersonal skills." In a March 1988 claim for increased compensation, the appellant indicated that he held his last full time employment in 1987 performing seasonal road work three months a year. He also indicated that he was currently self-employed raising Christmas trees from October to December for 20 hours a week. He attached a list of jobs he had held or applied for in the 1980's. He indicated he had lost jobs due to "disability," but he either did not specify the nature of the "disability," or he specifically mentioned disability of his back and leg. . From May to July 1988, the appellant was admitted to a VA PTSD program for intensive psycho-educational treatment, therapy group activities and supportive counseling. The appellant's prognosis was assessed as poor without further care, and as fair to good with established supportive care. The treating team recommended that the appellant undertake the program a second time. He was rehospitalized for three day periods in May and September 1991 and again from January to March 1993. The prognosis was guarded due to a lack of adequate PTSD aftercare follow-up groups in the appellant's area of Montana. A VA counseling report dated in August 1988 shows the appellant's employment goals were to become self employed raising Christmas trees. His difficulty working with people was noted, as was his nonservice-connected physical disabilities. The opinion was expressed that his service-connected and nonservice-connected disabilities were in direct conflict with his stated goal. The report indicated that testing showed the veteran might readily fit into work involving landscape design, drafting, architectural drafting and possibly management of a Christmas tree business. The report also noted the limited employment opportunities available in the community, and the fact that the veteran's wife was employed as a school teacher and the fact that their house was almost paid for, which precluded their movement to another community. An August 1988 report from E. Lee Simes contains the opinion that the veteran currently appeared to be unemployable due to his PTSD, but might be employable after further treatment. A September 1988 statement from Mr. Tonner expressed the opinion that the veteran had significant symptoms of PTSD and problems dealing with the VA which made him unemployable. At a hearing held before a hearing officer at the RO in November 1988, the appellant testified that he had not been employed on a full-time basis due to symptoms of his PTSD for nearly nine years. He also testified that he was no longer able to raise Christmas trees and had received Social Security disability benefits since May 1988. He believed this was due to PTSD. He reported that two years earlier he had held a job for five months straight, which was his most sustained employment in nine years. In a June 1989 statement of the appellant's income, net worth and employment, he revealed that he was self employed at Koocanusa Christmas Trees from October to December from 1983 to 1987. In January 1990 claim for increased compensation, the appellant stated that he last worked in any employment in 1980. In a March 1990 statement, Mr. Tonner indicated that the veteran's symptoms had increased in terms of his social isolation and that, in Mr. Tonner's opinion, the veteran's PTSD was severe and the veteran was unemployable. In a May 1990 report, E. Lee Simes, M.D., indicated that the veteran was "significantly disabled" due to PTSD and presently appeared to be unemployable. It was doubtful that without intervention his condition would change, but that with intervention, he could improve enough to allow employment. A September 1991 hospitalization summary reflects Axis I diagnoses of major depression and PTSD. A comment was recorded that no rapid change in his PTSD was realistically expected and that the veteran was "apparently unable to work." The report was signed by Herbert Gray, M.D. In a March 1991 statement, Dr. Gray, expressed his opinion that the appellant's disability had become increasing severe over the years and was now completely incapacitating. The Board also has the medical opinion of a VA examiner from the appellant's January to March 1993 hospitalization, indicating that the appellant was currently not employable but had made efforts to use therapy to help stabilize his condition. The medical reports from the appellant's January to March 1993 hospitalization state that the appellant was last employed in 1980, that he held 50 jobs between 1968 to 1980, that his longest lasting employment was 2 years, that the average length of employment was 6 to 8 months and he was involved in substance abuse secondary to his PTSD. (Elsewhere in the record, there are statements that there has been no substance abuse since 1974.) The veteran has also submitted additional statements from lay associates describing his difficulties with PTSD. In a January 1989 Financial Status Report, the appellant indicated his sole source of income was $792.00 per month from "pension, compensation, or other income." The record contains VA correspondence dated in March 1989 indicating that the veteran's authorized rate of compensation in January 1989 was $523.00 per month. In a Financial Status report completed in August 1993, he reported monthly income of $1599.00 in "monthly gross salary." This report reflected no deductions from his income (whereas such deductions were reported for his wife's income) and showed no income from "pension, compensation, or other income." He did not list any employment for himself for the past two years. The Board can not ascertain from this report whether the appellant actually was employed in August 1993, whether his reported "monthly gross salary" actually represented VA and Social Security benefits, or whether the sum of $1599.00 represents some combination of earned income and compensation or pension benefits. II. Analysis In evaluating impairment resulting from psychiatric disorders such as PTSD, social inadaptability is to be evaluated only as it affects industrial adaptability. The principle of social and industrial inadaptability, the basic criterion for rating disabilities from mental disorders, contemplates those abnormalities of conduct, judgment and emotional reaction which affect economic adjustment, i.e., which produce impairment of earning capacity. 38 C.F.R. § 4.129 (1993). The severity of a disability is based upon actual symptomatology as it affects social and industrial adaptability. Two of the most important determinants of a disability are time lost from gainful work and a decrease in work efficiency. VA must not underevaluate the emotionally sick veteran with a good work history, nor must it overevaluate his or her condition on the basis of a poor work record not supported by the psychiatric disability picture. It is for this reason that great emphasis is placed upon the full report of the examiner, descriptive of actual symptomatology. The record and history of complaints are only preliminary to the examination. The objective findings and the examiner's analysis of the symptomatology are the essentials. The examiner's classification of the disease as "mild," "moderate," or "severe" is not determinative of the degree of disability, but the report in the analysis of the symptomatology and the full consideration of the whole history by the rating agency will be. 38 C.F.R. § 4.130 (1993). As noted above, the current record contains significant contradictions concerning the veteran's work history (i.e. when he last worked), the reasons why he was not able to obtain or retain employment (the role of PTSD verses other disorders and his reputation in the community) and suggests that some of the medical opinions offered as to the veteran's employability may have been based upon statements of medical or employment history that are not elsewhere supported in the record, or that are actually contradicted in the record. It also appears that there is a conflict as to whether the appellant is receiving disability benefits currently from the Social Security Administration. (This point is raised by the evidence now of record that was not considered by the Court, and thus is not raised in contravention of the finding of the Court in its decision of August 1994.) As noted above, Dr. Gray, Dr. Simes and Mr. Tonner have concluded that the appellant is effectively unemployable. The undersigned has also noted that a recent VA examiner during the January to March 1993 hospitalization has indicated that the appellant is currently unemployable. However, the bases for these determinations are unclear. The February 1988 statement of Mr. Curtis lists the appellant's obstacles finding full time employment. Significantly, his PTSD condition is not raised. It is unclear if it is the opinion of the examiners that the appellant is unemployable based solely on the appellant's service-connected condition or unemployable based on the non- service connected difficulties noted by Mr. Curtis. Mr. Tonner, in his April 1986 statement, described how the veteran's back disability, and a reputation for litigiousness, cost the veteran jobs or compromised his employment prospects. Service connection for a back disability was denied by the RO in January 1987. However, as stated by the Court, in determining whether the appellant is entitled to a total disability rating based upon individual unemployability, the appellant's non-service-connected disabilities shall not be considered. Van Hoose v. Brown, 4 Vet.App. 361, 363 (1993). On the basis of the appellant's current claims pending before the RO, it appears he suffers from numerous disabilities which have not been service connected. The undersigned must also note that the appellant's employment noted by Mr. Tonner's April 1986 assessment as a "franchise custodial job," was not listed by the appellant is his claims for increased compensation based on unemployability. With specific regard to the probative value of the medical opinions of Dr. Gray and Dr. Simes and the VA examiner during the January to March 1993 hospitalization, the Court has written: The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches . . . as is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [Board as] adjudicators . . . . Guerrieri v. Brown, 4 Vet.App. 467, 470-71 (1993). The opinions of Drs. Gray and Simes appear to be based on examinations of the appellant and, importantly, his employment history as supplied by the appellant. However, as noted above, his statements regarding his employment history in some cases directly conflict with each other. "An opinion based upon an inaccurate factual premise has no probative value." Reonal v. Brown, 5 Vet.App. 458, 461 (1993). Although the examiners can render a current diagnosis based on their examinations, it bears emphasis that, without a thorough review of the record, their opinions regarding matters concerning the appellant's employability and whether his service connected disability is the sole cause of his unemployability, areas in which there is no indication that Drs. Gray and Simes or the VA medical examiner have any professional credentials or knowledge, can be no better than the facts alleged by the appellant. See Swann v. Brown, 5 Vet.App. 229, 233 (1993). In West v. Brown, U.S. Vet. App. 92-890 (August 8, 1994), the Court stated that the Board's reliance on a medical conclusion that was grounded on a questionable history of events was in error. The Court in West remanded the case to the Board to obtain a psychiatric evaluation that was based on a complete and accurate description of events during the veteran's service. Id. This principle is equally applicable to the facts of this case. Moreover, with regard to claims for a total rating based upon individual unemployability where the schedular rating is very high, the Court has written: For a veteran to prevail on a claim based on unemployability, it is necessary that the record reflect some factor which takes the claimant's case outside the norm of such veteran. See C.F.R. §§ 4.1, 4.15 (1992). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. See 38 C.F.R. § 4.16(a) (1992). Van Hoose, 4 Vet.App. at 363. With regard to the appellant's testimony that he is receiving Social Security benefits, the Court has held that "although the [Social Security Administration's] (SSA) decisions with regard to unemployability are not controlling for purposes of VA adjudications, the SSA's decision is "pertinent" to a determination of appellant's ability to engage in substantially gainful employment." Martin v. Brown, 4 Vet.App. 136, 140 (1993). VA has a duty to assist a veteran in the development of facts pertinent to a well-grounded claim. 38 U.S.C.A. § 5107(a); 38 C.F.R. § 3.103(a) (1993). The Court has held that the duty to assist includes the duty to obtain thorough contemporaneous VA examinations, including examinations by specialists, when indicated, and the duty to obtain pertinent records. Counts v. Brown, 6 Vet.App. 473 (1994); Hyder v. Derwinski, 1 Vet.App. 221 (1991); Greene v. Derwinski, 1 Vet.App. 121 (1991); Littke v. Derwinski, 1 Vet.App. 90 (1990). Where the record before the Board is inadequate to render a fully informed decision and clarification of the evidence is essential for a proper appellate decision, the Board must remand the case, specifying the action to be undertaken. 38 C.F.R. § 19.9 (1993). In view of the matters discussed above, this case is REMANDED to the RO for the following actions: 1. The RO should immediately effectuate the award of the Court of a 70 percent schedular rating for PTSD and assign an effective date. 2. Following the above, the RO should request the appellant to identify the names, addresses, and approximate dates of treatment for all health care providers who may possess additional records pertinent to his claims. Specifically, this request is in reference to treatment rendered since October 1990, and copies of any records the appellant submitted to the Office of the General Counsel during the course of litigation. With any necessary authorization from the appellant, the RO should attempt to obtain copies of those treatment records identified by the appellant which have not been previously secured. 3. The RO should obtain from the SSA a copy of any disability determination it has made for the appellant and copies of the medical records upon which any such original or continuing award was based. The SSA should also provide a copy of the appellant's reported earnings for the last seven years. The RO should respectfully invite the attention of the SSA to 38 U.S.C.A. § 5106 (West 1991). 4. The appellant should be requested to indicate whether he has received or applied for an award of workers' compensation benefits. With authorization from the appellant, the RO should obtain from any workers' compensation authority a copy of any disability determination made and a copy of the medical records upon which the award was based. 5. After the aforementioned documents have been obtained, the RO should arrange for the appellant to undergo a VA social and industrial survey in order to determine the impact of the PTSD on his social and industrial adaptability. The claim folder must be made available to the social worker in conjunction with the survey as it contains important historical data. The social worker should seek to accurately determine the veteran's employment history since his separation from service and to determine the reasons why the appellant failed to secure or failed to maintain each job. Particular attention should be focused on the appellant's employment history since 1980. If disability was a factor in the appellant's failure to obtain or to maintain various jobs, the Social Worker should seek to determine the nature of the disability or disabilities involved. 6. Following the above, the appellant should be examined by a panel of two VA psychiatrists who have not previously examined him to determine the nature and extent of his service-connected PTSD. The claim folder and a copy of this REMAND must be made available to the physicians in conjunction with the examinations. The psychiatrists should utilize the above requested social work survey as well as any psychological testing, or other testing, deemed pertinent in constructing an overall picture of the appellant's psychiatric status. The examiners should identify all psychiatric conditions which are present and distinguish conditions which are acquired from conditions which are of developmental or congenital origin, if any. If there are multiple disorders present, the examiners should express an opinion as to whether it is at least as likely as not that they are proximately caused by PTSD or due to service. To the extent possible, the psychiatrists should indicate the degree of impairment due to PTSD, and any disorders due to PTSD or service, as opposed to that due to other psychiatric disorders, personality defects, substance abuse (if any) and/or physical disabilities. Based upon a review of the record and the examination, the physician's should provide a Global Assessment of Functioning Score indicating the level of impairment produced by the service-connected PTSD, and any disorders due to PTSD or service. It is imperative that the examiners also provide a definition of the GAF score for purposes of due process under Thurber v. Brown, 5 Vet.App. 119 (1991). 7. The RO should review the examination reports and determine whether the findings comply with the requirements of paragraphs (5) and (6) above. If not, the reports should be returned to the Social Worker and/or the examining facility to correct any deficiencies. 8. Thereafter, the RO should undertake any other indicated development of the additional claims raised by the appellant. 9. The RO should adjudicate the applications to reopen claims of entitlement to service connection for stomach ulcer and hypertension on the basis of new and material evidence, entitlement to service connection for hearing loss on a direct basis, and entitlement to service connection for chloracne, weakness of extremities, loss of strength, easy fatigability, fatigue, headaches, loss of sensation, loss of hearing, weight gain, sleep disturbances, hypertension, abdominal pain, nausea, diarrhea, rectal bleeding, gastrointestinal disorders, depression, violent behavior, uncontrolled behavior, skin rash, feet and arm disability, "other" organ damage, aching muscles and lower back disability as the result of exposure to Agent Orange. The RO should then readjudicate the appellant's claim of entitlement to an increased evaluation for PTSD. If the foregoing determinations do not result in a grant of a 100 percent schedular rating, the claim for a 100 percent rating based on unemployability due to service-connected disabilities should be readjudicated. The rating decision should reflect consideration of 38 C.F.R. §§ 3.321(b)(1) and 4.16. All of the appellant's service-connected disabilities should be considered in this determination. The appellant is advised that the additional claims he has raised will not be before the Board unless the determination of the RO is unfavorable, and the appellant files a notice of disagreement and completes all procedural steps necessary to appeal a claim to the Board in accordance with 38 U.S.C.A. § 7105 (West 1991). If the benefit sought on appeal is not granted to the appellant's satisfaction, the RO should issue a supplemental statement of the case, and he and his representative should be provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if otherwise in order. In taking this action, the Board implies no conclusion, either legal or factual, as to any ultimate outcome warranted. RICHARD B. FRANK 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).