BVA9501015 DOCKET NO. 93-09382 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Washington, DC THE ISSUE Entitlement to service connection for a psychiatric disorder. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Anthony D. Dokurno, Associate Counsel INTRODUCTION The veteran performed active military service from July 1988 to May 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 1992 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for a personality disorder. The veteran and his representative presented evidence personally before the undersigned Member of the Board in July 1993. REMAND The threshold inquiry is whether the veteran's claim is well- grounded. Under the provisions of 38 U.S.C.A. § 5107 (West 1991), a person who submits a claim to the VA has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well-grounded. If the person meets this burden, the VA is obligated to assist in developing facts pertinent to the claim. A well-grounded claim is one that is plausible, that is, meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). The veteran and his representative have submitted reports of medical examinations substantiating his claim that symptoms of a psychiatric disorder manifested themselves during his active military service. The veteran also testified that his symptoms first appeared after he was physically abused during recruit training, and have continued to the present. The veteran and his representative also submitted a written statement from acquaintances who knew the veteran before service. The acquaintances asserted that the veteran's personality had changed markedly since service. They also stated that, in direct contrast with his pre-service personality, the veteran was unable to hold a steady job, maintain a steady train of thought, or avoid losing his temper. Under these circumstances, the veteran's claim is at least plausible and therefore well- grounded. Tirpak v. Derwinski, 2 Vet.App. 609 (1992). However, though the claim is well-grounded, significant factual questions require further development. The veteran's enlistment examination does not mention any evidence of the existence of a pre-service psychiatric disorder. The first mention of such a disorder is a service medical record entry dated February 1989. The examiner noted that the veteran had requested a formal interview with his commanding officer during which he stated he was sure that if he remained in service his relationship with his fiancée would end. If the relationship ended, he purportedly stated, he would kill himself. The veteran's unit then referred him to the medical unit for evaluation. During the evaluation itself, the examiner noted that the veteran denied any suicidal or homicidal ideation, previous psychiatric treatment, or psychotic manifestations, but did become "tearful" when discussing his military service and his relationship with his fiancée. The examiner also noted that the veteran's insight and judgment were intact, but influenced by marked denial and externalization. The examiner's diagnosis was of a dependent personality disorder, severe, existing prior to service, and not amenable to change through treatment. He recommended a follow-up appointment and administrative separation from service. Another examination, conducted in April 1989, listed an Axis II diagnosis of mixed personality disorder. During his hearing before a single member of the Board in July 1993, the veteran testified that he believed he had been administered the drug Tranxene during service. However, an April 1989 note made to the Problem Summary List in the service medical record has no mention of medications in the section entitled "Patient Problem List/Medications." The veteran's separation examination also listed no medications. The claims file contains no statements from physicians who may have treated the veteran since his separation from active service, but the veteran's October 1991 Application for Compensation or Pension lists three physicians who the veteran says have treated him since service. Additionally, during his July 1993 hearing, the veteran testified that he has been treated by private physicians since service. It is however unclear whether their treatments were pertinent to this claim. The Application for Compensation also lists two non-physician points of contact who the veteran asserts have knowledge of his condition, but the file contains a statement from only one. During his July 1993 hearing, the veteran also discussed his unsuccessful application for employment with a local police department and mentioned that a psychiatric examination was part of the employment process. It is unclear from the claims file whether any attempt was made to secure a copy of that examination. During the veteran's July 1993 hearing, he also testified that though he was currently employed, he had not had a stable employment history. He attributed this to his disorder's symptoms. The claims file, however, does not reveal whether an attempt was made to secure records substantiating this contention. The veteran and his representative have requested that the veteran receive a VA examination and a Social and Industrial Survey to confirm the disorder's detrimental impact on the veteran's employability. The veteran has yet to be accorded a VA examination. Accordingly, in light of the foregoing and the Board's duty under 38 U.S.C.A. § 5107(a) to assist the veteran in the development of facts pertinent to his claim, the case is REMANDED to the RO for the following actions: 1. The RO should request the veteran to provide a comprehensive statement regarding all medical treatment received for any reason post-service. This state- ment should include not only those treatments the veteran specifically sought or received for a personality disorder or another psychiatric or nervous disorder, but all other reports which may contain incidental evidence of medical history, as well. The veteran should be advised to supply the necessary signed authorizations for the release of this medical information. He should also be informed that his cooperation is vitally important to a resolution of his claim and that his failure to cooperate may have adverse consequences. After the veteran has submitted written authorizations for the release of any further information, the RO should take appropriate action to secure copies of these records. 2. The RO should advise the veteran to complete a statement regarding his employment since service, so that the effect of his disorder upon his industrial capability may be assessed. 3. The RO should schedule the veteran for a VA psychiatric examination. Before the examination, the veteran's claims folder must be made available to the examiner for review. After a review of the file, the examiner should conduct the examination to determine the nature and etiology of any neuropsychiatric disability the veteran now has. If needed to solve a diagnostic problem or obtain additional data, the examiner should utilize Social Work Service and/or psychological tests. See Physician's Guide for Disability Evalu- ation Examinations, Chapter 14. Primary personality disorders should be fully described and classified. The relationship between the veteran's currently diagnosed disorder, if any, and the personality disorder diagnosed in service should be discussed. Thereafter, the examiner should provide a Global Assessment of Functioning (GAF) scale code and discuss the nature and meaning of the GAF scale. 4. In light of any additional evidence obtained, the RO should readjudicate the veteran's claim and, if the benefit sought on appeal is not granted to the veteran's satisfaction, issue a supplemental statement of the case which summarizes the new evidence and provides detailed reasons and bases for the decision. The veteran and his representative should be provided an opportunity to respond. Thereafter, the case should be returned to the Board for further consideration, if otherwise warranted. By this REMAND, the Board intimates no opinion regarding any final outcome. The veteran is not required to perform any action until he is notified by the RO. GARY L. GICK 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 deter- mination. 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).