BVA9507291 DOCKET NO. 93-09 307 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to an increased evaluation for a psychophysiological gastrointestinal reaction, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Lois N. Petzold, Associate Counsel INTRODUCTION The veteran served on active duty from May 1942 to January 1946. This appeal arises from a July 1992 rating decision of the New Orleans, Louisiana, Regional Office (RO), which denied an increased rating for a psychophysiological gastrointestinal reaction, evaluated as 10 percent disabling. In his September 1992 substantive appeal the veteran also appears to be raising the issue of entitlement to a total disability rating based on individual unemployability due to his service connected disabilities. This matter is not in proper appellate status and is referred back to the RO for appropriate action. REMAND The appellant contends, in effect, that his stomach/anxiety disorder is more disabling than currently evaluated. He asserts he suffers from stomach spasms that cannot be controlled with medication and make him nauseous. He maintains that his stomach/anxiety disorder causes him to have nightmares which leave him tired and affect his ability to think. The VA has a duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a) (West 1991). The United States Court of Veterans Appeals (the Court) has held that the duty to assist the veteran in developing available facts and evidence to support his claim includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran that takes into account the records of prior medical treatment. Green v. Derwinski, 1 Vet.App. 121 (1991). This is to ensure that the evaluation of a disability is a fully informed one. The severity of psychiatric disability is based upon actual symptomatology as it affects social and industrial adaptability. See 38 C.F.R. §§ 4.129, 4.130 (1993). In this case, the May 1992 VA psychiatric examination is inadequate to evaluate the degree of disability present. It fails to adequately assess the degree of social and industrial inadaptability present. Multiaxial assessment V: global assessment of functioning (GAF) with respect to psychological, social and occupational functioning was not provided. 38 C.F.R. § 4.2 requires that if an examination report does not contain sufficient detail, it is incumbent upon the Rating Board to return the report as inadequate for evaluation purposes. The duty to assist also includes obtaining available medical records which are relevant to the claimant's appeal. Littke v. Derwinski, 1 Vet.App. 90 (1990). In the case at hand, the most recent treatment records associated with the veteran's claims folder are dated in January 1992. It is likely that the veteran has received treatment for his stomach/anxiety disorder since then, so the RO must attempt to obtain the records of any such treatment. In view of the foregoing, following the gathering of all available medical records, the veteran should be afforded a VA special examination in psychiatry. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. These requirements for evaluation of the complete medical history of the claimant's condition operate to protect claimants against adverse decisions based on a single, incomplete or inaccurate report and to enable VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). Moreover, VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Under the circumstances of this case, the Board finds that further assistance is required. Accordingly, the case is REMANDED to the RO for the following actions: 1. The RO should contact the veteran and obtain the names and addresses of all providers from whom he has received treatment for his psychophysiological gastrointestinal reaction since January 1992. After obtaining any necessary release from the veteran, the RO should obtain copies of all such treatment records and associate them with the claims folder. 2. Following completion of the above development, the veteran should be afforded a comprehensive VA psychiatric examination to determine the nature and extent of the disability present. This study must be conducted in accordance with the VA Physician's Guide for Disability Evaluation Examinations. All indicated tests, including appropriate psychological studies with applicable subscales, must be conducted. The claims file must be made available to and reviewed by the examiner prior to the requested study. The examiner must assign a Global Assessment of Functioning Score consistent with the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (3rd ed. rev., 1987), and explain what the assigned score represents. . 3. Following completion of the foregoing, the RO must review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, including if the requested examination does not contain all test reports, special studies or opinions requested, appropriate corrective action is to be implemented. Thereafter, the claim should be reviewed by the RO. If the claim continues to be denied, the veteran and his representative should be furnished an appropriate supplemental statement of the case, and afforded a reasonable opportunity to respond. The case should then be returned to the Board for further appellate consideration. C.W. SYMANSKI 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).