BVA9500936 DOCKET NO. 93-11 852 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for post-traumatic stress disorder and, if so, whether the reopened claim may be granted. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD B. Anderson, Counsel REMAND The appellant had active duty from October 1970 to January 1972. He served in Vietnam from March 1971 to January 1972, and his principle duty assignment was as a truckmaster. Combat service is not evident from the service department records associated with the claims file. Whereas an adjustment disorder with depressed mood was diagnosed at a mental health institute in September 1985 and polysubstance abuse was diagnosed at a Department of Veterans Affairs (VA) hospital in September 1993, these diagnoses plus post-traumatic stress disorder (PTSD) have been "diagnosed" at a county coun- seling center. It is not clear from the latter records whether the appellant has been examined or treated by medical personnel associated with the center. While the regional office (RO) has mounted serious attempts to corroborate the appellant's attenuated service history, the appellant has stated that he "can't" relive the experiences to assist the RO and his representative has argued that it is "difficult" for the appellant to recall events that took place over 20 years ago. Upon review, the Board of Veterans' Appeals (Board) concludes that further efforts in this area are warranted under the duty to assist. 38 U.S.C.A. § 5107(a) (West 1991). Accordingly, the case is REMANDED to the RO for the following actions: 1. The RO should obtain the names and addresses of all medical care providers who treated the appellant for a psychiatric disorder or substance abuse since January 1972. After securing the necessary release, the RO should obtain copies of medical records (not already in the claims folder) from all sources he identified and associate them with the claims file. 2. The RO should request from the appellant a comprehensive statement containing as much detail as possible regarding the stressors to which he alleges he was exposed in service. He should be asked to provide specific details of the claimed stressful events during service, such as dates, places, detailed descriptions of events, and identifying information concerning any other individuals involved in the events, including their names, ranks, units of assignment, or any other identifying detail. The appellant is advised that this information is vitally necessary to obtain supportive evidence of the stressful events and that he must be as specific as possible because, without such details, an adequate search for verifying information can not be conducted. 3. With the additional information obtained, the RO should review the file and prepare a summary of all of the claimed stressors. This summary, and all associated documents, should be sent to the United States Army and Joint Services Environmental support Group (ESG), 7798 Cissna Road, Springfield, VA 22150. ESG should be requested to provide any information which might corroborate the appellant's alleged stressors. 4. Following the above, the RO must make a specific determination, based upon the complete record, with respect to whether the appellant was exposed to a stressor or stressors in service, and if so, what was the nature of the specific stressor or stressors. The RO must specifically render a finding as to whether the appellant "engaged in combat with the enemy." In reaching these determinations, the RO should address any credibility questions raised by the record. Hayes v. Brown, 5 Vet.App. 60 (1993); Zarycki v. Brown, 6 Vet.App. 91 (1993); and West v. Brown, No. 92-890 (U.S. Vet. App. Aug. 8, 1994). 5. If, and only if, the RO determines that the record establishes the existence of a stressor or stressors, then the RO should arrange for the appellant to be accorded an examination by a board of two VA psychiatrists, if available, who have not previously examined him to determine the diagnoses of all psychiatric disorders that are present. The RO must specify for the examiners the stressor or stressors that it has determined are established by the record and the examiners must be instructed that only those events may be considered for the purpose of determining whether exposure to a stressor in service has resulted in current psychiatric symptoms and whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. The examination report should reflect review of pertinent material in the claims folder. The examiners should integrate the previous psychiatric findings and diagnoses with current findings to obtain a true picture of the nature of the appellant's psychiatric status. If the diagnosis of PTSD is deemed appropriate, the examiners should comment upon the link between the current symptomatology and one or more of the inservice stressors found to be established by the RO. The report of examination should include the complete rationale for all opinions expressed. All necessary special studies or tests, to include psychological testing and evaluation, such as the Mississippi Scale for Combat-Related Post-Traumatic Stress Disorders, should be accomplished. The claims folder must be made available to the examiners prior to the examination. 6. The RO should then review the record and ensure that all the above actions have been completed. When the RO is satisfied that the record is complete and the psychiatric examination is adequate for rating purposes, the claim should be readjudicated. If the benefit sought on appeal is not granted to the appellant's satisfaction, a supplemental statement of the case should be prepared and the appellant and his representative should be given a reasonable period of time for reply. Thereafter, the claim should be returned to the Board for further review, if otherwise in order. No action is required of the appellant until he receives further notice. The Board does not indicate any factual or legal conclusions as to any final outcome warranted in the appeal. 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 action has been taken in accordance with the Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 303, 108 Stat. 4645, ___ (1994), and 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).