BVA9500140 DOCKET NO. 93-02 922 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE 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 R. E. Smith, Counsel INTRODUCTION The veteran had active military service from December 1967 to September 1971. This appeal arises from a March 1992 rating decision of the Department of Veterans Affairs (VA) Reno, Nevada Regional Office (RO) which, in pertinent part, denied the veteran entitlement to service connection for PTSD. The issue of service connection for hypertension, a back condition with leg pain, and entitlement to vocational rehabilitation benefits under Chapter 31 of Title 38, United States Code, were the subjects of the statement of the case provided to the veteran in April 1992. At a personal hearing before a hearing officer at the RO in August 1992, the veteran said that he wanted to withdraw these issues from appellate consideration. A statement to this effect, signed by his representative at that time, is contained within the claims file. These issues, accordingly, will not be addressed in this decision. In a statement received in September 1992, the veteran has raised the issue of entitlement to service connection for peripheral neuropathy, involving his fingers, toes, and legs, as a residual of Agent Orange exposure. As the veteran was advised in November 1992 by the RO, consideration of claims for disorders asserted to be residuals of Agent Orange exposure has been deferred, pending regulatory action. This issue has not been developed for appellate review and is referred to the RO for action deemed appropriate. REMAND The record shows that the appellant served as an "electronic mechanic" while on active duty and that his military service included duty aboard the U.S.S. Oriskany while that ship was engaged in combat operations off the coast of Vietnam. His decorations included Vietnam Campaign Medal, the Vietnam Service Medal, and the Republic of Vietnam Meritorious Unit Citation (Gallantry Cross). There is, however, no record of the veteran's personal engagement in combat or that he was awarded any individual combat-related decoration. The veteran's testimony offered at his personal hearing on appeal at the RO did not reveal otherwise. Despite this fact, the veteran has submitted into evidence a March 1992 VA mental health intake progress note, signed by a doctor of clinical psychology, which records a diagnosis of PTSD based on "present symptomatology and his history." This history appears to refer back to an earlier entry recorded on this same progress note which indicated that the veteran had numerous unresolved conflicts concerning his "combat" in Vietnam. On an earlier August 1991 VA medical examination by a fee-basis Board psychiatrist, Donald L. Silverman, M.D., a diagnosis of PTSD was entertained. However, Dr. Silverman reported that, while the veteran had symptoms consistent with that diagnosis, it was unclear to him "that there has been a pattern of exposure to traumatic situations that would allow me to use this diagnosis." He further reported that the veteran's symptoms were also consistent with a diagnosis of generalized anxiety disorder with intermittent depression. Although a VA clinical psychologist has diagnosed the veteran as having PTSD, we note that critical elements of this diagnosis, most fundamentally those concerning the existence of a stressor or stressors, are not detailed in the March 1992 progress notes, and thus the diagnosis may be based wholly upon statements of history which may be less than accurate or incomplete. Statements made by the veteran, on file, in connection with his claim, including statements made as part of his testimony at an August 1992 hearing, show the veteran claimed stressors primarily consist of two separate incidents which occurred while he was aboard the U.S.S. Oriskany in 1969. One involved the death of a Commander Smiley who the veteran testified was either killed or missing in action after being shot down while flying a mission over Vietnam. The other stressor related incident involves an unsuccessful launching of an aircraft off the flight deck of the U.S.S. Oriskany. On this occasion the aircraft, which the veteran identifies as either an A-4, Skyhawk, or an A-7, crashed into the ocean. The veteran has also indicated in a statement received in August 1991 that additional stressors to which he was exposed include the crash landing of an F8 (apparently on the U.S.S. Oriskany) which killed the pilot, and a tragic incident involving a flight deck worker being sucked into the jet's intake of an airplane. He has also described an incident in which a plane's landing gear became detached and struck a compartmented wall behind which the veteran slept aboard ship. In Wilson v. Derwinski, 2 Vet.App. 614 (1992), the Court found that the Board was not required to grant service connection for PTSD solely on the basis that a physician or other health professional accepts an appellant's description of his Vietnam experiences as credible and diagnoses the appellant as suffering from PTSD. In other words, the question of whether an appellant has experienced a stressor or an event that is outside the range of usual human experience, which is a requisite criterion in establishing a diagnosis of PTSD is a finding of fact. It is the Board's judgment that there are insufficient service, administrative or personnel records, or other evidence on file which might confirm the existence of the veteran's combat experience, if any, or corroborate the veteran's description of stressor events during that service. See West v. Brown, No. 92- 890 (U.S. Vet. App. August 8, 1994). This matter needs to be examined before further appellate action on the claim can proceed. Furthermore, the record reflects that in May 1992, the appellant was awarded benefits from the Social Security Administration. Insofar as any medical records used to determine the veteran's entitlement to such an award may also contain medical history that would be relevant to the issue now before us, these records must be obtained. See generally, Murincsak v. Derwinski, 2 Vet.App. 363 (1992). In light of the foregoing, and the VA's duty to assist the veteran in the development of facts pertinent to his claims, as mandated by 38 U.S.C.A. § 5107(a) (West 1991), the case is REMANDED to the RO for the following actions: 1. The RO should contact the Social Security Administration and request a copy of the medical records upon which the administrative law judge reached his decision in May 1992 awarding the veteran's Social Security Administration benefits. 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. The veteran should be asked to provide specific details of the claimed stressful events during service, such as dates, places, detailed descriptions of events, and any other identifying information concerning any other individuals involved in the events, including their names, ranks, units of assignments or any other identifying detail. The veteran is advised that this information is vitally necessary to obtain supportive evidence of the stressful events and he must be asked to be as specific as possible because without such details an adequate search for verifying information can not be conducted. He is further advised that failure to respond may result in adverse action. 3. Thereafter, the RO should provide a copy of the veteran's "stressor" statement, DD Form 214, and any other relevant documentation, to the United States Army and Joint Services Environmental Support Group (ESG), 7798 Cissna Road, Springfield, Virginia 22150, for the purpose of verifying any of the stressor stories reported by the veteran. 4. After the above development is completed, the veteran should be examined by a psychiatrist experienced in the requirements to be met concerning the diagnosis of PTSD who has not previously examined him. A statement as to the psychiatric reliability of the veteran as a reliable historian is requested. The claims folder should be made available to the examiner so that the veteran's psychiatric history may be reviewed. It is requested that the psychiatrist should specifically confirm or rule out a diagnosis of post-traumatic stress disorder based on the accurate history of the veteran's service in Vietnam as documented in the claims folder by the veteran's service records and the report of the ESG. If it is concluded that a diagnosis of post-traumatic stress disorder is warranted, the examiner should specify the stressor(s) believed to have brought on the disorder and it should be specified what evidence was relied upon to determine that the veteran was exposed to such stressor(s). Any opinions expressed must be accompanied by a detailed rationale. Again, the claims folder must be made available to the psychiatrist for a detailed review as specified above prior to the examination. Any examination which does not fulfill all these requirements must be returned to the examiner as being inadequate. In particular, any examination report which relies on a questionable history must be returned as inadequate. Thereafter, the claim should be reviewed by the RO. If the decision is adverse to the veteran, a supplemental statement of the case should be issued to him and his representative and they should be provided a reasonable opportunity to respond to it. The case should then be returned to the Board for further appellate consideration. N. R. ROBIN Member, Board of Veterans' Appeals (CONTINUED ON NEXT PAGE) 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).