Citation NR: 9606362 Decision Date: 03/12/96 Archive Date: 03/16/96 DOCKET NO. 94-08 832 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, including post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Connecticut Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Kenneth E. Nielsen, Jr., Associate Counsel INTRODUCTION The veteran served on active duty from October 1968 to October 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 1993 rating decision by the Hartford, Connecticut Regional Office (RO) of the Department of Veterans Affairs (VA), which denied service connection for an acquired psychiatric disorder, including PTSD. REMAND The veteran and his representative contend that the veteran developed PTSD as a result of service in Vietnam. They attribute the claimed PTSD to the veteran’s exposure to traumatic stressors during his two tours of duty in Vietnam. The service department Form DD 214 reflects that the veteran served in Vietnam from May 1969 to April 1970 and from November 1970 to September 1971. The personnel records also show that the veteran was awarded the Vietnam Service Medal with 60 device and the Vietnam Campaign Medal with 2 stars. The veteran’s military occupational specialty (MOS) was field radio mechanic. No combat medals or awards were noted. The veteran has reported that he suffered traumatic stressors during his two tours of duty in Vietnam. Examples of the stressors the veteran indicated he was exposed to includes: 1) Observing a monk dousing his body in gasoline and lighting himself on fire; 2) shooting at children while on guard duty; 3) risking his life transporting supplies; 4) being fired upon by the enemy. The service medical records reveal a notation of severe depression in February 1971. In August 1971 it was noted that the veteran was addicted to opium and had reactive depression. In September 1971 it was noted that he had been taking Elavil for his nerves and had shot opium and speed one month ago. The claims file contains records of treatment and hospitalization, from both VA and private facilities, for a variety of psychiatric conditions beginning in March 1976 and continuing to present. Private medical records reflect that the first PTSD diagnosis occurred in October 1992. A provisional diagnosis of PTSD, related to the veteran’s two tours of duty in Vietnam, was made by Arthur F. Glickstein, Ph.D., in June 1993. A VA examination was conducted in June 1993. The examiner noted the veteran’s description of traumatic stressors he experienced in Vietnam. The diagnoses were panic disorder with agoraphobia, major depression and drug and alcohol dependence. In September 1993 the Social Security Administration awarded the veteran Social Security disability benefits. Precedent decisions of the United States Court of Veterans Appeals (Court) require that we obtain the medical records upon which the award of Social Security disability benefits was based. Masors v. Derwinski, 2 Vet.App. 181 (1992); Murincsak v. Derwinski, 2 Vet.App. 363 (1992). In an April 1994 letter, Grace Thrall, MD, noted that she had conducted structured clinical interviewing with the veteran in October and November 1993 and that, using the SCID and the SCAN-PSE-10, the veteran had met the criteria for a diagnosis of PTSD. Dr. Thrall also noted that the veteran’s PTSD had clear origins to his combat experiences in Vietnam beginning in 1968 and that more detailed supporting data about the diagnosis was available upon request. In an April 1994 letter from the Hartford VA Readjustment Counseling Center, a readjustment counseling therapist notes that the veteran had been coming to the center sporadically since 1984. It was also noted that the PTSD symptoms most mentioned in the veteran’s folder were nightmares, periods of anger, anxiety or panic, depression, substance abuse, difficulty with authority figures, alienation and inconsistent behavior. VA hospitalization records from July 1994 to May 1995 note that the veteran was hospitalized repeatedly with a variety of diagnoses, including PTSD. It is the opinion of the Board that further development is desirable prior to appellate resolution. Accordingly, this case is REMANDED for the following action: 1. The RO should obtain the veteran’s complete service personnel records from the National Personnel Records Center. 2. The RO should contact Dr. Thrall at the John Dempsey Hospital in Farmington, Connecticut and obtain a copy all of the veteran’s treatment records not already associated with the claims file, including any of the supporting data relied upon by Dr. Thrall in rendering her diagnosis of PTSD. 3. The RO should contact the VA Readjustment Counseling Service at the Hartford Veterans Center and obtain a complete copy of the veteran’s file. 4. The RO should contact the Social Security Administration and obtain all medical records upon which the September 1993 award of Social Security disability benefits was based, for association with the claims folder. 5. The RO should contact the veteran and ask him to provide a statement relating as many details as possible about his traumatic experiences while serving in Vietnam. Specific dates, places, units and names of individuals should be sought. Thereafter, the statement should be forwarded to the United States Army and Joint Services Environmental Support Group, 7798 Cissna Road, Springfield, Virginia 22150, for attempted verification of the claimed stressors. 6. After completion of the above, the veteran be afforded a VA psychiatric examination by a board of two psychiatrists to determine the nature and extent of any psychiatric disability now present, with particular reference to the diagnostic criteria for PTSD. Clinical findings should be reported in detail. Psychological testing should be performed. If PTSD is diagnosed, the examiners should identify the specific stressors and symptoms relied upon to support the diagnosis. Irrespective of what the examining physicians conclude as regards PTSD, in view of the above noted clinical findings in service medical records, they should express an opinion as to whether an acquired psychiatric disorder (irrespective of diagnosis) developed during service or is related to service. Their attention, in this regard, should be directed to the last paragraph on page 3 of the June 1993 report of VA psychiatric examination. The claims folder should be made available to and reviewed by the examiners prior to the veteran’s examination. 7. After the development requested above has been completed to the extent possible, the RO should again review the entire record. If the benefit sought on appeal remains denied, the veteran and his representative should be furnished a supplemental statement of the case and be given the appropriate opportunity to respond thereto. Thereafter, the case should be returned to the Board, if in order. The purpose of this REMAND is to procure clarifying data. The veteran need take no action until otherwise notified. BRUCE E. HYMAN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741 (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) (1995). - 2 -