Citation Nr: 9905381 Decision Date: 02/26/99 Archive Date: 03/03/99 DOCKET NO. 95-04 597 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for post-traumatic stress disorder. WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD R. A. Caffery, Counsel INTRODUCTION The veteran served on active duty from December 1966 to November 1968. This is an appeal from a September 1994 rating action by the Department of Veterans Affairs (VA) Regional Office Muskogee, Oklahoma, which denied entitlement to service connection for post-traumatic stress disorder. REMAND The veteran's service medical records do not reflect any complaints or findings regarding a psychiatric disability. His service records indicate that he served in the Republic of Vietnam from April to November 1968. His military specialty was that of a heavy vehicle operator. His units were the 670th Transportation Company and 24th Transportation Company. The veteran submitted a claim for VA disability benefits in June 1994. He submitted a statement regarding various stressors experienced in Vietnam including observing a Korean officer shoot a captive Vietcong soldier, being involved in a firefight, killing two enemy personnel and learning of the death of a high school friend, Kenneth W. Skinner, III, in June 1968 in Vietnam. VA outpatient treatment records were received by the regional office reflecting that the veteran was seen on several occasions in 1994 for psychiatric problems. An assessment of post-traumatic stress disorder was made. The veteran was examined by the VA in August 1994. He reported nervousness, headaches and depression since his military service. It was indicated that he had been started on Prozac by his family physician for his depression and since that time he had had very little depression, nervousness or headaches. It was reported that he infrequently dreamed and the dreams were not always related to Vietnam. He denied any nightmares or flashbacks. It was reported that he had friends and apparently got along reasonably well with others. The veteran appeared anxious and kept his hands tightly clenched. It was indicated that his mood was not depressed but his affect was flattened. The impression was dysthymia in remission. The examiner commented that there was no evidence to support a diagnosis of post-traumatic stress disorder. He stated that specific stressors were lacking and the veteran was not having significant intrusive thoughts. The regional office received records from Wendy Heller, M.D., reflecting treatment of the veteran from 1989 to 1994. In May 1989 it was indicated that he had been having a sleep disturbance, eating disorder and depression. It was reported that he had suffered a long time from post Vietnam trauma complex. During the course of a June 1995 hearing at the regional office, the veteran again described the stressors reported in his earlier statement. He indicated that he had never received the Combat Infantryman Badge even though he had been shot at on occasion and wound up having to shoot some people. He reported that he had not received any combat awards or decorations. In June 1996 the U.S. Army and Joint Services Environmental Support Group (now U.S. Armed Services Center for Research of Unit Records) provided copies of operational reports of the Headquarters of the 24th and 670th Transportation Companies at Cam Ranh Bay from February to October 1968. It was indicated that the incidents that the veteran described could not be documented. The Board notes that the Vietnam Veterans Memorial Directory of Names contains the name of the acquaintance referred to by the veteran as having died in Vietnam in June 1968. His home of record was Dell City, Oklahoma. The Board further notes that a January 1994 VA outpatient treatment record contains a diagnosis of post-traumatic stress disorder based partly upon the veteran's claimed Vietnam stressor of hearing that his friend died. Since there is a diagnosis of post-traumatic stress disorder based on a possible verified stressor and since the medical evidence of record is conflicting as to whether the veteran actually experiences post-traumatic stress disorder, further development is required. On the basis of the present record and in order to afford the veteran every consideration, findings of fact and conclusions of law are being deferred pending a REMAND for the following action: 1. The RO should request that the veteran identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated him since June 1994 for a psychiatric disability. With any necessary authorization from the veteran, the RO should attempt to obtain copies of pertinent treatment records identified by the veteran in response to this request, which have not been previously secured. 2. After the above records have been secured, the veteran should be examined by a board of two psychiatrists experienced in cases involving post- traumatic stress disorder in order to determine the nature and extent of any psychiatric disability present and whether symptoms consistent with a diagnosis of post-traumatic stress disorder are manifested. In addition, an opinion regarding the existence and the etiology of each psychiatric disability, including post-traumatic stress disorder, should be included in the examination report in accordance with DSM-IV. If post-traumatic stress disorder is diagnosed, each stressor found sufficient to serve as the basis for such diagnosis should be specifically identified. If post-traumatic stress disorder is not found, the VA examiners should discuss the findings of the private and VA medical professionals, who have stated that the veteran has such a disorder due to emotional trauma experienced by the veteran during service. It is essential that the claims file be made available to the examiners for review prior to conducting the examination. 3. After all examinations have been completed, the veteran's claim should then be reviewed by the regional office. If the denial is continued, he should be sent a supplemental statement of the case and be afforded the appropriate time in which to respond. When the above action has been completed, the case should be returned to the Board for further appellate consideration, if otherwise in order. No action is required of the veteran until he receives further notice. The purpose of this REMAND is to obtain clarifying information. The Board intimates no opinion as to the disposition warranted in this case pending completion of the requested action. ROBERT E. P. JONES Acting Member, Board of Veterans' Appeals 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) (1998).