Citation Nr: 0811384 Decision Date: 04/07/08 Archive Date: 04/23/08 DOCKET NO. 04-42 960 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to an initial rating in excess of 30 percent for post-traumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Helena M. Walker, Associate Counsel INTRODUCTION The veteran served on active duty from August 1968 to August 1970, including honorable combat service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which granted service connection for PTSD and assigned an initial rating of 30 percent, effective January 13, 2004. The veteran appeared and testified before the undersigned at a February 2008 hearing at the Central Office in Washington, DC. The hearing transcript is of record. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND In light of the VCAA, further evidentiary development is necessary. In May 2004, the veteran was granted service connection for PTSD, which was initially rated at 30 percent disabling. The veteran contends that due to the severity of his PTSD symptoms, he is entitled to a rating in excess of 30 percent. The Board notes that the veteran served in the Republic of Vietnam and received numerous decorations, including a Purple Heart, a Bronze Star Medal and a Combat Infantryman Badge. In 2002, the veteran first sought treatment for his PTSD symptoms. At the time of his initial treatment he experienced difficulty in his work environment due to strained work relationships. In July 2002, the veteran was first diagnosed as having chronic PTSD with depressive features. He reported experiencing 3 or more nightmares per night that were primarily reexperiencing in nature. The veteran was further noted have symptoms related to avoidance, decreased interest, detachment, flat affect, shortened sense of future, hypervigilance, insomnia, irritability, sense of guilt and had worsened nightmares. He was noted to have a Global Assessment of Functioning (GAF) score of 60. In August 2002, the veteran reported nightmares of Vietnam and was noted to have temper problems associated with flashbacks, intrusive thoughts, paranoia and hallucinations. He was again diagnosed as having PTSD and was given a GAF score of 40. In February 2004, the veteran underwent a VA examination regarding his service connection claim for PTSD. The veteran reported sustaining wounds while in service due to two distinct incidents. The veteran advised that he had difficulty sleeping-approximately two to five hours per night. He reported nightmares, including nightmares of combat and attempts to keep himself awake so as to not have Vietnam-related dreams. He further related frequent night sweats and thrashing during sleep. The veteran reported that five or 6 times per year, he heard his name being called and saw Vietcong soldiers. He advised to having intrusive thoughts of Vietnam several times per week. The veteran reported difficulty in crowds and isolation from his friends and family. He further noted difficulty with anger control and experiencing "emotional blunting." The veteran had a mild startle response to touch and sounds, as well as mild hypervigilance. At the time of the examination, the veteran denied suicidal or homicidal ideation. The veteran was noted to have mild, delayed-onset PTSD and a GAF score of 60. The examiner noted that the veteran experienced a mild degree of impairment in adaptation, interaction and social functioning. He further stated that the veteran may experience "a mild degree of impairment in flexibility and efficiency in an occupational setting, although it [did] not appear to be a significant problem with his employment." The examiner found the veteran's current level of disability to be mild. In his November 2004 notice of disagreement, the veteran asserted that his depression had worsened. He reported increasing thoughts of suicide and homicide. The veteran's VA mental health treatment records reflect the veteran's reluctance to discuss the details of his experiences in Vietnam. Also noted, was the veteran's reluctance to discuss the severity of his PTSD symptoms. The veteran's treating psychologist noted that the veteran's PTSD symptoms ranged from moderate to more severe in nature. In November 2004, the veteran was noted to have a GAF score of 50. In February 2005, the veteran underwent a subsequent VA examination. The veteran reported depressive symptoms, difficulty with concentration, anger, irritability, feelings of guilt, nightmares, isolation and withdrawal from others, and lessened participation in activities. The veteran advised that his symptoms significantly worsened due to exposure to news regarding the current war. He could not identify anything that reduced his PTSD symptoms-not even his medication. The veteran reported experiencing suicidal ideation two times per week, but denied making a plan or attempting suicide. The veteran's PTSD was noted to be chronic and moderate in nature. His GAF was found to be at 50. The examiner noted the veteran's difficulty with his short-term memory and his avoidance of newscasts and movies regarding war and combat. The veteran's symptoms were found to affect his ability to relate to his wife and coworkers and his symptoms led to difficulty with maintaining employment. The veteran's ability to perform the activities associated with daily living was found to be within normal limits. The examiner found the veteran's PTSD was moderate in nature. In an August 2005 VA treatment record, the veteran was noted to be continually reluctant to discuss his trauma and symptoms associated with PTSD. At this treatment, the veteran's speech was noted to be limited in spontaneity. The veteran's PTSD symptoms continued to include avoidance, hypervigilance, anger, irritability, and a notation was made that it was affecting his work. He was assessed a GAF score of 55. In March 2006, the veteran underwent another VA examination. At this examination, the veteran advised that he was unemployed and had difficulty finding work as no one would hire him. The veteran reported suicidal ideation one or two times per month with no plan to carry it out. The examiner found the veteran's GAF score to be 55 and noted that the veteran experienced a mild degree of impairment of social functioning with a mild to moderate degree of impairment of occupational functioning. The examiner opined that the veteran's current level of disability was mild to moderate in nature. At his February 2008 Central Office hearing, the veteran reported that his PTSD symptoms had worsened since his last VA examination in March 2006. The veteran advised that he believed his March 2006 VA examination was inadequate as the same examiner who performed his February 2004 VA examination, performed the most recent one. The veteran stated that the examiner talked to him for five minutes, asked him one or two questions, and left. He testified to having problems with authority, crowds and, more generally, in dealing with people. The veteran advised that he had nightly hallucinations and daily suicidal ideations. He reported two to two-and-a-half hours of sleep per night-including nightly flashbacks and night sweats. He testified that he sometimes has to change his shirt three to four times per night due to his night sweats. The veteran reported obsessively checking the perimeters of his home, as well as checking the lock on the doors. The veteran advised that he is unable to express himself to his wife, but makes an effort to see his children every other week. Given the evidence as outlined above, the Board finds the medical evidence of record insufficient upon which to render a decision. The veteran advised that his PTSD symptoms have worsened since his March 2006 VA examination. Thus, the claim must be remanded for a medical examination and report obtained as to the veteran's current level of disability. Accordingly, the case is REMANDED for the following action: 1. Request and obtain all outstanding medical treatment records regarding the veteran's PTSD. Perform all development deemed necessary. 2. Schedule the veteran for a VA examination with the appropriate specialist to determine the current severity of the veteran's PTSD. The veteran's claims folder should be made available to the examiner. The examiner is to perform all necessary clinical testing and render all appropriate diagnoses based upon the reported symptomatology. The examiner should pay specific attention to the veteran's reported increase in severity of his PTSD symptoms as reflected in the February 2008 hearing transcript. The examiner is then requested to make a finding as to the current level of the veteran's disability. 3. When the requested development has been completed, the case should be reviewed on the basis of the additional evidence. If the benefits sought are not granted, the veteran and his representative should be furnished a Supplemental Statement of the Case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The purpose of this REMAND is to obtain additional evidentiary development, and the Board, at this time, does not intimate any opinion as to the merits of the case, either favorable or unfavorable. The veteran is free to submit any additional evidence and/or argument he desires to have considered in connection with his current appeal. See Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the veteran until he is notified. However, the veteran is advised that failure to appear for any scheduled VA examinations without good cause could result in the denial of his claims. 38 C.F.R. § 3.655 (2006). See Connolly v. Derwinski, 1 Vet. App. 566, 569 (1991). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). _________________________________________________ LILA J. BAKKE Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (2007).