Citation Nr: 0812307 Decision Date: 04/14/08 Archive Date: 05/01/08 DOCKET NO. 07-00 080A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to an increased evaluation for post traumatic stress disorder, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD K. Millikan Sponsler, Associate Counsel INTRODUCTION The veteran served on active military duty from March 1967 to December 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Cleveland, Ohio, Regional Office (RO) of the Department of Veterans Affairs (VA). The appeal is remanded to the RO via the Appeals Management Center, in Washington, DC. REMAND VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2007). VA's duty to assist includes providing a new medical examination when a veteran asserts or provides evidence that a service-connected disability is worse than when originally rated and the available evidence is too old for an adequate evaluation of his current condition. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); see also 38 C.F.R. § 3.327(a) (2007) (noting that reexaminations are required if evidence indicates there has been a material change in a disability). At the September 2007 Board hearing, the veteran asserted that his post-traumatic stress disorder (PTSD) symptoms had worsened since the most recent November 2005 VA psychiatric examination. Accordingly, remand is required because the most recent November 2005 VA examination no longer provides a clear picture of the severity of the veteran's service- connected PTSD. Accordingly, the case is remanded for the following action: 1. The RO must provide notice as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006) and Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). 2. The RO must contact the veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claim, to include any medical treatment since October 2005. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain named records the RO is unable to secure same, the RO must notify the veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; and (c) describe any further action to be taken by the RO with respect to the claim. The veteran must then be given an opportunity to respond. 3. The RO must schedule the veteran for a comprehensive VA psychiatric examination to determine the current severity of the veteran's PTSD. The claims folder and a copy of this remand must be made available to the examiner for review in conjunction with the examination. The examiner must provide accurate and fully descriptive assessments of all psychiatric symptoms. The examiner must comment upon the presence or absence, and the frequency or severity of the following symptoms due to PTSD: depressed mood; anxiety; suspiciousness; panic attacks; chronic sleep impairment; mild memory loss (such as forgetting names, directions or recent events); flattened affect; circumstantial, circumlocutory, or stereotyped speech; difficulty in understanding complex commands; impairment of short- and long- term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation or mood; difficulty in establishing and maintaining effective work and social relationships; suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately, or effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships; gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal person hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. The examiner must also enter a complete multiaxial evaluation, and assign a Global Assessment of Functioning score together with an explanation of what the score represents in terms of the veteran's psychological, social, and occupational functioning. The examiner must provide an opinion as to whether the veteran's PTSD alone renders him unable to obtain or retain employment. A complete rationale for all opinions must be provided. Any report prepared must be typed. 3. The RO must notify the veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2007). In the event that the veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 4. The examination report must be reviewed to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the RO must implement corrective procedures. 5. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim must be readjudicated. If the claim remains denied, a supplemental statement of the case must be provided to the veteran and his representative. After the veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD 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).