Citation Nr: 0812466 Decision Date: 04/15/08 Archive Date: 05/01/08 DOCKET NO. 06-00 117A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an increased rating for post-traumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD Tanya A. Smith, Counsel INTRODUCTION The veteran served on active duty from July 1964 to December 1971. This case comes to the Board of Veterans' Appeals (Board) on appeal of a May 2005 rating decision rendered by the Togus, Maine, Regional Office (RO) of the Department of Veterans Affairs (VA). Jurisdiction over the case was subsequently returned to the RO in Roanoke, Virginia. REMAND The veteran submitted additional medical evidence after the last issuance of a supplemental statement of the case in June 2006. The additional evidence includes a discharge summary that indicates that the veteran was hospitalized for PTSD in May 2007. On admission he was assigned a Global Assessment of Functioning (GAF) score of 25. GAF scores are based on a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging from 21 to 30 are indicative of behavior that is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. Upon discharge, the summary notes that the veteran denied mood symptoms, psychotic symptoms, and lethal ideations. No GAF score, however, was reported. The veteran was last afforded a fee-basis VA compensation and pension examination by QTC Medical Services in February 2005. The veteran contends that his PTSD renders him unemployable. In light of the veteran's recent hospitalization, his prior history of hospitalizations for PTSD, and the fact that his last VA examination was conducted over three years ago, the Board finds that the veteran should be afforded a new examination addressing the current severity of his service- connected PTSD. A medical opinion should also be obtained on whether his PTSD renders him unable to secure or follow a substantially gainful occupation. The "duty to assist" requires a "thorough and contemporaneous medical examination" that is sufficient to ascertain the current level of disability, and accounts for its history. Floyd v. Brown, 9 Vet. App. 88, 93 (1995). This medical examination must consider the records of prior medical examinations and treatment in order to assure a fully informed decision. Caffrey v. Brown, 6 Vet. App. 377, 381 (1994). Accordingly, this case is REMANDED to the RO or the AMC in Washington, D.C., for the following actions: 1. The RO or the AMC should send the veteran a letter requesting him to provide any outstanding medical records pertaining to treatment or evaluation of his PTSD during the period of this claim or the identifying information and any necessary authorization to enable VA to obtain such records on his behalf. 2. The RO or the AMC should undertake appropriate development to obtain any pertinent evidence identified but not provided by the veteran, to include VA treatment records from the Hampton VA Medical Center dated from May 2007. If the RO or the AMC is unsuccessful in its efforts to obtain any such evidence, it should so inform the veteran and his representative and request them to submit the outstanding evidence. 3. Then, the veteran should be afforded an examination by a physician with appropriate expertise to determine the current degree of severity of his service-connected PTSD. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed. To the extent possible, the examiner should distinguish the manifestations of the service-connected PTSD from those of any non service-connected disorder. The examiner should also provide an opinion concerning the current degree of social and industrial impairment resulting from the service-connected psychiatric disability, to include whether it renders the veteran unemployable. In addition, the examiner should provide a global assessment of functioning score with an explanation of the significance of the score assigned. 4. The RO or the AMC should also undertake any other development it determines to be indicated. 5. Then, the RO or the AMC should readjudicate the issues on appeal on a de novo basis. If the benefits sought on appeal are not granted to the veteran's satisfaction, the veteran and his representative should be furnished a supplemental statement of the case and provided an appropriate opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is otherwise notified, but he has the right to submit additional evidence and argument on the matters the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This case 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). _________________________________________________ Shane A. Durkin 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).