Citation Nr: 1125077 Decision Date: 07/01/11 Archive Date: 07/14/11 DOCKET NO. 10-02 678 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to an initial increased rating for posttraumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD Shabnam Keyvan INTRODUCTION The Veteran served on active duty from September 1987 to September 1993. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from the February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which, in pertinent part, granted service connection for PTSD and evaluated it as 30 percent disabling, effective July 20, 2007. For the reasons set forth below, this appeal is being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND The law provides that VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires VA to assist a claimant in obtaining that evidence. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2010). Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2010). The Veteran's service-connected PTSD is currently evaluated as 30 percent disabling. After a complete and thorough review of the claims folders, the Board finds that a remand of the Veteran's claim for a higher rating for his service-connected PTSD is required. Specifically, further development of the record is required. During a July 2006 VA PTSD assessment, the Veteran described his in-service experiences and reported to have witnessed a number of traumatic events during his years in service. Since separation from service, the Veteran reported having nightmares every few weeks which center around his in-service traumatic events, and which he described as vivid in nature. According to the Veteran, his nightmares are so disturbing at times, that he becomes physically ill upon awakening from them. He indicated that he only sleeps for two hour increments, and considers 3-4 hours of uninterrupted sleep to be "great." He expressed feeling uncomfortable emotionally when having to share his experiences, and stated that he avoids the news as it brings up thoughts and feelings he would rather not deal with. He reported to feel cautious around people with certain ethnic backgrounds, and to avoid activities that involve large crowds due to his fear of being attacked. He further expressed a diminished interest in hobbies and activities he once enjoyed, and described a constant need to scan the environment and check for escape routes when in public and/or crowded places. He did not describe any suicidal or homicidal ideations and denied having any hallucinations. Based on her interview with the Veteran, the staff psychologist diagnosed the Veteran with chronic PTSD and assigned him a Global Assessment of Functioning (GAF) Score of 55. During a January 2008 VA psychiatric examination, the Veteran again discussed experiencing and witnessing various traumatic incidents while serving with the U.S. Marine Corps. Since separation from service, he described most of his days as "calm," but added that he is easily irritated and frequently goes inside his bedroom and closes his door to be alone. He experiences difficulty sleeping, and his only form of social activity is spent with a few of his former servicemen. Upon conducting a mental evaluation of the Veteran, the examiner observed that the Veteran was alert and oriented as to time, place, and person, that he did not display significant fine or gross motor impairments, that his mood was within normal limits, and that he displayed a good range of affect which was consistent with context. The examiner also conducted a Minnesota Multiphasic Personality Inventory (MMPI) evaluation and completed a PTSD Checklist concerning Veteran, the results of which were consistent with the diagnosis of PTSD. According to the examiner, individuals with profiles similar to the Veteran are likely to feel "anxious, agitated, tense, and easily startled." It was also noted that those with profiles similar to the Veteran are likely to experience sleep disturbance and significant depression, and tend to "bottle up" negative emotions and fear loss of control of their expression. The examiner further described individuals with profiles similar to the Veteran as intropunitive, and "meticulous and perfectionistic" in their daily activities. It was noted that this type of individual would likely to respond with rigid thinking when faced with a daily life problem. According to the examiner, when these test results were shared with the Veteran, he responded that "[he] tend[s] to hide everything." The examiner diagnosed the Veteran with chronic PTSD and concluded that the Veteran comes across as more adjusted and functional than he actually is. A January 2008 VA treatment report dated one week after the Veteran's VA examination reflects that the Veteran did not exhibit any suicidal or homicidal ideations, and his mood was described as pleasant and his affect as full. In his January 2009 notice of disagreement (NOD), the Veteran contends that his PTSD symptoms are more severe than his disability rating reflects. He specifically referenced his July 2006 VA PTSD assessment report which reflects his complaints of frequent nightmares, avoidant behavior, isolative nature, decreased energy level, symptoms of hyperarousal and hyper vigilant behavior. The Board observes that, while the January 2008 VA examiner took note of some of the Veteran's PTSD symptoms and made several determinations as to how a person with a profile similar to the Veteran might act and behave, the examination report itself does not include a discussion and/or explanation as to how the Veteran's actual symptoms have affected his day to day life, his interpersonal relationships with his family and friends, as well as his occupational duties and capabilities. Further review of the claims file reveals that the Veteran has not been afforded another VA psychiatric examination since the January 2008 evaluation, over three years ago. The duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. See Peters v. Brown, 6 Vet. App. 540, 542 (1994). As it has been over three years since the Veteran's last VA examination and the Board is precluded from reading its own unsubstantiated medical conclusions and is instead bound by the medical evidence of record on these matters, further development is required. See Jones v. Principi, 16 Vet. App. 219, 225 (2002), citing Smith v. Brown, 8 Vet. App. 546, 553 (1996) (en banc); Colvin v. Derwinski, 1 Vet. App. 171 (1991). Accordingly, the Board finds that the agency of original jurisdiction must afford the Veteran another psychiatric examination to determine the current severity of his service-connected PTSD. [For the reasons set forth herein, the medical evidence currently of record is insufficient for the Board's adjudication of this issue.] Accordingly, the case is REMANDED for the following action: 1. Request records of relevant psychiatric treatment that the Veteran may have received since January 2008 at the VA Medical Center in Dayton, Ohio. Copies of such records which are available should be associated with the claims folder. 2. Then, make arrangements with the appropriate VA medical facility for the Veteran to be afforded a psychiatric examination to determine the current nature and extent of his service-connected PTSD. The claims file, including a copy of this REMAND, must be made available to the examiner for review, and the examination report should reflect that such review was completed. The examiner should identify the nature, frequency, and severity of all current manifestations of PTSD. The examiner should also assign a Global Assessment of Functioning (GAF) score and provide an explanation of the assigned score. Also, the examiner should specifically comment on the impact of the Veteran's PTSD upon his social and industrial activities, including his ability to obtain and to maintain employment. A rationale for all opinions expressed must be provided. 3. Following completion of the above, re-adjudicate the issue of entitlement to an initial increased rating greater than 30 percent for the service-connected PTSD. If the decision remains in any way adverse to the Veteran, he and his representative should be provided with a supplemental statement of the case (SSOC). The SSOC must contain notice of all relevant actions taken on the claim for benefits, to include the applicable law and regulations considered pertinent to this issue as well as a summary of the evidence of record. An appropriate period of time should be allowed for response. No action is required of the Veteran until he is notified by the RO; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2010). The Veteran has the right to submit additional evidence and argument on the matter that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). _________________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board is appealable to the Court. 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) (2010).