Citation Nr: 1125440 Decision Date: 07/06/11 Archive Date: 07/14/11 DOCKET NO. 10-29 850 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUE Entitlement to an initial increased rating for posttraumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Jeany Mark, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Shabnam Keyvan INTRODUCTION The Veteran served on active duty from August 1968 to June 1971. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from the December 2008 rating decision in which the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas granted service connection for PTSD and evaluated the disability as 30 percent disabling. 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. He contends that his psychiatric symptoms are more severe than this current disability rating reflects. After a complete and thorough review of the claims folders, the Board determines that a remand of the Veteran's increased rating claim for his service-connected PTSD is required to allow for further development of the record. VA treatment records dated from October 2003 to May 2010 reflect that the Veteran has received psychiatric care and treatment throughout the years. During an October 2003 mental health evaluation, the Veteran discussed his military history and specifically recalled an incident in Vietnam during which he had to run under a truck when a rocket exploded near his position. VA Progress notes dated from April 2004 to April 2005 reflect that the Veteran routinely presented at the Wichita VAMC with complaints of symptomatology associated with PTSD. Specifically, the Veteran reported to experience difficulty sleeping, nightmares regarding his military experiences, intrusive thoughts and feelings of hypervigilance. An October 2005 outpatient note reflects the Veteran underwent a PTSD screening exam, the results of which were positive. During the November 2008 VA examination, the Veteran recalled his in-service trauma and how he suffered a head laceration after diving under a truck during a rocket attack. He described feeling intense psychological distress at being exposed to internal and external cues that symbolize an aspect of the trauma, "such as hearing helicopters fly over, cracks of thunder in a thunderstorm, and fireworks." According to the Veteran, he avoids any activities, places, or people that arouse recollections of the trauma, and feels a sense of detachment and estrangement from others. The examiner observed that the Veteran exhibited "a restricted range of affect," and a "markedly diminished interest or participation in significant activities." In addition, the Veteran reported to experience difficulty falling or staying asleep, and described an "exaggerated startle response" to certain types of stimuli. The Veteran maintains that, while he was able to continue working at the same company for 16 years, he chose to work the second shift in an effort to avoid dealing with people. He described feelings of irritability with his co-workers and generally when dealing with people, and reported to have difficulty establishing new friendships and little to no social life and. Based on his evaluation, the examiner diagnosed the Veteran with chronic PTSD and assigned him a Global Assessment of Functioning (GAF) score of 57. The examiner also noted that the Veteran's physical pain "has rendered him more emotionally susceptible to experiencing the PTSD symptoms," and that these symptoms "have likely manifested more fully as a result of his unemployment and thereby increased time available to reflect." In the July 2010 substantive appeal, the Veteran indicated that his PTSD is more severely disabling than the disability rating reflects and has in fact worsened since his last VA examination. The record reflects that the Veteran has not been afforded another VA psychiatric examination since the November 2008 evaluation, over two years ago. The duty to assist the Veteran requires VA to provide a medical examination or obtain a medical opinion when such an examination or opinion is necessary to make a decision on the claim. Moreover, when a claimant asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995). See also Snuffer v. Gober, 10 Vet. App. 400 (1997) & Caffrey v. Brown, 6 Vet. App. 377 (1994). Accordingly, the case is REMANDED for the following action: 1. Request records of relevant psychiatric treatment that the Veteran may have received since May 2010 at the VA Medical Center in Wichita, Kansas. 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 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. See 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).