Citation Nr: 1133775 Decision Date: 09/12/11 Archive Date: 09/22/11 DOCKET NO. 09-34 653 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to an initial disability evaluation in excess of 10 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD J. C. Schingle, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1966 to November 1968. This matter comes on appeal before the Board of Veterans' Appeals (Board) from a December 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office in Nashville, Tennessee (RO). In July 2011, the Veteran testified at a hearing conducted at the RO before the undersigned Veterans Law Judge. A copy of the hearing transcript has been associated with the claims file. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND Although further delay is regrettable, the Board finds that additional development is necessary prior to a final adjudication of the issue on appeal. During the current appeal, the Veteran, in essence, has reported a worsening of his service-connected PTSD symptoms since his most recent VA examination in October 2008. More specifically, the Veteran and his spouse describe a worsening in his mood swings, insomnia, anxiety, and forgetfulness. Additionally, he reports panic attacks two to three times per week. He also has indicated that work-related stress triggers many of the symptoms and that his spouse advised him to stop working. Notably, ongoing VA psychiatric treatment records, dated from 2008 to 2009, appear to reflect a worsening of the Veteran's PTSD symptoms. Indeed, these outpatient care reports include Global Assessment of Functioning (GAF) scores of 50, which are clearly much lower than the GAF score of 70 recorded at the 2008 VA examination. Accordingly, the Board finds that the most recent October 2008 VA examination of the Veteran's PTSD does not contemplate his current complaints regarding the severity of his pertinent symptoms or the most recent treatment records which appear to reflect a worsening of such symptomatology. Therefore, the Board finds a new VA examination is necessary to determine the Veteran's complete and current psychiatric disability picture. See Caffrey v. Brown, 6 Vet. App. 377 (1994) (holding that, when a claimant asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate). See also Peters v. Brown, 6 Vet. App. 540, 542 (1994) (holding that 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). Also on remand, records of ongoing VA PTSD treatment should be obtained. 38 U.S.C.A. § 5103A(c) (West 2002). See also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency and must be obtained if pertinent). Accordingly, the case is REMANDED for the following action: 1. After procuring the appropriate release of information forms where necessary, obtain copies of any outstanding records of recent PTSD treatment that the Veteran has recently received. The Board is particularly interested in copies of records of PTSD treatment that the Veteran has received at the Chattanooga Vet Center since October 2008 and at the Chattanooga VA Outpatient Clinic since November 2009. If any of these records cannot be located, that fact should be so stated in the Veteran's claims folder. All such available documents should be associated with his claims file. 2. Then, schedule the Veteran for a VA psychiatric examination to determine the extent and severity of his PTSD. The claims folder should be made available to and reviewed by the examiner. All indicated tests should be performed. Following examination of the Veteran, the examiner should identify any and all symptoms attributable to the service-connected PTSD. In addition, the examiner should assign a GAF score and explain the meaning of that score. In so doing, the examiner should discuss the effect, if any, of the Veteran's PTSD on his social adaptability and on his ability to engage in any type of full-time employment. A complete rationale for all opinions should be provided. 3. Following completion of the foregoing, review the claims folder and ensure that all of the foregoing development has been conducted and completed in full. In particular, determine whether the examiner has responded to all questions posed. If not, the report must be returned for corrective action. 38 C.F.R. § 4.2 (2010). 4. Then, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. 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).