Citation Nr: 1301743 Decision Date: 01/16/13 Archive Date: 01/23/13 DOCKET NO. 10-39 504 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to an increased evaluation for adjustment disorder with depressed mood, currently evaluated as 50 percent disabling. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD Elizabeth Jalley, Counsel INTRODUCTION The Veteran served on active duty from January 2002 to July 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. The June 2009 rating decision denied a rating in excess of 30 percent for adjustment disorder with depressed mood. In the course of the Veteran's appeal, this rating was increased to 50 percent, effective April 30, 2009, as reflected in a September 2010 Decision Review Officer (DRO) decision. The Board also notes that, in addition to the paper claims file, there is a paperless, electronic claims file associated with the Veteran's claim. A review of the documents in this file reveals that they are potentially relevant to the issue on appeal. Thus, any future consideration of this appellant's case should take into account the existence of this electronic record. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran has claimed entitlement to a rating in excess of 50 percent for service-connected adjustment disorder with depressed mood. The Board notes that the Veteran's most recent VA examination for this claim was in May 2009. The Court has held that a Veteran is entitled to a new VA examination where there is evidence, including his statements, that the disability has worsened since the last examination. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). The Court has also held that VA's statutory duty to assist the Veteran includes the duty to conduct a thorough and contemporaneous examination so that the evaluation of the claimed disability will be a fully informed one. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991). In the case at hand, the available medical evidence suggests that there has been an increase in severity in the Veteran's adjustment disorder with depressed mood since the May 2009 VA examination. This evidence of worsening is reflected, in part, in the marked decrease in the Veteran's Global Assessment of Functioning (GAF) scores since the May 2009 examination. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. Carpenter v. Brown, 8 Vet. App. 240 (1995). The May 2009 examination report reflects the assignment of a GAF score of 65, which indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Subsequent VA medical evidence notes GAF scores of 45 and 50, which indicate serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social or occupational functioning (e.g., no friends, unable to keep a job). Given the above, the Board finds it necessary to remand this claim for a new VA examination in order to assess the current severity of the Veteran's adjustment disorder with depressed mood. The Board further notes that the most recent medical evidence of record consists of an August 2010 VA mental health treatment record. While this case is on remand, the AMC should obtain any outstanding VA medical records and associate them with the claims file. In addition, given that the Veteran indicated in a May 2010 record that he may seek psychiatric treatment outside of VA, the AMC should also attempt to obtain any relevant private records on remand. Accordingly, the case is REMANDED for the following action: 1. Obtain copies of all of the Veteran's outstanding VA medical records. Ensure that those copies are associated with the claims file. 2. The Veteran should be asked to sign and return release forms authorizing VA to obtain any relevant outstanding private medical records. The Veteran should also be notified that he may submit any such records himself. The notification requirements of 38 C.F.R. § 3.159(c)(1) should be followed. VA should issue an initial records request and at least one follow-up request if the initial request yields no response. If these records cannot be obtained and there is no affirmative evidence that they do not exist, inform the Veteran of the records that could not be obtained, including what efforts were made to obtain them. All efforts to obtain these records should be recorded in the claims folder. 3. Following completion of the above, arrange for the Veteran to undergo a VA examination to determine the severity of his service-connected adjustment disorder with depressed mood. The claims folders must be thoroughly reviewed by the examiner in connection with the examination, and a complete history should be elicited directly from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. The examiner should be provided a copy of the rating schedule for mental disorders under 38 C.F.R. § 4.130 and should be advised that all manifestations covered in the rating schedule must be addressed so that the Board may rate the Veteran in accordance with the specified criteria. The examiner should also assign a Global Assessment of Functioning (GAF) score and provide an explanation as to the meaning of that score. The examiner should specifically discuss the extent to which the Veteran's adjustment disorder with depressed mood impacts his ability to seek and maintain employment. The examiner should also render an opinion as to whether the Veteran is unemployable due to his service-connected adjustment disorder with depressed mood. The examiner should explain the rationale behind this opinion. 4. After the development requested above has been completed, again review the record. If any benefit sought on appeal remains denied, the appellant and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters 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 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. 2012). _________________________________________________ WAYNE M. BRAEUER 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) (2012).