Citation Nr: 1315643 Decision Date: 05/13/13 Archive Date: 05/15/13 DOCKET NO. 12-00 640 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to a higher rating (evaluation), greater than 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. Schulman, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from May 1968 to December 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas which assigned a 30 percent increased rating for the Veteran's PTSD. In March 2009 an additional rating decision confirmed and continued the earlier decision. The Veteran appealed from the increased rating assigned, and the matter is now before the Board. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. 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 In the September 2008 rating decision on appeal, the Veteran was granted a 30 percent rating for PTSD effective April 10, 2008. The Veteran is now seeking a rating of greater than 30 percent for his PTSD. The claims file includes two VA examinations from separate doctors within the period on appeal. In a July 2008 VA examination, the examiner diagnosed mild PTSD, alcohol dependence, alcohol induced mood disorder, pain disorder associated with both psychological and general medical condition, and a not otherwise specified personality disorder. The Veteran's Global Assessment of Function (GAF) score was 70, however when asked to provide a separate GAF score to account only for the Veteran's PTSD, the examiner indicated that due to the "convoluted picture" associated with the Veteran's many diagnoses a separate GAF score could not be determined. On VA examination in September 2009 the examiner diagnosed mild PTSD, alcohol dependence, alcohol induced mood disorder, and a not otherwise specified personality disorder with antisocial features. The Veteran's GAF was 65-70, and the examiner opined that the Veteran's primary debilitating conditions include personality disorder and alcohol dependence. The Veteran's PTSD accounted for his GAF score of 65-70. In addition to the opinions of VA examiners, the record contains letters from Dr. M.Y. which indicated that he has been treating the Veteran for more than a year. In an April 2009 letter, Dr. M.Y. indicated that the Veteran's PTSD symptoms were becoming worse and in a November 2010 letter he stated that the Veteran's PTSD was now severe. In the April 2009 letter, Dr. M.Y. also indicated that he did not believe that the Veteran has an alcohol problem, but if he did, it was most likely the result of his Vietnam experience. Based on the foregoing, the Board finds indications in the record that the Veteran's PTSD symptoms have worsened since his last VA examination in September 2009. A veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination. Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Accordingly, a new examination is necessary to determine the current severity of the Veteran's service-connected PTSD. Any new examination should include identification of all of the Veteran's mental disorders, and an opinion should be offered differentiating, to the extent possible, symptoms associated with PTSD from symptoms related to non-service connected disorders. Additionally, the Board finds the discussion of the Veteran's private medical evidence to have been insufficient in the Veteran's previous VA examinations. Specifically, in the September 2009 VA examination, the examiner restated the Veteran's indication that he had been seeing Dr. M.Y. There is no indication, however that the examiner actually reviewed the letters from Dr. M.Y., or that the examiner considered the opinions advanced by Dr. M.Y. Thus any new examination must adequately consider outside medical evidence, including the opinions of Dr. M.Y. that the Veteran's PTSD is severe and that the Veteran does not suffer from alcohol abuse. If the opinions of Dr. M.Y., or other private clinicians, are flawed, the VA examiner should state that, and state why. Finally, the Board notes that the Veteran has identified potentially relevant evidence which is not of record including treatment records from Dr. M.Y. and records from a Dr. Carter, mentioned during the Veteran's September 2009 VA examination. Additionally, the Veteran has stated that he seeks some form of medical treatment from the VA, and updated VA records should be associated with the claims file. The RO should make efforts to acquire these records before a new VA examination is conducted. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a letter asking him to identify all sources of mental health treatment, including Dr. M.Y. and Dr. Carter, and include the necessary VA Forms 21-4142, Authorization and Consent to Release Information allowing VA to request the records identified. 2. Take appropriate steps to acquire any evidence of mental health treatment identified by the Veteran, and not already of record. 3. Associate with the claims file all VA mental health treatment records dated from than October 2011 to the present. 4. After completing the above development, schedule the Veteran for a VA examination. The examiner should conduct a complete mental health examination, and identify all mental health disorders. The examiner should set forth an opinion as to the level of severity of the Veteran's overall mental health picture that is attributable to the service-connected PTSD and set forth and discuss that symptoms associated with the service-connected PTSD. If the examiner is unable to differentiate the symptoms attributable to PTSD from symptoms associated with any other non-service-connected psychiatric disorder, the examiner is to indicate as much in the record and state why. The examiner should indicate the Veteran's GAF score due to PTSD and should state whether symptoms of PTSD more closely resembles: a) Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) b) Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships c) Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships; or d) Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Additionally, the examiner should specifically address private records associated with the claims file. This includes discussing and evaluating the assertions made by Dr. M.Y. 5. After completing all indicated development readjudicate the claim for entitlement to a higher rating for PTSD in light of all of the evidence of record. If any benefit sought on appeal remains denied, a Supplemental Statement of the Case should be furnished to the Veteran, and the Veteran should be afforded a reasonable opportunity response. 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). _________________________________________________ K. J. ALIBRANDO 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).