Citation Nr: 1322449 Decision Date: 07/15/13 Archive Date: 07/24/13 DOCKET NO. 10-02 273 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) with depression. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Jason A. Lyons, Counsel INTRODUCTION The Veteran served on active duty from February 2003 to December 2005, including for a period of time in Iraq. His Form DD-214 further reflects an additional two years and six months of prior active duty service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, which granted service connection and a 50 percent evaluation for PTSD with depression, effective September 23, 2008. The Veteran appealed therefrom as to the initial assigned disability rating. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (when a veteran appeals the initial rating for a disability, VA must consider the propriety of a "staged" rating based on changes in the degree of severity of it since the effective date of service connection). 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 On review of the existing evidence, the record does not provide a comprehensive depiction of the Veteran's mental health state. The last VA Compensation and Pension examination for psychiatric evaluation was conducted in June 2009, some four years ago, and therefore is not a reliable indicator of the current severity of psychiatric service-connected disability. Moreover, there is a nearly contemporaneous private psychological evaluation of May 2009 which describes substantially more severe impairment in various symptom areas, and ultimately offers the characterization of a Global Assessment of Functioning (GAF) score of 40. See Diagnostic and Statistical Manual of Mental Disorders (4th ed. 2000) (DSM-IV-R) (providing that a GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or an major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). Further medical inquiry would assist in resolving the disparity between VA and private clinical evaluations. Consequently, a new VA examination is warranted which includes accounting for any increase in symptomatology that may have manifested since the last psychiatric evaluation. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007), citing Caluza v. Brown, 7 Vet. App. 498, 505-06 (1998) ("Where the record does not adequately reveal the current state of the claimant's disability ...the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination."). See also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGPREC 11-95 (1995). As the case must be remanded for the foregoing reason, any recent treatment records should also be obtained. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to identify all VA and non-VA medical care providers that have treated him for his PTSD with depression since October 2008. Make arrangements to obtain all records that he adequately identifies. 2. Thereafter, schedule the Veteran for a VA psychiatric examination. The claims folder should be made available to and reviewed by the examiner. All indicated studies and tests should be performed. Following examination of the Veteran, the examiner should identify what symptoms the Veteran currently manifests or has manifested in the recent past that are attributable to his service-connected PTSD with depression. The examiner must conduct a detailed mental status examination. The examiner must also discuss the effect, if any, of the Veteran's PTSD with depression on his social and industrial adaptability. The examiner should assign a Global Assessment of Functioning score for the Veteran's PTSD with depression consistent with the DSM-IV-R and explain the significance of the score. The examiner should fully explain any opinion expressed. 3. After the requested examination has been completed, the report should be reviewed to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, it should be returned to the examiner for corrective action. 4. Finally, after undertaking any other development deemed appropriate, re-adjudicate the claim on appeal. If the benefit sought is not granted, furnish the Veteran and his representative with a Supplemental Statement of the Case (SSOC) and afford them an opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claim. His cooperation in VA's efforts to develop his claim, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655. 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). _________________________________________________ P.M. DILORENZO 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).