92 Decision Citation: BVA 92-20097 Y92 BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 DOCKET NO. 92-01 795 ) DATE ) ) ) THE ISSUE Entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. L. Schwartz, Associate Counsel INTRODUCTION This matter came before the Board of Veterans' Appeals (hereinafter the Board) on appeal from a rating decision of September 12, 1991, from the Los Angeles, California, regional office (hereinafter RO). The notice of disagreement was received on September 16, 1991. The statement of the case was issued on December 24, 1991. The substantive appeal was received on January 29, 1992. The appeal was received at the Board on March 6, 1992, and docketed on March 10, 1992. The appellant is represented by the Disabled American Veterans, to which the file was referred. That organization submitted additional written argument to the Board on May 19, 1992, and the case is now ready for appellate review. It has been certified that the veteran had active military service from July 1940 to August 1945. After review, it is our judgment that the record may not yet be ready for a final appellate decision on the merits of entitlement to the benefits being sought on appeal. REMAND The veteran asserts that he is entitled to service connection for post-traumatic stress disorder, contending that he was involved in heavy combat during World War II in the South Pacific Theatre. Additionally, based on his report of several combat related "stressors," and symptomatology consisting of flashbacks and nightmares, two official examination reports have yielded a diagnosis of post-traumatic stress disorder. Thus, the veteran asserts that service connection is warranted. As a matter of law, we must determine whether, in fact, the veteran has a confirmed diagnosis of post-traumatic stress disorder; and then, whether it is the result of "stressors" encountered during active military service. After careful review, we find that the current evidence of record is insufficient to allow us to make this determination. The Department of Veteran's Affairs Adjudication Procedure Manual M21-1 Paragraph 50.45, sets forth the criteria to be employed in evaluating claims for service connection for post-traumatic stress disorder. Fundamental in establishing the diagnosis of post-traumatic stress disorder is a careful review of the clinical history of the veteran with respect to prior psychiatric treatment so that any additional psychiatric diagnoses may be taken into account when making an assessment with respect to post-traumatic stress disorder. Paragraph 50.45 (c)(3). In this case we note that the veteran had been diagnosed with late life adjustment disorder and anxiety neurosis in the 1970's, and was prescribed medication for this disorder. However, neither of the examination reports in evidence reflect an assessment of this diagnosis or treatment in arriving at a diagnosis of post-traumatic stress disorder. Moreover, as pointed out by the veteran's representative, it does not appear that the veteran's clinical records where actually reviewed in conjunction with either of these assessments. As a result we find that the veteran must be re-evaluated in order to confirm the diagnosis of post-traumtic stress disorder, following those guidelines required by M21-1 Paragraph 50.45. In fact, because it appears that the veteran attempted to throw off the results of psychological testing, thereby invalidating the results, we request that the veteran be hospitalized for a period of observation in order to verify his reported symptomatology, especially that consisting of nightmares. Also, although the veteran in his most recent statement, indicates on-going psychiatric care, there are no current treatment records in evidence. We find that such records are likely to be quite probative in this adjudication, and request that they be obtained by the RO. As noted above, the second critical element in this determination is a verification of "stressors." In this case, the veteran provides only sparse descriptions of his alleged combat experiences, and there is no objective verification that the veteran was actually stationed in areas experiencing active combat. Although we note that an "Army Separation Qualification Record," dated in August 1945, revealing that the veteran performed under "combat conditions," is in evidence, it appears that this document is based entirely on the account of the veteran. In order to verify the character of the veteran's duty it is highly desirable that some sort of objective evidence to corroborate the veteran's account. In this regard, we note that the RO attempted to obtain information about those campaigns the veteran participated in and citations he received, also requesting his 201 file. However, the National Personnel Records Center failed to respond with this information, offering no explanation. Although we note that the veteran's service medical records were destroyed by fire, we have reason to believe that his personnel records are retreviable, based on a letter from the Disabled American Veterans to the veteran dated on January 28, 1978. In responding to an inquiry from the veteran regarding the fire destruction of his service medical records, the letter refers to a "form" that had been received by the veteran from the Department of Veterans Affairs containing information about his entitlement to medals. The letter explains that this form originated from a storage source apart from that area where service medical records were kept, and so was not indicative that the service medical records were still available. For our purposes, we agree that the issuance of such a form regarding entitlement to medals may well indicate that personnel records reflecting the veteran's tour of service may be available for review. Therefore, we find that the RO should again request this information, providing both the unit assignment indicated by the veteran, as well as that indicated on the Morning Reports in evidence. Accordingly, this case is REMANDED for the following development: 1. The RO should contact the veteran and ask him to identify all places he has received psychiatric treatment in the last ten years. Once identified, all pertient clinical records should be obtained and associated with the claims folder. Also, the veteran has specifically indicated recent treatment at the VAMC at Long Beach, Calfornia, and these records should be obtained. 2. The veteran should be hospitalized for a period of observation in order to conduct a comprehensive psychological evaluation, and to record all pertinent symptomatology with respect to a diagnosis of post-traumatic stress disorder. All pertinent medical records are to be made available to the examiner conducting this assessment, and the evaluation must be conducted within the guidelines set forth by M21-1 Paragraph 50.45. 3. The RO should conduct a search to obtain the veteran's military personnel records in order to ascertain whether the veteran was exposed to active combat situations. The unit assignment provided by the veteran (13th Field Artillery in 24th Division), as well as that indicated on the Morning Reports (52nd Field Artillery Battalion, Battery B) should be specifically indicated in the request to initiate this search. When this development has been completed, the claim should be reviewed by the RO. If the benefit sought on appeal is not granted, the appellant and his representative should be given a supplemental statement of the case with regard to the additional development and should also be afforded an opportunity to respond. The record should be returned to the Board for further appellate consideration, if in order. No action by the appellant or his representative is required until further notice is received. BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 * C. P. RUSSELL JACK W. BLASINGAME *38 U.S.C.A. § 7102(a)(2)(A) (West 1991) permits a Board of Veterans' Appeals Section, upon direction of the Chairman of the Board, to proceed with the transaction of business without awaiting assignment of an additional Member to the Section when the Section is composed of fewer than three Members due to absence of a Member, vacancy on the Board or inability of the Member assigned to the Section to serve on the panel. The Chairman has directed that the Section proceed with the transaction of business, including the issuance of decisions, without awaiting the assignment of a third Member. Under 38 U.S.C. 4052, only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. 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.