BVA9403189 DOCKET NO. 92-09 966 ) DATE ) ) ) THE ISSUES 1. Entitlement to an increased evaluation for a psychiatric disorder, currently rated as 10 percent disabling. 2. Entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs ATTORNEY FOR THE BOARD Sandra L. Smith, Associate Counsel INTRODUCTION The veteran had active service from March 1966 to March 1968. This appeal arises from a March 1992 rating decision which denied an increased evaluation for a psychiatric disorder. The Board notes that the veteran has raised the issue of service connection for post-traumatic stress disorder. This issue is inextricably intertwined with the issue on appeal; therefore the Board assumes jurisdiction of the additional issue. The title page has been amended to reflect both issues. REMAND The veteran is service-connected for psychoneurosis with tension and functional GI manifestations, rated as 10 percent disabling since March 1972. He now contends that his service-connected psychiatric disorder has increased in severity. Furthermore, it is his contention that he is suffering from post-traumatic stress disorder (PTSD) as a result of his combat experience in Vietnam. The veteran and his service representative have requested that the veteran be furnished with a VA medical examination to determine the nature and severity of his psychiatric disorders. With regard to PTSD claims, the evidence necessary to establish the occurrence of a recognizable stressor during service to support a claim of entitlement to service connection for PTSD will vary depending on whether or not the veteran was engaged in combat with the enemy. 38 U.S.C.A. § 1154(b), 38 C.F.R. § 3.304; and Veterans Benefits Administration Manual M21-1 (hereinafter M21-1). Where the veteran was engaged in combat with the enemy and the claimed stressors are related to such combat, the veteran's lay testimony regarding the claimed stressors must be accepted as conclusive as to their actual occurrence and no further development for corroborative evidence will be required, provided that the veteran's testimony is credible and consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d), (f); M21-1, Part VI, para. 7.46(e)-(f). However, if the RO determines that the claimed stressors are not related to such combat, the veteran's lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor. Instead, the record must contain service records which corroborate the veteran's testimony as to the occurrence of the claimed stressors. A review of the claims folder reveals that the veteran was exposed to combat during the Vietnam War. In addition, there are several statements from the veteran relating symptoms of nightmares and flashbacks of combat. The claims folder also contains medical records from a private psychiatrist, dated in December 1972, December 1974, and December 1975 which noted insomnia, nightmares, startle response, and other recognized symptoms of post-traumatic stress disorder; and a diagnosis which included "residuals of a war neuroses". The Board also notes that there is a diagnosis of PTSD on a VA hospital summary report, dated in August 1982. Furthermore, it appears that the veteran has not been afforded a VA psychiatric examination since January 1974. In addition it is noted that the veteran is receiving Social Security Administration (SSA) disability benefits, as well as a VA pension for nonservice-connected disabilities. The Court of Veterans Appeals (the Court) has held that once a person submits evidence of a well-grounded claim, the VA then has a duty to assist in developing facts pertinent to the claim. Murphy v. Derwinski, 1 Vet.App. 78, 80-81 (1991). This includes a duty to obtain records from any source, Littke v. Derwinski, 1 Vet. App. 90 (1990); including SSA records. Murincsak v. Derwinski, 2 Vet.App. 353 (1992). The Court has also held that the duty to assist includes providing a thorough and contemporaneous medical examination, which takes into account prior medical evaluations and treatment. Proscelle v. Derwinski, 2 Vet.App. 629, 632 (1992); Green v. Derwinski, 1 Vet.App. 121 (1991). In light of the above facts and cited laws and regulations, it is the determination of the Board that further development is necessary, therefore, the case is REMANDED for the following actions: 1. The RO should obtain from the SSA copies of all records pertaining to any disability determination, including copies of all medical records considered in adjudicating the veteran's eligibility for SSA benefits. 2. The veteran should be contacted and requested to provide information as to the dates, place, unit of assignment, and the circumstances of events that are the bases of his flashbacks and nightmares. The veteran should provide specific information, or his "best estimates" in regard to names and dates of the friends he saw killed, and other tragic experiences. The RO should inform the veteran that the detailed information is necessary to provide evidence of the stressful event(s) and that failure to respond may make it difficult or impossible to obtain this evidence which may result in denial of this claim. 3. Following receipt of the additional information from the veteran, the RO should determine if the veteran's statement are satisfactory evidence of a stressor (see above explanation). If the RO determines that the stressor(s) is not combat-related, the RO should contact the United States Army and Joint Service Environmental Support Group (ESG) in Washington, D.C. for the purpose of obtaining information relating to the veteran's claimed stressors causing his alleged PTSD. In preparing its requests for assistance, the RO should follow the guidelines in the Guide for the Preparation and Submission of Post-Traumatic Stress Disorder Research Request published by ESG in late 1988. If, during the course of this development, additional evidence or research is suggested by the ESG, the RO should pursue those leads. 4. The RO should obtain and associate with the claims folder all of the veteran's VA medical records from the Birmingham, Alabama Medical Center; Beckley, West Virginia Medical Center; and the Alvin C. York Medical Center in Murfreesboro, Tennessee. Both inpatient and outpatient records, dated since December 1985, should be requested. 5. The veteran's entire claims folder should be reviewed by a board of two VA psychiatrists who have not previously examined the veteran. After the above review, the Board of psychiatrists should examine the veteran in order to establish all of the psychiatric disorders. If there are different psychiatric disorders, the board is to associate, insofar as possible, the specific symptoms with each disorder. If the diagnosis of post-traumatic stress disorder is deemed appropriate, the examiners should specify the "stressors" that caused the disorder and the factual basis upon which they relied to establish the existence of the stressors. All necessary special studies or tests are to be accomplished, to include psychological testing and evaluation. The clinical findings are to be reported legibly and in detail. The diagnoses should be in accordance with DSM-III-R. If the claim remains denied, the veteran and his representative should be issued a supplemental statement of the case and they should be afforded the appropriate period of time within which to respond thereto. Then, if otherwise in order, the case should be returned to the Board for further appellate consideration. The Board intimates no opinion, either legal or factual, as to the ultimate disposition warranted in this case, pending completion of the requested development. BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 F. H. AYER H. STERLING, M.D. HOLLY E. MOEHLMANN Under 38 U.S.C.A. § 7252 (West 1991), 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. 38 C.F.R. § 20.1100(b) (1993).