BVA9508072 DOCKET NO. 93-14 509 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a chronic acquired psychiatric disorder. 2. Entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Ronald R. Bosch, Counsel INTRODUCTION The veteran served on active duty from February 1963 to February 1967. The claims file contains a report of a rating decision dated in March 1979 denying entitlement to service connection for a psychiatric disorder then diagnosed as emotional instability. The current appeal arises from an August 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The RO denied entitlement to service connection for post-traumatic stress disorder (PTSD), and found that new and material evidence had not been submitted to reopen a claim of entitlement to service connection for a psychiatric disorder. REMAND Service connection for post-traumatic stress disorder requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. 38 C.F.R. § 3.304(f) (1994). The appellant has been formally examined by VA and found to have PTSD. He has also been found to have psychiatric symptomatology which has been variously diagnosed. With respect to the claim of entitlement to service connection for PTSD the RO has taken the position that there is no evidence of exposure of the veteran to combat in view of his training as a stenographer. Significantly, however, the appellant was also trained as a medical corpsman and he served in Vietnam. Moreover, the provisions of the VA ADJUDICATION PROCEDURE MANUAL M21-1 (MANUAL M21-1) pertaining to the adjudication of PTSD provide that, "where records available to the rating board do not provide objective or supportive evidence of the alleged inservice traumatic stressor, it is necessary to develop this evidence." Manual M21-1, Part VI, 7.46(f)(2) (emphasis added). Accordingly, as the development outlined in MANUAL M21-1 includes providing information to the United States Joint Services and Environmental Support Group (ESG), such development is mandatory. Accordingly, further action is necessary. Additional development is also warranted in view of the fact that the diagnoses of PTSD appear to have been based on a history which has yet to be verified. As an examination based on a questionable history is inadequate for rating purposes, West v. Brown, 7 Vet.App. 70, 78 (1994), it is necessary that the veteran be provided an examination where the examiner has the accurate history of the appellant’s military service. Therefore, further development is warranted. Accordingly, pursuant to VA's duty to assist the veteran in the development of facts pertinent to his claim under 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1994), this case is REMANDED for the following action: 1. The RO should request from the veteran a statement containing as much detail as possible regarding any and all stressful events to which he was exposed in service. The veteran should be asked to provide specific details of the claimed stressful events during service, including dates, places, detailed descriptions, units of service, duty assignments, as well as the names, ranks, units of assignment and any other identifying information concerning other individuals involved in the events. The veteran is hereby informed that the United States Court of Veterans Appeals has held that asking the veteran to provide the underlying facts, i.e., the names of individuals involved, the dates, and the places of where the claimed events occurred, does not constitute either an impossible or an onerous task. Wood v. Derwinski, 1 Vet.App. 190, 193 (1991). 2. After obtaining the foregoing requested information from the veteran, the RO should forward the response received to the United States Army & Joint Services Environmental Support Group, 7798 Cissna Road, Springfield, Virginia 22150. Any information obtained is to be associated with the claims folder. 3. Following receipt of the ESG's report, and the completion of any additional development warranted or suggested by that office, the RO should prepare a report detailing the nature of any combat action, or inservice stressful event, verified by the ESG. If no combat or stressor has been verified, the RO should so state in its report. This report is then to be added to the claims folder. 4. Then, and only then, should the RO schedule the veteran for a VA psychiatric examination by a board of psychiatrists who have not previously seen or treated him. This examination is to be conducted in accordance with the diagnostic procedures outlined in the VA Physician's Guide for Disability Evaluation Examinations in order to determine the nature and extent of severity of any psychiatric disorder including post-traumatic stress disorder which may be present. All indicated studies, including post-traumatic stress disorder sub scales, are to be performed. The examination reports should include a detailed account of all pathology found to be present. If there are psychiatric disorders other than post-traumatic stress disorder, the examiners should reconcile the diagnoses and should specify which symptoms are associated with each of the disorders. If certain symptomatology cannot be dissociated from one disorder or another, that fact should be specified in the examiners’ report. In determining whether or not the veteran has post- traumatic stress disorder due to an inservice stressor the examiners are hereby notified that only the verified history detailed in the reports provided by the ESG and/or the RO may be relied upon. If the examiners believe that post-traumatic stress disorder is the appropriate diagnosis they must specifically identify which stressor detailed in the ESG's and/or the RO's report is responsible for that conclusion. The report of examination should include a complete rationale for all opinions expressed. The examiners should assign a Global Assessment of Functioning score which is consistent with the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, (3rd. ed. rev. 1987) (DSM-III-R), and define what the assigned score represents. The entire claims file and a copy of the REMAND must be made available to and reviewed by the examiners prior to the examinations. 5. The RO should then review the record to ensure that all of the foregoing development has been completed in full. In particular, the RO should review the VA psychiatric examination reports to verify that any diagnosis of PTSD was based on the verified history provided by the ESG and/or the RO. If the examiners relied upon a history which is not verified, those examination reports must be returned as inadequate for rating purposes. The Board emphasizes that the United States Court of Veterans Appeals has held that a diagnosis of post-traumatic stress disorder, related to service, which is based on an examination which relied upon an unverified history is inadequate. West, 7 Vet.App. at 77. 6. After undertaking any development in addition to that specified above, the RO should readjudicate the issues of whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a chronic acquired psychiatric disorder and service connection for post-traumatic stress disorder. If the benefits requested on appeal are not granted to the veteran's satisfaction, the RO should issue a supplemental statement of the case. A reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for further appellate review, if otherwise in order. By this REMAND, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. DEREK R. BROWN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. 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) (1994).