Citation NR: 9633760 Decision Date: 11/27/96 Archive Date: 12/04/96 DOCKET NO. 94-23 598 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for post-traumatic stress disorder. REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD Andrew P. Hinton, Associate Counsel INTRODUCTION The veteran served on active duty from January 1969 to April 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a June 1993 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The appellant is the veteran's legal custodian. REMAND The appellant contends that the veteran has a post-traumatic stress disorder as the result of events witnessed in service. A March 1996 Board decision remanded this matter back to the RO for further development. That decision noted that VA psychiatrists had already diagnosed the veteran with post- traumatic stress disorder (PTSD). It further noted that stressor information the veteran had supplied to the RO had not been referred to the Joint Services Environmental Support Group (ESG) to verify the claimed stressors. Thus, as the decision indicated, the PTSD diagnosis was not based on a verified history of the veteran’s military service, and therefore was inadequate for rating purposes under West v. Brown, 7 Vet.App. 70, 77-8 (1994). The Board therefore requested that the RO proceed with further development to ensure compliance with West. In the March 1996 decision, the Board basically requested that the RO do the following: 1) Obtain relevant VA treatment records subsequent to September 1995; 2) Request from the veteran a statement detailing the stressful events that the veteran experienced during service and were related to his PTSD; 3) Send that information and service personnel records to the United States Army and Joint Services Environmental Support Group (ESG), with a request that ESG attempt to verify any claimed stressor; 4) Only after the above development, the RO was requested to schedule the veteran for a psychiatric examination. In that examination, the examiner was to be requested to rely solely on the ESG verified military history in making a diagnosis of PTSD. 5) Following the above development, the RO was requested to ensure that the foregoing development had been completed in full. In particular the RO was requested to verify that any diagnosis of PTSD was based on the verified history provided by the ESG and/or RO. 6) Lastly, the RO was requested to undertake any additional development deemed appropriate, and readjudicate the issue of entitlement to service connection for PTSD. A review of the file indicates that the RO requested that the veteran provide the statement pertaining to stressors, but that the file contains no evidence of a response from the veteran to that request. The Board further observes that the stressor information which the veteran has previously supplied to the RO has not been referred to the United States Army and Joint Services Environmental Support Group (ESG) in an attempt to verify the claimed stressors. 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 in- service traumatic stressor, it is necessary to develop this evidence." MANUAL M21-1, Part VI, 7.46(f)(2). Accordingly, as the development outlined in MANUAL M21-1 includes providing the information submitted by the veteran to the ESG, such development is mandatory. The earlier-mentioned psychiatric examinations found that the veteran was suffering from PTSD, among other psychiatric disorders; however, examinations based on a questionable history are inadequate for rating purposes. West, 7 Vet.App. at 77-8. Thus, it is necessary that the veteran be provided an examination in which the examiner has the accurate history of the veteran's military service. The Board therefore believes that, after making one more request to the veteran for a statement regarding stressors, the RO should request verification by the ESG based on information already of record which the veteran has previously provided. In accordance with West, the veteran should then be provided a psychiatric examination which, with respect to stressor information, is based on a verified history of the veteran’s military service. Therefore, pursuant to the 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) (1995), this case is REMANDED to the RO for the following development: 1. The RO is to 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. He should be asked to provide specific details of the claimed stressful events to the best of his ability. The veteran's statement should include dates, places, detailed descriptions of the events, the number of times these events occurred, the locations, the identities of any individual he may have witnessed being killed or seriously wounded and any other identifying information concerning other individuals involved in the events. 2. After obtaining the foregoing requested information from the veteran, the RO should forward it, together with copies of the veteran's service personnel records and a copy of his record of service (DD Form 214), to the United States Army and Joint Services Environmental Support Group (ESG), Building 5089, Stop # 387, Fort Belvoir, Virginia 22060, in an attempt to verify any claimed stressor. If the veteran did not respond with the requested stressor information, the RO should forward any information obtainable from the claims file which would be helpful to the ESG in their task. In particular, the RO should report details pertaining to the two stressful episodes claimed by the veteran and described in detail in a February 1993 statement. Any information obtained from the ESG is to be associated with his claims file. 3. Following receipt of the ESG's report, and the completion of any additional development warranted or suggested by that office, see e.g. Zarycki v. Brown, 6 Vet.App. 91, 99 (1993), the RO should prepare a report detailing the nature of any combat action, or in-service stressful event, verified by the ESG. If no combat stressor has been verified, the RO should so state in its report. This report is then to be added to the claims folder. 4. Once the above-mentioned development has been accomplished, then, and only then, is the RO to arrange for the veteran to undergo appropriate medical examinations at a VA medical facility, to include a psychiatric examination by a board of two VA psychiatrists who are familiar with PTSD and, if reasonably possible, who have not previously seen or treated the appellant. These examinations must be conducted in accordance with the VA's Physician's Guide for Disability Evaluation Examinations. The veteran's claims file, together with a copy of this remand, must be provided to and reviewed by the examiners prior to their studies. In conducting the veteran's psychiatric examination, the board of two psychiatrists are to note and distinguish the symptomatology of any and all psychiatric disorders found. All indicated studies, including PTSD sub- scales, are to be performed. A Global Assessment of Functioning Score, consistent with the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, must be assigned for each and every psychiatric disorder, including PTSD, if existing, along with an explanation of what the assigned score represents. A complete rationale for the score assigned to each disorder must be provided. The examiners must give an example of the characteristics of each psychiatric disorder found, express an opinion as to the severity of these symptoms, and the effect each disorder has on his social and industrial adaptability. The examiners must express an opinion whether any psychiatric disability is linked to any specific incident or incidents in service. If symptoms of differing psychiatric disorders cannot be distinguished, the examiners should so state and explain why. The examination report should be typed. In determining whether or not the veteran has PTSD due to an in-service stressor, the board of two psychiatrists 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 PTSD is the appropriate diagnosis, they must specifically identify which stressor(s) detailed in the ESG's and/or the RO's report is (are) responsible for that conclusion. Any and all opinions expressed must be accompanied by complete rationale. 5. Following completion of the foregoing, the RO must review the claims file to ensure that all of the above-mentioned development has been completed in full. In particular, the RO should review the VA psychiatric examination report to verify that any diagnosis of PTSD was based on the verified history provided by the ESG and/or RO. If the examiners relied upon a stressor history which was not verified, that examination report must be returned as inadequate for rating purposes. The Board emphasizes that the Court has held that a diagnosis of PTSD, related to service, based on an examination which relied upon an unverified history is inadequate. West, 7 Vet.App. at 77. 6. After undertaking any development deemed appropriate in addition to that specified above, the RO should readjudicate the issue of entitlement to service connection for PTSD. If the benefit sought on appeal is 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 final 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. WARREN W. RICE, JR. Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741 (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) (1995). - 2 -