Citation NR: 9734881 Decision Date: 10/16/97 Archive Date: 10/24/97 DOCKET NO. 95-08 253 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to service connection for a skin condition and for fevers and sweats secondary to exposure to herbicides. 2. Entitlement to service connection for a shell fragment wound with residual facial scars. 3. Entitlement to service connection for a variously diagnosed acquired psychiatric disorder, to include post- traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD M.L. Rogoff, Associate Counsel INTRODUCTION The veteran served on active duty from September 1966 to September 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of rating determinations by the Department of Veterans Affairs (VA) Regional Office (RO). The issue of service connection for variously diagnosed acquired psychiatric disorders will be addressed in the remand portion of this decision. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that his exposure to herbicides in Vietnam caused his skin condition and caused him to have fevers with sweats since that time, thereby warranting entitlement to a grant of service connection. The veteran also contends that shell fragments from a grenade or pieces from a large pot behind which he took cover, were removed from his face and left residual scarring, thereby warranting entitlement to a grant of service connection. DECISIONS OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1997), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the claim for service connection for a skin disorder and fevers and sweats as secondary to herbicide exposure is not well grounded. It is the decision of the Board that the claim for service connection for a shell fragment wound with residual facial scarring is not well-grounded. FINDINGS OF FACT 1. The claim for service connection for a skin disorder and fevers and sweats as secondary to herbicide exposure is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. 2. The claim for service connection for a shell fragment wound with residual facial scars is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. CONCLUSIONS OF LAW 1. The claim for service connection for a skin disorder and fevers and sweats as secondary to herbicide exposure is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1997). 2. The claim for service connection for a shell fragment wound with residual facial scarring is not well grounded. 38 U.S.C.A. § 5107(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background Service medical records reveal that the veteran was treated from June 1967 through December 1967 for a skin disorder of the face caused by a fungus infection, which recurred in early 1968. The diagnosis was recurrent dermatophytosis. It was noted that he responded well to treatment which lasted 29 days and his final biopsies did not show any growth. Service medical records did not evidence any shell fragment wound. He was treated for a persistent fever in January 1968, and was diagnosed with influenza. The veteran was treated for a facial rash in September 1992. He stated that he had had a similar rash in the same place 25 years earlier. In December 1992, the veteran filed an initial claim for skin condition and for shrapnel wounds. He indicated that he was hospitalized at the Letterman Hospital for 6 months for these disorders. These records are associated with the claims folder. In July 1993, the veteran sought treatment for a rash on his back, arms and face. A September 1993 rating action determined that service connection for a skin disorder of the face and for a shell fragment wound was not warranted. The shell fragment wound was not evidenced in the service medical records and chronic residuals of a skin disorder were not found at the time of separation. In October 1993, the veteran claimed that he was feeling okay, but had a strange itchy rash on his legs and back. In a September 1994 treatment record, an examiner stated that the veteran had lesions on his wrist and shoulder, but the rest of his skin was okay at that time. A personal hearing was held in June 1995. The veteran testified that while in Vietnam he was in or near the area where herbicides were sprayed and had had symptoms of exposure, such as fever and night sweats. He stated that he was in Letterman Hospital in 1967 or 1968 for 6 or 7 months being treated for a fever and a skin condition. During his testimony, he pointed out sores and bite dots on his face, arms, legs and toes which he claimed to have ever since Vietnam. He stated that he had some kind of infection in his system. With regard to the shrapnel wound, he stated that while outside of the Landing Zone English, a hand grenade went off and two pieces causing acoustic trauma and shrapnel pieces to lodge in his face. He stated that the pieces were pulled out. He did not worry about it until the wound became infected. A personal hearing was held in December 1996. The veteran testified that he had had a skin condition since his discharge from service. He usually would take an antibiotic for a week to alleviate the inflammation. He showed the hearing officer the residual scarring of the outbreaks. He complained of having outbreaks at least 2 times a year. He claimed that he also continued to have fevers and sweats since service, especially at night while he slept. He indicated that he was treated during his military service for a fever of unknown etiology and was treated subsequent to service. The veteran’s wife submitted a letter, which was received in December 1996. She stated that she married the veteran when he returned in 1967. She stated that he had cold sweats at night. Analysis Under applicable law, a veteran is entitled to service connection for a disease or injury incurred in or aggravated while in service. 38 U.S.C.A. § 1110. If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected...even though there is no record of such diseases during service...chloracne or other acneiform disease consistent with chloracne, Hodgkin’s disease, multiple myeloma, non-Hodgkin’s lymphoma, porphyria cutanea tarda, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), or soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). Exposure to herbicides in service is conceded in view of the veteran’s tour of duty in Vietnam. However, these diseases must become manifest to a degree of 10 percent or more at any time after service, except that chloracne, or other acne disease consistent with chloracne, and porphyria cutanea tarda shall have become manifest to a degree of 10 percent or more within a year, after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a) (6) (ii) (1996). The Secretary has also determined that there was no positive association between exposure to herbicides and any other condition for which he has not specifically determined a presumption of service connection is warranted. 59 Fed. Reg. 341-46 (January 4, 1994). Effective November 7, 1996, presumptive service connection is warranted for two additional diseases under § 3.309(e): Acute and subacute peripheral neuropathy, and prostate cancer. See 61 Fed. Reg. 57, 586-57, 589 (1996) (to be codified at 38 C.F.R. §§ 3.307, 3.309). A threshold question to be answered is whether the veteran has presented a well grounded claim; that is, a claim that is plausible or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). Although the claim need not be conclusive, it must be accompanied by supporting evidence. An allegation alone is not sufficient. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In order for a claim to be well grounded, there must be competent evidence of a current disability (a medical diagnosis); of incurrence or aggravation of a disease or injury in service (lay or medical evidence); and of a nexus between the in-service injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). Skin condition, fevers, and sweats The Board’s evaluation of the evidence of record discloses treatment for a skin disorder and influenza during military service. However, the veteran does not have any disorder recognized by VA as linked to his exposure to Agent Orange in service. Dermatophytosis, as diagnosed in service, and fevers are not disorders recognized by VA as linked to exposure of veterans to herbicides in service. In addition, subsequent to service, the first clinical evidence of treatment for the veteran’s rashes and itchy skin was not until September 1992, 24 years after service. Therefore, even if the Board were to consider the veteran’s skin disorder as any such acne disease consistent with chloracne, a presumptive disorder, the presumptive period has long since expired. There is no clinical evidence of chronic fevers subsequent to service. The appellant’s claims are basically predicated on his allegations that he has a skin disorder and fevers with sweats as secondary to herbicide exposure. However, he is not competent to give a medical opinion on causation, diagnoses, or related matters. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Only persons trained in the medical field may do so. The Board does not dispute the veteran’s statements that he has had a skin disorder; however, a link between any such disorder and exposure to herbicides in service has not been presented. Moreover, although the veteran is competent to testify as to his fevers and sweats, he is not competent to provide an opinion as to causation or to diagnose such a disorder. Without a nexus between the in- service injury or disease and a current diagnosis of a disability associated with fevers and sweats, the veteran’s claim cannot be well grounded. Therefore, it is the judgment of the Board that the veteran has failed to meet his initial burden of submitting evidence of a well grounded claim for entitlement to service connection for a skin disorder and fevers and sweats as secondary to herbicide exposure. If a claim is not well grounded, the Board has no jurisdiction of the claim. Boeck v. Brown, 6 Vet. App. 14, 17 (1993). Shell fragment wound of the face with residual facial scars With regard to the veteran’s claim for service connection for a shell fragment wound of the face, service medical records do not evidence a shell fragment wound. The Board notes that the veteran did experience acoustic trauma during service, which the veteran attributed to an exploding grenade; however, there was no evidence of treatment for a wound as a result of that explosion, nor is there evidence of any current residual scarring of the face which might be attributable to the event described by the veteran. Without evidence of an in-service injury or a current disability linked to service, the claim for service connection for a shell fragment wound of the face with residual facial scars must be denied as not well grounded. Although the Board considered and denied the appellant’s claims on a ground different from that of the RO, which denied the claims on the merits, the appellant has not been prejudiced by the decision. This is because in assuming that the claims were well grounded, the RO accorded the appellant greater consideration than his claims in fact warranted under the circumstances. Bernard v. Brown, 4 Vet. App. 384 (1993). In light of the implausibility of the appellant’s claims and the failure to meet his initial burden in the adjudication process, the Board concludes that he has not been prejudiced by the decision to deny his appeal for service connection for a skin disorder, fevers and sweats as secondary to exposure to herbicides; and for a shell fragment wound with residual facial scars. The United States Court of Veterans Appeals (Court) has held that there was some duty to assist the veteran in the completion of the application for benefits under 38 U.S.C.A. § 5103(a) (West 1991 & Supp. 1997), depending on the particular facts found in each case. Beausoleil v. Brown, 8 Vet. App. 459 (1996); and Robinette v. Brown, 8 Vet. App. 69 (1995), as modified in this context by Epps v. Brown, 9 Vet. App. 341, 344 (1996), wherein the Court found there may be a duty to further assist in the development of the evidence when the veteran has reported the existence of evidence which could serve to render a claim well grounded. The veteran has not identified the existence of any such evidence. The facts and circumstances of this case are such that no further action is warranted. ORDER The veteran not having submitted a well grounded claim of entitlement to service connection for a skin disorder and fevers and sweats secondary to herbicide exposure, the claim is denied. The veteran not having submitted a well grounded claim of entitlement to service connection for a shell fragment wound with residual facial scarring, the claim is denied. REMAND This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Veterans Appeals for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans’ Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1997) (Historical and Statutory Notes). In addition, VBA’s ADJUDICATION PROCEDURE MANUAL, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. As a preliminary matter, the Board notes that a recent case from the United States Court of Veterans Appeals (Court), Cohen v. Brown, No. 94-661 (U.S. Vet. App. Mar. 7, 1997), alters the analysis in connection with claims for service connection for PTSD. Significantly, the Court points out that VA has adopted the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) in amending 38 C.F.R. §§ 4.125 & 4.126. See 61 Fed.Reg. 52695-52702 (1996). VA is also guided by the provisions of VA Adjudication Procedure Manual M21-1 (Manual M21-1) which refer to the third revised edition of the DSM. See e.g., Manual M21-1, Part VI, 11.38 (1996) (same PTSD criteria as DSM-III-R). The Court took judicial notice of the effect of the shift in diagnostic criteria. The major effect is this: the criteria have changed from an objective (“would evoke...in almost anyone”) standard in assessing whether a stressor is sufficient to trigger PTSD, to a subjective standard. The criteria now require exposure to a traumatic event and response involving intense fear, helplessness, or horror. A more susceptible individual may have PTSD based on exposure to a stressor that would not necessarily have the same effect on “almost everyone.” The sufficiency of a stressor is accordingly, now a clinical determination for the examining mental health professional. Cohen v. Brown, slip op. at 38-39 (Nebeker, Chief Judge, concurring by way of synopsis). The court has also noted that where “there has been an ‘unequivocal’ diagnosis of PTSD by mental health professionals, the adjudicators must presume that the diagnosis was made in accordance with the applicable DSM criteria as to both adequacy of symptomatology and sufficiency of the stressor (or stressors).” Id, at 39. The Court went on to indicate that when the RO or the Board believes the report is not in accord with applicable DSM criteria, the report must be returned for a further report. It appears to the Board that the regulatory amendments to 38 C.F.R. §§ 4.125 & 4.126, and the incorporation of DSM-IV, will have a potentially liberalizing effect in adjudicating claims for service connection for PTSD, particularly when an individual is not a combat veteran or who is not shown to have “engaged in combat with the enemy. Where the law or regulations change while a case is pending, the version more favorable to the claimant applies, absent congressional intent to the contrary. Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991). As such, the Board believes that further development in this case is necessary. The Board notes that an April 1973 letter from a private physician indicated that it was his impression that the veteran’s major problem was anxiety, and possibly also depression. A November 1981 treatment record revealed that the veteran was depressed and that he had lost a lot of friends. He stated that he had had a chronic case of diarrhea over the past 5 years and complained of depression, anxiety, heart palpitations, sweating and headaches. He also claimed to experience minor flashbacks to his experience in Vietnam. The assessment was generalized anxiety disorder. An assessment of anxiety, possible post-Vietnam stress was provided in December 1981. In October 1985, the veteran sought treatment at a VA Medical Center because he was depressed. He reported that he had lost his job, was in debt and his wife had attempted suicide. The veteran was noted as having some PTSD symptoms in a December 1992 treatment record. The diagnosis was dysthymia. In March 1993, the veteran reported to an examiner that he had never sought treatment for PTSD. The examiner stated that the veteran had PTSD and might benefit from treatment. A treatment record dated in September 1993 indicated that the veteran was depressed because he lost his job as a machinist. In October 1993, the veteran claimed service connection for PTSD and depression. He stated that he was treated at the VA Medical Center for these disorders. A December 1993 treatment record from a VA mental hygiene clinic revealed that the veteran felt depressed for the prior 6 months. The RO, in April 1994, requested additional evidence prior to processing his claim for PTSD. It was requested that the veteran submit a detailed description of the specific traumatic incidents which produced the stress that resulted in his claimed PTSD, including dates and places. A response was not received from the veteran. However, an outpatient treatment record dated in May 1994 noted that the veteran’s depression may have existed since Vietnam. In February 1995, after complaining of being extremely depressed, the veteran was diagnosed with anxiety and depression. A March 1995 treatment record provided a diagnosis of PTSD by history. An outpatient treatment record dated in June 1995 provided a diagnosis of PTSD and dysthymic disorder. An April 1996 VA examination for mental disorders indicated that the veteran was 48 years old, married and unemployed. He reported that he was under psychiatric care for approximately 25 years, and complained of chronic depression, sleep disturbance, and poor energy. He stated he had been seeing a physician from the mental hygiene clinic for the past several years and was taking Doxepin and Paxil. The examiner reported that a note from the mental hygiene clinic physician stated that the veteran had a depressive disorder. The veteran reported that his first outpatient treatment was in 1969 in Susanville, and that he had been on multiple antidepressants over many years. He denied suicidal or homicidal ideations. In summary, the examiner stated that the veteran was a 48 year old male with chronic low grade depression, who was overeating, had sleep disturbance, low energy, poor concentration and difficulty keeping jobs. The impression was dysthymia, late onset. He Global Assessment of Functioning Scale score was currently, and in the past year, 65. A personal hearing was held in June 1995. With regard to his claim for service connection for PTSD, the veteran testified that one of his best friends from school was killed in Vietnam and one of his friends was killed right in front of him in the Landing Zone English in April 1967. He provided names of these individuals, which were documented as part of the directory of the Vietnam Veterans Memorial. These individuals were listed as casualties in March 1969 and February 1970, subsequent to the veteran’s discharge. He also stated that his unit was overrun by the Viet Cong and there was mass confusion. The veteran indicated that he had nightmares of his friend’s death, spent most of his time alone or with his family, had difficulty maintaining employment. He stated that he was treated for depression and anxiety right after he was discharged from service. While outside of the Landing Zone English, he claimed that a hand grenade went off and two pieces of shrapnel stuck in his face, which were pulled out. He did not worry about it until the wound became infected. In April 1996, the Environmental Support Group (ESG), redesignated as the U.S. Armed Services Center for Research of Unit Records (USASCRUR) notified the RO that the veteran was not listed as wounded or injured during his Vietnam tour. However, he was sent to a Patient Casualty Company attached to the 249th General Hospital in March 1967. The exact medical reason was unknown, but it was noted as in the line of duty. In addition, the casualty data verified the death of one of the veteran’s friends in March 1969 as a result of burns received after his aircraft was hit by hostile small arms fire during a combat assault during a combat mission. It was suggested that the RO contact The National Archives and Records Administration (NARA) for additional information in order to verify the veteran’s alleged stressors. The ESG also included an analysis of herbicide exposure to the veteran’s unit and the Landing Zone English. The veteran was provided a diagnosis of depressive disorder in a July 1996 outpatient treatment record. An August 1996 outpatient treatment record diagnosed the veteran with PTSD, depression and anxiety. The veteran stated that he was depressed. A personal hearing was held in December 1996. With regard to his claim for PTSD, the veteran testified that his best friend died in Vietnam, which upset him greatly. He stated that he did not see him die, but he witnessed the death of an individual that was in his bunker. A mortar ran right by his friend and he was med-evaced off. He didn’t go with him, so that was all he could say about the incident. He stated that what really bothered him was an incident which occurred while he was at a car wash laundry to wash the Lieutenant Commander’s Jeep. While he was there a grenade was thrown. He managed to take cover behind a big metal pot that they used to boil water. He indicated that he was knocked unconscious, but when he came to he saw a person all torn up. He stated that he has had nightmares about the incident about once a month. The veteran testified that he was treated for depression after his discharge and in 1973. He claimed that ever since his discharge he has been depressed and had sought treatment at the VA mental hygiene clinic. His last job was a little over a year ago and he believed his nervousness played a part in his losing that employment. In adjudicating a claim for service connection for PTSD, the Board is required to evaluate the supporting evidence in light of the places, types, and circumstances of service, as evidenced by the veteran's military records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(f); see Hayes v. Brown, 5 Vet. App. 60, 66 (1993). Additionally, service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by the medical evidence, between current symptomatology and the claimed in-service stressor. See Zarycki v. Brown, 6 Vet. App. 91, 97 (1993). In West v. Brown, 7 Vet. App. 70 (1994), the Court elaborated on the analysis in Zarycki. In Zarycki, the Court held that in addition to demonstrating the existence of a stressor, the facts must also establish that the alleged stressful event was sufficient to give rise to PTSD. Id. at 98-99. In West, the Court held that the sufficiency of the stressor is a medical determination, and therefore adjudicators may not render a determination on this point in the absence of independent medical evidence. Id. at 79. The Court also held in West that a psychiatric examination for the purpose of establishing the existence of PTSD was inadequate for rating purposes because the examiners relied, in part, on events whose existence the Board had rejected. Id. at 78. Upon reviewing Zarycki and West, it appears that in approaching a claim for service connection for PTSD, the question of the existence of an event claimed as a recognizable stressor must be resolved by adjudicatory personnel. If the adjudicators conclude that the record establishes the existence of such a stressor or stressors, then and only then, the case should be referred for a medical examination to determine the sufficiency of the stressor and whether the remaining elements required to support the diagnosis of PTSD have been met. In such a referral, the adjudicators should specify to the examiner(s) precisely what stressors have been accepted as established by the record, and the medical examiners must be instructed that only those events may be considered in determining whether stressors to which the veteran was exposed during service were of sufficient severity as to have resulted in current psychiatric symptoms. In other words, if the adjudicators determine that the existence of an alleged stressor or stressors in service is not established by the record, a medical examination to determine whether PTSD due to service is present is pointless. Likewise, if the examiners render a diagnosis of PTSD that is not clearly based upon stressors in service whose existence the adjudicators have accepted, the examination would be inadequate for rating purposes. The Board notes that the RO has referred the stressor information provided by the veteran to ESG to verify the claimed stressors. However, the RO was instructed to request additional information to attempt to verify the veteran’s claimed stressors from NARA. In this respect, the Board acknowledges that the information provided by the veteran probably is not as complete as the NARA will need to verify the existence of his claimed stressors. Nevertheless, 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) (emphasis added). Accordingly, providing the information submitted by the veteran to the NARA is mandatory. The Board observes that while the record contains documentation of PTSD, an examination based on a questionable history is inadequate for rating purposes. West v. Brown, 7 Vet. App. 70, 77-8 (1994). Thus, it is necessary that the veteran be provided an examination where the examiner has the accurate history of the appellant’s military service. In accordance with the statutory duty to assist the veteran in the development of evidence pertinent to his claim, the case is REMANDED for the following actions: 1. The RO should again request the veteran to provide a written statement which provides more specific details concerning the stressful events which he witnessed during service, if more can be remembered, including specifics about the incident involving the grenade attack while he was at the laundry and the death of the member of his bunker, which he claimed to have witnessed. Specific dates, places and names of individuals involved should be provided, to include the names of any individuals killed. The veteran is advised that this information is vitally necessary to obtain supportive evidence of the stressful events and that he must be as specific as possible because without such details an adequate search for verifying information can not be conducted. In this respect, the Board takes this opportunity to inform the veteran that the Court has held that asking the veteran to provide the underlying facts, i.e., the names of individuals involved, the dates, and the places where the claimed events occurred, does not constitute an impossible or an onerous task. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). 2. As was suggested by the USASCRUR Director in his December 1995 letter, the RO should request a copy of the veteran’s Official Military Personnel File (OMPF) from the National Archives and Records Administration (NARA), ATTN: U.S. Army Liaison, 9700 Page Boulevard, St. Louis, Missouri 63132. 3. After obtaining the foregoing requested information from the appellant and from NARA, the RO should forward it together with copies of his service personnel and medical records (on file), a copy of his record of service (DD-214) and a copy of his hearing transcript to the U.S. Armed Services Center for Research of Unit Records (USASCRUR), 7798 Cissna Road, Suite 101, Springfield, Virginia 22150-3197 in an attempt to verify any claimed stressor(s). Any information obtained is to be associated with the claims file. 3. Following receipt of the USASCRUR’s report, and the completion of the above development and any additional development deemed warranted or suggested by the agency, the RO should prepare a report detailing the nature of any combat action, or in service stressful event, verified by USASCRUR. If no combat stressor has been verified, the RO should so state in its report. In reaching this determination, the RO should address any credibility questions raised by the record. This report is then to be added to the claims folder. 4. If a stressor(s) has been verified, then and only then, should the RO schedule the veteran for a psychiatric examination by a board of two VA psychiatrists. The RO is to stress to the veteran the seriousness of the scheduled examination, the importance of a definite psychiatric diagnosis, and the obligation of reporting to the examination at the proper place and time. Any appropriate studies, including PTSD sub scales are to be performed. The claims file and separate copies of this remand must be made available to and reviewed by the examiners prior to conduction and completion of the examination. The examiners should consider the variously diagnosed psychiatric disorders of the veteran, to include depression, dysthymia, and PTSD. An opinion should be provided as to whether separate and distinct psychiatric disorders exist or if his symptoms are attributable to one specific disorder, which should be identified. If a diagnosis, other than PTSD, is determined, then the examiners should state whether it is as least as likely as not, considering the November 1973 letter which addressed depression and anxiety, that the veteran’s psychiatric disorder was related to service. Prior to the examination, the RO is to inform the examiners of the results of its determination in paragraph (3) above as to the existence of a stressor or stressors. The examiners should report all Axis I and II diagnoses present, if any, discuss any psychosocial stressors, and resolve any conflicts found between their findings and the diagnostic findings noted in the evidence associated with the claims file. With regard to PTSD, the RO must specify for the examiners the stressor or stressors that it has determined are established by the record and the examiners must be instructed that only those events may be considered for the purpose of determining whether the appellant was exposed to a stressor in service. The examination report should reflect review of pertinent material in the claims file. In determining whether or not PTSD is present due to an in service stressor the examiners are hereby notified that only the verified history detailed in the reports provided by USASCRUR 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 reports is/are responsible for that conclusion. The examiners should specify (1) whether each alleged stressor found to be established by the record by the RO was sufficient to produce PTSD; (2) whether the remaining diagnostic criteria support the diagnosis of PTSD have been satisfied; and (3) whether there is a link between the current symptomatology and one or more of the in-service stressors found to be established by the record by the RO and found to be sufficient to produce PTSD by the examiners. Any and all opinions expressed must be accompanied by a complete rationale. The examiners must assign a Global Assessment of Functioning Score (GAF) which is consistent with the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, and explain what the assigned score means. 5. Following completion of the foregoing the RO should review the claims file to ensure that all of the foregoing development has been completed. In particular, the RO should review the psychiatric examination report to verify that any diagnosis of PTSD was based on the verified history provided by the record. If the examiners relied upon a 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. See West, 7 Vet. App. at 77. 6. After undertaking any development deemed appropriate in addition to that specified above, the RO should re- adjudicate the issue of entitlement to service connection for a variously diagnosed acquired psychiatric disorder, to include 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 in this case. No action is required of the veteran until he is notified by the RO. RONALD R. BOSCH Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1997), a decision of the Board of Veterans’ Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans’ Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans’ Appeals. Appellate rights do not attach to those issues addressed in the remand portion of the Board’s decision, because a 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) (1996). - 2 -