Citation Nr: 1551931 Decision Date: 12/11/15 Archive Date: 12/16/15 DOCKET NO. 09-49 337 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for an acquired psychiatric disorder to include post traumatic stress disorder to include due to military sexual trauma. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Tittsworth, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1966 to December 1969. This matter comes before the Board of Veterans' Appeals (Board) from a June 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Augusta, Maine. The appeal was certified to the Board by the Detroit, Michigan RO. The Veteran testified at a videoconference hearing before the undersigned in October 2015. A transcript of the hearing is associated with the claims file. The Veteran's claims file has been converted from a paper file to an electronic file managed in the Veterans Benefits Management System (VBMS). There are also records in Virtual VA. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran claims entitlement to service connection for an acquired psychiatric disorder to include post traumatic stress disorder due to military sexual trauma. In support of his claim, the Veteran submitted a July 2013 statement written by his physician at Battle Creek, Michigan VA Medical Center. The physician, Dr. A.W., writes that the Veteran receives treatment for post traumatic stress disorder caused by military sexual trauma. However, the claims file only contains medical records from Battle Creek VA Medical Center dated through March 2008, none of which specifically document treatment by Dr. A.W. Thus, remand is necessary to obtain additional relevant treatment records. VA recognizes that personal trauma is an extremely personal and sensitive issue, and many incidents of personal trauma are not officially reported, and the victims of this type of in-service trauma may find it difficult to produce evidence to support the occurrence of the stressor. It is often necessary to seek alternative evidence. Thus, special evidentiary procedures exist for post traumatic stress disorder claims based on personal assault. See Patton v. West, 12 Vet. App. 272, 278 (1999); See also VA ADJUDICATION MANUAL M21-1, Part IV, subpart ii.1.D.17. As noted in the November 2009 statement of the case examples of alternative evidence to support the occurrence of a personal trauma include, but are not limited to: records from law enforcement authorities, mental health counseling centers, hospitals, or physicians; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is also one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the occurrence of the stressor include, but are not limited to: a request for a transfer to another duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether such evidence indicates the occurrence of a personal assault. In light of the Veteran's claimed stressors, and the regulatory provisions discussed above, the Board finds the Veteran should be provided a VA examination to determine if the evidence supports the assertion of an in-service personal assault and, if so, whether the currently diagnosed PTSD is etiologically related to this, or any other verified in-service stressor. An opinion should also be obtained regarding any relationship between service and any other current psychiatric diagnosis. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file all outstanding VA treatment records, including all records generated by the Battle Creek VA Medical Center since March 2008. If the RO cannot locate such records, the RO must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 2. Following completion of the above, schedule the Veteran for a VA examination to determine the nature and etiology of any current acquired psychiatric disorder. The entire claims file, to include the appellant's VBMS and Virtual VA files, must be reviewed by the examiner in conjunction with the examination. All appropriate tests and studies should be conducted, and any consultations deemed necessary should be accomplished. After reviewing the record and examining the Veteran, the examiner is to address the following: (a) Does the Veteran meet the DSM-V criteria for a diagnosis of PTSD? (b) If so is it at least as likely as not that the Veteran's PTSD is the result of any in-service assault? If you find that the Veteran was assaulted while in service you must identify the evidence which independently corroborates the claim that the alleged assault took place in service. (c) Is it more likely than not that the Veteran entered active duty in February 1966 with a preexisting psychiatric disorder, to include post traumatic stress disorder? If so, is it more likely than not that the disorder was NOT aggravated inservice? Or is it more likely than not that the appellant entered active duty with a preexisting psychiatric disorder that was permanently aggravated inservice? (d) As to any other currently diagnosed psychiatric disability, opine whether it is at least as likely as not that the disability had its onset during service or whether the disorder was compensably disabling within the year following discharge from active duty, or is otherwise etiologically related to service. A complete a fully reasoned rationale must be provided for any opinion offered. 3. After the development requested has been completed, the AOJ should review any examination reports or opinions to ensure that they are in complete compliance with the directives of this REMAND. The AOJ must ensure that all examiners documented consideration of the entire claims file and any relevant records in Virtual VA and VBMS. If any report is deficient in any manner, the AOJ must implement corrective procedures at once. 4. After completing the above, and any other development deemed necessary, readjudicate the Veteran's claim based on the entirety of the evidence. If the benefit sought on appeal is not granted to the appellant's satisfaction, he and his representative, if applicable, should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (2015).