Citation Nr: 1754956 Decision Date: 11/30/17 Archive Date: 12/07/17 DOCKET NO. 13-07 975 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement service connection for a psychiatric disorder, to include bipolar disorder and posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Penelope E. Gronbeck, Attorney WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD E. Kunju, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1980 to July 1980. This case comes to the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision by the Department of Veterans' Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. In February 2014, the Veteran testified at a travel board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the claims file. In March 2015, the Board remanded this claim for additional development. It has since been returned to for further appellate consideration. After the most recent Supplemental Statement of the Case, the Veteran requested a second hearing. See August 2016 Correspondence. The Veteran has already had a Board hearing on the service connection claim on appeal and has not presented argument as to why an additional hearing is necessary. See e.g., 38 U.S.C. § 7102(a) (2017); 38 C.F.R. § 19.3(b) (2017); Cook v. Snyder, 28 Vet. App. 330 (2017). This case consists of documents in the Veterans Benefits Management System (VBMS) and in Legacy Content Manager (LCM). LCM includes VA treatment records. Otherwise, documents in LCM are duplicative of those in VBMS or are irrelevant to the issues on appeal. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND Remand is required to obtain an adequate examination and opinion. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A central issue in determining the probative value of an examination is whether the examiner was informed of the relevant facts in rendering a medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). A medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions. Stefl, 21 Vet. App. at 124. The Veteran was afforded a VA examination in July 2016. The examiner diagnosed unspecified personality disorder (antisocial traits). Regarding PTSD, the examiner noted the Veteran's stressor as "see[ing] a guy catch his face on fire; 6 incidents with one recruit; an incident with [Veteran's] drill sergeant, and an incident...where [Veteran] was hit with a 2 by 4 board and then discharged from the Army because [he] beat the boy up a day or two later." The examiner indicated that the stressor was not adequate to support the diagnosis of PTSD. The examiner also marked that the Veteran's described stressor was not related to "personal assault, e.g. military sexual trauma." The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service event. Although the examiner conceded that the Veteran had past treatment for bipolar disorder, he opined that based on his evaluation, the Veteran did not report any symptoms that would meet the requisite for diagnoses of bipolar disorder or PTSD; however what was reported, observed, and taken from a review of records were symptoms consistent with personality disorder. The examiner further explained that personality disorder diagnoses are developmental in nature with an onset in adolescence or early adulthood. The Board finds that an addendum opinion is required. When the Veteran's claimed stressor is not related to combat with the enemy or to a military sexual assault, it does meet the definition of personal assault. See VA Adjudication Procedures Manual, Part IV, Subpart ii, Chapter 1, Section D, Paragraph 17 (providing that personal assault is an event of human design that threatens or inflicts harm, including rape, physical assault, domestic battering, robbery, mugging, stalking, and harassment). With this in mind, a new opinion from the examiner is necessary to determine if the examiner still finds there is no adequate stressor to support PTSD. Additionally, as the stressor is an alleged personal assault, the examiner may provide an opinion as to whether the evidence of record indicates that a personal assault occurred. See 38 C.F.R. § 3.304(f)(4) (2017); Patton v. West, 12 Vet. App. 272, 280 (1999). This was not done. Accordingly, the case is REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, provide the Veteran an examination as to the etiology of a psychiatric disorder, to include PTSD. The entire claims file must be made available to and be reviewed by the July 2016 examiner, if available. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. Based on the review of the claims file and the results of the examination, particularly the Veteran's psychiatric history as elicited during the examination and as provided at the Board hearing and at the 2016 VA examination, the examiner is requested to provide an opinion as to whether it is at least as likely as not (i.e., a probability of at least 50 percent or more) that the Veteran exhibited symptoms and behaviors consistent with behavioral changes expected to follow from the claimed personal assaults, and if so, whether any of his current psychiatric diagnoses, to include PTSD, are related to the alleged incident(s). The examiner is also requested to address generally whether PTSD is etiologically related to an event, injury or disease in service. 4. Ensure compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 5. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim must be readjudicated. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter 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). _________________________________________________ K. MILLIKAN 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) (2017).