Citation Nr: 18140015 Decision Date: 10/02/18 Archive Date: 10/02/18 DOCKET NO. 16-16 875 DATE: October 2, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and unspecified depressive disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from October 1988 to August 1994. The Board’s review of the record reveals that further development is warranted for the matter of entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depressive disorder. The Veteran has consistently contended that he developed a psychiatric disorder as a result of events during his active military service, to include an in-service stressor or personal assault. A review of the Veteran’s post-service treatment records indicates he has been diagnosed with the following psychiatric conditions: PTSD; alcohol use disorder, severe, in early remission, in controlled environment; unspecified schizophrenia spectrum and other psychotic disorder; and unspecified depressive disorder. The Veteran has asserted that his psychiatric disabilities were caused by an in-service sexual assault. In a September 2014 statement, the Veteran reported that he had been assaulted by his sponsor, a high-ranking NCO, which led him to abuse alcohol. The Veteran also reported feelings of anxiety, and suicidal/homicidal ideation due to service during Desert Storm. In addition, the Veteran alleged that he experienced depression, anxiety, and mood swings in service, and he was assaulted by German police officers. While the Veteran was provided VA Form 21-0781, Statement in Support of Claim for Service Connection for PTSD, in connection with his PTSD claim based upon a stressful event, he has never been provided with notice under 38 C.F.R. § 3.304 (f)(5) that describes the available types of evidence to corroborate his reported stressor of military sexual trauma. The Veteran must be provided with VCAA notice regarding the methods for substantiating a psychiatric claim related to a personal assault stressor. The Board notes that the Veteran was initially discharged for bad conduct after he was found guilty by special court martial of operating a loaded fuel tanker while drunk and wrongfully appropriating a fuel tanker. The Veteran’s character of discharge was later changed to general, under honorable conditions. The Veteran contends that his court martial transcript contains evidence of behavioral changes that support his claim for PTSD based on personal assault. The RO obtained the Veteran’s personnel file. However, it does not appear that the reported court martial documents were requested. Further development is necessary to obtain the transcript of the court martial and any other documentation to corroborate the Veteran’s reported personal assault stressor. Additionally, the evidence contains VA treatment records through January 2016. Any VA treatment records are within VA’s constructive possession, and are considered potentially relevant to the issue on appeal. A remand is required to allow VA to obtain updated treatment records. Furthermore, the Veteran should also be offered the opportunity to submit any private treatment records in support of his claim. At the November 2014 VA examination, the examiner opined that the Veteran’s psychiatric disabilities were less likely than not related to his military service or reported stressors. However, an addendum opinion should be obtained following completion of the above development of the Veteran’s reported personal assault stressor. The matters are REMANDED for the following action: 1. Send the Veteran notice required for PTSD claims based on personal assaults, and allow time for a response. Notify the Veteran regarding the potential submission of the various alternative forms of evidence (other than service records) to corroborate his report of an in-service sexual assault. Then, attempt to corroborate the Veteran’s in-service stressor based on personal assault, including the reported sexual assault by the Veteran’s sponsor. If more details are needed, contact the Veteran to request the information. 2. Associate with the record all updated VA treatment records. 3. The AOJ should take appropriate action to obtain the complete records pertaining to the Veteran’s special court martial proceedings in 1990, to include any transcripts, disciplinary records, and records of Article 15, as well as any other service personnel records not previously furnished to VA. If these records are not available, a negative reply is required. 4. After completion of the foregoing, the case should be returned to the examiner who conducted the November 2014 VA examination for an addendum opinion. The examiner may request that the Veteran be recalled for another examination, if warranted. If the November 2014 examiner is not available, the Veteran should be scheduled for a new examination by another clinician. The examiner must opine whether the evidence of record, including the Veteran’s lay statements, court martial records, service records, and evidence of behavior changes corroborate the claim that a personal assault occurred in service (38 C.F.R. § 3.304(f)(5)). If the examiner finds that evidence indicates that a personal assault occurred during the Veteran’s active service, the examiner must opine whether any PTSD is at least as likely as not related to the in-service personal assault. If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Freeman, Associate Counsel