Citation Nr: 18141131 Decision Date: 10/09/18 Archive Date: 10/09/18 DOCKET NO. 16-27 563 DATE: October 9, 2018 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran had active duty service from May 1976 to August 1977. This matter comes before the Board of Veterans’ Appeals (Board) on an appeal from a January 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. The Board notes the Veteran has a significant history associated with mental health treatment, and he is currently service connected for a “nervous condition” rated as 100 percent disabling. See VA Rating Decision, dated in March 2007. At the time he was awarded service connection for a nervous condition in March 2007, he had been diagnosed as having paranoid schizophrenia, substance abuse, and anxiety neurosis. The Veteran asserts that he also has PTSD that is attributable to his active service. More specifically, in his May 2016 VA Form 9, he asserted he developed PTSD as a result of having a gun pointed at his head by other servicemembers. The Veteran has detailed the personal assault in other statements throughout the record. A review of the Veteran’s medical records shows he has tested both positive and negative during screenings for PTSD. A March 2008 problem list includes PTSD. In October 2011, it was noted the Veteran’s past psychiatric diagnoses include depression, schizophrenia, and PTSD. Accordingly, the Veteran should be afforded with a VA psychiatric examination and opinion as to the likely etiology of any separately diagnosable PTSD. The Board also notes that in August 2013, the RO’s JSRRC coordinator determined the information required to corroborate the Veteran’s stressful event was insufficient to send to the U.S. Army and Joint Services Records Research Center. Since the Veteran contends he suffers from PTSD as a result of in-service personal assault and VA has special processing rules for such claims, including the provision of additional notification, on remand, the Veteran must be provided with such notification. Additional efforts should also be undertaken to obtain the Veteran’s complete service treatment records, service personnel records, and Social Security Administration (SSA) disability records. The matter is REMANDED for the following action: 1. Furnish the Veteran with the notice required under 38 C.F.R. § 3.303(f) for PTSD claims based on personal assault. He should be asked to provide as many details as possible concerning his reported incidents of having a gun held to his head during service by another servicemember named “Brock,” by his roommate, and/or by people at a party. 2. Undertake any appropriate stressor development, based upon any information provided by the Veteran. 3. Obtain the Veteran’s VA treatment records, dated from June 2017 forward. 4. Obtain the Veteran’s complete service treatment records, to include all mental health treatment records and all clinical records. A specific request should be made for any records from N.S.A. Hospital at Fort Meade, MD, dated from May 1977 to August 1977. See VA Form 21-526, dated April 16, 1979. 5. Obtain the Veteran’s complete service personnel records, to include all records concerning the circumstances of his periods of AWOL from March 28, 1977 to March 29, 1977, and from July 5, 1977 to July 10, 1977; any disciplinary records; all records concerning the circumstances and reasons for his Restriction of Assignment and Travel in August 1977; and all records concerning the circumstances and reasons for his separation from service listed on his DD Form 214 as MARCORSEPMAN JFG8 PARA 6012.1f(4). 6. Obtain from the SSA complete copies of any disability determination(s) it has made concerning the Veteran and copies of the medical records that served as the basis for any such decision(s). See VA examination report dated in February 2007 and VA hospitalization report dated in February 1998. 7. Next, schedule the Veteran for a VA examination by a psychiatrist or psychologist. The entire claims file and a copy of this REMAND must be made available to the examiner in conjunction with the examination. The examiner must note in the examination report that the evidence in the claims file has been reviewed. (a) A specific determination should be made as to whether the Veteran has a diagnosis of PTSD under the DSM-5 criteria. (b) If the Veteran has PTSD, the examiner should review the claims folder to specifically include any evidence reflecting behavior changes at any time following the claimed personal assault(s) in service, including service treatment records and service personnel records, and provide an opinion as to whether the evidence indicates that the Veteran likely sustained a personal assault in service, as asserted. If so, then the examiner must comment as to whether the diagnosed PTSD is related to the in-service personal assault(s). A supporting rationale for all opinions expressed must be provided. If the examiner is unable to provide any opinion as requested, the examiner should fully explain the reason why such opinion could not be rendered. P. M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs