Citation Nr: 18143792 Decision Date: 10/22/18 Archive Date: 10/22/18 DOCKET NO. 16-22 112 DATE: October 22, 2018 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include as posttraumatic stress disorder (PTSD), depression, alcohol use disorder, unspecified personality disorder, unspecified bipolar and related disorder, anxiety, panic disorder, and amphetamine abuse, is reopened. REMANDED Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), depression, alcohol use disorder, unspecified personality disorder, unspecified bipolar and related disorder, anxiety, panic disorder, and amphetamine abuse disorder, is remanded. FINDINGS OF FACT 1. In a final decision dated June 2014, the AOJ denied the Veteran’s claim for entitlement to service connection for an acquired psychiatric disorder to include PTSD and depression. 2. Evidence received since the June 2014 rating decision regarding an acquired psychiatric disorder to include posttraumatic stress disorder and depression is not cumulative or redundant of the evidence of record at the time of the last prior final denial of the claim, does relate to an unestablished fact necessary to substantiate the claim, and does raise a reasonable possibility of substantiating the claim. CONCLUSION OF LAW New and material evidence has been received sufficient to reopen the claim of entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder, depression, alcohol use disorder, unspecified personality disorder, unspecified bipolar and related disorder, anxiety, panic disorder, and amphetamine abuse. 38 U.S.C. §§ 5108, 7103; 38 C.F.R. § 3.156. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from September 1984 to July 1987. This case comes before the Board of Veterans’ Appeals (Board) from an October 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Fort Harrison, Montana. While the Veteran’s initial claim for an acquired psychiatric disability currently on appeal was adjudicated as entitlement for service connection for an acquired psychiatric disorder claimed as posttraumatic stress disorder and depression by the RO, the medical evidence of record reveals diagnoses/treatment for depression, anxiety, panic disorder, PTSD, unspecified bipolar and related disorder, alcohol use disorder, amphetamine abuse, and unspecified personality disorder. A claim for service connection for a mental disability may encompass claims for service connection of any medical disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Therefore, the issue has been recharacterized as shown on the title page and encompasses all reasonably related acquired psychiatric disorder, to include PTSD, alcohol use disorder, unspecified personality disorder, depression, unspecified bipolar and related disorder, anxiety, panic disorder, and amphetamine abuse disorder. New and Material Evidence for an acquired psychiatric disability. The Veteran was originally denied service connection for an acquired psychiatric disorder to include PTSD and depression in a June 2014 rating decision, which she did not appeal. Therefore, it is a final decision. 38 U.S.C. §§ 5108, 7103; 38 C.F.R. § 3.156. The October 2015 rating decision represents the most recent decision regarding the issue of entitlement to service connection for an acquired psychiatric disorder to include PTSD and depression. The evidence of record at the time of the June 2014 rating decision included the Veteran’s service treatment records, military personnel records, developmental letter to Veteran dated March 2014, various VA treatment records from October 2009 to May 2014, and statements by the Veteran. In its decision, the RO found that the weight of the evidence was against a finding that the Veteran has a current diagnosis of PTSD that was directly related to her military sexual trauma during service, in order to permit a finding of service connection. Since then, VA subsequently received more VA treatment records from August 2013 through October 2015, which documented several VA psychiatric treatments, a VA psychologist diagnosis of PTSD, and other diagnoses of psychiatric disorders under the DSM-5 criteria. Therefore, the Board finds that this medical evidence is both new and material as it raises a reasonable possibility of substantiating the claim for a diagnosis of PTSD and other acquired psychiatric disorders, that were not previously provided. Accordingly, reopening of the recharacterized claim for service connection for an acquired psychiatric disorder, to include as posttraumatic stress disorder, depression, alcohol use disorder, unspecified personality disorder, unspecified bipolar and related disorder, anxiety, panic disorder, and amphetamine abuse, is granted. REASONS FOR REMAND Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), depression, alcohol abuse disorder, unspecified personality disorder, unspecified bipolar and related disorder, anxiety, panic disorder, and amphetamine abuse disorder, is remanded. After review of the record, the Board finds that a remand is necessary for further development and clarification to adjudicate the claim in accordance with VA’s duty to assist. Regarding the Veteran’s PTSD, there is conflicting evidence of record. Post-service VA treatment records for Sheridan VAMC reflect the Veteran was treated and diagnosed with PTSD by a VA psychologist under the DSM-5 criteria in December 2013 and April 2014. This same psychologist wrote a letter addressed to the Court in November 2013, stating that she is currently working with the Veteran in individual psychotherapy to focus and address the Veteran’s PTSD symptoms caused by her military trauma, to which the psychologist believes that the Veteran’s trauma symptoms contributed significantly to her substance abuse problems. However, in a subsequent VA examination for PTSD conducted in August 2015, the examiner, also a VA psychologist, found no diagnosis of PTSD under the DSM-5 criteria, and did not address the previous diagnosis or the etiology opinion provided by the 2013-2014 treating VA psychologist. Instead, the examiner merely notated that the Veteran was diagnosed with PTSD by the Veteran’s therapist. Additionally, the August 2015 examiner diagnosed the Veteran with unspecified bipolar and related disorder, alcohol use disorder, and unspecified personality disorder. The examiner thoroughly noted the Veteran’s other psychiatric diagnoses throughout the years, however, did not properly assess each disorder reflected in the record as to whether it directly relates to the Veteran’s military sexual trauma in service. As a result of the August 2015 VA examination containing missed material facts regarding the Veteran’s PTSD diagnosis, as well as a limited or no etiology opinion pertaining to all the diagnoses of record, the Board finds that a remand is necessary so a new and/or supplemental VA examination and opinion can be obtained. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006) (noting “low threshold” standard for determining when a VA examination is necessary has been met). Further development for the Veteran’s reported personal assault is also needed. The Veteran reported an in-service stressor involving a personal assault occurring in April or May 1987. Specifically, the Veteran described an incident with a fellow serviceman where she was attacked and sodomized while visiting the serviceman one night while he was drunk. The Veteran stated that she did not report this incident while in service, nor did she provide any additional information in support of this claim before the Board; thus, the record does not reflect any affirmative evidence that the assault occurred. Therefore, because the occurrence of the alleged in-service personal assault is not corroborated, additional development is needed to adjudicate the claim. The matter is REMANDED for the following action: 1. Request the Veteran to identify all medical providers (VA and private) from whom she has received treatment for an acquired psychiatric condition, and obtain any outstanding records and associate them with the Veteran’s claims file. 2. Send the Veteran notice required for PTSD claims based on personal assaults, and allow time for a response. Then, attempt to corroborate the Veteran’s in-service stressors by requesting the Veteran to provide additional information relevant to the occurrence of the claimed personal assault. If more details are needed, contact the Veteran and request the information. 3. After associating all newly acquired records with the claims file, and after the Veteran’s reported stressor has been developed, schedule the Veteran for a VA mental health examination to determine the nature and etiology of any PTSD. The entire claims file, including a copy of this remand, must be made available to the examiner, and note review of the record in the examination report. Any indicated tests or studies should be performed, and all material relevant evidence should be discussed. 4. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. The examiner must opine whether the evidence of record, including the Veteran’s lay statements, 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. The examiners are reminded that the Veteran is competent to attest to matters of which she has first-hand knowledge. The examiner must specifically address any diagnosis of PTSD contained in the record in their explanation for the opinion provided. 5. If any other acquired psychiatric disorders are diagnosed, to include depression, alcohol abuse disorder, unspecified personality disorder, unspecified bipolar and related disorder, anxiety, panic disorder, and amphetamine abuse disorder, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease, to include any documented personal assault shown during active service. A clear explanation based on specific facts for the case, as well as relevant medical history and principles is needed. 6. If the examiner is unable to offer the requested opinions, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resorting to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). M. H. HAWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Hodges, Associate Counsel