Citation Nr: 18147131 Decision Date: 11/02/18 Archive Date: 11/02/18 DOCKET NO. 17-36 380 DATE: November 2, 2018 REMANDED The claim of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) as due to military sexual trauma (MST), is remanded. REASONS FOR REMAND The Veteran had honorable active duty service with the United States Army from May 1980 to November 1987. Pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Board is broadening the Veteran’s claim of entitlement to service connection for PTSD to a claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, as reflected in the issues section above. See id. at 5 (the claim “cannot be limited only to that diagnosis, but must rather be considered a claim for any mental disability that may be reasonably encompassed...”). The Veteran has perfected appeals regarding the issues entitlement to service connection for a low back disability, a chest condition, left lower extremity sciatica, and bilateral knee disabilities. She requested a Board hearing regarding these issues. As the Veteran is still awaiting her requested hearing, these issues are not ripe for adjudication, and thus, will be addressed in a later decision. 1. The claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD as due to MST, is remanded. The Board cannot make a fully informed decision regarding the claim of entitlement to service connection for PTSD, to include as due to MST, as a medical examination has not been provided to the Veteran. The Veteran reports that her first husband was physically abusive to her during their marriage. The record indicates that she married her first husband in September 1982, during her active duty service. The Veteran married her second husband in April 1987, and she reports that he was verbally and emotionally abusive to her. VA treatment records from June 2015 note that the Veteran reported that during service she was routinely sexually harassed, and at least once assaulted. Specifically, she reported that a superior approached her with his genitals exposed with the implication that she should perform sexual acts. She also reported that her backside was fondled by another solider without her consent. She asserts that her psychiatric symptoms included “emotional eating,” which has escalated over time. The Veteran’s service treatment records reflect that she was placed on a weight control program during her marriage to her first husband. Additionally, a July 6, 2018 VA mental health record suggests that the Veteran’s current sleep eating may be due to her anxiety. As for the requirement of credible supporting evidence that a claimed in-service stressor occurred, VA recognizes that, because a personal assault is a personal and sensitive issue, many incidents are not officially reported, which in turn creates a proof problem in establishing they did. It is not unusual for there to be an absence of service records documenting the events the Veteran has alleged. Therefore, evidence from sources other than service records may corroborate an account of a stressor incident that is predicated on a personal assault. See, e.g., Patton v. West, 12 Vet. App. 272, 277 (1999). Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. 38 C.F.R. § 3.304(f)(5) (2018). Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in the mentioned sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military 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 received to an appropriate mental health professional for an opinion as to whether it indicates that a personal assault occurred. Id. The Veteran’s in-service inclusion in the weight control program may represent a behavioral change for the purposes of corroborating her in-service stressors, particularly considering her current sleep eating behaviors. Given the evidence discussed above, to include the nature of the Veteran’s alleged in-service stressors, the Board finds that that the Veteran should be afforded a VA mental health examination to obtain medical information needed to resolve this claim. See 38 U.S.C. § 5103A (d) (2012); 38 C.F.R. § 3.159 (c)(4) (2018); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Additionally, in an April 11, 2012 statement, the Veteran reported additional stressors that reportedly occurred while she stationed in Germany. Specifically, she reports seeing other soldiers dying, overdosing, being put in wall lockers, and physically assaulted. While the Veteran has provided details regarding her reported MST, she has not provided details regarding her other reported stressors. As the claim is being remanded for other development, she should be afforded another opportunity to provide information regarding the incidents detailed in her April 11, 2012 statement. The matter is REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently provided mental health treatment. After securing any necessary releases, the AOJ should request any relevant records identified. In addition, obtain updated VA treatment records. If any requested records are unavailable, the Veteran should be notified of such. 2. Attempt to corroborate the Veteran’s in-service stressors, which are detailed in her April 11, 2012 statement. If more details are needed, contact the Veteran to request the information. 3. After the above is completed to the extent possible, schedule the Veteran for a VA PTSD examination. The claims file should be reviewed by the examiner in conjunction with the examination. All indicated tests should be conducted and the results reported. Following review of the claims file and examination of the Veteran, the examiner should identify all psychiatric disorders present and then respond to the questions presented: (a.) If the Veteran is diagnosed with PTSD, the examiner should indicate the stressor(s) upon which the diagnosis is based. (b.) If PTSD based on personal assault / MST is diagnosed, the examiner should review the claims folder and render an opinion as to whether there is evidence of changed behavior after the Veteran's alleged assault, or any other evidence of record / MST markers, which would be consistent with the alleged trauma. (c.) For each diagnosed psychiatric condition, other than PTSD, state whether it is at least as likely as not that the conditions arose during service or are otherwise related to the Veteran’s military service. In so opining, the examiner should address the April 11, 2012 statement from V. S. H. indicating that during the Veteran’s military service she observed the Veteran have, what appeared to be, a panic attack. In answering the questions posed above, the examiner is advised that the Veteran is competent to report injuries and symptoms, and that her reports must be considered in formulating the requested opinion. If the Veteran’s reports are discounted, the examiner should provide a rationale for doing so. A complete rationale for all conclusions and opinions should be provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 4. Following completion of the foregoing, the AOJ should review the record and readjudicate the claim on appeal. If it remains denied, the AOJ should issue an appropriate supplemental SOC, afford the Veteran and her representative an opportunity to respond, and return the case to the Board. J. A. Anderson Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Fisher, Associate Counsel