Citation Nr: 18147208 Decision Date: 11/02/18 Archive Date: 11/02/18 DOCKET NO. 13-06 460A DATE: November 2, 2018 REMANDED The claim for service connection for posttraumatic stress disorder (PTSD) is remanded. The requests to reopen a claim for service connection for substance abuse, to include as secondary to PTSD, and to reopen a claim for service connection for an ulcer, to include as secondary to substance abuse, are remanded. The claim for a total disability rating due to individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1979 to September 1982. These matters come before the Board of Veterans’ Appeals (Board) from June 2010 and May 2012 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2012, the Veteran testified at a hearing before a Decision Review Officer (DRO). A transcript of the hearing has been associated with the claims file. In September 2016, Veterans’ Law Judge (VLJ) Strommen remanded these matters for additional development. She also remanded issues concerning the right knee, left knee, right foot, left foot, and hepatitis C; however, the Veteran withdrew these claims during his October 2012 DRO hearing. Therefore, these claims were not properly before the Board for consideration in 2016 and are not currently before the Board. 1. PTSD The Veteran seeks service connection for an acquired psychiatric disorder, claimed as depression and PTSD, to include as due to military sexual trauma (MST). VA treatment records show a diagnosis of depression. VA treatment records dated throughout 2015 and 2016 show a diagnosis of PTSD due to MST, and document the Veteran’s report of being assaulted during service. He also alleges that his PTSD is related to an incident in service when he saw a soldier’s body after the soldier committed suicide by hanging. A memorandum dated in September 2011 shows that VA was unable to verify the stressor related to the suicide. However, in June 2012, evidence was received confirming that a soldier died as described by the Veteran. The Veteran is competent to report that he saw the body. Regarding MST, it does not appear that attempts have been made to verify the reported stressor. Given the highly sensitive nature of sexual assault cases, the Board finds that the Veteran should be given an opportunity to present corroborating evidence to support his claim. In this regard, the AOJ must contact the Veteran to attempt to gather more detailed information on the alleged sexual assault. He should be given an opportunity to submit credible supporting evidence that the claimed in-service stressor occurred. He should provide the date, location, and name of the assailant he alleges committed the assault. The Veteran may include evidence from sources other than his service records. 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; tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these 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. See 38 C.F.R. § 3.304(f). A January 2012 compensation and pension report shows a diagnosis of depression. However, the examiner did not provide an opinion indicating whether the Veteran’s depression was related to service. Further, in December 2015, the Veteran was diagnosed with PTSD related to MST. Based on the foregoing, the Board finds that on remand, an examination must be scheduled to determine whether the Veteran has a diagnosis of PTSD that is related to the in-service stressor related to a soldier’s suicide or whether he has a diagnosis of any other acquired psychiatric disorder, such as depression, that is related to service. If the Veteran provides corroborating evidence as to the MST, the examiner should provide an opinion addressing the nature and etiology of his PTSD diagnosis in light of the alleged sexual assault. 2. Substance Abuse The Veteran seeks to reopen a claim for service connection for substance abuse, to include as secondary to his acquired psychiatric disorder. However, since the claim for service connection for an acquired psychiatric disorder is remanded for additional development, this claim must also be remanded as the claims are inextricably intertwined. 3. Ulcer The Veteran seeks to reopen a claim for service connection for an ulcer, to include as secondary to his substance abuse. However, since the claim for service connection for substance abuse is remanded for additional development, this claim must also be remanded as the claims are inextricably intertwined. 4. TDIU The Veteran seeks a TDIU. Since his combined schedular evaluation depends on whether any of the disabilities addressed above are granted service connection, and depends on the impact of any such service-connected disability on the Veteran’s ability to work, the Board remands the issue of entitlement to a TDIU as it is intertwined with these appeals for entitlement to service connection. The matters are REMANDED for the following action: 1. Associate with the claims file VA treatment records dated since September 2018. If possible, the Veteran should submit them to expedite the case. 2. Contact the Veteran and request a more detailed description of the alleged sexual assault, to include specific information regarding the incident such as date, location, and name of the assailant, as well as any additional corroborating evidence of the assault. Notify him of the kinds of evidence that may be used to substantiate his claim. See above and 38 C.F.R. § 3.304(f). 3. Undertake any necessary development to independently verify the in-service stressor of sexual assault described by the Veteran, to include obtaining personnel records and performance reports, if available. If the search for corroborating information leads to negative results, notify the Veteran and his representative of this fact, explain the efforts taken to obtain this information, and describe any further action to be taken. If the described stressor lacks sufficient information for verification, such should be noted in a formal finding. 4. Schedule a VA examination to determine the etiology of any diagnosed acquired psychiatric disorder, to include depression and PTSD. The examiner must be provided access to the electronic claims file, and he or she must indicate review of the file in the examination report. After conducting an examination of the Veteran and performing any clinically-indicated diagnostic testing, the examiner should indicate whether it is at least as likely as not (50 percent or greater probability) that the Veteran has PTSD related to the in-service stressor associated with his report of seeing the dead body of a soldier after he committed suicide. In the alternative, if there is enough corroborating evidence to suggest that the in-service stressor of sexual assault may have occurred, ask the examiner to determine whether it is at least as likely as not that the Veteran displayed any behavior in service that would be consistent with his claim of sexual assault. If the examiner believes that a personal sexual assault occurred, the examiner should then state whether the Veteran’s PTSD is the result of or aggravated by such assault. For any other acquired psychiatric disorder diagnosed during the pendency of the claim, to include depression, the examiner must provide an opinion indicating whether it is at least as likely as not (50 percent or greater probability) that the diagnosis is related to service. The examiner must provide a rationale in support of all opinions provided. In providing the opinion(s), examiner must consider the Veteran’s mental health history as well as the findings documented at the time of the examination. If any opinion cannot be provided without resorting to speculation, the examiner must explain why this is so. 5. Undertake any additional development necessary. John Crowley Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Alderman, Amanda G.