Citation Nr: 18151741 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 16-45 015 DATE: November 20, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD) and a depressive disorder, is remanded. REASONS FOR REMAND The Veteran had active service from June 1975 to December 1975. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). Initially, as VA treatment records document diagnosed psychiatric disorders other than PTSD, including a depressive disorder, the Board has broadened the claim on appeal in this case as noted above. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In this case, in a March 2018 statement, the Veteran asserts that the repeated physical assault by petty officers demanding a portion of his monthly pay and forcibly dunking his head underwater constitutes a personal assault stressor. He additionally submitted an April 2013 statement from his friend, C.Y., in which she stated that she grew up with the Veteran and that the Veteran changed after he returned from the Navy. C.Y. also stated that the Veteran began doing drugs after he returned from service; she recounted that the Veteran told him about the incidents in service and that he was afraid to go in the water and that he used drugs to help him cope with his nightmares. Also, in an April 2013 statement, the Veteran’s spouse stated that they went on a cruise for their honeymoon and that the Veteran would not go around the cruise and seemed to act paranoid. She also stated that it was not until after the cruise that he told her about his incidents in service. The Veteran’s spouse stated that to this day, the Veteran does not take any baths and that he is hesitant about the showers he takes. VA treatment records from November 2016 reflect that the treating clinician attributed PTSD to the Veteran’s military service. No VA examination has been afforded to the Veteran in this case. The Veteran’s reports raise the issue of personal assault and in such cases, evidence from sources other than service department records may provide credible support evidence to corroborate the stressor. 38 C.F.R. § 3.304 (f)(5). Any evidence of behavior changes from lay persons following the claimed assault is one type of relevant evidence that may constitute credible evidence of the stressor. Then, VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. 38 C.F.R. § 3.304 (f)(5). Accordingly, as no VA examination has occurred in this case, a remand is necessary in order for such to be accomplished in this case. See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Finally, on remand, the Board also finds that any identified outstanding private and VA treatment records should also be obtained. See 38 U.S.C. § 5103A(b), (c); 38 C.F.R. § 3.159(b); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016) (where the Veteran “sufficiently identifies” other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, this matter is hereby REMANDED for the following action: 1. Obtain any and all VA treatment records not already associated with the claims file from the La Vegas and San Diego VA Medical Centers, or any other VA medical facility that may have treated the Veteran and associate those documents with the claims file. 2. Ask the Veteran to identify any private treatment that he may have had for his psychiatric disorders, which is not already of record. After securing the necessary releases, attempt to obtain and associate those identified treatment records with the claims file. If any identified records cannot be obtained and further attempts would be futile, such should be noted in the claims file and the Veteran should be notified so that he can make an attempt to obtain those records on his own behalf. 3. Ensure that the Veteran is scheduled for a VA examination with an appropriate examiner in order to determine whether any current psychiatric disorder is related to military service. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. Following review of the claims file and examination of the Veteran, the examiner should identify all psychiatric disorders currently found under the DSM-V, to include any PTSD and/or depressive disorder. If PTSD is diagnosed, the examiner should specify the incident or stressor with which that diagnosis is being made and whether such stressor occurred during military service. For each psychiatric disorder found, to include PTSD and/or depressive disorder, the examiner should provide an opinion regarding whether each disorder more likely, less likely, or at least as likely as not (50 percent or greater probability) began in or is otherwise related to military service, to include any allegations of a repeated physical assault by petty officers demanding a portion of his monthly pay and forcibly dunking his head underwater. In addressing that alleged incident, the examiner should discuss whether the evidence in the Veteran’s service personnel records and any other evidence of record, particularly the noted evidence-types in 38 C.F.R. § 3.304(f)(5), corroborates the occurrence of the personal assault during service. The examiner should specifically address the Veteran’s noted Absence without Leave (AWOL) and the disciplinary actions during military service noted in his service personnel records; the examiner should address whether such is corroborative of the alleged personnel assault during service. The examiner should additionally address the statements from the Veteran’s spouse and his friend, C.Y., including his fear of water and post-service substance abuse, and whether such evidence of corroborative of the alleged personal assault during military service. If the stressor supporting a diagnosis of PTSD is based on in-service personal assault, the examiner should clearly indicate whether the claims file reflects evidence of behavior changes in response to the stressor to indicate that the personal assault stressor occurred. Finally, the examiner should also specifically discuss the Veteran’s lay statements regarding being forced to be vaccinated as such relates to a stressor or incident in service regarding etiology due to service, as well as any lay statements of record regarding onset of symptoms and any continuity of symptomatology since onset and/or since discharge from service. The examiner should also consider any other pertinent evidence of record, as appropriate. All findings should be reported in detail and all opinions must be accompanied by a clear rationale. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Hammad Rasul, Associate Counsel