Citation Nr: 18155351 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 16-56 514 DATE: December 4, 2018 REMANDED Entitlement to service connection for posttraumatic stress disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from January 2002 to May 2004. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2015 rating decision. The Veteran did not request a Board hearing. 1. Entitlement to service connection for posttraumatic stress disorder is remanded. Effective March 19, 2015, VA amended the portion of the Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to remove outdated references to the DSM-IV, and replace them with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See 80 Fed. Reg. 53,14308 (March 19, 2015). The provisions of the final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction on or after August 4, 2014. The Veteran’s claim was pending before the RO on November 24, 2014. The Veteran contends that she has posttraumatic stress disorder (PTSD) due to military sexual trauma. The record includes a November 2014 letter in which it is noted that the Veteran has been diagnosed and treated for a mood disorder but no link was provided to the Veteran’s service. In an October 2016 letter, Dr. R.H. noted that the Veteran had been a patient since 2011 and was diagnosed with PTSD, borderline personality disorder, and major depressive disorder but no link was provided to the Veteran’s service. VA treatment records show the Veteran was diagnosed and treated for childhood sexual trauma, military sexual trauma, depression and anger since a 2008 motor vehicle accident, and emotional distress due to divorce and recent break-up. Lastly, a November 2018 disability benefits questionnaire (DBQ) was submitted by Dr. N.L. which showed the Veteran had a diagnosis of PTSD, major depressive disorder, insomnia, and alcohol use disorder. Dr. N.L. commented in the DBQ that the Veteran’s PTSD was due to sexual assault from 2002 to 2003 related incidences but does not account for the Veteran’s entire mental health picture. There is no indication that Dr. N.L. reviewed the Veteran’s service treatment records, VA treatment records, or other private treatment records. The Veteran has never been afforded a VA examination. In light of all of the above, the Board finds that the Veteran should undergo a comprehensive VA psychiatric examination. The matter is REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for Dr. N.L. and Dr. R.H. Make two requests for the authorized records from Dr. N.L. and Dr. R.H., unless it is clear after the first request that a second request would be futile. 2. Obtain VA treatment records dated from July 2016 to the present. 3. Schedule the Veteran for a psychiatric examination to determine the nature and etiology of any acquired psychiatric disorder. Based on examination of the Veteran and review of the file, including the November 2014 letter from E.A., the October 2016 letter from Dr. R.H., the January 31, 2013 VA mental health evaluation, and the November 2018 DBQ from Dr. N.L., the examiner is asked to do the following: (a) In regard to PTSD, the examiner must opine whether the evidence of record, including the Veteran’s lay statements, and the Veteran’s service records, corroborate the claim that a personal assault occurred in service. 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. (b) In regard to mood disorder and major depressive 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 sexual assault and harassment of the Veteran. (c) In regard to borderline personality disorder, the examiner must opine whether such disorder was at least as likely as not subject to a superimposed disease or injury resulting in additional disability (i.e., aggravated) in service due to sexual assault and harassment of the Veteran. (d) The examiner must opine whether the Veteran clearly and unmistakably entered service with a pre-existing psychiatric disorder, and if yes, whether such psychiatric disorder clearly and unmistakably was not aggravated by service. A complete rationale must be provided for all opinions expressed. If any requested opinion cannot be provided without resorting to speculation, then the examiner must explain why this is so. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Alexia E. Palacios-Peters, Associate Counsel