Citation Nr: 18156654 Decision Date: 12/11/18 Archive Date: 12/10/18 DOCKET NO. 16-58 510 DATE: December 11, 2018 REMANDED Service connection for a psychiatric disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1974 to March 1978. She reported in January 2014 that in February 1975, she was coerced into having sex by her drill instructor after he found out that she had gone out the night before and missed curfew. He advised her to meet him in a stairwell later, which is where approached her very closely, made her turn around, pulled down her pants, bent her over, and raped her. About a week later, this drill sergeant told her that if she was nice to another man who was in uniform, her curfew violation would not be exposed. This man did the same thing to her in the stairwell and then afterward, he and the drill sergeant laughed and told her to go to class. She stated that she felt extreme shame and never told anyone until Dr. Constance in 2013. The Veteran’s service treatment records are silent for reference to psychiatric symptomatology, and the first evidence of record showing psychiatric problems is dated in 2009, more than 30 years post-service. At the time, it was reported that the Veteran had lost her daughter in a motor vehicle accident 7 years prior, and was now the primary caregiver for her daughter’s 2 children. She also reported prior psychiatric treatment, which included being prescribed medication for several years, from a Dr. Carroll Patterson, a psychiatrist in Liberty. Dr. Patterson’s records should be obtained as they are relevant to the current claim. In December 2010, during a VA psychiatric intake examination, she denied experiencing military sexual trauma. She later reported that the above-mentioned sexual assaults occurred in service. In March 2013, her diagnoses were posttraumatic stress disorder; possible major depressive disorder; and adjustment disorder with anxiety due to a 2010 divorce. In January 2014, she was feeling overwhelmed due to the caregiving responsibilities for her grandchildren. This claim is being treated as one for service connection for any psychiatric disorder reasonably raised by the record, including posttraumatic stress disorder and adjustment disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran filed her claim under the Fully Developed Claim (FDC) program in October 2012. However, the provisions of 38 C.F.R. § 3.304(f) indicate that VA will not deny a posttraumatic stress disorder claim that is based on a personal assault without first advising the claimant that evidence from sources other than the Veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. VA has not advised the Veteran of this yet, in a notice letter, as required, and so VA must do this on remand. Those provisions also indicate that 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. In June 2018, the Veteran’s representative asked for a VA examination to assist in the substantiation of the Veteran's testimony regarding in service personal assaults. To date, no VA psychiatric examination has been conducted. A VA psychiatric examination should be conducted as indicated below. Accordingly, the matter is REMANDED for the following action: 1. Advise the Veteran that evidence from sources other than service records or evidence of behavior changes may constitute credible supporting evidence of her personal assault stressors and allow her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. 2. Make arrangements to obtain all additional psychiatric treatment records which have not been incorporated into the claims folder, including any recent VA treatment records (since January 2018) and, after obtaining any necessary authorizations, all past records of private treatment, including treatment beginning prior to 2009 by Dr. Carroll Patterson in Liberty, Missouri. 3. Schedule the Veteran for a VA psychiatric examination. Provide the examiner with the claims file. All necessary special studies or tests, including psychological testing if indicated, are to be accomplished. The examiner is to review the claims folder, including the service medical records, the service personnel records, and all post-service psychiatric records. a) All current (existing at any point since the October 2012 claim date) psychiatric disorders should be clearly diagnosed. The examiner must express an opinion as to whether the Veteran meets the criteria for posttraumatic stress disorder contained in DSM 5, and adequately explain why, providing supporting details. b) If the examiner diagnoses posttraumatic stress disorder, he or she is to provide an opinion as to whether a personal assault at least as likely as not occurred in service. The examiner should consider and discuss the December 2010 denial of military sexual trauma during a VA psychiatric intake examination. c) The psychiatrist must express an opinion as to whether such posttraumatic stress disorder can be related to the service stressors reported by the Veteran. d) Regardless of whether a diagnosis of posttraumatic stress disorder is rendered, the examiner should offer an opinion as to whether it is at least as likely as not that any other current acquired psychiatric disorder which is present is causally related to service, to include the service experiences reported above. If the Veteran fails to report for the examination, the examiner should nevertheless undertake a review of the claims file and respond to the above-posed questions. The examiner must provide a comprehensive report including complete rationales for all conclusions reached. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Lawson, Counsel