Citation Nr: 18157702 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 16-59 633 DATE: December 13, 2018 REMANDED The Veteran served on active duty from October 1976 to October 1979. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) denying the Veteran’s claim for entitlement to service connection for posttraumatic stress disorder (PTSD). The Veteran contends that she has PTSD caused by sexual assaults that occurred in service. Prior to the instant claim, a January 2005 rating decision denied a claim for service connection for depression. That decision was not appealed and therefore became final. 38 U.S.C. § 7104; 38 C.F.R. § 20.1103. The Veteran did not claim military sexual trauma as a basis for this claim. Service connection for PTSD is a new claim with a different diagnosis and a new factual basis. VA treatment records show that the Veteran in March 2010 was diagnosed with PTSD by her VA treating psychiatrist and that this diagnosis is continuing. The Veteran has submitted a statement alleging three instances of sexual assault that occurred while she was in service. She argues that there is evidence of record to corroborate that these stressor events occurred, including service treatment records that she exited service reporting that she had contracted and received treatment for a sexually transmitted disease, that she sought and continued to receive treatment for abdominal/vaginal pain, and that an emergency-room visit for fainting and hyperventilation showed she was experiencing anxiety or panic attacks. The Veteran also submitted a buddy statement attesting to one of the assaults. The Veteran’s treating VA psychiatrist has authored a letter stating that the Veteran’s psychiatric conditions are related to multiple incidents occurring before, during, and after service. The Board finds that there is insufficient medical evidence of record for the Board to make a fully informed decision on this issue. The Board notes that the Veteran has not yet been afforded a VA examination, and therefore the Board will remand for a VA examination and accompanying opinions regarding her claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board notes that in the Veteran’s VA Form 9 she indicated that she participates in therapy for PTSD at the Childersburg VA Clinic, and so the Board will remand for those files to be uploaded to the Veteran’s file. Accordingly, the matter is REMANDED for the following action: 1. Obtain any outstanding VA treatment records to include therapy sessions with therapist M.S. at Childersburg VA clinic. 2. Then, schedule the Veteran for an examination to determine the nature and etiology of any acquired psychiatric disorder, to include posttraumatic stress disorder. (A) If the Veteran is diagnosed with any psychiatric disorder, the examiner should opine on the following: Did the Veteran have a psychiatric disorder (other than a personality disorder or a substance abuse disorder) that clearly and unmistakably existed prior to her entrance on active duty? In answering, please consider the September 9, 2014 letter from Dr. M.K., the Veteran’s treating psychiatrist, regarding the Veteran’s history of trauma. If the examiner determines that the Veteran had a psychiatric disorder that clearly and unmistakably existed prior to entrance on active duty, please identify the specific psychiatric disorder. (i) If there is clear and unmistakable evidence that a disorder pre-existed service, the examiner is asked to opine as to whether there is clear and unmistakable evidence that the pre-existing disorder(s) did not undergo an increase in the underlying pathology during service, i.e., was not aggravated during service. If there was an increase in the severity of the Veteran’s disorder, the examiner should offer an opinion as to whether such increase was clearly and unmistakably due to the natural progression of the disease. (ii) If there is no clear and unmistakable evidence that a current disorder pre-existed service, then the examiner is asked whether it is at least as likely as not that the disorder is directly related to service, to include the Veteran’s claimed in-service stressors. (B) If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and additionally opine on the following: (i) Is the Veteran’s PTSD at least as likely as not related to service, to include the claimed in-service stressors? (ii) Does any of the following evidence of record, or any other evidence of record, corroborate the Veteran’s claim that a personal assault occurred in service: the Veteran’s own statements; statements submitted by the Veteran’s buddy; service treatment records showing the Veteran entered service not reporting, but exited active duty reporting, a sexually transmitted disease; service treatment records regarding a diagnosis of a sexually transmitted disease; service treatment records showing treatment sought and administered for abdominal/vaginal pain or other conditions; an emergency record describing that the Veteran had fainted and was hyperventilating, and whether this relates to panic or anxiety without an identified cause. In making these determinations, the examiner is asked to consider and discuss the September 9, 2014 letter from Dr. M.K., the Veteran’s treating VA psychiatrist, regarding his opinion on the Veteran’s diagnosis of PTSD and its etiology. K. PARAKKAL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Davis, Associate Counsel