Citation Nr: 18161308 Decision Date: 12/31/18 Archive Date: 12/31/18 DOCKET NO. 17-03 171 DATE: December 31, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), a major depressive disorder, and an anxiety disorder, is remanded. REASONS FOR REMAND The Veteran had active military service from February 2012 to May 2012. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from July 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for an acquired psychiatric disability, to include PTSD, a major depressive disorder, and an anxiety disorder, is remanded. Review of the claims file reveals that further action on the claim of entitlement to service connection for an acquired psychiatric disability, to include PTSD, a major depressive disorder, and an anxiety disorder, is needed. The Veteran states that she was “attacked by another soldier” in her training company in Fort Leonard Wood, Missouri. See September 2015 VA 21-0781a, Statement in Support of Claim for PTSD Secondary to Sexual Assault. The Veteran reported that a statement was taken by Sergeant First Class (SFC) Fisher and Commanding Officer, S. Dusarow. See March 2014 VA 21-0781a, Statement in Support of Claim for PTSD Secondary to Sexual Assault. As a result of this attack, the Veteran stated that she has nightmares, intrusive thoughts, hypervigilance, agitation and social avoidance. See March 2014 VA 21-4138 Statement in Support of Claim. Service treatment records are negative for any psychiatric-related symptoms. Specifically, in the March 2012 entrance examination and the May 2012 separation examination, the Veteran was noted to have no anxiety, depression, or sleep disturbance, and he denied having any suicidal or homicidal ideation. See May 2016 STR – Reserve STR. However, the records show that the Veteran was approved for leave due to “attack on person (hip injury).” The Board finds this evidence probative as it indicates that the main reason for the leave request was primarily due to an attack. See March 2014 Military Personnel Record. Based on the Veteran’s statement and the records, the Board finds that the Veteran provided sufficient information to trigger the VA’s duty to assist and verify the alleged in-service stressor. The Board further notes that the Veteran was afforded a VA examination in June 2014. In the examination, the examiner did not render a diagnosis for any mental impairments. The examiner opined, based on the results of the Minnesota Multiphasic Personality Inventory (MMPI) II test results, that the Veteran did not appear to meet the criteria for PTSD per DSM 5 or DSM IV. The examiner explained that the test results was just short of being invalid. As such, the Veteran may have been malingering or exaggerating symptoms as a plea for help. The examiner noted that, although the Veteran reported avoidant behavior, it was more likely than not a reflective of a personality characteristic rather than a function of having been exposed to a possible trauma. The examiner concluded that a diagnosis of PTSD could not be rendered as the Veteran’s clinical picture was unclear and as the evidence was inconclusive as to the reported in-service attack. Subsequent to the June 2014 VA examination, the Veteran submitted additional medical records pertinent to her appeal, to include a psychological evaluation from the Tennessee Disability Determination Services that diagnosed her with PTSD and major depression. See November 2015 Request for Certification by Social Security Administration. In light of the new evidence, the Board finds that the Veteran should be afforded a new VA examination to address her acquired psychiatric disability. The matter is REMANDED for the following action: 1. Obtain outstanding records of pertinent medical treatment from VA or private health care providers. 2. Attempt to corroborate the Veteran’s alleged PTSD stressors, which includes an attack by fellow service member. Document such attempts as well as the results of these efforts. 3. Thereafter, schedule the Veteran for a VA examination by an appropriately qualified examiner to determine the nature and etiology of any current psychiatric disorder, to include PTSD, a major depressive disorder, and an anxiety disorder. The claims file, including a copy of this remand, must be made available to the examiner. A record of the review of the claims file should be documented in the examination report. Following the examination of the Veteran and a review of the record, the examiner must: a. identify each psychiatric disorder diagnosed. b. If PTSD is diagnosed, identify the stressor(s) upon which such diagnosis is based. If PTSD is not diagnosed, the examiner must address the May 2014 psychological evaluation conducted by the Tennessee Disability Determination Services. c. If a psychiatric disability other than PTSD is diagnosed, opine as to whether it is at least as likely as not (50 percent probability or more) that such disorder had its onset in service or is otherwise etiologically related to service. A detailed rationale for all opinions must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. Noh, Associate Counsel