Citation Nr: 18115167 Decision Date: 06/29/18 Archive Date: 06/29/18 DOCKET NO. 15-24 027 DATE: June 29, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1985 to July 1987. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The Board has expanded the claim on appeal to one of service connection for an acquired psychiatric disability, to include PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). The change is also reflected above. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2).   Entitlement to service connection for an acquired psychiatric disorder, to include PTSD is remanded. While further delay is regrettable, additional development is necessary prior to adjudication of the Veteran’s service connection claim. The Veteran contends that his current psychiatric disorder is the result of his service. Specifically, in a May 2013 correspondence, the Veteran reported two incidents of sexual trauma. First, the Veteran stated that he was sexually molested by a neighbor when he was about 10 years old. Second, the Veteran reported that he was sexually assaulted in the military when he was stationed in Germany. The Veteran stated that “[s]omehow some of the situation of what happened when I was a young and what happened in the Army connected and I became very remorseful and really depressed . . . .” Military personnel records documented disciplinary action taken against the Veteran for drug use and driving under the influence. See May 1987 Department of Army Letter; June 1987 Letter of Reprimand. In May 2015, the Veteran was afforded a VA mental health examination. During the examination, the Veteran reported a long history of psychiatric symptoms, sexual assault, and substantive abuse. In particular, the Veteran reported being sexually molested by an adult male when he was eight years old. Regarding the aforementioned alleged assault during service, the Veteran reported that he was sexually assaulted within a few days of arriving at his first duty station in Germany. He stated that “[o]ne evening, a soldier in uniform (BDUs) came into his room, very intoxicated, forced him to perform oral sex and then pushed him to the ground and raped him.” To cope, the Veteran “stayed drunk 24 hours a day to ward it off.” After interviewing the Veteran and performing a psychiatric examination, the examiner found that the Veteran did not meet the criteria for a PTSD diagnosis, but that he did meet the criteria of borderline personality disorder, alcohol use disorder, cocaine use disorder, cannabis use disorder, opioid use disorder, sedative hypnotic, or anxiolytic use disorder. The examiner did not address whether an additional psychiatric disability was superimposed on the Veteran’s borderline personality disorder during service. In November 2016, VA mental health treatment records verified current diagnoses of PTSD, major depressive disorder (r/o bipolar disorder), alcohol use disorder, cocaine use disorder, and opioid use disorder. During the psychiatric evaluation, the Veteran reported that the “MST was the worst event and currently the most distressing to him.” Further, the clinician noted that “Mr. Sellers’ reported difficulties with depression, anxiety, and trauma-related symptoms are consistent with current diagnoses.” In light of the recent medical treatment records documenting diagnoses of major depressive disorder, and the fact that the May 2015 VA examiner did not discuss the possibility that the Veteran’s psychiatric conditions were superimposed upon his personality disorder-a permissible path to service connection, the Board finds that remand is necessary in order to obtain an addendum opinion regarding the nature and etiology of the Veteran’s acquired psychiatric disorder. 38 C.F.R. §§ 3.303(c), 4.9, 4.127; see VAOPGCPREC 82-90, 55 Fed. Reg. 45,711 (July 18, 1990). The matter is REMANDED for the following action: 1. Update the file with any VA treatment records relevant to the Veteran’s claim. If any requested records are unavailable, the Veteran and his representative should be notified of such. 2. Obtain an addendum opinion from an appropriate clinician to determine the etiology of any diagnosed psychiatric disorder, to include major depressive disorder, borderline personality disorder, and PTSD. An examination is not necessary, unless deemed so by the examiner. (a.) Please identify all of the Veteran’s psychiatric disorders since shortly before, at the time of, or during the pendency of his April 2013 claim (even if currently asymptomatic or resolved). If he or she finds that the Veteran did not meet the DSM-5 criteria for PTSD at any time, such a finding should be reconciled with the evidence of record demonstrating such a diagnosis, to include a November 2016 VA treatment record, which diagnosed PTSD based, in part, on the Veteran’s reports of military sexual trauma. (b.) The examiner should specifically indicate whether the Veteran meets the DSM-5 diagnostic criteria for PTSD and whether such diagnosis is the result of an in-service stressor, to include the Veteran’s alleged personal assault. In answering this inquiry, the examiner must carefully review the record, including the Veteran’s description of the incident and his reaction to it. The examiner must also indicate whether the service personnel and/or treatment records contain indicators of behavioral changes consistent with an individual who has been assaulted, to include the aforementioned disciplinary incidents. Furthermore, the examiner must consider whether there were any behavior changes during service that are consistent with an individual who has been assaulted. (c.) Did the Veteran have a psychiatric disorder (other than a personality disorder) that clearly and unmistakably existed prior to his entrance on active duty? If so, please identify the specific psychiatric disorder. 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 progress of the disease. (d.) 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 alleged in-service sexual assault, and whether the Veteran’s behavioral problems during service could have been earlier manifestations of a subsequently diagnosed psychiatric disorder. (e.) For all diagnosed personality disorders, such as borderline personality disorder, the examiner must state whether there was an additional disability due to disease or injury superimposed upon such personality disorder during the Veteran’s military service. If so, please identify the additional disability. (f.) If the examiner is unable to provide the requested opinions without resort to speculation, the examiner should clearly indicate that and describe what facts or information is missing that would permit a non-speculative opinion. A rationale for all opinions offered should be provided. A.J. Spector Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD I. Altendorfer, Associate Counsel