Citation Nr: 18136458 Decision Date: 09/19/18 Archive Date: 09/18/18 DOCKET NO. 15-37 594 DATE: September 19, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran had active service from August 1978 to August 1982. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2014 rating decision. In August 2016, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record. The Board has recharacterized the issue of entitlement to service connection for PTSD as entitlement to service connection for an acquired psychiatric disorder, to include PTSD, as is reflected on the cover page. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). On review, the Board finds that additional development is necessary prior to final adjudication of the Veteran’s claim. During the August 2016 hearing, the Veteran reported two stressors during his military service. Specifically, he stated that he was physically assaulted during boot camp and that he was involved in a motor vehicle accident. Concerning the boot camp assault at Fort Sill in Oklahoma, the Veteran has related that he was thrown from his rack by a drill sergeant on multiple occasions because he overslept. See December 2012 VA treatment note, April 2014 stressor statement. He also stated that other members of his unit were angry with him because they were being punished with physical training (PT) when the Veteran overslept. He reported that members of his unit jumped him, covered him in a blanket so he was unable to defend himself, and beat him in August 1978. See July 2013 VA treatment note, April 2014 stressor statement. He indicated that he reported the incident to his first sergeant, but nothing was done. See April 2014 statement. He stated that he began getting into fights after the “blanket party” and that he was reprimanded during service for disorderly conduct. See August 2016 hearing transcript. Regarding the motor vehicle accident, the Veteran has provided varying accounts of when and where the accident occurred. For instance, during the August 2016 hearing, he testified that the accident occurred in Germany between 1980 and 1982. However, earlier in the appeal, he reported that it occurred at Fort Ord, California (see April 2014 stressor statement) and during boot camp (see December 2012 VA treatment note). The Veteran has stated that he was knocked unconscious when the driver of the truck lost control of the vehicle, drove into a ditch, and the truck went down an embankment during night maneuvers. He stated that he fell out of the back of the truck and hit his head on a bench during the accident. See August 2016 hearing transcript. See also December 2012 VA treatment (the Veteran indicated that he suffered head trauma after he fell from a truck during a night training exercise); July 2013 VA treatment note (he stated that the vehicle that he was riding in went over a cliff and fell approximately 50 feet and that he jumped from the vehicle and hit his head). During the August 2016 hearing, the Veteran indicated that he was treated by a field medic for head and neck complaints and that he was placed on light duty for several days. In support of his claim, the Veteran also submitted an April 2014 statement from R.M., another service member from the Veteran’s unit who was riding in the vehicle at the time of the accident. The Board notes that the service treatment records and service personnel records currently associated with the record do not include any references to the motor vehicle accident, injuries, or light duty. On remand, the AOJ should attempt to obtain any outstanding service treatment records and service personnel records. In addition, during a December 2012 VA treatment note, the Veteran described witnessing a deceased body being placed on a stretcher after an artillery training exercise fatality. He stated that a forward observer was struck and killed with an artillery round. The Board notes that attempts have not been made to verify any of the stressors that the Veteran has reported during the course of the appeal. Rather, in April 2014, the Agency of Original Jurisdiction (AOJ) determined that the information required to corroborate the stressful events described by the Veteran was insufficient to send to the United States Army and Joint Service Records Research Center (JSRRC) and/or insufficient to allow for meaningful research of Marine Corps or National Archives and Records Administration (NARA) records. On remand, the Board finds that the AOJ should attempt to verify these stressors. Further, there appear to be outstanding private treatment records. For example, in July 2014 correspondence from the Veteran’s attorney at that time, the attorney referenced enclosed private psychiatric treatment records dated from October 2013 to February 2014. However, the private psychiatric treatment records are not associated with the claims file. In addition, in a December 2012 VA treatment note, the Veteran reported past private psychiatric care in the 1980s. He stated that he was referred for mental health treatment by his employer and that he was treated for outpatient care for approximately six months. On remand, the AOJ should attempt to obtain these records. The matter is REMANDED for the following action: 1. The AOJ should send the Veteran a notice letter in connection with his claim for service connection for an acquired psychiatric disorder, to include PTSD. The letter should: (1) inform him of the information and evidence that is necessary to substantiate the claim, (2) inform him about the information and evidence that VA will seek to provide, and, (3) inform him about the information and evidence that he is expected to provide. This letter should be compliant with 38 C.F.R. § 3.304(f), advising the Veteran of specific examples of alternative forms of evidence to corroborate an in-service assault and that behavioral changes may constitute credible supporting evidence of such a stressor. 2. The AOJ should secure any outstanding service personnel and service treatment records, to specifically include, but not limited to, any records pertaining to charges of disorderly conduct and/or treatment following a motor vehicle accident during service. 3. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for a psychiatric disorder. A specific request should be made for private psychiatric treatment records from Fayetteville Psychiatric Associates dated from October 2013 to February 2014 (see July 2014 letter from the Veteran’s attorney at that time) and for records pertaining to outpatient psychiatric treatment for approximately six months in the 1980s (see December 2012 VA treatment note). After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 4. After the above development has been completed, the Veteran should be afforded a VA examination to determine the nature and etiology of any acquired psychiatric disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed, but should include psychological testing, including PTSD sub scales. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he had first-hand knowledge, such as observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify all current psychiatric disorders. If any previously diagnosed psychiatric disorders are not found on examination, the examiner should address whether they were misdiagnosed or have resolved. For each disorder identified other than PTSD, the examiner should state whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to the Veteran’s military service. With respect to PTSD, the AOJ should provide the examiner with a summary of any verified in-service stressors, and the examiner must be instructed that only these events and any personal assault that he or she determines to have occurred in service may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in PTSD. If there is a verified stressor or if the examiner determines that a personal assault occurred in service, he or she should determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. If the PTSD diagnosis is deemed appropriate, the examiner should then comment upon the link between the current symptomatology and any verified in-service stressor, including personal assault if found. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 5. After completing the above actions, the AOJ complete any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Osegueda, Counsel