Citation Nr: 20021287 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 17-65 455 DATE: March 25, 2020 REMANDED Service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD), depressive disorder, and anxiety, is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Air Force from December 1979 to November 1981. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2019, the Board remanded the Veteran’s claim to obtain VA treatment records from the Houston, Texas VA Medical Center (VAMC) and the Orlando, Florida, VAMC. In this respect, the July 2017 Statement of the Case (SOC) noted review of VA treatment records from the Orlando and Houston VAMCs from 1994 to 2017, but those records were not associated with the record. Following the Board’s December 2019 remand, VA treatment records from the Orlando VAMC from July 2016 to December 2019 and records from the Houston VAMC from July 2001 to February 2019 were obtained. Because the SOC indicated that earlier records were reviewed and are not associated with the record, remand is warranted to obtain complete records from the Orlando and Houston VAMCs. While this action might normally be accomplished through administrative means, in connection with the reasons for remand which follow actual remand for action is required. In addition, the Board recognizes a May 2017 VA note from the Veteran’s VA psychiatrist who stated that the Veteran’s service treatment records indicated that the Veteran was evaluated by mental health at Patrick Air Force Base in September 1981. The psychiatrist opined that it was “more likely than not” that the Veteran’s current depressive symptoms were related to mental health symptoms that led to the evaluation in September 1981. In addition, the psychiatrist indicated that the service records documenting pelvic inflammatory disease (PID), urinary tract infection (UTI), and other abdominal pain were at least as likely as not markers of sexual trauma. The psychiatrist had also provided diagnoses of PTSD in VA treatment records, indicating that the diagnosis was related to the Veteran’s military sexual trauma. However, the Board finds that the evidence is insufficient to warrant a grant of service connection at this time. The Veteran’s psychiatrist referenced a September 1981 mental health record; however, after careful review, the Board has been unable to locate that record. In addition, the Board recognizes that the service treatment records document PID, UTI, and abdominal pain. However, it is unclear that the psychiatrist reviewed the remainder of the service records, which did not reveal any psychiatric complaints or reports of a sexual assault, or reviewed the VA treatment records which contain the Veteran’s contradictory statements denying in-service assault. Accordingly, the Board finds that all service mental health treatment records must be requested, and the Veteran must be provided a VA medical examination. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The matter is REMANDED for the following action: 1. Obtain the complete VA treatment records from VAMC Orlando prior to July 2016 and after December 2019 and obtain complete VA treatment records from VAMC Houston prior to July 2001 and from February 2019. 2. Request all service mental health treatment records and ask the Veteran to submit any copy of the September 1981 service mental health record referenced by her VA psychiatrist. 3. Schedule the Veteran for a VA psychiatric examination. The claims folder must be reviewed by the examiner. The examiner must address whether the Veteran has a diagnosis of PTSD and, if so, whether it is at least as likely as not related to alleged in-service personal assaults. The examiner must address the VA psychiatrist’s opinion that the Veteran’s PID, abdominal pain, and UTI, were at least as likely as not markers of a sexual assault. The examiner must also address whether any other psychiatric disability is at least as likely as not related to active service. Rationale must be provided for any opinion reached. 4. Thereafter, readjudicate the remanded issue. If the benefit sought remains denied, the Veteran should be provided with a supplemental statement of the case. The case should then be returned to the Board for appellate review if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Seay, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.