Citation Nr: 20043501 Decision Date: 06/26/20 Archive Date: 06/26/20 DOCKET NO. 14-06 814 DATE: June 26, 2020 REMANDED Entitlement to service connection for any acquired psychiatric disorder, to include Obsessive Compulsive Disorder (OCD) and Post-Traumatic Stress Disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Army from May 1978 to May 1982. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a February 2013 rating decision by the Regional Office (RO) of the United States Department of Veterans Affairs (VA). Although the Veteran initially requested a Board hearing in his December 2013 VA Form 9, in May 2017 correspondence, he expressed his desire to withdraw the hearing request. 38 C.F.R. § 20.704(e). Therefore, there is no outstanding hearing request. With respect to psychiatric disorders, a claim for service connection encompasses all pertinent symptomatology, regardless of how that symptomatology is diagnosed. See Clemons v. Shinseki, 23 Vet. App. 1, 5, 9 (2009). Although the Veteran originally brought two separate claims for OCD and PTSD, the RO recharacterized the claims as a single issue, an acquired psychiatric disorder, to include OCD or PTSD. In November 2017, the Board remanded the matter for additional development; substantial compliance with the Board’s prior remand orders is demonstrated. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). However, further remand is required in order to appropriately address the Veteran’s contention regarding entitlement to service connection for PTSD based on military sexual trauma (MST). Although the Veteran has consistently sought service connection for an acquired psychiatric disorder since 2011, he has only recently raised MST as a possible PTSD stressor. Although the Veteran mentioned the alleged MST incident during both April 2019 and February 2020 examinations, the Veteran has not submitted a stressor statement concerning this incident to the VA, or notified the RO of the new allegation, and therefore, has not been afforded assistance in developing the claim. Incidents of MST are by their nature not frequently documented, and VA therefore recognizes that alternative records and evidence are often helpful in substantiating the allegations. To that end, there is specific development and notice to be undertaken in connection with personal assault claims. Such has not been accomplished here. Accordingly, the Veteran should be provided a VA Form 21-0781a upon remand, provided notice of the types of relevant and alternative evidence and information helpful to his claim, and be afforded the opportunity to further develop this theory of entitlement. Furthermore, although there is no dispute that the Veteran is diagnosed with an acquired psychiatric disorder, clarification is necessary with regard to the exact diagnosis. During the April 2019 examination, the examiner initially indicated that a PTSD diagnosis could not be given on the basis that ¬the MST claim had not been submitted to the VA or otherwise developed. Although the examiner reversed this determination in an addendum opinion, stating that a PTSD diagnosis was warranted, the examiner maintained that he was unable to further opine as to the MST and any markers involved without the claim on file. It is unclear how a valid diagnosis is rendered is no valid stressor has been identified. During the February 2020 examination, the examiner provided a PTSD diagnosis, specifically indicating in the examination report that such was warranted based on the MST stressor. However, this examiner also opined that the Veteran’s PTSD was not due to the alleged MST and stated that he had significant concern as to the veracity of the Veteran’s report. Moreover, earlier examiners have declined to diagnose PTSD and have instead raised conditions such as bipolar disorder, OCD, and depression in addition to noting substance abuse. Accordingly, after the MST claim is afforded appropriate development, the Veteran should be afforded an additional examination in order to clarify a diagnosis, and to secure a fully reasoned nexus opinion. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Send the Veteran a notice letter and VA Form 21-0781a to be completed in connection with his claim for service connection for an acquired psychiatric disorder, to include PTSD, based on alleged in-service MST. Such letter must inform him of the types of alternative evidence and information which may assist him in supporting his claim. 3. Following completion of such, schedule the Veteran for a VA mental disorders/initial PTSD. The claims folder must be reviewed in conjunction with the examination. The examiner should identify any current acquired psychiatric disorders. PTSD, bipolar disorder, OCD, depression, and substance abuse, as well as any other condition indicated in the record, must be discussed. For each diagnosed condition, the examiner must opine as to whether such is at least as likely as not caused or aggravated by military service, to include allegations of MST. If a condition is related to MST, commentary on markers and indicators of the occurrence of the incident would be helpful. A full and complete rationale for any opinion expressed is required. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). Jones v. Shinseki, 23 Vet. App. 382 (2010). 4. Then, 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 S.P. Faris 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.