Citation Nr: 21001145 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 19-20 374 DATE: January 7, 2021 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran had active service from January 1993 to January 2013. This appeal to the Board of Veterans' Appeals (Board) arose from a May 2018 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. Entitlement to service connection for PTSD is remanded. Although the Board regrets the additional delay, remand is necessary to for additional development. The Veteran claims entitlement to service connection for PTSD due to personal trauma during service. The Veteran has provided a consistent account of an assault in service. Post-service treatment records show complaints of depression. The report of an April 2020 VA mental disorders examination indicated a diagnosis of unspecified trauma- and stressor-related disorder, but no diagnosis of PTSD. The Veteran, through the representative, contends that a PTSD examination should be provided to fully address whether PTSD is present. On remand, the Board finds that the Veteran should be provided with a VA PTSD examination for clarification of the diagnoses and an etiology opinion regarding the claimed PTSD. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Additionally, any outstanding records of private treatment for PTSD should be requested and pertinent, updated VA treatment records should be associated with the record. The matters are REMANDED for the following action: 1. Obtain any outstanding private and VA treatment records and associate them with the claims file. 2. Then, schedule VA PTSD examination with a psychologist or psychiatrist to determine whether or not the Veteran has PTSD, and if so, the etiology. The examiner must review the claims file and should note that review in the report. Any tests deemed necessary should be administered. The examiner should address the Veteran’s March 2018 and July 2019 lay statements, including regarding onset, symptoms during service, and continuity of symptomatology since service. The examiner should provide a complete rationale for all opinions and conclusions and reconcile the opinions with all pertinent evidence of record, to specifically include the May 2014, April 2018, and April 2020 mental disorders examinations. After a review of the evidence, an interview with the Veteran, and an examination, the examiner must address the following: (a) The examiner should provide a full multi-axial diagnosis. The examiner should specifically state whether or not a diagnosis of PTSD is warranted. The examiner should specifically state whether or not each criterion for a diagnosis of PTSD is met. (b) If a PTSD diagnosis is deemed appropriate, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that PTSD is due to the claimed incident in service. The examiner should comment on any link between current symptomatology and the in-service stressor reported by the Veteran. The examiner should opine whether there is evidence supporting the claim of personal assault. Sources other than service records can corroborate a veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals 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.