Citation Nr: 21061575 Decision Date: 10/04/21 Archive Date: 10/04/21 DOCKET NO. 16-40 154 DATE: October 4, 2021 REMANDED Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD) and depression, is remanded. REASONS FOR REMAND The Veteran had active naval service from February 1978 to April 1982. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2014 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). In July 2021, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The Board finds that additional development is required before the claim on appeal is decided. The Veteran maintains that her current psychiatric disability is related to two events that occurred during service. The first series of incidents involved a senior officer coercing and trading sex for privileges while the Veteran was under certain restrictions. The second incident involved a boyfriend beating her up and raping her during the summer of 1980. A review of the record indicates that the Veteran was not provided with the notice regarding alternative sources of evidence that may constitute credible supporting evidence of a stressor involving personal assault. See 38 C.F.R. § 3.304(f)(5) (2020). Therefore, the Board finds that a remand is necessary so that notice can be provided. In a March 2015 letter, a social worker (K.H.) at a Vet Center indicated that the Veteran had been diagnosed with PTSD resulting from military sexual trauma. Although the social worker submitted a November 2014 intake assessment, no further treatment records from the Vet Center have been obtained. Therefore, a remand is necessary so those records can be secured. The Board notes that the Veteran's private treatment records show a past medical history of attention deficit disorder, depressive disorder, and generalized anxiety disorder, but no diagnosis of PTSD or mention of any in-service stressors. Based on the foregoing, the Board finds that a remand is necessary so that the Veteran can be afforded a VA examination to determine the nature and etiology of her claimed psychiatric disability. The matters are REMANDED for the following action: 1. Provide the Veteran a notice letter in connection with her claim for service connection for PTSD based on in-service personal assault. The letter should (1) inform her of the information and evidence that is necessary to substantiate the PTSD claim based on personal assault; (2) inform her about the information and evidence that VA will seek to provide; and (3) inform her about the information and evidence that she is expected to provide. Specifically, 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 her account of an in-service assault and that behavioral changes may constitute credible supporting evidence of the stressor. She should thereafter be provided the opportunity to furnish this type of evidence and/or to advise VA of potential sources of such evidence. 2. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file, to include records from the Vet Center in Greenville, South Carolina, and the Vet Center Outstation in Rutherford, North Carolina. 3. Then, schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of any psychiatric disorder that may be present. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed. After examining the Veteran, and considering the pertinent medical history and lay statements regarding reported symptoms, the examiner should identify all psychiatric disorders that are present. For each diagnosis identified, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or better) that the disability manifested during active service or is otherwise causally or etiologically related to her active service, to include any in-service personal assault. If a PTSD diagnosis is deemed appropriate, the examiner should then provide an opinion as to whether it is at least as likely as not (50 percent probability or better) the Veteran exhibited any behavioral changes during service that are reflective of the occurrence of an in-service physical assault. 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. With respect to PTSD, if the VA examiner believes that behavioral changes are reflective of the occurrence of an in-service physical assault, the VA examiner should opine whether it is at least as likely as not (50 percent probability or better) that any current PTSD symptomatology is attributable to the occurrence of an in-service physical assault. A rationale for all opinions expressed must be provided. 5. Confirm that the VA examination report and all opinions provided comport with this remand and undertake any other development found to be warranted. 6. Then, readjudicate the issue on appeal. If a decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Mishalanie, 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.