Citation Nr: 21062396 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 14-41 265A DATE: October 7, 2021 REMANDED Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REASONS FOR REMAND The Veteran served on active duty from October 1979 to April 1980 and from March 1981 to March 1985. She had additional Reserve service. Although the Veteran was scheduled for a virtual hearing before a Veterans Law Judge in August 2021 and was properly informed of the hearing, she failed to appear without explanation and has not requested that the hearing be rescheduled. As such, the hearing request is considered withdrawn. The Veteran contends that service connection is warranted for PTSD because it is due to an in-service personal assault. Specifically, she has claimed that she was gang raped during service in 1980. The record contains conflicting evidence regarding whether the Veteran has a diagnosis of PTSD. Notably, a June 2013 VA examination report and the VA treatment records reflect that she did not meet the criteria for a diagnosis of PTSD. On the other hand, an August 2016 private psychological assessment authored by Dr. D. reflects a diagnosis of PTSD. However, Dr. D. did not provide any details regarding whether the PTSD diagnosis meets the DSM-V criteria and there are no private treatment records from Dr. D. in the record. As such, a remand is required to obtain the Veteran's treatment records from Dr. D. In addition, there is conflicting evidence regarding a nexus. The June 2013 VA examiner noted that the Veteran's currently diagnosed psychiatric disorder (mood disorder/bipolar) was not the result of service and was more likely the result of what presented as an abusive and chaotic childhood as described by the Veteran (she reported being physically abused by her mother and sexually abused as a child). The VA examiner acknowledged that a January 1980 service treatment record (STR) stated that the Veteran was seen by a psychiatrist for reportedly experiencing distress and anxiety because she did not have adequate privacy, but indicated that there was no notation in the STR that the Veteran may have victimized by any personal assault. The examiner also felt that there were inconsistencies in the Veteran's report of her stressor. Namely, the examiner felt that the stressor statement (that in 1980, she was gang raped by male soldiers in a cubicle during AIT) was an improbable situation because it would have been during a training when the event would have occurred in full public view. The examiner also noted that there were discrepancies as far as the reported date of the stressor (1979 versus 1980) and the reported location of the stressor (barracks versus cubicle at AIT). Based on these discrepancies, review of the record, and the diagnosis of borderline personality disorder, the examiner felt that the claimed inservice stressor had not occurred and it was either being fantasized or fabricated. A review of the STRs reflects that the January 1980 STR indicated the Veteran displayed neat appearance, fair eye contact and full orientation. She was mildly depressed and cried some during the interview. Her affect was appropriate to mood. She had abnormal thought content, vague suicidal ideation, and fair insight and judgment. The diagnosis was adjustment reaction. In addition, the STRs include a February 1980 entry which reflected that the Veteran had a gynecological examination for complaints of small bumps, discharge, and itching. The diagnosis was vaginitis. There are numerous subsequent STRs noting gynecological complaints, including a suspected STD. Moreover, the service personnel records document a request for reassignment/discharge and some difficulty getting along with others/conforming to military standards. As such, the examiner rendered an opinion without addressing all of the relevant service records. Under the circumstances, the Board finds that a remand for an addendum VA medical opinion which addresses these additional service records is necessary. The matter is REMANDED for the following actions: 1. Contact the Veteran and request that she complete and return a VA Form 21-4142, Authorization and Consent to Release Information, for the private psychological treatment records from Dr. D. 2. If the Veteran completes and returns the VA Form 21-4142, Authorization and Consent to Release Information, contact the appropriate medical care provider and request copies for association with the electronic claims file of any and all records of treatment that she received from the medical care provider. 3. Any documents received by VA pursuant to the request for private treatment records should be associated with the record. At least two requests for the private records should be made, unless it is made evident by the first request that a second request would be futile in obtaining such records. 4. Any negative responses should be properly documented in the record. Notify the Veteran and the representative if the private treatment records are unavailable. 5. Thereafter, direct the claims file to an clinician to obtain an addendum medical opinion regarding the etiology of the Veteran's current psychiatric disorder(s). The clinician is asked to review the claims file, to specifically include all STRs, service personnel records, and the newly-obtained private treatment records. The examiner should provide an opinion as to the following: whether it is at least as likely as not (i.e., 50 percent or greater probability) that the Veteran's currently-diagnosed psychiatric disorder(s) is/are causally or etiologically related to service, to include the claimed inservice stressor being gang raped during her first period of service. The examiner must specifically address the psychiatric findings (including the abnormal thought content, suicidal ideation and) found in the January 1980 STR as well as the subsequent STRs showing gynecological complaints, in terms of whether they support the Veteran's claimed stressor. If the clinician cannot provide the requested opinion without an examination, one should be scheduled. L. HOWELL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Redman, 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.