Citation Nr: 21006604 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 17-23 280 DATE: February 4, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1966 to October 1966. This matter comes to the Board of Veterans’ Appeals (Board) from a July 2015 rating decision that denied entitlement to service connection for PTSD. In March 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. Given diagnoses of depression and anxiety in the record, the Board has broadened the Veteran’s PTSD claim as a claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Entitlement to service connection for an acquired psychiatric disability, to included PTSD, is remanded. The Board finds that remand is required because the claims file does not indicate that the Veteran was provided with the special notice requirements for cases involving personal assault. A PTSD claim based on in-service personal assault may not be denied without first advising the veteran that evidence from sources other than the veteran’s service records or evidence of behavioral changes may constitute credible supporting evidence of the stressor incident and allowing the veteran the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. See 38 C.F.R. § 3.304(f)(5). While a VA Form 27-0820 indicates that a personal assault call was completed, it is not clear from this form that the Veteran was advised of the evidence that could be submitted for his claim, and there is no other notice in the claims file informing the Veteran of such evidence. The Board further finds that the August 2016 VA examination is inadequate. A VA examiner must address all relevant evidence. See Falzone v. Brown, 8 Vet. App. 398, 404 (1995). While the August 2016 VA examiner considered three potential markers of the claimed in-service stressor, the examiner did not consider a February 9, 1966, service treatment record noting, in part, complaints of a history “of 4+ anxiety” and generalized abdominal pain. The Veteran has estimated that the personal assault occurred within two to three weeks of entry to service, and the Board notes that this service treatment record is not too far outside this estimate and, as a result, should be considered as a potential marker of the claimed in-service stressor. The Board notes that an August 24, 1966, service record identified a personality disorder and the August 2016 VA examiner declined to provide an opinion on such a diagnosis unless requested. On remand, the examiner should opine whether the Veteran has a personality disorder and whether the Veteran’s PTSD is at least as likely as not superimposed on a personality disorder during active service and resulted in additional disability. The Board notes that, on remand, the AOJ should update the Veteran’s VA treatment records because the most recent record is from February 2017. The matter is REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records for the period from February 2017 to the present. 2. Send the Veteran the notice required for PTSD claims based on an in-service personal assault and allow time for a response. Then, attempt to corroborate the Veteran’s in-service stressor based on personal assault. If more details are needed, contact the Veteran to request the information. 3. After the Veteran’s reported stressors have been developed, schedule the Veteran for a psychiatric examination to determine the nature and etiology of any psychiatric disabilities, to include PTSD. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. The examiner must opine whether the evidence of record, including the Veteran’s lay statements and the Veteran’s service records, corroborate the claim that a personal assault occurred in service (38 C.F.R. § 3.304(f)(5)). If the examiner finds that evidence indicates that a personal assault occurred during the Veteran’s active service, the examiner must opine whether any PTSD is at least as likely as not related to the in-service personal assault. The examiner should consider the potential markers identified in the August 2016 VA examination and the potential marker of the February 9, 1966, service treatment record and explain whether these potential markers are sufficient to support an allegation of personal assault. If a personality disorder is diagnosed, the examiner must opine whether the Veteran’s PTSD is at least as likely as not superimposed on a personality disorder during active service and resulted in additional disability. If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Craig Ormson, Associate 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.