Citation Nr: 21009209 Decision Date: 02/19/21 Archive Date: 02/19/21 DOCKET NO. 16-61 738 DATE: February 19, 2021 REMANDED Entitlement to service connection for a variously diagnosed psychiatric disability, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from November 1982 to November 1986. This matter is before the Board on appeal from an April 2015 Department of Veterans Affairs (VA) rating decision. In October 2020, a videoconference hearing was held before the undersigned; a transcript is in the record. At the hearing the Veteran requested, and was granted, a 90 day abeyance period for the submission of additional evidence; such evidence was received. Entitlement to service connection for a variously diagnosed psychiatric disability is remanded. The Veteran alleges he has PTSD related to a specific alleged stressor event. He has consistently reported a personal assault by a lieutenant commander, between March and June 1983, after his completion of corpsman school. He contends that he was at the top of his class but, after he declined the lieutenant commander’s sexual advances, he was put on front gate guard duty in retaliation. He testified that after two months he realized what had happened and requested a transfer. Service connection for PTSD has been denied in part based on a lack of credible corroborating evidence of a stressor event in service. When, as here, a PTSD claim is based on an alleged stressor of MST in service, evidence from alternate (other than the Veteran’s service records) sources may serve to corroborate the Veteran’s account of the alleged stressor incident. 38 C.F.R. § 3.304(f)(5). Examples of such evidence include: evidence of behavior changes following the claimed assault, such as a request for 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. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion whether it indicates that a personal assault occurred. Id. The Veteran’s account of military sexual trauma (MST), which appears to be the basis for the diagnoses noted in VA treatment records, was first reported in the compensation-seeking process and would not of itself suffice to constitute credible corroborating evidence of a stressor event in service. He has submitted a statement from his sister, who states that their mother often talked of his time in the Navy, and shared many of his experiences, including “an incident of quid pro quo from [his] superior officer”. He also submitted statements from two friends who stated that, in 1983, he told them about an incident involving a superior officer who made sexual advances toward him and, when he refused, he was treated unfairly in retaliation. The nonspecific nature of the descriptions of the claimed “sexual assault” raises a medical question regarding sufficiency of the alleged stressor event to support a diagnosis of PTSD. The evidence of record is also equivocal as to whether the Veteran’s symptoms support a diagnosis of PTSD. He has not yet been afforded a VA examination to determine whether a diagnosis of PTSD would be warranted if a sufficient stressor event in service is found to be credibly corroborated. Accordingly, a remand for corrective action is necessary. The matter is REMANDED for the following action: 1. Review all of the Veteran’s and supporting lay statements and testimony in the record and make findings of fact for the record regarding to what extent, if any, the Veteran’s accounts of a “personal assault” stressor event is corroborated by credible supporting evidence. The rationale for the conclusions reached should be explained in detail. 2. Then arrange for the Veteran to be examined by an appropriate psychiatrist or psychologist to determine the nature and etiology of his claimed psychiatric disability(ies). The Veteran’s claims file (specifically including this remand and the AOJ finding regarding what, if any, alleged stressor event is corroborated by credible supporting evidence) must be reviewed by the examiner in conjunction with the examination. On review of the record and interview/examination of the Veteran, the examiner should provide opinions that respond to the following: (a.) Identify (by diagnosis) each psychiatric disability found. Specifically, does the Veteran have a diagnosis of PTSD based on the alleged MST trauma in accordance with DSM-5 criteria? The rationale for the opinion should include: (i) Independently of the AOJ’s findings of what alleged stressor event is found to be corroborated by credible supporting evidence, are the Veteran’s allegations such as being assigned to guard duty after being near the top of the class in corpsman school, the type of behaviour changes that support that an alleged MST trauma had occurred? (ii) Sufficiency of the alleged stressor (if accepted as credible) to support a diagnosis of PTSD? (iii) Sufficiency of symptoms to support a diagnosis of PTSD in accordance with DSM-5? (b.) If a psychiatric disability other than PTSD is diagnosed (and anxiety, depression, and insomnia have been reported), regarding each such psychiatric disability entity, is it at least as likely as not (a 50% or better probability) that the diagnosed psychiatric disability is etiologically related to the Veteran’s service/events therein? If not, identify the etiology for the disability that is considered to be more likely (and explain why that is so). All opinions must include rationale that cites to supporting clinical and other factual data and medical principles, addresses any credibility issues raised, and addresses (explains the reasoning for disagreement with) any conflicting medical evidence in the record (see Veteran’s hearing testimony regarding been seen at VA and found to have psychiatric a psychiatric disability related to his service/events therein). GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Schechner, 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.