Citation Nr: 21021417 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 16-25 144 DATE: April 12, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depressive disorder due to military sexual trauma (MST), is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1984 to April 1990. The Veteran asserted that she experienced MST during her active service. She reported that she was raped during her active service. She reported that afterwards she experienced depression and anxiety. She reported that she also began to abuse alcohol. The Veteran’s service treatment records (STRs) from her entrance physical indicate that she attended group counseling at a juvenile detention center prior to service. In addition, she had prior marijuana use and other drug abuse. During her active service, she underwent an HIV test in July 1988 and pregnancy tests in May 1987 and September 1989. In October 1988, she was referred to the base Counseling and Addiction Center (CAAC) in October 1988 for alcoholism and compulsive overeating. Records from CAAV indicate, “There were incidents of abuse disclosed during the course of the interview which may have imposed undue behavioral and emotional difficulties during adolescence and adulthood.” After her separation from active service, the Veteran’s medical records show that in January 2011, she reported a history of MST and sexual trauma as a child. In August 2011, she reported that she was raped while in service. She was diagnosed with PTSD and depressive disorder. In May 2014, the Veteran was afforded a VA examination. The examiner found there was no evidence nor markers to confirm and verify the occurrence of the MST during active service. If a PTSD claim is based on in-service personal assault, evidence from sources other than the veteran’s service records may corroborate the 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. VA will not deny a PTSD claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the veteran’s service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. 38 C.F.R. § 3.304 (f)(5). Accordingly, the Board finds that a new opinion regarding the Veteran’s acquired psychiatric disorder is required in order to adjudicate the claim. Specifically, a new VA examination that addresses whether the Veteran had a preexisting acquired psychiatric disorder prior to her active service and opine as to the etiology of any acquired psychiatric disorder. The matter is REMANDED for the following actions: 1. Obtain all outstanding VA and private medical records that pertains to the Veteran’s acquired psychiatric disorder. 2. Schedule the Veteran for a VA examination by a VA psychiatrist or psychologist to determine the nature and likely etiology of any acquired psychiatric disorder. The examiner should provide opinions responding to the following: a. What is (are) the diagnosis(es) for the Veteran’s current acquired psychiatric disorder(s), if any? b. For each acquired psychiatric disability diagnosed, please offer the following opinions: 1) Is it at least as likely as not (50 percent or greater) that any current acquired psychiatric disorder clearly and unmistakably existed prior to the Veteran’s active service? Why or why not? The examiner should discuss the Veteran’s entrance physical noting group counseling and drug abuse prior to her active service and post-service medical records suggesting childhood trauma. 2) If an acquired psychiatric disorder did clearly and unmistakably exist prior to active service, provide an opinion as to whether the preexisting acquired psychiatric disorder clearly and unmistakably (obviously, manifestly, and undebatable) was not aggravated (meaning the underlying disability increased in severity beyond the natural progression of the disability) during her active duty service. Why or why not? 3) If an acquired psychiatric disorder did not clearly and unmistakably exist prior to active duty service, provide an opinion whether it is as least as likely as not (50 percent probability or greater) that any diagnosed acquired psychiatric disorder either began during or was otherwise caused by her active service? Why or why not? The examiner should address the multiple psychiatric diagnoses in the claims file (PTSD and depressive disorder), the findings of the previous May 2014 VA examiner, and the multiple lay statements regarding her experienced MST. Timothy Berryman Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.M. Edwards, 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.