Citation Nr: 21021507 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 12-19 892 DATE: April 13, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), anxiety, major depressive disorder (MDD) with psychotic disorder, borderline personality disorder, and alcohol use disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1995 to May 1999 and June 2001 to November 2001. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a May 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The matter was remanded in December 2014 and June 2019 for additional development. In the June 2019 remand, the Board expanded the Veteran’s claim for service connection to include her diagnoses of borderline personality disorder and alcohol use disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, anxiety, MDD with psychotic disorder, borderline personality disorder, and alcohol use disorder. The Board notes the Veteran has two periods of active service. Additional development is needed to clarify several issues, particularly the onset of the Veteran’s psychiatric disorders in light of her two separate periods of active service. The Veteran contends that service connection is warranted for a psychiatric disorder due to military sexual trauma (MST) while on active duty in Naples, Italy. If a PTSD claim is based on in-service personal assault, evidence from sources other than a veteran’s service records may corroborate the veteran’s account of the stressor incident. 38 C.F.R. § 3.304(f)(5). 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. Id. The Veteran contends the MST occurred in July 1997 during her first period of active service, in which she served honorably. The Veteran submitted a July 2010 statement that she went to the hospital after the sexual assault occurred, reporting that she suffered from severe itching for several days. The record contains an undated gynecology exam taken in Naples, Italy that found scabs in the Veteran’s pubic hair and what appeared to be infected hair follicles in the genital area. The Veteran was administratively discharged after her second period of active service for a failure to disclose her mental health history during her reenlistment intake medical screening. See personnel records. She is currently diagnosed with PTSD, MDD, borderline personality disorder, anxiety, and alcohol use disorder. See July 2014 and August 2016 VA treatment records. Per the June 2019 Board remand, a medical opinion was sought to determine the etiology of the Veteran’s acquired psychiatric disorders, including causation and whether the acquired psychiatric disorders preexisted the Veteran’s service in May 1995 or June 2001. In January 2020, a VA examiner opined that all the Veteran’s acquired psychiatric disabilities, including PTSD, anxiety, MDD with psychotic disorder, borderline personality disorder and alcohol use disorder, clearly and unmistakably existed prior to entrance into service in May 1995 or June 2001. She reasoned that borderline personality disorder is a condition which starts in childhood and is frequently associated with childhood sexual abuse. The VA examiner noted the Veteran has had PTSD stressors starting at the age of five, and that her borderline personality disorder contributed to her pre-service depression, pre-service PTSD, pre-service suicide attempts, and pre-service anxiety. See January 2020 VA examination. The January 2020 VA opinion is inadequate for multiple reasons. Indeed, because the Veteran’s active service includes two different periods, each period of service must be addressed separately. However, the examiner in the opinion stated that the disability pre-existed the entry into service in 1995 or 2001. It is unclear whether the examiner concluded it pre-existed both periods of active service or just one. It is noteworthy to state that the examiner used the term “or” rather than “and.” Moreover, the examiner did not provide an opinion as to whether the disability clearly and unmistakably was not aggravated by service. Rather, the examiner recited a number of facts, none of which included the evidence noted above provided by the Veteran which could be considered proof of an MST in service. Thus, a remand is necessary for addendum opinions so the Board can proceed with adjudication of the issue. Moreover, corroboration of the Veteran’s contentions of MST and the medical evidence of record is unclear at this time. In a December 2013 VA examination, the examiner opined that the Veteran’s preexisting MDD was exacerbated by PTSD from her alleged MST. See December 2013 VA examination. However, the December 2013 VA examiner later submitted addendum opinions in December 2013 and January 2014 expressing that he was unable to identify specific aspects that correlated to diagnoses of PTSD and MST. He noted that his medical opinion was based on the Veteran’s report of symptoms and alleged history in service yet found there was no specific behavioral pattern which could predict specifically the diagnoses of PTSD and MST. See December 2013 addendum opinion. The VA examiner concluded that overall, he could not substantiate diagnoses of PTSD and MST despite his earlier findings. See January 2014 addendum opinion. Thus, the record is unclear as to whether the December 2013 VA examiner considered the Veteran’s gynecology exam that was taken in Naples, Italy. As this evidence may corroborate the Veteran’s account of the MST, it should be addressed upon remand. The matter is REMANDED for the following action: 1. The AOJ should arrange for addendum medical opinions, with an examiner other than the one who provided the January 2020 VA opinion, that addresses the following: (a) Did the Veteran’s psychiatric disabilities, including PTSD, anxiety, MDD with psychotic disorder, borderline personality disorder, and alcohol use disorder clearly and unmistakably preexist the Veteran’s first period of active service of May 1995 to May 1999? (b) If it is found that the psychiatric disabilities did not preexist the Veteran’s first period of active service, is it at least as likely as not (50 percent or greater probability) that the Veteran’s psychiatric disabilities were incurred during this first period of active service due to MST? (c) If the examiner finds that it is less likely than not the Veteran’s psychiatric disabilities were incurred during the first period of active service and did preexist the first period of active service (May 1995 to May 1999), were the Veteran’s psychiatric disabilities clearly and unmistakably not aggravated during the first period of active service? (d) Did the Veteran’s psychiatric disabilities clearly and unmistakably preexist the Veteran’s second period of active service of June 2001 to November 2001? If so, were the Veteran’s psychiatric disabilities clearly and unmistakably not aggravated during the second period of active service? The examiner must address each period of active service individually, with full and detailed rationale for each opinion rendered. The examiner should review the Veteran’s medical history, service treatment records, and post-service VA and private treatment records. Additionally, the examiner must specifically address the Veteran’s lay statements regarding MST during service and the undated gynecology exam that was performed in Naples, Italy. (Continued on next page) 2. If upon completion of the above action the appeal remains denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Marcus K. Jones, 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.