Citation Nr: 21026967 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 17-44 215 DATE: May 4, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include depression, anxiety, and posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from July 1984 to August 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2014 rating decision by the Waco, Texas, Regional Office (RO) of the Department of Veterans Affairs (VA). In May 2020, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge. The transcript of that hearing is of record. In Clemons v. Shinseki, 23 Vet. App. 1 (2009), the United States Court of Appeals for Veterans Claims (hereinafter "the Court") held that an initial claim of entitlement service connection for PTSD should also be read as including other psychiatric disorder diagnoses reasonably raised by the symptoms described and all information obtained in support of the claim. Therefore, the issue on appeal has been revised to include consideration of the other applicable diagnoses of record. 1. Entitlement to service connection for an acquired psychiatric disorder, to include depression, anxiety, and PTSD, is remanded. The Veteran contends that he has an acquired psychiatric disorder as a result of active service. He states that in July 1987 he was sexually assaulted and he began experiencing depression approximately six months after his discharge from active service. He describes having been raped by three sailors and having sustained a bruised neck and an injury to the jaw. He says his jaw was "hurt pretty bad" but was not fractured. Service treatment records (STRs) are negative for report of neck or jaw injuries. The STRs also show the Veteran denied having or having ever had frequent trouble sleeping, depression, excessive worry, or nervous trouble of any sort in June 1988. Service personnel records show he received awards including a meritorious mast in December 1987 and a conduct rating of 4.6 in January 1988. No offenses or punishments were reported. VA treatment records dated in October 2013 include an initial impression that the Veteran sustained a sexual assault in service. Based upon reported symptoms, the examiner concluded that the criteria for PTSD due to military sexual assault and major depressive disorder had been met. A September 2020 private medical report found the Veteran's PTSD and moderate major depression more likely than not are related to military service events. It was noted that the Veteran experienced trauma in service and was sexually assaulted by three men who also broke his jaw. The Veteran reported that he hid himself from his commanding officer and others for several days until he recovered from his injuries. He said he felt nervous and never went anywhere by himself. He stated that he experienced depression and issues sleeping, began drinking, and as his behavior changed began accruing disciplinary infractions. The history provided to the September 2020 examiner and at his personal hearing appear to be in conflict with the service treatment and personnel records. There is inconsistent evidence as to injuries the Veteran sustained in service and his behavior after July 1987, which was not addressed by the private examiner. Additional development is required for an adequate determination. VA regulations also provide that 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. See 38 C.F.R. § 3.304(f)(5). There is no indication the Veteran has been provided such notice. The matter is REMANDED for the following action: 1. Send the Veteran notice required for PTSD claims based on personal assaults, and allow time for a response. Then, attempt to corroborate the Veteran's in-service stressor. If more details are needed, contact the Veteran to request the information. 2. After the Veteran's reported stressors have been developed, schedule him for a psychiatric examination to determine the nature and etiology of any acquired psychiatric disorder. The examiner should addressing the following questions: a. Identify/diagnose any acquired psychiatric disorder that presently exists or that has existed during the appeal period. b. If a diagnosis of PTSD is not made, the examiner must identify the missing criteria. The examiner must also reconcile such a finding with the opinion provided by Q.A.S. in December 2020. c. If the Veteran is diagnosed with PTSD, the examiner must opine whether it is at least as likely as not related to a verified in-service stressor. d. If the Veteran's stressor is based on an in-service personal assault, the examiner must opine whether the evidence of record, including the Veteran's lay statements and service records, corroborate the claim that a personal assault occurred in service. e. 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. f. 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. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Douglas 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.