Citation Nr: 21040227 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 16-26 709 DATE: July 2, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder to include post-traumatic stress disorder (PTSD) and adjustment disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1993 to July 1996, and from October 1998 to May 2003. This appeal comes to the Board of Veterans' Appeals (Board) from a January 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In December 2018 and December 2020, the Board remanded the case to the AOJ for additional development. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and adjustment disorder, is remanded. Although the Board regrets the additional delay, further development is needed prior to adjudication of the Veteran's claim. In that regard, in December 2020, the Board remanded this claim to obtain a medical opinion that addressed whether the Veteran had a currently diagnosed psychiatric disorder and whether any such disorder was caused by her military service, to include her described military sexual trauma (MST). The examiner was asked to explicitly discuss the Veteran's description of in-service assaults and the evidence of MST markers in her personnel file, to include poor performance reviews and being transferred to another unit. Pursuant to the Board's remand directive, a records review was conducted by a psychologist in March 2021. Regarding a current diagnosis, the psychologist concluded that the Veteran did not have PTSD, noting that a substantiated MST is not, on its own, sufficient for a PTSD diagnosis. Regarding adjustment disorder, which was diagnosed by an August 2019 VA examiner, the psychologist concluded the disorder was related to a specific stressor (marital discord) and was in full remission. However, the psychologist did not reconcile that conclusion with the Veteran's ongoing psychiatric symptoms that appear to post-date a marital discord stressor, to include her description, during treatment in 2015 and 2017, of exacerbation of symptoms when working with veterans. Regarding the Veteran's reported stressors, the psychologist who conducted the March 2021 records review concluded that an October 2001 personnel action documented in the Veteran's service personnel records was not a sufficient marker for a 1994 MST the Veteran reported in her stressor statement. However, the Veteran reported a second stressor that occurred close in time to the October 2001 disciplinary action. See October 2014 VA 21-0781a. In April 2021, the Veteran submitted correspondence further clarifying that the encounter with her sergeant, described in the October 2014 submission, occurred in 2001. Based on the foregoing, an opinion that reconciles the Veteran's described symptoms with a finding that she has no psychiatric diagnosis and that addresses the stressor that occurred in 2001 is needed. The matter is REMANDED for the following action: Send the claims file to a licensed mental health clinician specializing in MST and/or sexual trauma. The examiner is to be provided with a copy of the Veteran's claims file, as well as a copy of these remand directives. If an additional examination is deemed necessary to respond to the questions posed, one should be scheduled. Following review of the claims file, the clinician is asked to respond to the following: 1. Please identify all current psychiatric disorders. In doing so, please specifically discuss the psychiatric diagnoses of record, including but not limited to PTSD and adjustment disorder. In addition, please specifically discuss the Veteran's reports, during treatment in February 2015 and June 2017, of exacerbation of psychiatric symptoms when working with veterans. 2. For each psychiatric disorder diagnosed, is it at least as likely as not (50 percent probability or greater) that the condition is caused by, or due to, the Veteran's military service? Please explain why or why not, specifically considering and discussing the Veteran's reported in-service assaults (see October 2014 VA 21-0781a and April 2021 correspondence) and the evidence of MST markers in her personnel file (see October 2001 NCO Evaluation Report and subsequent personnel records showing a change in station thereafter). Please note that the Veteran is competent to report symptoms, treatment, and injuries, and that her reports must be taken into account in formulating the requested opinion. A complete rationale for the opinions rendered must be provided. If you cannot provide the requested opinions without resorting to speculation, please expressly indicate this and provide a supporting rationale as to why that is so. L. STEPANICK Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Billinger, 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.