Citation Nr: 22012183 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 17-13 404 DATE: March 2, 2022 REMANDED Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD), anxiety, depression, bipolar disorder, and personality disorder, is remanded. REASONS FOR REMAND The Veteran had active service in the U.S. Marine Corps from March 1981 to July 1983. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2016 rating decision issued by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). In February 2016, the Veteran was notified that an attempt was made to locate his service treatment records (STRs), but they could not be found. The AOJ indicated that all efforts to obtain the information had been exhausted and that further attempts to obtain the records would be unsuccessful. When service treatment records are unavailable through no fault of a veteran, there is a heightened obligation on the part of VA to assist the claimant in the development of his case, explain findings and conclusions, and to carefully consider the benefit of the doubt rule. Washington v. Nicholson, 19 Vet. App. 362, 369-70 (2005); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board's analysis of the Veteran's claim is undertaken with these heightened duties in mind. 1. Entitlement to service connection for a psychiatric disorder is remanded. The Veteran is seeking entitlement to service connection for PTSD and has not yet been afforded a VA medical examination. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159(c)(4). An examination or opinion is necessary if the evidence of record (1) contains competent evidence that the claimant has a current disability or persistent or recurrent symptoms of a disability; (2) establishes that the claimant suffered an event, injury, or disease in service, or has a presumptive disease or symptoms of such a disease manifesting during an applicable presumptive period; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service, or with another service-connected disability; but (4) does not contain sufficient competent medical evidence to decide the claim. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006) (discussing the four elements to consider in determining whether a VA medical examination must be provided). In a January 2015 stressor statement, the Veteran reported two incidents during service where he was physically assaulted. The first reported incident occurred in January 1981 when he was walking with two sergeants. The Veteran reported that he was ordered to follow them down a path away from the platoon, and once they were at the end of the path, the sergeants punched, stomped, and kicked him to the ground. The Veteran elaborated that the altercation went on for several minutes. The second reported incident occurred in January 1982 when the Veteran was reportedly struck on the back of the head with a wooden stick by a platoon gunnery sergeant because he was falling behind. The Veteran reported that his vision was blurred, and he had a lump on the back of his skull. The Veteran further reported that he had migraines for several months afterward and throughout the time of his service. In addition to the Veteran's reports, treating records include a diagnosis of PTSD under the DSM-V in February 2016. These records also document reports by the Veteran that he experienced psychological and physical abuse from superiors during service. Treating records also document diagnoses of anxiety, depression, bipolar disorder, and personality disorder in addition to PTSD. Accordingly, the Board finds that it is appropriate to recharacterize the Veteran's claim as entitlement to service connection for a psychiatric disorder, to include PTSD, anxiety, depression, bipolar disorder, and personality disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). As the Veteran is competent to report the onset and continuity of his symptoms and given that the Veteran has current diagnoses for PTSD, anxiety, depression, bipolar disorder, and personality disorder, a VA examination is warranted to determine the nature, onset, and etiology of these conditions. See Layno, 6 Vet. App. at 470; see also Jandreau, 492 F.3d at 1377, see also McLendon v. Nicholson, 20 Vet. App. 79, 81-22 (2006). The matters are REMANDED for the following action: 1. Obtain and associate with the Veteran's claims file any outstanding VA treatment records. 2. Schedule the Veteran for a VA examination to determine the nature, onset, and etiology of his psychiatric disability. The Veteran is competent to attest to observable events and symptomatology and such reports must be acknowledged and considered in formulating any opinions. If the Veteran's reports are discounted, the examiner should provide a reason for doing so. The examiner should provide an opinion as to the following: (a) The examiner is asked to indicate whether the Veteran has a current diagnosis for PTSD in accordance with the DSM-5 and explain why or why not. * In reaching a conclusion, the examiner must address the PTSD diagnosis made under the DSM-V in February 2016. (b) The examiner is also asked to identify any other psychological diagnoses supported by the record, to include depression, anxiety, bipolar disorder, and personality disorder. (c) The examiner is then asked to provide an opinion on the following: (i) Whether it is at least as likely as not (a 50 percent or greater probability) that a verified stressor supports a diagnosis of PTSD and explain why or why not. (ii) Whether it is at least as likely as not (a 50 percent or greater probability) that any psychiatric diagnosis identified is related to, or had its onset during, the Veteran's active service and explain why or why not. 3. After ensuring that the opinions comply with the terms of this remand, the AOJ should re-adjudicate the claim. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Beech, 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.