Citation Nr: 22018254 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 17-00 868 DATE: March 28, 2022 REMANDED Entitlement to service connection for an acquired psychiatric disorder, claimed as posttraumatic stress disorder (PTSD) is remanded. INTRODUCTION The Veteran served on active duty from April 1972 to January 1978. In October 2021, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge at the RO. A transcript of that hearing is of record. REASONS FOR REMAND While further delay of this matter is unfortunate, the Board finds additional development is required before the claim on appeal is decided. Initially, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted above, the Veteran seeks service connection for PTSD. He asserts his disability was the result of an in-service military sexual trauma (MST). His service treatment records demonstrate neither treatment for or a diagnosis of an acquired psychiatric disorder, nor reports of a sexual assault. However, pursuant to 38 C.F.R. § 3.304 (f)(5), 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 lay statements, evidence of behavior changes following the claimed assault, or requests for a transfer to another military duty assignment. By way of an April 2016 VA examination request, the RO acknowledged several potential "markers" which may corroborate the Veteran's reported assault. The Veteran underwent a VA examination in May 2016. At that time, he was diagnosed with PTSD, which is consistent with diagnoses provided by both the Veteran's private clinician and treating psychiatrist at the Portland VAMC. The May 2016 VA examiner acknowledged the Veteran's reports of childhood sexual abuse. Though the examiner indicated the Veteran's childhood sexual abuse and his military sexual assault stressors contributed in some degree to his current PTSD, he failed to provide a medical opinion on the matter. The Board also acknowledges August 2015 and March 2016 letters from the Veteran's treating clinician. In the March 2016 letter, his private clinician intimates the Veteran's PTSD is consequentially related to his military service, but he did not provide a rationale for this conclusion or discuss the Veteran's childhood traumas. For these reasons, the Board finds a remand is required in order to obtain a comprehensive examination and medical opinions addressing the Veteran's complex history. Accordingly, these matters are REMANDED for the following actions: The Veteran should be afforded an examination by a VA Psychiatrist or Psychologist to determine the etiology of all acquired psychiatric disorders present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated studies should be performed. Based on the review of the Veteran's pertinent history and the examination results, the examiner should identify all acquired psychiatric disorders that have been present during the period of the claim. A diagnosis of PTSD should be confirmed or ruled out. If the examiner determines PTSD has not been present during the period of the claim, the examiner should explain why a diagnosis of PTSD is not warranted. In this regard, the examiner should fully discuss all relevant evidence. If PTSD is diagnosed the examiner should identify the elements supporting the diagnosis. Additionally, if the examiner finds a diagnosis of PTSD is warranted, the examiner should provide a detailed rationale, which explains the stressor deemed sufficient to support this diagnosis, as well as the specific evidence the examiner found persuasive in corroborating the existence of that stressor. The examiner should fully discuss and consider the Veteran's reports of experiencing an MST in service, as well as the potential markers noted by the RO in the April 2016 examination request. With respect to each acquired psychiatric disorder, other than PTSD, that has been present during the period of the claim, the examiner should state an opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that such disorder originated in service or is otherwise etiologically related to service. A complete rationale must be provided for all opinions given. If the examiner is unable to provide any required opinion, he/she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner must provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Fraser, 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.