Citation Nr: 23058167 Decision Date: 10/26/23 Archive Date: 10/26/23 DOCKET NO. 20-12 034 DATE: October 26, 2023 REMANDED Service connection for posttraumatic stress disorder (PTSD). REASONS FOR REMAND The Veteran served on active duty from March to July 1983 and January 1984 to October 1988. The Veteran contends that service connection is warranted for PTSD based on an in-service assault during a training exercise in November or December 1984, and that his daughter was sexually assaulted in December 1987 by an officer that lived in the same building. Of note, he is already service connected for a major depressive disorder associated with a low back disability. The record contains conflicting evidence regarding whether the Veteran has a diagnosis of PTSD. Notably, a December 2016 VA examination report reflected that he did not meet the criteria for a diagnosis of PTSD. On the other hand, a June 2020 private treatment summary authored by Dr. L.J. reflects a DSM-5 diagnosis of PTSD. However, there are no private treatment records from Dr. L.J. in the record. As such, a remand is required to obtain the Veteran's treatment records from Dr. L.J. In addition, there is conflicting evidence regarding a nexus. In December 2016, the VA examiner found the Veteran did not have a confirmed diagnosis of PTSD. An etiology opinion as to the nature of the claimed PTSD disorder was not rendered at this time. Accordingly, the December 2016 VA examination report is incomplete to decide the claim. Accordingly, another medical opinion is needed to assess the nature and etiology of the claimed PTSD. The matter is REMANDED for the following actions: 1. Contact the Veteran and request that he complete and return a VA Form 21-4142, Authorization and Consent to Release Information, for the private psychological treatment records from Dr. L.J. 2. If the Veteran completes and returns the VA Form 21-4142, Authorization and Consent to Release Information, contact the appropriate medical care provider and request copies for association with the electronic claims file of any and all records of treatment that he received from the medical care provider. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. Any documents received by VA pursuant to the request for private treatment records should be associated with the record. At least two requests for the private records should be made, unless it is made evident by the first request that a second request would be futile in obtaining such records. Any negative responses should be properly documented in the record. Notify the Veteran and the representative if the private treatment records are unavailable. 3. Direct the claims file to a clinician to address the etiology of the Veteran's mental health complaints, with a focus on PTSD. The clinician is asked to address the following: " Does the evidence support a diagnosis of PTSD under DSM 5? " What stressors form the basis of the diagnosis of PTSD? " Is there a causal relationship between the current diagnosis and claimed in-service stressors, including whether the claim of a personal assault during a training exercise in November 1984 and a sexual assault on a family member in December 1987 are sufficient to support a diagnosis of PTSD. 4. The clinician is asked to address the November 1984 STR showing multiple contusions after a claimed assault during POW training and the request for a hardship separation in July/August 1988, in terms of whether they support the Veteran's claimed stressor. ? 5. If the clinician determines that an examination is necessary in order to provide the requested opinions, then one should be scheduled. L. HOWELL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Oettle, T. 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.