Citation Nr: 0204996 Decision Date: 05/23/02 Archive Date: 06/03/02 DOCKET NO. 97-17 528 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Sioux Falls, South Dakota THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD R. A. Seaman, Associate Counsel INTRODUCTION The veteran served on active duty from November 1975 to August 1979. This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 1996 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Sioux Falls, South Dakota, which denied the veteran's claim of service connection for PTSD. This case was previously before the Board in July 1998, at which time it was remanded for additional development. After readjudicating the veteran's claim service connection for PTSD, and with consideration given to the additional development, the RO issued an April 1999 determination which continued the previous denial of the veteran's claim. The claim is now before the Board for further appellate consideration. As a preliminary matter, the Board finds that the RO has complied with the directives of the July 1998 remand. See Wood v. Derwinski, 1 Vet. App. 190 (1991). Accordingly, and in light of the Board's decision herein, a new remand is not required to comply with the holding of Stegall v. West, 11 Vet. App. 268 (1998). In the July 1998 remand, the Board noted that, in a May 1998 informal brief, the veteran's representative set forth contentions pertinent to a claim of service connection for depression. The Board construed those statements as a request to reopen a previously denied claim for depression, and referred that issue to the RO so that appropriate action could be taken. In an April 1999 rating decision, the RO continued the previous denial of service connection for depression, holding that no new and material had been submitted to reopen said claim. The record reflects that the veteran has not disagreed with that decision. In this regard, the Board notes that a claimant's timely filed notice of disagreement (NOD) initiates an appeal of an adjudicative determination by the agency of original jurisdiction and expresses the desire to contest the result of such an adjudication. As the veteran has not addressed the issue of whether new and material evidence has been submitted to reopen her claim in either a notice of disagreement or any other communication since the April 1999 RO decision, the issue of entitlement to service connection for depression is not now before the Board. See 38 C.F.R. §§ 20.200, 20.201 (2001). In addition, the Board also observed in the July 1998 remand that the veteran had filed a claim for compensation under 38 U.S.C.A. § 1151 for residuals of injuries sustained in an automobile accident, which was denied by an April 1998 RO decision. It was further noted that the issue was not in appellate status since the veteran had not filed an NOD to initiate an appeal from the RO's decision. Based on statements by the veteran subsequent to the July 1998 remand, received in October 1998, which are construed by the Board as a timely NOD, the issue of entitlement to compensation under 38 U.S.C.A. § 1151 for residuals of injuries sustained in an automobile accident is addressed below in the REMAND section of this decision. FINDINGS OF FACT 1. There is ample competent medical evidence of a diagnosis of PTSD and of a nexus between the veteran's PTSD and her alleged in-service stressors. 2. While most of the veteran's claimed in-service stressors have not been verified, there is medical evidence of behavioral changes during service which are consistent with the veteran's history of sexual assault during that time; the evidence is evenly divided as to whether such occurred during service, and the veteran's PTSD cannot be reasonably dissociated from that event. CONCLUSION OF LAW The veteran's PTSD was incurred during active service. 38 U.S.C.A. §§ 1131, 5102, 5103, 5103A, 5107 (West 1991 & Supp. 2001); 38 C.F.R. §§ 3.303, 3.304(f) (2001). REASONS AND BASES FOR FINDINGS AND CONCLUSION There has been a significant change in the law during the pendency of this appeal. On November 9, 2000, the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified as amended at 38 U.S.C.A. § 5102, et seq. (West Supp. 2001)) became law. This legislation provides, among other things, for notice and assistance to claimants under certain circumstances. VA has also revised the provisions of 38 C.F.R. § 3.159, in view of the new statutory changes. See 66 Fed. Reg. 45,620-45,632 (August 29, 2001). Except for the amendment to 38 CFR 3.156(a) (not applicable here), the second sentence of 38 CFR 3.159(c), and 38 CFR 3.159(c)(4)(iii), the provisions of this final rule apply to any claim for benefits received by VA on or after November 9, 2000, as well as to any claim filed before that date but not decided by VA as of that date. In accordance with the revised statute, VA has a duty to notify a claimant of the evidence needed to substantiate his or her claim. VA also has a duty to assist a claimant in obtaining such evidence, including obtaining private records, if a reasonable possibility exists that such assistance would aid in substantiating the claim. In the case of a claim for compensation benefits, the duty to assist also includes obtaining the veteran's service medical records and other records pertaining to service; records of relevant treatment at VA facilities, or provided at the expense of VA; and any other relevant records held by any Federal department or agency identified by the veteran. If VA is unable to obtain records identified by the claimant, VA must provide notice of the identity of the records that were not obtained, explain the efforts to obtain the records, and describe any further action to be taken to obtain the records. Also in the case of a claim for disability compensation, the duty to assist includes providing a medical examination or obtaining a medical opinion if such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. §§ 5103 and 5103A. The RO did not have the benefit of the explicit provisions of the VCAA and its implementing regulations when it adjudicated the issue pertinent to this case in May 1996. Nevertheless, after reviewing the claims folder, the Board finds that, with regard to the claim of entitlement to service connection for PTSD, there has been substantial compliance with the assistance provisions set forth in the new law and regulations and VA's duties have been fulfilled in this case. By virtue of the May 1996 RO decision, in a statement of the case issued in August 1996, and in supplemental statements of the case, the veteran was given notice of the information and medical evidence necessary to substantiate her claim of service connection for PTSD. The RO has obtained all identified medical evidence, and there is no indication that there is any outstanding relevant evidence pertaining to the disabilities at issue, to include VA and private medical records, that has not been obtained. The veteran has been provided VA compensation examinations that are adequate for adjudication of the issues in this case. Accordingly, the Board concludes that remanding this case for additional development under the new statute is not necessary, and reviewing the claim without remanding it is not prejudicial to the veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). In sum, the facts relevant to the claim in this case have been properly developed and there is no further action which should be undertaken to comply with the provisions of the VCAA and its implementing regulations. Background The veteran filed a claim of service connection for PTSD in September 1995. In essence, she contends that she suffers from PTSD and related emotional problems as a result of sexual assaults and harassment that occurred in service. Essentially, the veteran reports the following in-service stressors: ? During her service, the veteran dated a man who was killed in a car accident that she witnessed. ? While the veteran was stationed in the Philippines, a superior officer harassed her and traumatized her with a great deal of verbal abuse, especially after the veteran learned of a "black market" operation in which the officer was allegedly involved. The veteran alleges that the officer excluded her from various office activities and threatened her with physical harm. ? She was hospitalized by a Philippine doctor for two weeks due to a "possible thyroid problem," and the physician repeatedly raped the veteran while she was sedated by medication. ? The veteran was physically assaulted and verbally harassed by officers and fellow servicemen "all the time" throughout her military career. The service medical records include the May 1975 medical examination report and report of medical history on the veteran's induction into service. A psychiatric clinical evaluation at that time was normal, and the records are negative for a psychological or emotional disorder. An August 1978 outpatient report, along with an in-service hospitalization report shows that the veteran was treated in August and September 1978 after being admitted with a diagnosis of hypothyroidism. She complained at that time of progressive generalized body weakness of two months duration, sleepiness, feeling cold, and a voice change. She reported a weight gain of approximately 20 pounds over the prior six months, and told the service-physician that she had to "drag" herself to do anything physical. The hospitalization report does not indicate that the veteran mentioned any prior or current history of sexual abuse or harassment. A physical examination was generally unremarkable, and her hospital course shows treatment for thyroid supplement, headache, and constipation. An October 1978 outpatient record shows that the veteran experienced depression and helplessness related to her father's terminal cancer and a recent break-up with a boyfriend. She complained of sleeplessness, loss of appetite, and an inability to concentrate while performing her duties. The report noted that she informed the service examiner she had "problems with some of the people around her." The diagnosis was situational depression. The veteran was hospitalized for a week in March 1979 after complaining of progressive weight gain, constipation, and anxiety. The veteran continued to be treated for hypothyroidism, and also for her weight gain, which was associated with constipation. The hospital record notes that the veteran was "concerned very much about her work wherein she was bothered most of the time and harassed by her office mates." The report further notes that the veteran "did not know what to do and she decided to make an appointment with the internal Medicine Clinic and was subsequently admitted." The hospital course involved treatment mainly directed at her diet and constipation. The diagnosis was hypothyroidism and situational reaction. The record, however, indicates that the veteran complained of depression and anxiety, and had crying spells during the hospitalization. She expressed that she was very concerned about what would happen to her when she returned to her work, and she noted that almost all of her office mates had negative attitudes toward her, including her most immediate supervisor. The service physician reported that the veteran was recommended to be seen by a psychiatrist due to the problems she experienced at her job. The psychiatrist, after diagnosing situational reaction, suggested that the veteran should have a 20 day convalescent leave, "[a]fter which time this present situation at her work will be straightened out." Another in-service hospitalization report shows that the veteran was admitted in July and August 1979 because of alleged acute and chronic alcoholism. The veteran reported that she was referred for treatment by her commander because of "job performance troubles." It was noted that the veteran started drinking when she was 16 years old, and her consumption of alcohol had increased over the prior three years. Upon admission, the veteran did not appear to be in any major emotional distress, and a mental status examination showed no evidence of psychosis, disabling neurosis, or organic brain syndrome. The physician noted that the veteran showed a great deal of manipulative behavior and self-pity, and she needed a great deal of positive peer pressure and support in order to be able to deal with even mild stress. It was further noted that the veteran was very careful when it came to "taking chances and opening up." The final diagnosis was chronic alcoholism under control. On the August 1979 report of medical history on her separation from service, the veteran answered "yes" when responding to whether she had or ever had frequent trouble sleeping, depression or excessive worry, and nervous trouble. When reporting on prior operations or hospitalizations, the veteran noted only that she had been treated for eye and thyroid disorders, and for depression. The August 1979 medical examiner's report, however, is negative for any psychiatric or emotional disorder, and the examiner did not refer or report any hospitalization or treatment the veteran received while on active duty. Post-service medical records include VA outpatient records dated from 1990 to 1997, indicating that the veteran was counseled and treated for numerous physical and psychological health problems. The VA medical records show that the veteran was involved in individual and group therapy for sexually abused women, and reveal her complaints of forgetfulness, along with severe depression related to traumatic sexual experiences and abusive relationships. The records documenting the veteran's private and group therapy sessions are essentially negative for reference to the abuse and harassment the veteran alleges to have occurred during service. During an individual counseling session in 1991, the physician noted that the veteran had a "sense of something shameful about herself that others will discover if they get too close." The VA records consistently reveal diagnoses including major depression. Post-service medical records also show that the veteran was hospitalized in February 1990, from March to June 1990, and in October 1991. Diagnoses shown on the hospitalization records include seizure disorder and depression. The October 1991 hospital report shows diagnosis of adjustment disorder with anxiety, and depression along with borderline personality with hysterical traits. From the record, it appears that the veteran's first post- service account of her in-service trauma was during a VA psychological evaluation in January 1995. The veteran gave a history of recurrent major depression and substance abuse that became a serious problem while in the Navy, and became a major factor in her life until she regained sobriety two years prior to the evaluation. Subjectively, the veteran felt that her experiences in the Navy radically changed her life. She described that although she was raised in a physically, sexually, and verbally abusive environment, she was able to "'rise above the situation and bury all of that stuff' to be able to function at a high degree among peers and in the community." She reported that after completing "A-school" in the Navy, she went with a date to a movie, but her date drove elsewhere and raped her. She reported that she pressed charges and found out that the man was a Naval officer, and his fellow officers blocked disciplinary actions. That incident left the veteran feeling powerless, and she felt as though she began to attract individuals who wanted to treat her in a similar manner. She reported feeling "enslaved...under a spell...[with] no control," due to the initial and subsequent forcible sexual contact with superior officers. She also reported that the officer who raped her then made her polish a large bell outside an administration building while standing on a ladder and wearing a dress uniform. She recalled that the servicemen walking by would look up her dress and tease and humiliate her. The veteran felt that the attitude toward women in general was responsible in large part for many of the humiliating and traumatic experiences she endured during her service. She reported that she began to have nightmares in 1978 about being physically attacked. She began to avoid men for fear of having sex, and stated that she "gained considerable weight in order to make herself unattractive and not noticed." She described that she "shut down her feelings," and did not fit in with her friends "who had petty problems compared to the living Hell that I went through in the Navy." The objective mental status evaluation in January 1995 revealed that the veteran was quite anxious, and she burst into tears when recalling the traumatic events of her service. At other times she displayed considerable anger toward the trauma she endured. The physician noted that the veteran's claims folder was reviewed, and there was a "great lack of detail from her hospitalizations when taking a history when compared to what materials were found in the chart." The Axis I diagnosis was PTSD and history of major depression. The Axis II diagnosis was personality disorder, not otherwise specified, with histrionic traits. The Axis IV diagnosis was severe marital discord and impaired interpersonal relationships. As far as testing was concerned, the physician reported that hospitalization and/or further testing did not seem necessary to make the diagnosis, "unless one was to feel that [the veteran's] memory loss was due to an organic cause and not amnesia for multiple events which does not appear to be the case." On VA psychiatric examination in February 1996, the veteran reported that she had cousins who had sexually and physically abused her on many occasions when she was between the ages of two and twelve. She told the examiner that her parent's were aware of the abuse, and she didn't tell them because she had been threatened by her cousins had threatened her. She also reported that she was sexually molested by an 8th-grade teacher but managed to get away from him. The veteran felt very upset that, due to the abuse she experienced during her childhood, she had learned to fear men and "gave into them" when she dated. Regarding the alleged stressors during her military service, the veteran reported that she was relatively happy in the Navy initially. She started dating, but was "hurt all the time, as she "gave into" the men. She recalled that her male comrades appeared resentful of female service members, and constantly made sexual innuendoes to her. She reported that her feeling of helplessness increased when she was reassigned to an F-14 division, where she described daily harassment. She stated that certain officers repeatedly attempted, and/or managed, to reach under her dress, pinch her, and make other sexual gestures. She recalled that fellow servicemen were constantly making lewd comments. Because she was relatively isolated in her assignment, she did not talk with other women about her problems, and she cried and drank a lot instead. She noted that her alcohol use escalated to the point of daily drinking. Another stressful episode allegedly occurred when a man whom the veteran dated broke a date they had. The veteran found him getting drunk with another women in the Enlisted Men's Club, and the veteran confronted him. Her boyfriend apparently drove away from the club with a friend. The veteran was following in her car, and she witnessed his car crash into a bridge abutment and explode, killing both occupants of the automobile. The veteran further reported that she was assigned to a drug and alcohol abuse office at one point during service, where all of her work mates were men. Apparently, sexual harassment and inappropriate language recurred at the drug and alcohol abuse office. On another occasion, the veteran accidentally witnessed her supervisor in his office, drinking and smoking marijuana, and with a naked woman on his lap. The veteran stated she was able to remove herself from that situation without her supervisor knowing, but he eventually found out that she witnessed his behavior. From that time on, the way her supervisor treated her dramatically worsened. She stated that he was verbally abusive and demeaning on a daily basis, and there were attempts by her supervisor and his staff to make her appear incompetent at her job, or to make her think she was "going crazy." The veteran also reported another traumatic in-service event that occurred when she was stationed in the Philippines. She alleged that a doctor had her hospitalized, claiming that she was had a serious thyroid problem. The veteran alleges that the doctor overmedicated her during the hospitalization and raped her. The veteran also told the examining physician that during her in-service separation examination, she tried to tell the service examiner about her problems in service, but was told that if the problems were recorded "we'll have to keep you here indefinitely." The veteran decided not to make an issue of it, as she wanted to return to her parents as soon as possible because her father was seriously ill. The Axis I diagnosis was continuous and severe PTSD; alcohol dependence, in remission; history of major depression, in partial remission, associated with PTSD. By a May 1996 rating decision, the RO denied service connection for PTSD, finding that there was no evidence to confirm the veteran's alleged in-service stressors. As noted above, this case was previously before the Board in July 1998, when it was remanded with directives that the RO should attempt to verify the veteran's alleged stressors, and to schedule her for a VA PTSD examination. On VA PTSD examination in March 1999, the physician reported that the veteran was able to able to get "improved information" from the veteran regarding her alleged stressors. The veteran essentially reported the same stressors as outlined above, but in somewhat more detail. The physician reported that there was no point providing a diagnosis, as the veteran had been fully diagnosed during the February 1996 VA PTSD examination outline above. The physician recorded the same diagnosis as was reported on the February 1996 VA examination. It was also noted, however, that "there does not seem to be any major changes in the . . . diagnoses, but the psychosocial stressors of PTSD . . . cannot be identified adequately at this point to help the Board . . . beyond this point." On VA PTSD examination in August 2001, the veteran complained of a labile, sad mood on most days. She slept poorly, had poor energy, and had low concentration. She had nightmares at least three to four time weekly, in which she was running in the Philippines in the rain and trying to escape. The veteran informed the physician about the traumatic events she alleges to have endured during her military service, and she gave a history of recurrent, intrusive, distressing recollections of events that occurred to her in the Philippines. She reported that she has flashbacks of the Philippines when she smelled "frying smells." She made efforts to avoid thoughts and feelings associated with the trauma from the Philippines. The veteran had markedly diminished interest in significant activities in her life, and she described feelings of detachment and estrangement for others. She had difficulties including a sense of a foreshortened future, hypervigilance, and exaggerated startle response. On assessment of the veteran's PTSD, the physician noted that she gave a history that met the DSM-IV stressor criteria, "particularly with respect to when she was repeatedly raped in the Philippines by a military Filipino doctor, as previously described." The Axis I diagnosis was PTSD; major depression, recurrent, in partial remission; and pain disorder. The Axis II diagnosis was personality disorder, not otherwise specified, with histrionic features. The physician performing the August 2001 examination note that all of the veteran's available records, and the claims folder, had been reviewed. It was noted that the veteran gave a fairly consistent history of PTSD stressors on previous VA PTSD examinations, as well as during the current examination. The physician noted that based on all available current date, it appeared that that the veteran met the PTSD stressor criteria, particularly in relation of her history of a rape experienced while in the Philippines. The physician further reported that there were no pre-trauma risk factors that might have rendered the veteran vulnerable to developing PTSD. The veteran demonstrated a definite impairment in ability to tolerate the increased mental demands and stress of the workplace, secondary to PTSD. Finally, the physician reported that it was very difficult to determine whether or not the veteran was exaggerating her symptoms. In written correspondence dated in May 2001, the veteran's representative noted that the veteran wished to furnish additional evidence regarding her stressors, and asked that she be given an extension in time in which to submit such records. The veteran was informed that her record on appeal would be left open for 45 days in order to allow to obtain any such evidence. However, the record reflects that the only information pertaining to the claim in this case received by VA since that time was presented in an informal brief submitted by the veteran's representative in February 2002. Legal Criteria and Analysis Service connection may be granted for a disability resulting from personal injury incurred or disease contracted in the line of duty or for aggravation of a preexisting injury or disease. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. On June 18, 1999, VA published a final rule in the Federal Register which amended 38 C.F.R. § 3.304(f) to bring that regulation into compliance with the Court's holding in Cohen v. Brown, 10 Vet. App. 128 (1997). Pursuant to the amendment, service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (1999); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 64 Fed. Reg. 32,807-32,808 (June 18, 1999) (to be codified at 38 C.F.R. § 3.304(f) effective March 7, 1997, the date of the Court's decision in Cohen). Effective March 7, 2002, VA published a final rule in the Federal Register which amended 38 C.F.R. § 3.304(f) in reference to the proof necessary to establish occurrence of a stressor in claims of service connection of PTSD resulting from personal assault. It also requires that VA not deny such claims without: (1) advising claimants that evidence from sources other than a veteran's service records, including evidence of behavior changes, may constitute credible supporting evidence of the stressor, and (2) allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. See 67 Fed. Reg. 10,330-10,332 (March 7, 2002). If a post- traumatic stress disorder 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: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA will not deny a post-traumatic stress disorder 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. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. Id. Similarly, the VA Adjudication Manual M21-1 (M21-1) provisions on PTSD claims generally require that in cases where available records do not provide objective or supportive evidence of the alleged in-service stressor, it is necessary to develop for this evidence. M21-1, Part III, 5.14(b)(3). As to personal-assault claims, requirements are established regarding the development of "alternative sources" of information, as service records "may be devoid of evidence because many victims of personal assault, especially sexual assault . . . do not file official reports either with military or civilian authorities." Id. at 5.14(c)(5). Of particular pertinence to the veteran's claim are the provisions of subparagraphs (8) and (9) which, respectively, indicate that behavior changes that occurred at the time of the incident may indicate the occurrence of an in-service stressor, and that secondary evidence may require interpretation by a clinician, especially if it involves behavior changes; and that evidence which documents such behavior changes may require interpretation in relationship to the medical diagnosis by a VA neuropsychiatric physician. Examples of behavioral changes that might indicate a stressor are (but are not limited to): visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment; lay statements describing episodes of depression, panic attacks, or anxiety but no identifiable reasons for the episodes; evidence of substance abuse such as alcohol or drugs; and increased disregard for military or civilian authority. See M21-1, Part III, 5.14(c)(8)(a - o). There is ample competent medical evidence of record which establishes a diagnosis of PTSD, and of a nexus between the veteran's PTSD and her claimed in-service stressors. As noted above, several thorough and comprehensive psychiatric examination reports have provided a diagnosis of PTSD dating from 1995. Those diagnoses of PTSD appear substantially based upon the veteran's account of in-service sexual assaults and harassment, and the examination reports relate the diagnosis of PTSD at least in part to the veteran's alleged in-service stressors. Thus, the central question is whether there is adequate verification of any of the veteran's claimed stressors during service cited by the any of the examining psychiatrists who provided a diagnosis of PTSD. The several VA examinations resulted in a diagnosis of PTSD based upon the veteran's detailed accounts of her experiences of in-service sexual assaults and harassment. The service medical records are devoid of any findings of the alleged stressors. This history is not apparent in the record until more than 10 years after service. The veteran has not submitted any evidence to corroborate any of her alleged in- service stressors. The Board further finds that much of the veteran's history borders on the incredible. For example, she alleges that a physician sedated and repeatedly raped her, countless fellow enlisted men and officers sexually assaulted, harassed, and/or threatened her, and that she witnessed a car crash and blow-up, killing her boyfriend and another woman. While she was evaluated on numerous occasions for a variety of complaints and ailments, none of these alleged incidents appear in the service medical records or for many years thereafter. Nevertheless, the veteran was evaluated for psychiatric complaints while on active duty, to include anxiety and depression, and she also indicated having difficulties with co-workers during that time. Moreover, there is indication of some behavior changes that occurred proximate to the time of the alleged incidents. Specifically, the veteran was evaluated for depression and weight gain, employment difficulties, and alcohol abuse during the period of time in question. While some of her symptoms, to include weight gain, was attributed to hypothyroidism, it is clear that at least one psychiatrist believed that she had underlying depression that required evaluation and possible treatment. Under M21-1, Part III, 5.14, behavior changes that occurred at the time of the alleged incident may indicate the occurrence of that stressor. It is the Board's judgment that, in light of the in-service findings of behavioral changes and evaluation for psychiatric symptoms, and the absence of any indication in the post-service psychiatric reports that questions the veteran's veracity in providing her in-service history of sexual assault and harassment, the evidence is in relative equipoise on the question of whether there is sufficient verification of an in-service stressor of sexual assault and/or harassment. Resolving the reasonable doubt raised by such evidence in favor the veteran, the Board finds that the veteran's PTSD cannot be reasonably dissociated from such in- service stressors. Accordingly, service connection for PTSD is warranted. 38 U.S.C.A. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.304(f). ORDER Service connection for PTSD is granted. REMAND As noted above, by an April 1998 decision, the RO denied the veteran's claim for compensation under 38 U.S.C.A. § 1151 for residuals of an automobile accident. When this case was previously before the Board in July 1998, it was noted that the veteran's 38 U.S.C.A. § 1151 was not in appellate status at that time as she had not filed an NOD to initiate an appeal from the RO's decision. However, the Board's current review of the claims folder indicates the veteran submitted a VA Form 21-4138 in October 1998, wherein she stated that she took "considerable exception" to facts enumerated by the RO in the decision which denied her claim under 38 U.S.C.A. § 1151. On the circumstances of this issue, the Board notes that a written communication from a claimant or a representative expressing dissatisfaction or disagreement with an adjudicative determination by the RO and a desire to contest the result will constitute an NOD. 38 C.F.R. § 20.201 (2001). While special wording is not required, a notice of disagreement must be in terms which can be reasonably construed as disagreement with a determination and a desire for appellate review. Id. Liberally construing the language of the veteran in the October 1998 VA Form 21-4138, the Board accepts her statement as an NOD with the issue of entitlement to compensation under 38 U.S.C.A. § 1151 for residuals of injuries sustained in an automobile accident. See 38 C.F.R. § 20.201. Therefore, the record reflects that the veteran has submitted a timely NOD with the April 1998 decision which denied her claim under 38 U.S.C.A. § 1151. See 38 C.F.R. § 20.302 (2001) (an appeal to the Board is commenced by a notice of disagreement which must be filed within one year of the date that the originating agency mailed the written notice of the determination to the claimant). If a claim has been placed in appellate status by the filing of a notice of disagreement, the Board must remand the claim to the RO for preparation of a statement of the case as to that claim. See Manlicon v. West, 12 Vet. App. 238 (1999); Godfrey, 7 Vet. App. at 408-410; see also Archbold v. Brown, 9 Vet. App. 124 (1996); VA O.G.C. Prec. Op. No. 16-92 (July 24, 1992). Accordingly, this case is REMANDED to the RO for the following action: The RO should issue a statement of the case to the veteran and her representative addressing the issue of claim for compensation under 38 U.S.C.A. § 1151 for residuals of injuries sustained in an automobile accident. The veteran should also be advised of the time period in which to perfect her appeal. 38 C.F.R. § 20.302(b). Then, only if, the veteran files a timely substantive appeal, should the case be returned to the Board for appellate review. By this remand, the Board intimates no opinion as to any final outcome warranted. The veteran has the right to submit additional evidence and argument on the matter remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). R. F. WILLIAMS Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.