Citation Nr: 0210594 Decision Date: 08/27/02 Archive Date: 09/05/02 DOCKET NO. 95-25 259 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, other than a schizoaffective disorder, claimed as post traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Mark R. Lippman, Attorney WITNESSES AT HEARING ON APPEAL Appellant and her brother. ATTORNEY FOR THE BOARD D. L. Wight, Associate Counsel INTRODUCTION The veteran served on active duty from November 1978 to March 1982 with service in Germany from August 1980 to October 1981. This case arises before the Board of Veterans' Appeals (Board) by means of a March 1994 rating decision rendered by the Nashville, Tennessee, Regional Office (RO) of the Department of Veterans Affairs (VA) wherein service connection for post traumatic stress disorder (PTSD) was denied. The veteran filed a notice of disagreement in November 1994. A statement of the case was furnished to her in June 1995. The veteran perfected her appeal through a VA Form 9 in July 1995. The issue on appeal was previously the subject of a July 1999 Board decision. However, the Board decision on this issue was vacated and remanded to the Board by means of a November 1999 Order of the United States Court of Appeals for Veterans Claims (Court), pursuant to a November 1999 Joint Motion to Vacate BVA Decision, to Remand the Claim, and to Stay Further Proceedings. In June 2000 and May 2001, the Board remanded the case to the RO for further development. Said development having been completed, the case is returned to the Board for further appellate consideration. As noted in the prior Board Remands, the Board was asked by the Court to determine whether there are two pending unadjudicated claims: one for an acquired psychiatric disorder, and one for a total disability rating on the basis of unemployability. With respect to the issue of entitlement to an acquired psychiatric disorder, the Board notes that the RO denied a prior claim for a schizoaffective disorder by means of a September 1989 rating decision. An undated notice of this decision was furnished to the veteran. She filed a notice of disagreement in April 1991, which the Board finds timely since the notice date is unknown. The veteran was furnished a statement of the case in May 1991; however, the evidence does not show that she perfected a timely appeal of this claim. Accordingly, the September 1989 rating decision is final as to service connection for schizoaffective disorder, and the issue on appeal is appropriately identified as entitlement to service connection for an acquired psychiatric disorder, other than a schizoaffective disorder, claimed as post-traumatic stress disorder. With respect to the issue of entitlement to a total disability rating on the basis of unemployability, the Board notes that the veteran's substantive appeal received in July 1995 indicates that the veteran was unemployable due to her "mental condition." This matter was referred to the RO for additional development as necessary. By rating action in April 2002, the RO denied entitlement to individual unemployability. The evidence does not show that the veteran has perfected an appeal of this decision. FINDINGS OF FACT 1. VA has made all reasonable efforts to assist the veteran in the development of her claim and has notified her of the information and evidence necessary to substantiate her claim. 2. The medical evidence shows that the veteran is presently diagnosed with paranoid schizophrenia. In addition, an October 1998 VA outpatient treatment record notes that she has PTSD secondary to an alleged in-service sexual assault. 3. The record does not show that the veteran engaged in combat with the enemy. 4. The veteran's alleged in-service stressors have not been verified by official records or corroborated by service records or other credible evidence. 5. The diagnosis of PTSD is not based on a corroborated stressor. 6. Schizoaffective disorder was denied by means of an unappealed rating action of March 1990. CONCLUSION OF LAW An acquired psychiatric disorder, other than a schizoaffective disorder, claimed as post-traumatic stress disorder (PTSD) was not incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1153 (West 1991 & Supp. 2001); 38 C.F.R. §§ 3.104, 3.303, 3.304, 3.306 (1996)(2001); VA ADJUDICATION PROCEDURE MANUAL M21-1, Part III, 5.14 (April 30, 1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION At the outset, the Board must consider the impact of the Veterans Claims Assistance Act of 2000 (VCAA) on the veteran's claim. 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5126 (West Supp. 2001); McQueen v. Principi, 14 Vet. App. 300 (2001) (per curiam). The law provides that VA has a duty to assist veterans and other claimants in developing their claims for VA benefits. The Board notes that the veteran's application for the benefits at issue is complete. The VCAA provides that upon receipt of an application for VA benefits, VA shall notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, not previously provided that is necessary to substantiate the claim. 38 U.S.C.A. § 5103A; 66 Fed. Reg. 45,630 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. § 3.159(b)). The veteran was informed of the information necessary to substantiate his claim by means of a statement of the case and supplemental statements of the case issued during the course of this appeal. Similarly, in a September 2001 letter, the veteran was informed of the enactment of the VCAA and what information she could submitted to substantiate her claim. Accordingly, the Board finds that the duty to inform the veteran of required evidence to substantiate her claim has been satisfied. 38 U.S.C.A. § 5103(a). The VCAA also provides that VA has a duty to assist the claimants in developing their claims. VA is specifically required to make "reasonable efforts to obtain relevant records (including private records)." 38 U.S.C.A. § 5103A. The veteran has not referenced, nor does the evidence show, the existence of any additional medical evidence that is not presently associated with the claims folder and which is obtainable. According, the Board finds that VA's duty to assist the claimant in this regard is satisfied. 38 U.S.C.A. § 5103(a); 66 Fed. Reg. 45,630 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. § 3.159(c)). Additionally, as set forth in the VCAA, the duty to assist requires medical examination when such examination is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A; 66 Fed. Reg. 45,630 (Aug. 29, 2001) (to be codified as amended at 38 C.F.R. § 3.159(c)(4)). In the present case, the veteran was afforded psychiatric examination. The RO has completed all development of this claim that is possible without further input by the veteran. The veteran has been duly notified of what is needed to establish entitlement to the benefits sought, what the VA has done and/or was unable to accomplish, and what evidence/information he can obtain/submit herself. Accordingly, the Board finds that the requirements set forth in the VCAA with regard to notice and development of the appellant's claim, have been satisfied, and that returning the case to the RO to consider the requirements of VCAA would serve no useful purpose, but would needlessly delay appellate review. Evidentiary Background: The veteran's September 1978 entrance examination report is negative for any treatment, complaint, or diagnosis of an acquired psychiatric disorder. Service medical records dated in April 1981 indicate that the veteran reported to the emergency room with complaints of chest pains, diarrhea, and nausea. She stated that she was "forgetting thing." She had forgotten to go to work on the date of this treatment. An impression of viral syndrome, mild, is indicated. In October 1981, the veteran was afforded an examination in conjunction with her pending separation from active service. The examination report indicates that her psychiatric system was within normal limits. Service personnel records show that the veteran requested an enlistment for a period of three months in November 1981. This request was subsequently approved. In January 1982, the veteran delivered a baby at the Rancocas Valley Hospital. A physical examination report indicates that her nervous system was "grossly normal." Following her separation from active service, the veteran served in the Army Reserves from April 1982 to October 1987. Army Reserve personnel records show that she received a Certificate of Training from the Army for successfully completing an Administrative Specialist Course in July 1982. Additionally, she received a Letter of Commendation for performances of duties as a Clerk Typist during annual training at Ft. Campbell, Kentucky, in April 1984. A March 1983 reserve examination report indicates that the veteran's psychiatric system was within normal limits. A report of medical history completed by the veteran indicates that she complained of dizziness and memory loss associated with pregnancy; however, she denied frequent trouble sleeping, depression or excessive worry, and nervous trouble of any sort. In December 1987, the veteran was admitted to Moccasin Bend Mental Health Institute with complaints of depression with perceptual disturbance and paranoid delusions. She also had ideas of reference regarding telepathy and radiation form television affecting her. Pertinent diagnosis was schizoaffective disorder. In January 1988, the veteran was admitted on an emergency basis to Moccasin Bend Mental Health Institute because of threats to harm her family. Diagnosis was schizoaffective disorder. Private medical records from the Fortwood Center, Inc., dated in May 1988, show that the veteran presented with an apparent history of mental problems beginning in 1987. She experienced auditory and visual hallucinations and had paranoid delusion. The report indicates that the veteran's mother believed that the veteran started to deteriorate after leaving the military. However, the veteran reported that she had a very poor childhood and felt that part of her psychological problems stem from her treatment as a child. The veteran reported that she had a six year old son who she had with a man she met while in the military. She and the father of this son never married. She married a different man in 1987 whom she had met in 1984; however, this marriage only lasted a few months. She had two children from her ex- husband. Diagnosis of schizoaffective disorder is indicated. From December 1988 to February 1989, the veteran was hospitalized by court order at Moccasin Bend Mental Health Institute due to suicidal and homicidal threats. She was delusional and felt that she was being watched by the Secret Service in Washington. While she denied having auditory or visual hallucinations, the hospital records indicate that she appeared to be hallucinating. Pertinent diagnosis was schizoaffective disorder. Private medical treatment records from Erlanger Medical Center dated in August 1989 show that the veteran was brought to the emergency room by police. She had set fire to her house as she thought someone was trying to harm her. She was noted to be paranoid, anxious, and fidgety. She was transferred to the Moccasin Bend Mental Health Institute due to violent, destructive, dangerous behavior. She was hospitalized at Moccasin Bend from August 1989 to September 1989. This was her fourth admission at this facility. She was on neuroleptics and Lithium; however, she was noted to be noncompliant with medication. Hospital records indicate a diagnosis of schizoaffective disorder. In September 1989, the veteran filed a claim of entitlement to service connection for headaches. She indicated treatment at Fortwood Center and Moccasin Bend Mental Health Institute. In October 1989, the RO requested medical records from the Fortwood Center and Moccasin Bend Mental Health Institute. In reply to the RO's request for information, Fortwood Center replied by letter dated in October 1989. This letter indicates that the veteran was hospitalized in December 1987 at Moccasin Bend Mental Health Institute complaining of depression with perceptual disturbance and paranoid delusions. She was stabilized at the time with Navane and Cogentin; however, she did not keep appointments consistently. She was readmitted to Moccasin Bend Mental Health Institute in 1988 for the same presenting symptoms. She dropped out of subsequent outpatient treatment after two visits. She was readmitted to Moccasin Bend Mental Health Institute in August 1989. Her medications included Haldol, Cogentin, and Lithium carbonate. Diagnosis was schizoaffective disorder. In January 1990, the Social Security Administration awarded Supplemental Security Income to the veteran due to unemployability. From October 1990 to November 1990, the veteran was admitted to Moccasin Bend Mental Health Institute for psychiatric evaluation by court order as she was threatening to kill herself. Pertinent diagnosis was schizoaffective disorder. From January 1991 to February 1991, the veteran was hospitalized at Moccasin Bend Mental Health Institute for psychiatric evaluation. The veteran had been noncompliant with her medication and refused to attend her aftercare treatment. She gradually deteriorated to the point of being agitated and paranoid and she threw a television out of a window. As her family was afraid of her, he mother filed a petition for 48 hour commitment. Pertinent diagnosis was schizoaffective disorder. In April 1991, the RO received a statement from an acquaintance of the veteran, C. R. C. R. indicated that she had known the veteran "for a while now." She indicated that the veteran had been talkative and friendly in the past; however, at certain times she would become withdrawn and depressed. The veteran had difficulties dealing with day to day problems of life. Because she needed someone to tell her what to do, the veteran joined the Army and seemed to enjoy it until she became pregnant. After her pregnancy, she became upset because "she knew she couldn't reside in the Army barracks with a child, and . . . she was terrified about going back home to her parents." After her discharge, the veteran lived with C. R. The veteran was described as difficult, non-violent, moody and depressed. In April 1993, the veteran was hospitalized at Moccasin Bend Mental Health Institute on an emergency basis due to agitation and paranoid delusions. She had thoughts that people were out to get her, that the police were harassing her, and that he mother was not her mother. She had also exhibited recent bizarre behavior by taking her 5 week old baby out in the rain. During the course of her admission, she insisted on discharge and tried to leave the facility. When she was not allowed to leave, she became agitated and was physically aggressive. She had to be secluded for her own safety as well as for the safety of others. She had to be given emergency medication since she refused to sign consent. Pertinent diagnosis was schizoaffective disorder. In November 1993, the veteran submitted a claim for service connection for PTSD. She claimed that she had sought assistance for psychosis from 1982 to 1987 with "Contact, Hot Line;" however, records pertaining to this treatment were destroyed. She also contented that she was sent to Monteith Troop Health Clinic for psychosomatic evaluation in 1981 because she could not stop crying. She indicated that she was in receipt of social security disability benefits due to her mental disorder and could no longer work. In her November 1994 notice of disagreement, the veteran stated that she experienced memory loss and PTSD. After service, she sought treatment from Contact, a counseling service, with symptoms of depression, paranoia, auditory hallucinations, and visual hallucinations. However, she indicated that she did not received treatment until 1987. She indicated that she required the assistance of her mother due to her memory loss. In February 1995, the veteran was afforded a VA PTSD examination. Prior to service she worked in housekeeping at Ramada Inn. Following basic training, she trained as a supply clerk and was transferred to Germany. She became pregnant while in Germany and returned to the United States to deliver her child. The examination report indicates that the veteran did not engage in combat. Following service, she moved in with her mother. She stated that she spends most of her day caring for her children, shopping, going to movies, and going to church on Sundays. She denied any drug or alcohol problems. She reported that her first admission for psychiatric treatment was in 1987 followed by numerous inpatient psychiatric admissions. Following service, she reported that her longest job was with the post office. This job lasted 21/2 months. She stated that, "I couldn't complete the tasks and I told them something crazy, and they fired me." During the 1980s, she had jobs at three different hospitals; however, these jobs lasted only a day or two before she would quit. In 1988, she worked at DuPont for a month and quit as she "couldn't do right." She last worked as a store clerk for two months in 1994. She quit because she "became paranoid about being robbed." She reported being paranoid and depressed. She also reported auditory hallucinations and mood swings when off her medication. She stated that had nightmares about 4 nights per week in which she dreamt of a two-faced man and that that somebody was after her or doing something to her. She stated that her paranoia was worse when she watched violence on television. She did not avoid any particular activities and denied any amnesia. She reported feeling estranged from other; however, she was able to express love feelings to her children. She did not expect to have a career, marriage, more children, or a long life. She reported 5 hours of sleep per night on Benadryl HS. She also reported being irritable, having a short fuse, and having difficulty concentrating. She denied a startled response, but did state that she was hypervigilant due to paranoia. The examiner reported that the veteran was fidgety during the examination. She had a neutral mood with a bland affect. She was oriented x3 and in good contact with reality. Her thought content concerned her symptomatology. There was no overt psychosis or extrapyramidal symptom (EPS). While she denied hallucinations at the time of the interview, she admitted to paranoid ideations in that people were trying to harm her. She functioned within the low-average range of intelligence. She denied homicidal or suicidal ideation. Her judgment and insight were impaired. Pertinent diagnosis was schizoaffective disorder, chronic and severe. The veteran reported that she attempted suicide with a can opener in 1979. A November 1996 private physician's report of medical examination in support of pension indicates that the veteran had a diagnosis of schizoaffective disorder with history of mood fluctuations, and depressed episodes with psychotic symptoms. In July 1997, the veteran's claims folder, to include the February 1995 VA examination, was forwarded to a VA psychologist in order to determine whether the criteria for a diagnosis of PTSD under the most recent DSM-IV was warranted. The examiner noted that, after reviewing the prior 1995 examination and private hospitalization summaries, no change in the diagnosis proffered in February 1995 was warranted and a diagnosis of PTSD was not indicated. From July 1997 to August 1997, the veteran was hospitalized at Moccasin Bend Mental Health Institute on an emergency basis. The discharge summary indicates that she threatened to purchase a gun and kill herself. She appeared unable to care for herself at the time of admission and her mother obtained a court order for the veteran to be evaluated and treated. The veteran reported hearing voices and laughing inappropriately. Diagnosis was schizophrenia, chronic, undifferentiated type. In October 1997, the RO received a statement from R. M. indicating that he had worked with the veteran from April 1980 to November 1981 in Germany. He recalled several instances wherein the veteran confided in him that she felt as though the people that she worked with were "out to get her" and that she exhibited a keen sense of nervousness. R.M. also stated that he observed radical mood swings and violence in the veteran. He described her behavior as "unpredictable" and paranoid. In October 1997, the veteran submitted a VA Form 21-4138, Statement in Support of Claim, wherein she alleged that her "psychiatric disorder was due to my pregnancy and the birth of a baby." She indicated that she had not had any psychiatric disorder prior to that time. In a letter of August 1998, the veteran claimed that she had been raped while in service. As such an event was extremely traumatic, she stated that she had blocked the experience form her mind. She contends that the rape was the catalyst for her nightmares. Similarly, in January 1999, she submitted a letter wherein she again expressed her contention that she was raped during service. She also indicated that her mother had recently passed away and she was unable to pay the mortgage on the home that she and her mother had been living in. VA outpatient treatment records from May 1998 to September 2001 show that the veteran was treated primarily for schizophrenia. A Social Work Service General Note dated in September 1998 indicates that the veteran reported a rape while service in Germany in 1981. She was encouraged to discuss this with her VA psychiatrist during her next appointment. Subsequently, during an October 1998 VA outpatient treatment the veteran reported an inservice rape. She indicated that she had flashbacks of this incident. The examiner noted the veteran's status as schizophrenia with thoughts of suicide without any specific plans and post traumatic stress disorder as secondary to alleged rape. However, while subsequent VA outpatient records indicate a history of inservice sexual trauma, they do not indicate a diagnosis of PTSD. A December 1998 VA outpatient records indicated that the veteran reported flashbacks of an inservice rape. These flashbacks did not occur as often as in the past and she was less terrified. Her psychosis was in remission with her present medication. Diagnosis was schizophrenia without homicidal or suicidal plans. A January 1999 VA outpatient treatment record indicates that the veteran reported thoughts of a rape in Germany while in the military. She indicated that she did not tell a psychiatrist what happened to her for fear of being kicked out of the military. The VA examiner indicated that this type or response was not unusual for someone who had been raped and fits in nicely with her behavior of not revealing her hallucinations for fear of being kicked out of the military. Diagnosis was schizophrenia without homicidal or suicidal ideation. A March 1999 letter from N. J., an acquaintance of the veteran, indicates that she had known the veteran for 22 years. N. J. found the veteran to be "a very trustworthy young lady." Prior to joining the Army, she was intelligent in school, active in extracurricular activities, and active in the neighborhood. After her discharge, "she was a changed person." She was very nervous and exhibited crying spells. She also became argumentative and paranoid. N. J. indicated that the veteran did not "like to be around people, it makes her itch." A March 1999 statement from E. M. indicated that she had known the veteran for 25 years and that her children were friends of the veteran. According to E. M., the veteran was an ideal student with good grades prior to service. E. M. reported that the veteran's mother told her that the veteran was having problems coping with life. After returning from service, the veteran was not the same as prior to service and she acted as though "her mind was gone." A March 1999 letter from the veteran's sister indicates that she "personally witnessed the emotional and physical deterioration of my sister's health early on when she was still in the service at Fort Dix, New Jersey in 1981." At the time the veteran was 7 month pregnant and constantly depressed and "stressed about the Army's rush to process her out of the service." The veteran's sister reported that the delivery of her baby had a profound affect on her physical and mental condition. In March 1999, the veteran appeared at a hearing before the undersigned Member of the Board sitting at the RO. She testified that she was raped during active service in Nuremberg, Germany. She reported that she was walking by a big brick wall with trees and a building behind it when an assailant appeared behind her and hit her head against a tree. She was then dragged down and raped. She reported that he had a scarf over his head and an accent. According to the veteran, her wrist area was bruised and she injured her head. She stated that there was no one in the area to witness the assault. She stated that she was ashamed of what happened and did not report the incident to anyone. At the time of the assault, she was 7 months pregnant. She placed the date of the rape in September 1981. She reported that she had seen a psychiatrist during active service, but she did not tell him about the rape and there were no medical records of her consultations. Following the alleged assault, she returned to her barracks and bathed. She did not tell anyone, as she was ashamed. Following service, she stated that received assistance from a counseling service immediately after service; however, she indicated that records of her calls were not available. The veteran's brother testified that she was a changed person following the birth of her child during service. He had not become aware of the alleged rape until the month prior to the hearing. In a letter dated in October 1999, the veteran stated that she had come out of a shell and was now able to tell people that she was raped while in the military. She further stated that she did not know why it took her 18 years to tell anyone. She did not want her mother to find out about her alleged rape. After her mother passed away, the veteran had the courage to tell someone. In a letter dated in February 2000, N. J. indicated that the veteran had problems related to a rape that occurred while she was on active duty. N. J. wrote that, since the veteran was raped, she found it hard to have a loving relationship with a man and that she cries a lot, has mood swings, and is paranoid and depressed. The evidence also contains a February 2000 letter from E. M. E. M. indicated that the veteran had been raped in service and experienced mental and physical abuse. E. M. indicated that this had left the veteran with a mental problem. She further indicated that the veteran had confided in her in confidence about the rape. Legal Criteria: Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991 & Supp. 2001); 38 C.F.R. § 3.303(a) (2001). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for PTSD now requires: medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (conforming to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)); 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. 38 C.F.R. § 3.304(f). Prior to the effective date of 38 C.F.R. § 3.304(f) on June 18, 1999, and at the time the veteran filed her claim for service connection for PTSD, the requirements for service connection for PTSD were: medical evidence establishing a clear diagnosis of the condition; credible supporting evidence that the claimed stressor actually occurred; and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f) (1998). Generally, when a law or regulation changes while a case is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). In this case, the Board finds that the new regulation is potentially more beneficial in this veteran's case because it only requires medical evidence of a current diagnosis of PTSD in accordance with DSM-IV, but no longer requires a "clear" diagnosis of PTSD (which could include a diagnosis based on a version of DSM prior to the DSM-IV). However, in light of the Board's grant of the appeal, the Board finds that the veteran was not prejudiced by not being notified of the change in the regulation. See Bernard v. Brown, 4 Vet. App. 384 (1993). With regard to the claimed stressor involving allegations of personal assault, VA recognizes that veterans claiming service connection for disability due to an in-service personal assault face unique problems documenting their claims. Personal assault is an event of human design that threatens or inflicts harm. Although these incidents are most often thought of as involving female veterans, male veterans may also be involved. These incidents are often violent and may lead to the development of PTSD secondary to personal assault. VA ADJUDICATION PROCEDURE MANUAL M21-1, Part III, 5.14 (April 30, 1999) (hereinafter M21-1). Because assault is an extremely personal and sensitive issue, many incidents of personal assault are not officially reported, and victims of this type of in-service trauma may find it difficult to produce evidence to support the occurrence of the stressor. Therefore, alternative evidence must be sought. The M21-1 includes a sample letter to be sent to the veteran, asking him to provide detail as to any treatment he had received, any family or friends he had communicated with concerning this claimed personal assault, and any law enforcement or medical records pertaining to the alleged assault. M21-1, Part III, 5.14 (April 30, 1999). See also YR v. West, 11 Vet. App. 393 (1998) (5.14 is a substantive rule and the equivalent of a VA regulation). With respect to claims involving personal assault, all available evidence must be carefully evaluated. If the military records do not document that a personal assault occurred, alternative evidence might still establish an in- service stressful incident. Behavior changes that occurred at the time of the incident may indicate the occurrence of an in-service stressor. Examples of behavior changes that might indicate a stressor are (but are not limited to): (a) visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment; (b) sudden requests that the veteran's military occupational series or duty assignment be changed without other justification; (c) lay statements indicating increased use or abuse of leave without an apparent reason such as family obligations or family illness; (d) changes in performance and performance evaluations; (e) lay statements describing episodes of depression, panic attacks, or anxiety but no identifiable reasons for the episodes; (f) increased or decreased use of prescription medications; (g) increased use of over-the- counter medications; (h) evidence of substance abuse such as alcohol or drugs; (i) increased disregard for military or civilian authority; (j) obsessive behavior such as overeating or undereating; (k) pregnancy tests around the time of the incident; (l) increased interest in tests for HIV or sexually transmitted diseases; (m) unexplained economic or social behavior changes; (n) treatment for physical injuries around the time of the claimed trauma but not reported as a result of the trauma; and (o) breakup of a primary relationship. M21-1, Part III, 5.14(7). In personal assault claims, secondary evidence may need interpretation by a clinician, especially if it involves behavior changes. Evidence that documents such behavior changes may require interpretation in relationship to the medical diagnosis by a VA neuropsychiatric physician. M21-1, Part III, 5.14(8). In adjudicating a claim for service connection for PTSD, the evidence necessary to establish the incurrence of a stressor during service to support a claim of entitlement to service connection for PTSD will vary depending on whether or not the veteran was "engaged in combat with the enemy." See Hayes v. Brown, 5 Vet. App. 60, 66 (1993). If it is determined through military citation or other supportive evidence that a veteran engaged in combat with the enemy, and the claimed stressors are related to combat, the veteran's lay testimony regarding the reported stressors must be accepted as conclusive evidence as to their actual occurrence and no further development or corroborative evidence will be necessary, provided that the testimony is found to be satisfactory, that is, not contradicted by service records, and "consistent with the circumstances, conditions, or hardships of such service." 38 U.S.C.A. § 1154(b) (West Supp. 2001); 38 C.F.R. § 3.304(d),(f) (2001); Doran v. Brown, 6 Vet. App. 283, 289 (1994). However, if it is determined that a veteran did not engage in combat with the enemy, or the claimed stressor is not related to combat, the veteran's lay testimony alone will not be enough to establish the occurrence of the alleged stressor. In such cases, the record must contain service records or other corroborative evidence which substantiates or verifies the veteran's testimony or statements as to the occurrence of the claimed stressors. See Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). Analysis: In this case, there is no objective evidence that the veteran "engaged in combat with the enemy." See VAOPGCPREC 12-99. The veteran's DD Form 214 and service personnel records do not indicate references to combat, but reflects that the veteran was an administration specialist and earned no combat decorations, medals, badges, ribbons, or awards. Moreover, the veteran does not even allege that the claimed in-service stressful event of a personal assault was related to combat with the enemy in service. For these reasons, the Board finds that the veteran did not engage in combat with the enemy and that the reported stressor is not claimed to be related to combat. Because the veteran did not engage in combat with the enemy, her lay testimony alone is not enough to establish the occurrence of the alleged stressor of personal assault. After a review of the evidence, the Board finds that the credible evidence of record does not show that the veteran's alleged stressor of a personal assault actually occurred as required under 38 C.F.R. § 3.304(f). Service medical and personnel records are silent for any complaint of, or treatment for, a personal assault. The Board has specifically considered whether behavior changes occurred at the time of the incident, or soon thereafter, as indicated by the M21-1, which may indicate the occurrence of an in-service stressor. The M21-1 contemplates that visits to a medical clinic without a specific diagnosis or specific ailment is a behavior change occurring at the time of the incident that might indicate a stressor. In this veteran's case, the veteran's service medical records do not show that she sought medical treatment at the time of the alleged raped in September 1981. Subsequent, in-service examinations are silent for any complaints, treatment, or diagnoses of a psychiatric disorder or residuals of a personal assault. Additionally, the veteran has indicated that no medical records existed that would document medical treatment during service. Changes in performance and performance evaluations are behavior changes contemplated by M21-1 that might indicate a stressor. The evidence does not show any changes in performance that would evidence a behavior change. Despite lay statements indicating that the veteran's personality changed following her separation from active duty, her service personnel records are silent for any behavior changes. On the contrary, despite recent statements from the veteran that she was not happy in the Army, the veteran voluntarily requested and was granted an extension of her enlistment in November 1981. Similarly, the month after her separation from active duty, she enlisted in the Reserves. Personnel records during her reserve service are silent for any behavior changes; rather, she was given a letter of commendation for performance of her duties. Evidence of alcohol abuse is also a behavior change indicated by M21-1 as behavior that might indicate a stressor. In this case, the evidence does not show that the veteran developed alcohol abuse during service or shortly thereafter. Similarly, obsessive behavior is a change contemplated by M21-1 that might indicate a stressor. However, despite assertions that the veteran experienced mood swings and became irrational after service. The contemporaneous service records and subsequent reserve service records do not evidence an obsessive behavior. The first evidence of a nervous condition was schizoaffective disorder categorized as a psychotic disorder over 51/2 years after the veteran's separation from active service. Similarly, the only evidence of a diagnosis of PTSD is an October 1998 VA outpatient treatment record over 16 years following her separation from active service. The veteran has testified under oath at a personal hearing regarding the incurrence of a rape in service in September 1981. The Board finds that her testimony regarding this event, as well as other significant facts he reported, are not consistent with the service medical evidence and other corroborative evidence. While she contends that received counseling shortly after service, she indicated that record of this treatment do not exist. The Board notes that the record is devoid of medical or counseling treatment records following the incident, military or civilian police reports, reports from crisis intervention or other emergency centers, or medical or counseling notes to verify the occurrence of the rape. While the veteran submitted statements E.M. and N.J. in February 2000 indicate that the veteran had told them that she had been raped, these statements are not probative as they rely on history reported by the veteran. It is noted that prior statements from these individuals nearly a year earlier in 1999 do not reference an in-service rape. Likewise, the veteran earlier attributed her psychiatric illness to an in-service pregnancy. The April 1991 letter from C.R. indicates that the veteran seemed to enjoy the Army until she got pregnant and became upset because she knew she could not reside in the barracks with a child. She also stated that the veteran was terrified to return home to her parents and that the veteran had mood swings and would become irrational with a short temper after separating from active service. The Board finds that the evidence contemporaneous to the veteran active service to include service personnel and medical records is more probative than the lay statements submitted nearly 18 years after the veteran's separation from active duty. Based on this evidence, the Board finds that the evidence of record is not sufficient to establish that the alleged stressor of a personal assault occurred in 1981 during the veteran's active duty service. Thus, the Board finds that the reported stressor of a personal assault is not supported by the evidence. 38 C.F.R. § 3.102. Accordingly, service connection for PTSD is not warranted. 38 C.F.R. § 3.304(f). Having determined that service connection for PTSD is not warranted, it is necessary to determined whether the veteran has an acquired psychiatric disorder, other than PTSD that would warrant a grant of service connection. Other than PTSD, the evidence shows that the veteran's only other diagnosed psychiatric disorder is schizophrenia. As noted in the INTRODUCTION, entitlement to service connection for a schizoaffective disorder was denied by means of a March 1990 rating decision. She filed a notice of disagreement in April 1991 and was furnished with a statement of the case in May 1991. However, she did not perfect a timely appeal of this decision to the Board. As the record does not show that an appeal was perfected within one year after notification of the RO's decision. Therefore, this rating decision denying service connection for a schizoaffective disorder is final. 38 C.F.R. § 3.104 (2001). Accordingly, service connection for an acquired psychiatric disorder other than PTSD is not warranted. ORDER Service connection for an acquired psychiatric disorder, other than a schizoaffective disorder, to include PTSD is denied. MARK W. GREENSTREET 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.