Citation Nr: 0312942 Decision Date: 06/16/03 Archive Date: 06/24/03 DOCKET NO. 97-28 121 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in No. Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for a chronic seizure disorder. 2. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD). 3. Entitlement to service connection for a chronic respiratory disorder, to include bronchial asthma. 4. Entitlement to a total rating due to individual unemployability (TDIU). WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Vavrina, Counsel INTRODUCTION The veteran served on active duty from October 1960 to September 1962. This case comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the North Little Rock, Arkansas, Department of Veterans Affairs (VA), Regional Office (RO). In a November 1996 rating decision, the RO denied service connection for an acquired psychiatric disorder to include PTSD, a chronic respiratory disorder to include bronchial asthma, and a chronic seizure disorder. The veteran presented testimony at an RO hearing in June 1997 and at a Travel Board hearing held by the undersigned Veterans Law Judge at the RO in May 1999. In August 1999, the Board remanded the case to the RO for additional development. In the remand the Board observed that, in November 1996, the RO denied entitlement to service connection on a direct basis for a claimed seizure disorder. However, a review of a statement received from the veteran in September 1996 and her June 1997 RO hearing testimony revealed that the veteran referred solely to this issue in the context of entitlement to benefits under 38 U.S.C.A. § 1151 (West 2002) (the veteran's claimed "seizures" are apparently secondary to withdrawal from medications prescribed for her psychiatric disorder). Later, entitlement to benefits under 38 U.S.C.A. § 1151 was formally denied by the RO, in a February 1998 rating decision. The veteran did not file a timely notice of disagreement with that decision. Inasmuch as the veteran had not formally withdrawn her seizure disorder claim, the Board remand instructed the RO to ask the veteran to clarify whether she was seeking entitlement to VA compensation for her claimed seizure disorder on the basis of direct service connection or under 38 U.S.C.A. § 1151. If the veteran was no longer seeking direct service connection for a seizure disorder, the RO was to request that the veteran withdraw in writing that issue from appellate consideration in accordance with 38 C.F.R. § 20.204 (2002). In August 1999 and December 2000 letters, the RO asked the veteran to clarify the seizure disorder issue as instructed by the remand. The veteran did not clarify her intent nor did she withdraw her claim seeking direct service connection for a seizure disorder; thus, issue remains on appeal. Subsequently, in a September 1999 rating decision, the RO denied entitlement to TDIU; the veteran perfected an appeal. This issue, along with service connection for a chronic respiratory disorder, to include bronchial asthma, is addressed in the REMAND portion of this decision. The Board notes that the veteran appointed James W. Stanley, Jr., attorney-at-law, as her representative. VA revoked Mr. Stanley's authority to represent VA claimants, effective from October 10, 2001. In a letter April 7, 2003, the veteran was given notice of this development and advised of the options that she had with respect to representation. The veteran did not respond, so the Board assumes that she will represent herself in this appeal. FINDINGS OF FACT 1. VA has notified the appellant of the evidence needed to substantiate her claims and has obtained and fully developed all evidence necessary for the equitable disposition of the claims addressed in this decision. 2. There is no competent medical evidence linking a claimed seizure disorder to active-duty service. 3. The veteran did not engage in combat with the enemy. 4. The record includes a medical diagnosis of PTSD, competent evidence that supports the veteran's assertion of in-service incurrence of the stressful event of a personal assault, and medical evidence of a nexus between diagnosed PTSD and the stressful event of personal assault in service. CONCLUSIONS OF LAW 1. Claimed chronic seizure disorder was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2002). 2. With resolution of reasonable doubt in the veteran's favor, PTSD was incurred in service. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304(f), 4.125(a) (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS During the pendency of the appeal, the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), now codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002), was enacted and became effective. The VCAA essentially eliminates the requirement that a claimant submit evidence of a well-grounded claim and provides that VA will notify the claimant and the claimant's representative, if any, of information required to substantiate a claim and will assist the claimant in obtaining evidence necessary to substantiate a claim. VA has also revised the provisions of 38 C.F.R. § 3.159 in view of the VCAA statutory changes. See 66 Fed. Reg. 45,620-32 (Aug. 29, 2001). The amendments were effective November 9, 2000, except for the amendment to 38 C.F.R. § 3.156(a), which is effective August 29, 2001. VA is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The Board also notes that VA has changed the criteria set forth in 38 C.F.R. § 3.404(f) pertaining to service connection for PTSD twice during the pendency of this appeal. The first amendments became effective on June 18, 1999. See Direct Service Connection (Post-Traumatic Stress Disorder), 64 Fed. Reg. 32,808 (June 18, 1999). The second amendments became effective March 7, 2002. See Post-Traumatic Stress Disorder Claims Based on Personal Assault, 67 Fed. Reg. 10,330, 10,332 (Mar. 7, 2002) (codified as amended at 38 C.F.R. § 3.304(f) (2002)). The 1998 and 1999 criteria for evaluating PTSD claims are substantially the same, as both versions of the regulations require medical evidence establishing a diagnosis of the condition, credible supporting evidence that the claimed in-service stressor occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304(f) (1998), (2002). The 1999 amendments primarily codified the decision of the United States Court of Appeals for Veterans Claims (Court) in Cohen v. Brown, 10 Vet. App. 128 (1997), and brought 38 C.F.R. § 3.304(f) in line with the governing statute, 38 U.S.C.A. § 1154(b) (West 1991), which relaxed certain evidentiary requirements for PTSD claimants who have combat-related stressors. The Board notes that the 2002 amendments codified manual procedures pertaining to PTSD claims resulting from personal assault. Where laws or regulations change after a claim has been filed or reopened and before the administrative or judicial process has been concluded, the version most favorable to the appellant will apply unless Congress provided otherwise or has permitted the Secretary of Veterans Affairs to do otherwise and the Secretary has done so. See Karnas v. Derwinski, 1 Vet. App. 308 (1991). The Board finds that, as the revised version of 38 U.S.C.A. § 5107 in the VCAA eliminates the "well-grounded claim" requirement of 38 U.S.C.A. § 5107 (West 1991) and the 1998 and 1999 criteria for evaluating PTSD claims are substantially the same or codify the pre-existing manual procedures for personal assault claims, they are, therefore, applicable law under the holding in Karnas, supra. 38 U.S.C.A. § 5107 (West 2002). The Board finds no prejudice to the appellant in this case by proceeding with the adjudication of the service-connection claims for a claimed seizure disorder and for a claimed psychiatric disorder to include PTSD, as VA has complied with the notice and duty to assist provisions of the VCAA. See generally Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). In this regard, the Board notes that collectively, in a May 1997 statement of the case (SOC), SSOCs issued in July 1997, July 2002 and November 2002, the hearing officer's and the Veterans Law Judge's statements, and various letters to the veteran, VA has advised her of the information needed to substantiate her service-connection claims. The veteran was advised that she needed to provide medical evidence establishing a diagnosis of the claimed seizure disorder and a link to service or a diagnosis of PTSD, credible supporting evidence that the claimed in-service PTSD stressor occurred, and a link, established by medical evidence, between current symptomatology and claimed in-service stressor(s) and that VA would obtain identifiable medical records and service personnel records. In compliance with the Board remand, in an August 1999 letter, the Board observes that, the RO asked the veteran to identify both VA and non-VA healthcare providers and to sign release forms to obtain non-VA medical records and to clarify whether she was seeking entitlement to VA compensation for a claimed seizure disorder on the basis of direct service connection or under 38 U.S.C.A. § 1151. If she was not seeking direct service connection, the veteran was to so state on an enclosed VA Form 21-4138, so that the issue could be withdrawn from appellant consideration. A December 2000 VA Form 119, Report of Contact, reflects that the veteran indicated that she did not know if she was claiming direct service connection for a seizure disorder or compensation for a seizure disorder under 38 U.S.C.A. § 1151 and she asked that VA send her a letter explaining the status of her appeals. In December 2000, the RO responded by: indicating that they had requested copies of her medical records from the Social Security Administration (SSA); reiterating that she needed to clarify whether she was claiming direct service connection for a seizure disorder because it was incurred in or aggravated in service or if she was claiming a seizure disorder based on VA Medical Center treatment under 38 U.S.C.A. § 1151 and, if she was not seeking direct service connection, to return an enclosed VA Form 21-4138 so stating; and giving her notice that, when the SSA records had been received, another SSOC would be mailed to her. She did not respond or return the enclosed VA Form 21-4138. In a June 2001 letter, the RO advised the veteran of the provisions of the VCAA, informed her of the information already obtained, informed her that VA had requested copies of her service personnel records and SSA records, requested a statement informing VA if she wished to withdraw her request for service connection for a seizure disorder on a direct basis, and gave her 60 days to supply additional evidence pertinent to her claims. The RO obtained the SSA and service personnel records. During the pendency of this appeal, both the veteran and her former attorney provided additional argument. In addition, the veteran supplied lay statements from her ex- husband, two of her sons and her niece, J. Y, in support of her claims. In July and November 2002, the RO readjudicated the appellant's claims and issued SSOCs. Given the foregoing, the Board finds that VA has substantially complied with the Board's August 1999 remand. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). With regard to VA's duty to assist, the Board finds that all relevant and available service and post-service VA medical records, service personnel records, non-VA, VA, and SSA medical records and evaluations, the birth certificate for the veteran's first daughter, and VA examination reports dated in July and October 1996 have been associated with the claims file. The veteran and her former attorney have been given the opportunity to supplement the record on numerous occasions. Transcripts of the veteran's testimony at her RO and Travel Board hearings and additional statements from the veteran, her attorney, and her family members have been associated with the claims file. Furthermore, the Board is not aware of the existence of additional relevant evidence that could serve to establish service connection for claimed seizure and psychiatric disorders to include PTSD. In light of the foregoing, the Board finds no prejudice to the veteran in this case by proceeding with the adjudication of the veteran's claims for service connection for claimed seizure and psychiatric disorders to include PTSD, as VA has complied to the extent possible with the notice and duty to assist provisions of the VCAA. Moreover, in light of the fact that the veteran has not been diagnosed with a seizure disorder and the Board's decision granting service connection for PTSD, the Board finds that there has been no prejudice to the veteran in this case that would warrant further notice or development, her procedural rights have not been abridged, and the Board will proceed with appellate review. Bernard v. Brown, 4 Vet. App. 384, 393 (1993). Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. See 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. §§ 3.1(k), 3.303(a) (2002). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as psychosis, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2002). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Further, if a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. See 38 C.F.R. § 3.303(b). Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service. In order to prevail in a claim for service connection there must be medical evidence of a current disability as established by a medical diagnosis; of incurrence or aggravation of a disease or injury in service, established by lay or medical evidence; and of a nexus between the in-service injury or disease and the current disability established by medical evidence. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Medical evidence is required to prove the existence of a current disability and to fulfill the nexus requirement. Lay or medical evidence, as appropriate, may be used to substantiate service incurrence. The Court has held that "where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence is required." Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); see also Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). In the absence of proof of a present disability there can be no valid claim." Brammer v. Brown, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Claimed Seizure Disorder The veteran has no current medical diagnosis of a seizure disorder. Thus, she fails to satisfy the first element of a claim, that is, a current disability, and her claim for service connection fails. Even assuming that the veteran has a seizure disorder, there is no competent medical evidence linking the claimed seizure disorder to service. Service medical records do not reflect complaints or diagnosis of, or treatment for, a seizure disorder. The veteran's claim appears to be based on her contention that VA medical personnel in late 1994 failed to recognize her emotional state, made a faulty diagnosis, over utilized medication, and failed to recognize that her medication was causing adverse affects, all of which relate to events with their onset more than 31 years after discharge from active duty. At a VA neurological examination in October 1996, the veteran reported that her paroxysmal episodes began in August 1994, after she discontinued taking Xanax. She indicated that the episodes begin without warning, occur 2 to 3 times per month and consist of a dream-like state lasting from 5 to 15 minutes. The veteran stated that splashing cold liquids on her face or smelling an alcohol-soaked swab could abort the "spells." During such episodes, the veteran stated that she could do fairly complex activities, such as drive a car. Usually, when they begin while she is driving, the veteran stated that she pulls over to the side of the road. She had no documented loss of consciousness and no focal neurological symptoms with her claimed seizures. The veteran said that she got short of breath with her attacks and sometimes had tingling of her hands and feet. She described feeling very anxious and "phobic." There were no particular provocative factors that she had been able to identify or history of headaches, paresis or other focal neurological symptoms. She complained of decreased memory, but denied a history of head trauma, meningitis or central nervous system insults. A private computed tomography (CT) scan of the head done in the 1980s was normal. On examination, the veteran was alert, attentive, cooperative, and oriented to person, place and time. Her recall seemed to be good. Neurological clinical findings were essentially normal. Sensory examination was normal. Deep tendon reflexes were normal and were 2+ and symmetrical; Achilles tendon jerks were 1+ and symmetrical. Following the examination, the examiner had the veteran hyperventilate for 30 seconds and all of her symptoms were completely reproduced. She became very anxious, began to wring her hands, and stood up from the chair. When instructed to go to the sink and put water on her face, she did it promptly and was able to follow other commands. She was able to recall a nursery rhyme and later recall it when asked about it. The diagnosis was paroxysmal episodes as described above with a normal neurological examination. The examiner opined that, based on her history, observation of the episode that she experienced with a brief period of hyperventilation, and normal neurological examination as well as her MMPI findings, he believed that it was doubtful that she had epileptic seizures. Private medical records received from SSA indicate that, in the 1990s, the veteran suffered from panic attacks. They do not reflect a diagnosis of a seizure disorder. At a February 1999 SSA mental status examination and evaluation of adaptive functioning performed by Sam Boyd, Ph.D., the veteran reported that she had been in therapy off and on for as long as she could remember. She stated that she was last in outpatient mental health treatment at the VA in 1994 and added that her doctor "almost killed her with medication." The veteran also indicated that she sometimes left the store and left her cart full of groceries or purchases sitting in the store without paying for them, because she became agitated while standing in line. The diagnoses included panic disorder with agoraphobia and histrionic personality disorder. Although the VA examiner indicated that he had reviewed the claims file, the SSA examiner had not. Neither the VA examiner nor the SSA examiner diagnosed a seizure disorder nor offered an opinion linking one to service. The only evidence the veteran has submitted that supports her service-connection claim for a seizure disorder is her own statements. She, as a layperson, with no apparent medical expertise or training, and is not competent to comment on the presence, or etiology, of a medical disorder. Rather, medical evidence is needed to that effect. See Lathan v. Brown, 7 Vet. App. 359, 365 (1995); Espiritu, 2 Vet. App. at 494-95 (holding that laypersons are not competent to offer medical opinions). Thus, the veteran's statements do not establish the required evidence needed, and the claim must be denied. As noted above, there is no medical evidence of record of a current diagnosis of a seizure disorder, or medical evidence establishing a relationship between such claimed disorder and service. The veteran offers only lay opinion as to diagnosis and nexus to service, which is insufficient for establishing a service connection claim, and, thus, the appeal must be denied. The Board considered the benefit of the doubt doctrine, however, as the preponderance of the evidence is against the veteran's claim for service connection for a claimed seizure disorder; the doctrine is inapplicable. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2002); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). PTSD The veteran contends that she currently suffers from PTSD as a direct result of a personal assault, or rape, by an enlisted soldier in June 1962, during her active service. She specifically contends that she sought to ascertain whether she was pregnant, but did not tell service medical personnel of the personal assault. The veteran contends that she did not tell her commanding officer or first sergeant of the assault because her rapist had threatened her if she told anyone. But she did tell her niece, J. Y., who told her to take a shower. She did not tell anyone else about the assault until after her discharge from service. The veteran further contends that her last performance appraisal in service of "unknown" is a manifestation of this assault and that she experienced other behavioral problems in service and soon after service. She did not report the in-service sexual assault to a medical provider until April 1996, when she told a counselor at the Vet Center. With regard to PTSD, VA regulations reflect that symptoms attributable to PTSD are often not manifest in service. Accordingly, service connection for PTSD requires a current medical diagnosis of PTSD (presumed to include the adequacy of the PTSD symptomatology and the sufficiency of a claimed in-service stressor), credible supporting evidence that the claimed in-service stressor(s) actually occurred, and medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor(s). See 38 C.F.R. § 3.304(f) (2002); 67 Fed. Reg. 10,330, 10,332 (Mar. 7, 2002) (codified as amended at 38 C.F.R. § 3.304(f)); see also Cohen, 10 Vet. App. at 138 (citing Moreau v. Brown, 9 Vet. App. 389, 394-95 (1996)). Specifically, to establish entitlement to service connection for PTSD under the former regulation, the veteran must submit "...medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in- service 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 (1996). Under the revised regulation, the veteran must submit "...medical evidence diagnosing the condition in accordance with Sec. 4.125(a) of this chapter; 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) (2002). 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 her to provide detail as to any treatment she had received, any family or friends she 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). In particular, the Board observes that the Court held in Patton v. West, 12 Vet. App. 272 (1999), that the provisions in M21- 1, Part III, 5.14(c), which address PTSD claims based on personal assault are substantive rules which are the equivalent of VA regulations and must be considered. See also YR v. West, 11 Vet. App. 393, 398-99 (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 2002); 38 C.F.R. § 3.304(d),(f) (2002); 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). 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 does not indicate references to combat, but reflects that the veteran was a personnel specialist. Her Form DA 20 shows that she was a company clerk and was stationed at Fort McClelland, Alabama from August 1961 until her discharge due to pregnancy in September 1962. She earned no decorations, medals, badges, ribbons, or awards. Nor does the veteran 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. However, after a review of the evidence, the Board finds that the service records and other evidence of record is sufficient to raise a reasonable doubt as to whether the alleged stressor of a personal assault occurred in June 1962 during the veteran's active duty service. The Board has specifically considered behavior changes that 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 and pregnancy tests around the time of the incident are behavior changes occurring at the time of the incident that might indicate a stressor. At an August 1962 gynecological (GYN) annual examination, the veteran denied any missed periods but did complain of early morning nausea. She denied being married but wore a wedding ring. The veteran testified that a girlfriend had told her to wear a wedding band, so that if she was pregnant, it would look all right. After further questioning, the examiner confronted the veteran with the suspicion that she was pregnant and she changed her story, stating that her last period was in June and that she wanted the test to see if the examiner could tell if she was pregnant. At a September 7, 1962 clinic visit, the veteran reported that she had had no period since June 15, 1962. She still wanted to know if she was pregnant. The impression was intrauterine (IU) pregnancy probable. Five days later, it was confirmed that she was 12 to 14 weeks pregnant and a Notification of Pregnancy form was completed indicating that the veteran was pregnant, approximately 12 weeks gestation, and that her last menstrual period was June 15, 1962. It was recommended that she be separated from the service. Changes in performance and performance evaluations are behavior changes contemplated by M21-1 that might indicate a stressor. The only specific or quantified measures of the veteran's performance during the period following the alleged personal assault is a September 1962 Performance Report which reflects the veteran's conduct and efficiency was "Unknown," in sharp contrast to the two previous performance reports which listed "Excellent" in both categories. This report was based on the period from July 18 to September 19, 1962, after she suspected she might be pregnant, was determined to be pregnant, and was discharged for that pregnancy. Moreover, the veteran was discharged from service in September 1962, well before the end of her four-year service agreement. The veteran testified that her first sergeant and the company commander had noticed changes in her behavior. They told her that she wasn't doing her work right but did not want to give her a bad rating, so just put unknown. It appears that a change in behavior in service occurred around the time of her first missed menstrual period. The record also reflects that the veteran's personal conduct toward the end of service changed dramatically, she became a "party pooper," was afraid to be alone in the office, had poor concentration, had to redo work, and was afraid to go out at night. Evidence of overeating is also a behavior change indicated by M21-1 as behavior that might indicate a stressor. In this case, the evidence shows treatment for depression, anxiety, and panic attacks, on and off, for nearly thirty years and obesity in the early 1990s. Her post-service behavior is documented by lay statements from family members and non-VA and VA medical treatment records. This tends to indicate a behavioral change consistent with the occurrence of a stressful event in service. Evidence of breakup of a primary relationship is also a behavior change indicated by M21-1 as behavior that might indicate a stressor. In this case, she told the July 1996 VA examiner that she had actually planned to marry a guy from her home town and she had wanted to be a virgin when she got married. But because of the rape, she could not go back and therefore she married someone else as soon as she could. This tends to indicate a behavioral change consistent with the occurrence of a stressful event in service. The veteran has testified under oath at two personal hearings regarding the incurrence of a rape in service in June 1962. The Board finds that, although the veteran does not recall the exact date of occurrence of the in-service rape, her essential testimony regarding this event, as well as other significant facts she reported, are consistent with the service medical record evidence and other corroborative evidence. The veteran's testimony includes that she did not have a problem with depression prior to service; that she was raped in service in June 1962; that she did not report the assault, except to her niece J. Y., but she did try to ascertain if she was pregnant; that her behavior changed in service, including avoidance of men and going out at night, sleeplessness, and poor job performance prior to discharge from service; that she told her first husband about the rape when she married him, that her first daughter was the product of that rape and was born in March 1963, and that she first mentioned the assault to a counselor at the Vet Center in 1996. The other evidence of record does not otherwise demonstrate that the veteran's essential testimony is not credible. The post-service medical evidence of record tends to corroborate the veteran's testimony as it reflects that the veteran initially reported the occurrence of an in- service rape to her first husband and her niece and that her niece told the veteran to wash herself thoroughly and to make sure that she did not have any semen in her, as corroborated by their lay statements. Based on this evidence, the Board finds that the service records and other evidence of record is sufficient to raise a reasonable doubt as to whether the alleged stressor of a personal assault occurred in June 1962 during the veteran's active duty service. Resolving reasonable doubt on this question in the veteran's favor, the Board finds that the reported stressor of a personal assault occurred in June 1962. 38 C.F.R. § 3.102. The record includes a medical diagnosis of chronic PTSD, delayed (non-combat - rape) and medical evidence of a nexus between diagnosed PTSD and the stressful event of personal assault in service, the two additional elements required to establish a claim for service connection for PTSD. 38 C.F.R. § 3.304(f). A July 1996 VA examiner noted that he had reviewed the claims file and the veteran's June 1994 statement in support of her claim. The latter told of having depression, nightmares, anger, fear, panic attacks, inability to breathe, inability to trust others, lack of interest, mood swings, lack of friends, feeling guilty, suicidal ideations, sleeplessness, and leaving and quitting jobs due to unexplained actions. The veteran explained that she never discussed having been raped, because she was afraid her daughter would find out. The examiner noted that a progress note from the McClelland Army Hospital noted that the veteran was pregnant when they did a routine examination while in service. She also had seen a counselor at the Vet Center in April and May 1996. The veteran described her rape, indicated that she had wanted to make a career out of the Army, but added that she ended up pregnant and had to leave the service when they found out that she was pregnant. The pregnancy resulted in a daughter. After service she tried different jobs but something would happen and trigger an emotional reaction and she would have one of her spells. This would trigger bad memories and she would have to leave because it would upset her so much and she could not work. The veteran indicated that she had problems with sexual activity from the very start of her marriage. She had actually planned to marry a guy from her home town and she had wanted to be a virgin when she got married, but because of the rape, she could not go back and therefore she married someone else as soon as she could. The veteran never told anyone in service about the rape. After an examination, the examiner diagnosed the veteran with chronic PTSD, delayed (non-combat - rape), major depressive disorder secondary to her PTSD, and rule out generalized anxiety disorder. The examiner added that the veteran gave ample stressors and ample symptomatology to make a PTSD diagnosis. As indicated, the record includes a medical diagnosis of PTSD, competent evidence that supports the veteran's assertion of in-service incurrence of the stressful event of a personal assault, and medical evidence of a nexus between diagnosed PTSD and the stressful event of personal assault in service. For these reasons, and with the resolution of reasonable doubt in the veteran's favor, the Board finds that the veteran's diagnosed PTSD was incurred in service. 38 U.S.C.A. §§ 1131, 5107, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304(f), 4.125(a). ORDER Service connection for PTSD is granted. Service connection for a chronic seizure disorder is denied. REMAND As noted earlier, the VCAA eliminates the requirement that a claimant submit evidence of a well-grounded claim, and provides that VA will assist a claimant in obtaining evidence necessary to substantiate a claim; however, VA is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. It also includes new notification provisions. As part of the notice, VA is to specifically inform the claimant of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The medical examination and etiology opinion requested below are, in part, to comply with this provision. In order to give the veteran every consideration with respect to the present appeal, and to ensure compliance with the VCAA, it is the Board's opinion that an examination is warranted for the purpose of determining whether the veteran has a respiratory disorder that began during or as the result of some incident of active service. In this regard, the Board observes that that an October 1996 VA examiner diagnosed the veteran with bronchial asthma and allergic rhinitis. Service medical records show treatment for an upper respiratory infection, sore throats and colds and reveal that she was given Benadryl. The veteran testified that she began receiving allergy shots for similar symptoms within one year after her discharge from active duty and post-service records from the mid-1975s show continuing treatment and hospitalization for asthma, bronchitis, sinusitis, and rhinitis. The veteran testified that she was unable to obtain records from the two doctors, who had treated her in the 1960s, as their records were no longer available or had been retired. Except to say that no asbestos- or chemically-related lung disease was found, the October 1996 examiner did not comment on whether the diagnosed disorders were related to service. Finally, the Board observes that the contentions raised on appeal and the establishment of an initial rating for PTSD are so closely tied together with each other and the issue of entitlement to TDIU that a final decision on the latter issue cannot be rendered until a decision on the service connection issue has been rendered, and thus are "inextricably intertwined." See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The Board must therefore defer action on the issue of entitlement to TDIU at this time. Accordingly, further appellate consideration will be deferred and the case is REMANDED to the RO for the following actions: 1. The RO should schedule the veteran for a comprehensive VA examination to assess the nature and etiology of a claimed respiratory disorder (s), to include bronchial asthma and allergic rhinitis. All tests and studies deemed necessary should be accomplished. The claims file and a copy of this remand must be made available to, and be reviewed by, the examiner in connection with the examination. After reviewing the claims file and examining the veteran, the examiner should determine whether the veteran has a current respiratory disorder(s). If there is a respiratory disorder(s), the examiner should determine the etiology and the nature and extent of such disorder(s). For each identified disorder, the examiner should offer an opinion as to whether it is at least as likely as not (50 percent or more probability) that such disorder began during, or was aggravated (worsened), as the result of some incident of active service. The rationale for any opinion and all clinical findings should be reported in detail. 2. Then, in light of the additional evidence of record and in conjunction with the entire record, the RO should readjudicate the issue of entitlement to service connection for a respiratory disorder(s). 3. Thereafter, the RO should schedule the veteran for a comprehensive examination(s) to ascertain whether her service-connected disability(ies), together or alone, including PTSD, render the veteran unemployable. 4. After completion of the above, and a review of the entire record, the RO should readjudicate the intertwined issue of entitlement to a TDIU. If any benefit sought remains denied, the veteran should be furnished a supplemental statement of the case, and afforded an opportunity to respond before the case is returned to the Board for further appellate review. The purpose of this REMAND is to obtain additional information and afford the veteran due process. The Board does not intimate any opinion as to the merits of this case, either favorable or unfavorable, at this time. No action is required of the veteran until she receives further notification from the RO. The Board notes that the veteran's cooperation in reporting for any scheduled examination is essential to her appeal, and that any failure to report may result in a denial of her claims. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West 2002) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. ______________________________________________ A. BRYANT Veterans Law Judge, 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.