Citation Nr: 1120768 Decision Date: 05/27/11 Archive Date: 06/06/11 DOCKET NO. 97-06 642A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Wilmington, Delaware THE ISSUE Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran served on active duty from August 1990 to December 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 1996 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, in which the RO, in pertinent part, denied service connection for PTSD. During the pendency of the appeal, the Veteran's claims file was transferred to the jurisdiction of the Wilmington, Delaware RO. In March 1996, the Veteran testified before a Hearing Officer at the RO. A transcript of that hearing is of record. In a July 2005 decision, the Board denied service connection for PTSD. The Veteran, in turn, appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In November 2007, the Court issued a Memorandum Decision vacating the Board's July 2005 decision and remanding the claim to the Board for proceedings consistent with the Court's decision. In May 2008, the Board remanded the claim for service connection for PTSD for further development. As a final preliminary matter, the Board notes that the claims file reflects that the Veteran was previously represented by Disabled American Veterans (as reflected in a May 1995 VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative). In November 2004, the Veteran filed a VA Form 21-22, appointing Vietnam Veterans of America as her representative. The Board recognizes the change in representation. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim on appeal has been accomplished. 2. There is credible evidence of record that tends to corroborate the occurrence of the reported stressor of an in-service sexual assault. 3. The record reflects a diagnosis of PTSD that has been associated, at least in part, with an in-service sexual assault. CONCLUSION OF LAW Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for PTSD are met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.125(a) (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010). The Court, in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), has held that the VCAA notice requirements apply to all elements of a claim. Given the favorable disposition of the claim on appeal, the Board finds that all notification and development actions needed to fairly adjudicate this claim have been accomplished. Law and Regulations Service connection may be established for disability resulting from personal injury or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability on the basis of the merits of such claim is focused upon (1) the existence of a current disability, (2) the existence of the disease or injury in service, and (3) a relationship or nexus between the current disability and any injury or disease during service. See Cuevas v. Principi, 3 Vet. App. 542 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Service connection for PTSD requires medical evidence establishing a diagnosis of the disorder; a link, established by medical evidence, between current symptomatology and the claimed in-service stressor(s); and credible supporting evidence that the claimed in-service stressor(s) actually occurred. 38 C.F.R. § 3.304(f). [Parenthetically, the Board notes that the version of the law in effect at the time the Veteran initially filed her claim for service connection for PTSD in 1993 required a "clear" diagnosis of PTSD; that requirement has since been eliminated. As regards the first of the three regulatory criteria, the revised version requires only a diagnosis rendered in accordance with 38 C.F.R. § 4.125(a), which incorporates the provisions of the 4th Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).] During the pendency of this appeal, 38 C.F.R. § 3.304(f) was amended, effective March 7, 2002, with respect to claims based on personal assault. See 67 Fed Reg. 10330-10332 (March 7, 2002), codified at 38 C.F.R. § 3.304(f)(4). The present case falls within the category of situations, to include allegations of personal assault, in which it is not unusual for there to be an absence of service records documenting the events of which the veteran complains. See, e.g., Patton v. West, 12 Vet. App. 272, 281 (1999). The amendments to 38 C.F.R. § 3.304(f) noted above reflect a recognition that service records may not contain evidence of personal assault, and that alternative sources, including testimonial statements from confidants such as family members, roommates, fellow service members, or clergy, may provide credible evidence of an in-service stressor premised on personal assault. See YR v. West, 11 Vet. App. 393, 399 (1998). See also VA Adjudication Manual, M21-1MR, Part IV, Subpart ii, Chapter 1, Section D, Topic 17, Developing Claims for Service Connection for PTSD Based on Personal Trauma (Sept. 8, 2009). Specifically, under 38 C.F.R. § 3.304(f)(4), if a PTSD claim is based on in-service personal assault, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: 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. See 38 C.F.R. § 3.304(f)(4). VA more recently amended its regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard to establishing the required in-service stressor. Specifically, 38 C.F.R. § 3.304 was amended to include a paragraph which, in pertinent part, states that, if a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(f)(3) (effective July 13, 2010); 75 Fed. Reg. 39843 (July 13, 2010). While the amended regulation applies to all claims seeking service connection for PTSD that were appealed to the Board by July 13, 2010 but not yet decided by the Board as of that date, the Board finds the amended regulation is not for application in this case because the Veteran's reported stressor does not involve fear of hostile military or terrorist activity, as contemplated by the regulation. Instead, as discussed below, the Veteran claims service connection for PTSD related to an in-service sexual assault. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one that exists because of an approximate balance of positive and negative evidence which does satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. 38 C.F.R. § 3.102. See also 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Factual Background and Analysis Considering the pertinent evidence of record in light of the above-noted legal authority, the Board finds that service connection for PTSD is warranted. The Veteran asserts that she has PTSD related to an in-service sexual assault which occurred in March 1992. As noted in the Board's prior remand, several attempts by VA to obtain the Veteran's service treatment records have met with only limited success. When, as here, at least a portion of the service records cannot be located, through no fault of the Veteran, VA has a "heightened" obligation to more fully discuss the reasons and bases for its decision and to carefully consider applying the benefit- of-the-doubt doctrine. See, e.g., O'Hare v. Derwinski, 1 Vet. App. 365 (1991). Service personnel records associated with the claims file reflect that, in June 1991 and February 1992, the Veteran was issued an Armed Forces Traffic Ticket for speeding. In April 1992, she wrongfully consumed alcoholic beverages while under the age of 21, for which she received punishment under Article 15 of the Uniform Code of Military Justice (UCMJ). The report regarding this incident reflects that the Veteran was described as falling in and out of consciousness, and she was transported to the hospital for treatment, where she had a blood alcohol concentration (BAC) of 0.0997 percent. A May 1992 evaluation of performance for the period from August 1990 to April 1992, reflects that the Veteran was an excellent performer who consistently produced high quality work; had extensive knowledge of all primary duties and related positions; met Air Force standards; was effective at leading; consistently exceeded all training requirements; and was consistently able to organize and express ideas clearly and concisely. However, the Veteran's conduct on/off duty was rated as unacceptable, and she was not recommended for promotion. The indorser's comments noted that the Veteran had increased system knowledge by briefing student weapons controllers on current weapons systems, had exceeded squadron goal in her role as a crew blood drive representative, was involved in the community, and had achieved 42 semester hours towards a degree, with a 3.5 GPA; however, her conduct was rated unacceptable based on her consumption of alcohol as a minor. In response to this evaluation, several memorandums from fellow service members were submitted in May 1992. Notably, SSgt. J.C. indicated that she had known, supervised, and worked with the Veteran for over a year, and her character and behavior had been above reproach. She added that the Veteran's initiative, integrity, and professionalism were indicative of her cheerful personality, and her attitude towards her work and completing all tasks assigned with little or no supervision made her job easier. Sgt J.V. discussed the Veteran's duty performance under his supervision, and stated that her duties and responsibilities had always been accomplished in a timely manner, with tasks thoroughly and correctly completed without any complaint or evasiveness. TSgt. C.B. indicated that he had been the Veteran's supervisor for the past six months, during which time she had performed her duties outstandingly, in addition to volunteering for numerous additional duties. He added that, because of her "can-do" attitude, self-motivation, and professionalism, he had come to rely on her to get the job done. Service treatment records which have been associated with the claims file include records of treatment for alcohol abuse in August 1992. During this hospitalization, the Veteran reported that she had her first drink at age 13 and was first drunk at age 16. She added that, during her senior trip to Mexico, she drank nearly the entire week. She also described a history of physical and sexual abuse as a child. The Veteran stated that she was approximately age 19 when something occurred of which she did not approve, but added that this had never been a "real problem" for her. She did not elaborate as to what had occurred. A September 1992 memorandum from the Interim Director of the Alcoholism Rehabilitation Center (ARC) reflects that the Veteran entered a 28-day program, which she did not complete, with psychological issues, including unresolved childhood abuse by her father and a recent rape issue. While she made mention of these and other issues, the Interim Director commented that she made no known attempts to resolve any of her issues. Twice in November 1992, the Veteran failed to go to her appointed place of duty at the time prescribed. In a record of counseling regarding one of these incidents, the counselor acknowledged that the Veteran was having problems getting to sleep, which resulted in difficulties getting up for work, and recommended that she see a physician about her sleeping problem. Later that month, after arriving for her detail, she disappeared approximately an hour later, without being released or accomplishing all assigned tasks. One week later, she fell asleep while performing her duties on two separate occasions. In December 1992, she failed to go to her appointed place of duty at the time prescribed. In December 1992, the Veteran's commander recommended that she be discharged for a pattern of misconduct consisting of minor disciplinary infractions. In response to the recommendation for discharge, the Veteran indicated that she was only 20 years old and was, for the first time, out on her own. She described herself as young and inexperienced, and stated that her inexperience and naiveté had led to wrong choices and affected her decisions. The Veteran was discharged in December 1992. Her Form DD 214 reflects that she received a general discharge under honorable conditions. The reason for separation was involuntary, specifically, a pattern of misconduct. In March 1993, the Veteran filed an application for an upgrade of her discharge. In this application, she stated that, in April 1992, she went to a local nightclub with the intention to get drunk, as she was trying to forget about being raped the weekend before. She added that her friends brought her to the emergency room, where she had a BAC of 0.0997 percent, which was too high, as she was under age and not able to hold alcohol because she did not normally drink. She added that, after this incident, she started to have problems falling asleep, which made it difficult to get up on time, and she was late for work a few times. The records regarding the Veteran's discharge upgrade include a March 1994 memorandum authored by Captain B.E.B., an Action Officer which noted that the Veteran's medical records were missing from her files. She then contacted the physician at Behavioral Sciences, Dr. B.. He indicated that the Veteran's mental health records were at that facility, and he agreed to review them. Dr. B. reported that the medical records did not allude to sexual abuse until October 1992; although, at that time, the Veteran did not discuss the event in detail. Her counselor asked her to write the trauma down and bring it to her next appointment. While no written description of the incident was included in the file, Dr. B. stated that it was not unusual for such a document not to be kept in the records, as it was more likely destroyed. He added that the Veteran discussed the incident in more detail in November 1992, when she was referred to a counselor at the Salvation Army. The Veteran's Behavioral Sciences counselor was also contacted. He stated that the Veteran did not fully reveal that she was a rape victim as an adult until November 1992, and that he had encouraged her to get rape counseling at the Salvation Army. In July 1994, the Air Force Discharge Review Board concluded that the character of the Veteran's discharge should be changed to honorable. A new Form DD 214 was issued. On VA general medical examination in April 1993, the Veteran reported that she was raped in March 1992 and underwent counseling, as she had symptoms referable to the stress. The pertinent diagnosis was history of stress secondary to rape. On VA psychiatric examination later in April 1993, the Veteran reported that she had been raped in April 1992 in Mexico Beach, but that she did not report the incident to the police because she "just wanted to drop it." She reported that she saw a doctor approximately one month later and had a pelvic examination done. She stated that she had contracted Chlamydia and was tested for AIDS. She indicated that she lost 20 pounds in the month following the rape, and that she had had intrusive thoughts and dreams about the incident. She stated that, one week following the rape, she got drunk and was subsequently subjected to nonjudicial punishment and alcohol counseling. The diagnostic impression following examination was adjustment reaction with mixed anxiety and depressive symptoms. The psychiatrist noted that there were some PTSD symptoms present, but that it was impossible to validate that a rape occurred. In correspondence dated in May 1995, the Veteran's aunt reported that she and her husband were aware of the "traumatic incident" that happened to the Veteran at Mexico Beach in April 1992, as she had called and told them about it. In correspondence dated in May 1995, a Vet Center counselor indicated that the Veteran had been seen at the Pensacola Vet Center on a regular basis for individual counseling for sexual trauma suffered while in the military, since January 1995. She added that she began attending a sexual trauma support group for female veterans who had suffered sexual trauma while in the military in May 1995. The counselor reported that the Veteran had described two sexual assaults in service, indicating that, after the first assault she "got on with her life" but that the second assault was so devastating she began to drink excessively to "block out" the event. In March 1996, the same Vet Center counselor reiterated that the Veteran attended individual and group counseling, and that she reported being sexually assaulted twice during service. In both letters, the counselor noted that the Veteran experienced nightmares, insomnia, depression, anxiety attacks, isolation and problems with personal relationships. During the March 1996 hearing, the Veteran indicated that she was unable to forget about the in-service assault, and that she subsequently went out with friends and got drunk so she would not have to think about it anymore. She reported that she did not receive treatment from her discharge from service until she started seeing the Vet Center counselor in January 1995. She added that her counselor had told her that her problem was stress due to the traumatic incidents she had experienced. Records of VA treatment dated from 1996 to 2000 reflect several periods of hospitalization with diagnoses including substance dependence (to include alcohol, cocaine, stimulant, opioid, and nicotine dependence); eating disorder, not otherwise specified; borderline personality disorder; depression; and PTSD. Of note, the discharge summary from a period of hospitalization in June and July 1997 reflects Axis I diagnoses of heroin dependency, history of migraine, cocaine dependency, PTSD, and borderline personality disorder. Records of treatment during this hospitalization, as well as a period of hospitalization earlier in June 1997, reflect that the Veteran's psychiatric problems included PTSD. During hospitalization in September 1996, the Veteran reported that her relapse had been triggered to forget things that happened in the military, specifically, a rape. Also during this hospitalization, she gave a history of significant alcohol and stimulant use daily since age 19. During treatment in September 1996, she described recent rapes in April 1992, December 1994, and July 1996. In discussing her abuse history, she reported being raped by a male relative at age 13, by a male who was possibly a friend or acquaintance in 1992, and by a male acquaintance in the military in 1994. She stated that these incidents were not reported. A psychological assessment from this period of hospitalization indicates that the Veteran should be assessed to determine whether what appeared to be borderline symptoms might also reflect PTSD. During hospitalization from December 1996 to April 1997, the Veteran reported being raped from the ages of 10 to 13 by her stepfather, and stated that she was also raped in the military. She also indicated that she was raped after service, in 1994 and 1996, and gave a history of physical emotional, and verbal abuse in her family. During treatment in February 1997, the Veteran's psychiatrist noted that she had anxiety/panic attacks while in an elevator and outside; which was typical in PTSD patients. An April 1997 treatment record reflects that the Veteran had a sense of futility about her future due to multiple factors, including sexual abuse while in the military. Also in April 1997, the Veteran described her legal history, and reported that she had been arrested for driving under the influence, public disturbance, disorderly conduct, and threatening a police officer, in 1992, 1994, and 1996. A record of treatment from a period of hospitalization later in April 1997 notes that the Veteran's psychiatric problems included PTSD. In January 2005, the Veteran underwent a VA examination by a psychologist and a physician. The examiners indicated that the Veteran's service treatment records were not available, but that she was felt to be a generally reliable historian. In discussing her social history, the Veteran reported that she was raped by her stepfather at age 13; that she had her first drink at age 13; and that she was first drunk at age 16. She stated that she currently drank on the weekends and sometimes during the week. The examiners summarized the Veteran's psychiatric history, including treatment from 1992 to 2001. They noted that, during treatment in 2001, a VA psychologist documented that the Veteran "started drugs in high school and then quit when a friend died from an overdose. [She] suffered a sexual trauma in military and resumed drug use again." In discussing her military history, the Veteran reported that she was raped on active duty and that, as a result of the rape, she got drunk and was brought to the emergency room and hospitalized. On mental status examination, the Veteran answered all questions posed, but did not provide great detail. She declined to discuss any details concerning the rape incident on active duty. The examiners noted that the Veteran did not volunteer any symptoms that were unequivocally specific for PTSD, but that an invitation to respond to a list of specific symptoms produced an endorsement, with little elaboration, as to the following: avoidance of television programs that trigger some psychological distress, occasional bad dreams, feeling anxious in open places, avoiding close friends, being nervous and jumpy, and startling easily. The psychiatric diagnoses on Axis I and Axis II were alcohol abuse; alcohol dependence, reported to be in remission; heroin abuse and dependence, reported to be in remission; polysubstance abuse (cocaine, amphetamine, marijuana, nicotine); eating disorder, not otherwise specified; anxiety disorder, not otherwise specified; and personality disorder, not otherwise specified. The psychosocial stressors listed on Axis IV included enduring of rape by stepfather and rape while on active duty. The examiners noted that they had each interviewed the Veteran and fully reviewed the medical records. In response to being asked to determine whether the Veteran was exposed to a stressor in service, they indicated that exposure to a stressor in service could not be determined by a psychological and psychiatric examination, but should be determined administratively. They indicated that the Veteran did endorse some symptoms of PTSD, and that such symptoms overlapped with symptoms resulting from alcohol and substance abuse and could not be unequivocally assigned as deriving specifically from the reported rapes. They pointed out, however, that even if the reported symptoms were specifically derived from the reported rapes, such symptoms would not meet the full diagnostic criteria for the diagnosis of PTSD. They concluded that PTSD was not an appropriate diagnosis for the Veteran. They pointed out that although the reported in-service rape might be linked to a few of the Veteran's currently reported symptoms, the more likely cause of such symptoms was her long history of alcohol and polysubstance abuse, personality disorder, and pre-military developmental and sexual abuse issues. The Veteran was most recently afforded a VA examination to evaluate her claimed PTSD in April 2010. The psychologist noted that the Veteran did not admit to sexual abuse by her stepfather until directly asked, when she indicated that he sexually abused her once at age 13. The examiner noted that her records indicated sexual abuse between the ages of 10 and 13 as well as verbal and emotional abuse. The examiner further noted that the Veteran's records reflected that she had a close friend who died from a drug overdose. She described the in-service stressor of being sexually assaulted on Mexico Beach in March 1992. The examiner noted that the Veteran's records indicated multiple sexual traumas since (specifically, in 1994 and 1996). In regard to PTSD symptoms, the Veteran described persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, and persistent symptoms of increased arousal. The examiner commented that the disturbance caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. She added that the Veteran endorsed severe symptoms of PTSD since her military trauma. The examiner indicated that the Veteran met the DSM-IV stressor criterion, based on multiple sexual traumas, verbal and emotional abuse, and loss of a friend to drug overdose. The examiner stated that the Veteran met the DSM-IV criteria for a diagnosis of PTSD. The Axis I diagnoses were PTSD, chronic, severe; alcohol dependence; and polysubstance dependence in early remission per Veteran's report. The examiner commented that the Veteran denied any symptoms of PTSD related to her sexual abuse by her stepfather, claiming that she dated in a normal fashion and had good academic standing prior to her military service. However, the examiner opined that, based on review of the record, the Veteran did not have a stable home life growing up, as she experienced sexual, verbal, and physical abuse, and lost a friend to drug overdose. She noted that this friend's mother held the Veteran responsible for the death of her daughter. The examiner also noted that the Veteran began drinking and using drugs at age 16. The examiner opined that the Veteran's current psychosocial impairment was mainly due to her long lasting history of alcohol and polysubstance dependence and her borderline personality disorder, which originated from her childhood experiences and traumas. The examiner commented that the Veteran was quite familiar with PTSD symptoms, and had endorsed many of them; enough to meet the full criteria for PTSD. The examiner went on to note that the Veteran's psychiatric problems other than PTSD shared many symptoms with PTSD, and it was difficult to tease all of these symptoms apart, and acknowledged that a July1997 treatment record included a diagnosis of PTSD. The examiner added that the Veteran was not cooperative with providing detailed information about her military sexual trauma and that, if this trauma could be substantiated, it only played a smaller contributing role to the Veteran's current psychosocial impairment and mental health status. The examiner also noted changes in the Veteran's functional status and quality of life following trauma exposure, including her performance in employment, family role functioning, social/interpersonal relationships, and recreation/leisure pursuits, commenting that the Veteran was divorced, had not been dating since her divorce, did not have any friends, and had only minimal leisure activities. The most recent VA examination reflects a current diagnosis of PTSD. Thus, the first element of the service connection claim is satisfied. Regarding the second element, a link between current PTSD and an in-service stressor, the Board observes that, in her April 2010 VA examination report, the examiner opined that, if in-service sexual trauma could be substantiated, it played a smaller contributing role to the Veteran's current psychosocial impairment and mental health status. While the service records associated with the claims file do not specifically document the claimed March 1992 assault, as noted above, where the stressor is within the category of personal assault, it is not unusual for there to be an absence of service records documenting the events of which the veteran complains. See Patton, 12 Vet. App. at 281. In Patton, the Court stated that in two places, the VA Adjudication Procedure Manual M21-1, appeared to improperly require that the existence of an in-service stressor be shown by "the preponderance of the evidence" and held that any such requirement was inconsistent with the benefit of the doubt doctrine found in 38 U.S.C.A. § 5107(b). Therefore, the evidence need only be in relative equipoise to prevail on the question of existence of the stressor. Patton at 280. While complete service treatment records have not been associated with the claims file, service records which have been obtained reflect that, during hospitalization for alcohol abuse in August 1992, the Veteran stated that something of which she did not approve occurred when she was 19 (her age in March 1992), although she did not elaborate. The September 1992 memorandum from the Interim Director of the ARC indicates that the Veteran entered that program with a recent rape issue. The physician at Behavioral Sciences, Dr. B., reported in March 1994 that the Veteran's in-service mental health records did not allude to sexual abuse until October 1992, and her counselor at that facility reported that she revealed that she was a rape victim as an adult in November 1992. In addition, the while the Veteran has been somewhat inconsistent in describing her substance abuse history (for example, reporting her first use of various substances at different times from age 16 to 19 during VA treatment in 1996 and 1997 and indicating in her March 1993 application for an upgrade in her discharge that she did not normally drink while other records reflect that she began drinking at age 16), service records do document underage drinking with a BAC of over 0.09 percent in April 1992, shortly after the reported assault. In addition, during VA hospitalization in September 1996, the Veteran described significant alcohol and stimulant use daily since age 19. While the evidence of record reveals drug use prior to service, the January 2005 VA examination report reflects that VA treatment records indicated that the Veteran had quit using drugs after the death of a friend, but resumed following the reported sexual trauma in service. Of note, the Veteran was described as a generally reliable historian by the VA examiners who evaluated her in January 2005. Moreover, while she was issued two traffic tickets for speeding prior to the reported sexual assault in March 1992, her service personnel records include several memorandums from fellow service members dated in May 1992, which reflect good attitude and work performance. Further, her May 1992 performance evaluation reflects that the Veteran performed satisfactorily or better in all areas of evaluation other than her conduct on/off duty. However, service personnel records reflect that, after the reported sexual assault in March 1992, the Veteran was counseled for failure to go to her appointed place of duty at the time prescribed, disappearing from her detail, and falling asleep while performing her duties. Further, in April 1997, the Veteran reported that she had been arrested for driving under the influence, public disturbance, disorderly conduct, and threatening a police officer, in 1992, 1994, and 1996. The Board finds that the foregoing evidence tends to reflect behavior changes following the claimed assault, applicable under 38 C.F.R. § 3.304(f). When taken in conjunction with the lay evidence from the Veteran's aunt, indicating that the Veteran had told her and her husband about a "traumatic incident" that happened to the Veteran at Mexico Beach in April 1992, the Board finds the evidence to be at least in equipoise as to the Veteran's claim of an in-service sexual assault, and thus the benefit of the doubt rule applies. See Gilbert, 1 Vet. App. at 55. Therefore, the Board finds the Veteran's claimed in-service sexual assault stressor to have occurred. While the April 2010 VA examiner opined that the claimed in-service sexual assault only played a smaller contributing role to the Veteran's current psychosocial impairment and mental health status, for service connection, the in-service assault need not be the only stressor resulting in the Veteran's PTSD; it must only be a contributing cause. Thus, the Veteran's current PTSD has been attributed, at least in part, to the in-service sexual assault. Given the foregoing, and with resolution of all reasonable doubt in the Veteran's favor, the Board finds that the three requirements for establishing service connection have been satisfied. See 38 C.F.R. § 3.304(f). Accordingly, service connection for PTSD is warranted. ORDER Service connection for PTSD is allowed. ____________________________________________ RENÉE M. PELLETIER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs