Citation Nr: 1325417 Decision Date: 08/12/13 Archive Date: 08/16/13 DOCKET NO. 11-10 936 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). ATTORNEY FOR THE BOARD Marne Marotta, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1980 to June 1984. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. FINDING OF FACT Affording the Veteran the benefit of the doubt, her current diagnosed PTSD is related to service. CONCLUSION OF LAW The criteria for service connection for PTSD have been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 and 3.304(f) (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Notice and Assistance VA has duties to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Sufficient evidence is of record to grant the Veteran's claim of entitlement to service connection for PTSD. Accordingly, whether or not VA has met its duties of notice and assistance is of no consequence, as there is no prejudice to the Veteran. II. Service Connection Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); 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). 38 C.F.R. § 4.125(a) requires that diagnoses of mental disorders conform to the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV). When a claim for PTSD 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 ... records from ... physicians." 38 C.F.R. § 3.304(f)(5). "VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred." Id. III. PTSD The Veteran states that she was sexually assaulted by her husband on several occasions while on active duty, beginning in late 1981 or early 1982. In support of her claim, the Veteran submitted a completed personal trauma PTSD questionnaire and statement dated September 2008. The Veteran contends that on one occasion after retiring for the evening, she had an argument with her husband. She turned away, but the Veteran's husband grabbed her by the shoulders and forced her onto their mattress. While he held her down with one arm across her shoulders, the husband raped the Veteran. The Veteran contends that on another occasion, her husband grabbed her around the neck, forced her down on the floor, forcibly tore her clothing and raped her. The Veteran also states that she tried to commit suicide by swallowing "a bunch of pills," but sought treatment and that she "lie[d] out of fear of him." Veteran Statement, dated September 2008. The Veteran also noted in her claim that she is not currently living with her husband because "[h]e was the one responsible for the PTSD." The Veteran's service treatment records (STRs) and service personnel records (SPRs) are silent of for complaints, findings, treatment, or diagnosis of any psychiatric disability, and for any signs of behavioral changes or requests for tests for sexually transmitted diseases. The Veteran's STRs do, however, indicate that the Veteran became pregnant in November 1982 and desired an abortion. In a 1987 Record of Emergency Data, the Veteran named two daughters born in 1984 as her only children. In June 2008, the Veteran was screened for a VA research study entitled "Manualized Treatment for Veterans with Military Sexual Trauma." After a screening interview, the Veteran was referred for VA psychological testing, where she was diagnosed with PTSD, chronic, severe and major depressive disorder, recurrent, severe without psychotic features. The Veteran was accepted into the research study, where she completed 11 of 12 sessions. During the assessment, the examiner administered the PTSD scale for DSM-IV (CAPS) and conducted a clinical interview for DSM-IV-TR Axis 1 disorders. Most significantly, the examiner noted that the Veteran suffered from "a series of ongoing sexual assaults by her husband that occurred during her tour in the United States Army." VA PTSD Evaluation, dated June 2008. The examiner also noted that "[d]iagnostic interview questions focused on these events to determine the presence and severity of PTSD." The examiner found that the Veteran's detailed description and reaction to repeated sexual assaults by her husband during service satisfied Criterion A (stressor) for PTSD. The examiner noted that the Veteran met the criteria for three symptoms of Criterion B (intrusive recollection) for PTSD, when only one is required. These symptoms included "recurrent and intrusive distressing recollections of the rapes that occurred several times per week, caused considerable distress and interfered significantly with completing daily activities such as housework and personal grooming and meeting responsibilities." For Criterion C (avoidant/numbing), the Veteran met five of the seven symptoms within the last month when only three are required. The examiner reported that the Veteran made conscious effort to avoid thoughts or feelings associated with the rapes about twice per week during the previous month; made conscious efforts to avoid activities, places, and people that aroused recollections of the trauma several times a week; generally stayed at home when she was not working, and experienced a loss of interest in activities that she had previously enjoyed. The Veteran also reported four symptoms that satisfy the symptoms of Criterion D (hyper-arousal), when two are required. The examiner noted that the Veteran had extreme difficulty sleeping; felt especially irritable about twice a week; and had difficulty concentrating about one-third of the time. Criterion E (duration) was met because the Veteran experienced symptoms that caused her distress within the last month. The Veteran's global assessment of functioning (GAF) score was 45. The Board finds that entitlement to service connection for PTSD is warranted. The Veteran's service treatment records do not reveal any complaint, diagnosis, or treatment for any psychiatric disorder. In addition, service personnel records that have been associated with the claims file do not reveal any complaints or requests for transfer or poor evaluations. However, the Veteran has competently and credibly reported that she was sexually assaulted on several occasions in service. In addition, the Veteran has competently and credibly reported that she has had symptoms of a stress disorder since service. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Although there is no evidence of the Veteran's reported sexual harassment in her service treatment records or any indication of poor performance appraisals or requests to be transferred in the service personnel records associated with the claims file, evidence of record associates the Veteran's PTSD with events in service. In PTSD cases where the alleged in-service stressor is a sexual assault, a medical opinion based on a postservice examination of the Veteran can be used to establish the occurrence of the stressor. Menegassi v. Shinseki, 638 F.3d. 1379 (Fed. Cir. 2011). Aware that the Veteran was being considered for a VA military sexual trauma study, a VA examiner diagnosed the Veteran with PTSD based on a series of sexual assaults that occurred while the Veteran served on active duty. VA PTSD Evaluation, dated June 2008. The examiner noted that the Veteran was open, frank and detailed in her description of the assaults and found that there was an in-service stressor that satisfied Criterion A for a PTSD diagnosis. The Board finds that the stressor has been corroborated. As the Veteran has competently and credibly reported that she was sexually assaulted in service and as a VA medical examiner has associated the Veteran's current PTSD with the sexual assaults in service, the Board finds that the evidence is at least in equipoise that the Veteran's PTSD is related to her active duty service. As such, entitlement to service connection for PTSD is granted. ORDER Service connection for PTSD is granted. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs