Citation Nr: 21067375 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 15-04 210A DATE: November 4, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. FINDING OF FACT The Veteran has PTSD that is related to her military service. CONCLUSION OF LAW Resolving all reasonable doubt in the Veteran's favor, PTSD was incurred in active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from September 1966 to September 1969. She had additional service in the United States Army Reserve. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO), which is the Agency of Original Jurisdiction (AOJ). In July 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record. In September 2018, the Board remanded the case to the AOJ for further development. That development was completed, and the case has since been returned to the Board for appellate review. In an October 2020 letter, the Board notified the Veteran that she may request a virtual tele-hearing instead of waiting for a travel board hearing; however, that letter was sent in error, as the record shows that the Veteran has not requested a second hearing. See Quinn v. Wilkie, 31 Vet. App. 284 (2019) and October 2020 Board memorandum. Based on the foregoing, there is no outstanding hearing request. Law and Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). 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). Service connection for PTSD requires (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) credible evidence that the claimed in-service stressor occurred; and (3) a link, established by medical evidence, between current symptoms and an in-service stressor. 38 C.F.R. § 3.304(f). Where a veteran's claimed stressor is not related to combat with the enemy, the veteran's lay testimony alone is generally insufficient to establish the occurrence of said stressor. 38 C.F.R. § 3.304(f). However, in Patton v. West, 12 Vet. App. 272 (1999), the Court held that special consideration must be given to claims for service connection for PTSD based on personal assault as a result of the sensitivity and difficulty in establishing proof of the assault in such claims. Patton also held that medical evidence could be used to corroborate the veteran's claimed stressor in personal assault PTSD claims. Further, 38 C.F.R. § 3.304(f)(5) also allows the veteran to use evidence other than the service treatment records to corroborate his or her account of the stressor incident. This evidence includes, but is not limited to: medical records, police records, statements from the veteran's family and friends, and changes in behavior, to include, substance abuse, a request for a transfer to another military duty assignment, and unexplained changes in social behavior. This evidence is still subject to a credibility analysis. Menegassi v. Shinseki, 638 F.3d 1379, 1382 (Fed. Cir. 2011). A mental disorder diagnosis must conform to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), or, for claims received by or pending before the Agency of Original Jurisdiction (AOJ) on or after August 4, 2014, the DSM-5 (Fifth Edition). See 38 C.F.R. §§ 4.125, 4.130; 79 Fed. Reg. 45093 (Aug. 4, 2014). Because the Veteran's PTSD claim was certified to the Board after August 2014, the regulations pertaining to the DSM-5 are for application. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In considering the evidence under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to service connection for an acquired psychiatric disorder, diagnosed as PTSD. The Veteran has contended that she developed an acquired psychiatric disorder due to events in service, including personal assault and harassment. The Veteran's service records are negative for any treatment or diagnosis of an acquired psychiatric disorder. An August 1966 enlistment examination report noted a normal psychiatric examination, and in an associated report of medical history, the Veteran denied having frequent or terrifying nightmares and depression or excessive worry. An August 1969 separation examination also did not reveal any psychiatric abnormalities, and she denied having a history of depression or excessive worry. However, the Veteran did report having frequent or terrifying nightmares at that time. The Veteran's post-service treatment records show diagnoses of and treatment for acquired psychiatric disorders, including PTSD, depression, and anxiety. The record also documents a long history of physical, sexual, and mental abuse during both her childhood and as an adult. In an April 2009 VA mental health record, a nurse practitioner noted that the Veteran was diagnosed with PTSD from rape, abuse, and neglect as a child and as an adult. In a March 2011 VA mental health record, a clinical social worker noted that the Veteran was struggling with significant depression and that it was clear that the Veteran's depression stemmed from military sexual trauma and a lack of support while she was in the Army. In a December 2011 VA mental health record, a clinical social worker reported that the Veteran had documented PTSD as a result of military sexual trauma and other physical assault while in service. During an October 2014 VA examination, the Veteran was diagnosed with PTSD, an unspecified depressive disorder, and an unspecified alcohol-related disorder in remission. The examiner noted that she had reported that she was sexually abused by various people during her childhood, that she was sexually assaulted by a sergeant in her company while on active duty at Fort Dix, and that she was raped while serving in the Reserves in 1974. The examiner reported that each of the reported stressors were adequate to support the diagnosis of PTSD. In a November 2014 VA addendum opinion, the VA examiner opined that the Veteran's PTSD was less likely than not incurred in or caused by service. She noted that the Veteran had a history of childhood sexual abuse, and therefore, she was unable to draw a nexus between the Veteran's report of nightmares at the time of her separation from service and the reported military sexual assault. The examiner indicated that she was unable to link the Veteran's diagnosis of PTSD solely to her alleged in-service stressors given the history of childhood sexual abuse. In a December 2019 VA opinion, the VA examiner noted that the Veteran had current diagnoses of complex PTSD due to military and childhood trauma and bipolar II disorder. The examiner noted that there was no documented pre-military mental health history in the record. The examiner observed that the Veteran had consistently been diagnosed with PTSD due to pre-military and military trauma. The examiner also noted that the Veteran had been diagnosed with alcohol abuse and depression that occurred prior to service. The examiner found that there was no evidence of an increase in severity or worsening of any psychiatric conditions on active duty. The examiner further indicated that there was no evidence that the Veteran's bipolar disorder (previously diagnosed as a depressive disorder) had its onset during active duty. The examiner stated that there was no verified stressor to support the occurrence of a diagnosis of PTSD during service; however, the examiner did note that the Veteran met the criteria for PTSD due to reported childhood abuse as well as military sexual trauma. The Board acknowledges that the Veteran's service records do not document any incidents of personal trauma or harassment. However, as previously noted, the Veteran did report that she had frequent or terrifying nightmares at the time of her separation examination, which she had previously denied at the time of her enlistment. Moreover, there is medical evidence showing that the Veteran has PTSD that is, at least in part, a result of military sexual trauma. Indeed, a VA clinical social worker has stated that the Veteran had documented PTSD as a result of military sexual trauma and other physical assault in service, and the December 2019 VA examiner diagnosed the Veteran with PTSD due to both military and childhood trauma. These records provide credible supporting evidence of the Veteran's reported stressors. 38 C.F.R. § 3.304(f)(5); Menegassi v. Shinseki, 638 F.3d 1379, 1383 (Fed. Cir. 2011); Bradford v. Nicholson, 20 Vet. App. 200, 207 (2006); Patton v. West, 12 Vet. App. 272, 280 (1999). Therefore, resolving all reasonable doubt in favor of the Veteran, the Board finds that the overall evidence of record shows that in-service personal assault or harassment occurred. Based on the foregoing, the Board finds that the most probative evidence shows that the Veteran's acquired psychiatric disorder, diagnosed as PTSD, is related to personal assault or harassment during service. Accordingly, service connection for PTSD is warranted J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Osegueda, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.