Citation Nr: 21076957 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 18-31 793 DATE: December 28, 2021 ORDER New and material evidence having been submitted, the claim of entitlement to service connection for epidermolysis bullosa is reopened. Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for epidermolysis bullosa is remanded. Entitlement to service connection for a sleep disorder, to include insomnia, is remanded. FINDINGS OF FACT 1. A June 2014 rating decision denied the Veteran's claim for service connection for epidermolysis bullosa. The Veteran did not appeal or submit new and material evidence within a year of the rating decision; thus, the June 2014 rating decision became final. At the time of the June 2014 rating decision, the Agency of Original Jurisdiction (AOJ) found the Veteran did not have nexus evidence. Since then, the Veteran testified as to how her ACDUTRA service aggravated her skin condition and that it has persisted since her discharge. This evidence is new and material and raises a reasonable possibility of substantiating the claim. 2. Resolving reasonable doubt in the Veteran's favor, the medical evidence shows a diagnosis of PTSD based on a claimed in-service stressor. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen the claim of entitlement to service connection for epidermolysis bullosa. 38 U.S.C. § 7105 (2019); 38 C.F.R. §§ 3.104, 3.156, 20.302 (2020). 2. The criteria for service connection for PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5013A, 5107 (2019); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the Army National Guard with active duty for training (ACDUTRA) from February 2012 to May 2012. She appeals a November 2016 rating decision by the Department of Veterans Affairs (VA) AOJ denying entitlement to service connection for PTSD and sleep impairment, in addition to denying reopening the claim of entitlement to service connection for epidermolysis bullosa. A Board of Veterans' Appeals (Board) hearing was held in September 2021. A transcript is of record. A veteran is entitled to VA disability compensation if there is a current disability resulting from personal injury or disease incurred in, or aggravated by, active service. 38 U.S.C. §§ 1110, 1131. Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167 (2004). Service connection for PTSD requires medical evidence establishing a diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). Within the legal framework for evaluating claims of service connection for PTSD, the sufficiency of a stressor is a medical determination, while the occurrence of the stressor is a legal determination. Sizemore v. Principi, 18 Vet. App. 264 (2004). The Veteran has a clinical diagnosis of PTSD; thus, the first element for service connection is met. See December 2016 VA treatment records. She contends her PTSD is secondary to military sexual trauma (MST). VA regulations provide that, 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. See 38 C.F.R. § 3.304(f)(5). Examples of such evidence include records from mental health counseling centers, hospitals, or physicians and statements from family members or roommates. Id. To that end, a medical opinion based on post-service examination of a Veteran may be used to corroborate the occurrence of a personal assault stressor. See Menegassi v. Shinseki, 683 F.3d 1379, 1382 (2011). Additionally, behavioral changes following the claimed assault may constitute credible evidence of the occurrence of a stressor, such as: 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)(5). Here, as the in-service event, or stressor element, the Veteran asserts she was sexually assaulted one night in May 2012, shortly before her separation, by her "battle buddy" in the laundry room while stationed at Fort Leonard Wood, Missouri. See September 2016 VA Form 21-0781a. While the Veteran is not competent to opine on the etiology of her PTSD, she is competent to testify to facts she personally observed and endured; this includes recalling the traumatic in-service event. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board finds the Veteran's statements are also credible as she recounts the facts consistently throughout the record. See, e.g., December 2016 VA treatment records; see also September 2021 Board Hr. Tr. at 9. The Veteran's in-service records do not contain any report of the incident; however, the Veteran stated she did not report the assault to anyone because she was embarrassed. Id. To bolster the credibility of the Veteran's lay statements regarding her assault, military personnel records confirm the Veteran's other lay statements surrounding her stressor; namely, that her period of ACDUTRA was served at Fort Leonard Wood, Missouri with the C-787th Battalion. See DD Form 214; see generally service treatment records (STRs). The Board finds the Veteran's testimony of in-service assault credible due to the consistency and accuracy of her statements of record. Additionally, the Veteran testified that she had significant behavioral changes after the incident. For example, the Veteran stated she suffered from insomnia shortly after the event and has suffered from chronic sleep disturbances and nightmares ever since. See September 2021 Board Hr. Tr. at 10. Vista Community Clinic (VCC) treatment records reflect the Veteran sought treatment for chronic insomnia that she stated began four years ago, in 2012. See September 2016 VCC records; see also April 2017 VCC records ("sleeps an average of three hours per night since 2012, no caffeine, racing thoughts; sleep disturbances"). The Board also finds the Veteran's statements credible, as they were made for the purpose of medical treatment and are trustworthy. See White v. Illinois, 502 U.S. 346, 356 (1992). The Veteran also testified that since the assault, she needs to be where she can see an exit, and she a voids enclosed spaces and crowded places. Id. The Veteran noted this affects her employability and she is unable to retain a job due to her psychiatric symptoms. Id. The record reflects the Veteran denied use of any narcotics prior to enlistment, but after service, the record reflects the Veteran was diagnosed with substance abuse disorders and she stated she began use shortly after the assault and her discharge from service. See January 2012 enlistment form; see also December 2016 VA treatment records. Finally, during a December 2016 VA mental health intake, the Veteran noted prior suicide attempts in 2014 and October 2016, and recent physical violence in an October 2017 VA treatment record. The Veteran's STRs and record prior to service do not note any legal or psychiatric issues. As such, the Board finds the totality of the evidence establishes the occurrence of an in-service stressor and the second element for service connection is met. See Menegassi, supra. In December 2016, a VA psychologist conducted a detailed mental health examination. After the examination, the psychologist confirmed the Veteran "reported a history of trauma related symptoms, relating to her MST in 2012" diagnosed the Veteran with PTSD, and found the in-service MST a sufficient stressor for a PTSD diagnosis. See December 2016 VA treatment records. The Board finds the December 2016 VA treatment record probative as the psychologist thoroughly examined the Veteran, reported her history and symptoms, and the psychiatric examination was for the purpose of medical treatment, not VA compensation benefits. Thus, the Board finds the third Shedden element is also met. Thus, providing the benefit of the doubt, the aforementioned lay and medical evidence sufficiently establishes the occurrence of an in-service stressor and links it to the Veteran's PTSD. See Menegassi, supra. The third element is met and the Board grants service connection for PTSD. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). REASONS FOR REMAND Sleep Disorder A veteran is entitled to a VA examination if there is (1) competent evidence of a current disability, (2) evidence that an injury occurred in service, and (3) an indication that the disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran is now service connected for PTSD. However, she contends her sleep impairment is also related to her in-service assault. April 2017 VCC records reflect the Veteran was diagnosed with "insomnia, unspecified type." It is unclear from the record whether her insomnia is a symptom of her now service-connected PTSD or a separate diagnosis related to her in-service MST. As the Veteran has not yet been afforded a VA examination, a remand is required. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Epidermolysis Bullosa The Veteran contends her skin condition was aggravated by her service. See September 2017 Notice of Disagreement (NOD). Specifically, she stated her skin condition was mild before service, but once she began her period of ACDUTRA, "it started to act up" with "blisters, scars, and [peeling skin] due to the stress level and training." Id. She also noted her hands and feet would ache, it would hurt to put her boots on, and sores would heal and "re-blister because of the pressure." See September 2021 Board Hr. Tr. at 4. In October 2013, a VA examiner noted the Veteran was separated from service for this skin condition and opined her in-service symptoms were the "natural progression of the disorder and was not likely aggravated by military service." The VA examiner provided no rationale for this opinion. Further, the Veteran has since provided relevant lay statements noting that her condition was aggravated in service and has maintained the same severity since. Id. at 3. Thus, the October 2013 VA examination is inadequate for Board review and a remand is required. The matters are REMANDED for the following action: 1. Obtain any relevant updated private and VA treatment records that have not already been obtained and associate the same with the claims file. 2. Thereafter, schedule the Veteran for an examination by an appropriately qualified clinician to determine the nature and etiology of any sleep disorder, to include insomnia. Any required or indicated tests or studies should be provided. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. A complete history should be elicited directly from the Veteran and the opinion should include a notation that this record review took place. After a thorough review of the record, the examiner should answer the following: (a). Is it at least as likely as not (a 50 percent probability or more) that any current sleep disorder, to include insomnia, was the result of her in-service assault during a period of ACDUTRA? (b). Is it at least as likely as not (a 50 percent probability or more) that any current sleep disorder, to include insomnia, was (1) caused or (2) aggravated by her service-connected PTSD? The examiner is directed to consider April 2017 Vista Community Clinic records noting a diagnosis of "insomnia, unspecified type." The examiner should note the Veteran is competent to report her symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, a reason for doing so should also be provided. A full and complete rationale for all opinions must be provided, and a discussion of the facts and medical principles should be considered. 3. After the development of #1 above is complete, schedule the Veteran for an examination by an appropriately qualified clinician to determine the nature and etiology of her epidermolysis bullosa. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. A complete history should be elicited directly from the Veteran and the opinion should include a notation that this record review took place. After a thorough review of the record to include all in-service and post-service treatment records, the examiner should answer the following: Is it at least as likely as not (a 50 percent probability or more) that the Veteran's epidermolysis bullosa was incurred in or aggravated by disease or injury incurred during ACDUTRA or injury incurred during a period of INACDUTRA? The examiner is directed to consider the Veteran's September 2021 Board testimony on pages 3-5 that her symptoms worsened in service due to the pressure and stressful environment and have persisted since service. The complete rationale for all opinions should be set forth, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. (Continued on the next page) 4. After the above has been completed to the extent possible, readjudicate the claim. If any benefit sought remains denied, provide the Veteran and her representative with an SSOC and return the case to the Board. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Bona, Associate 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.