Citation Nr: 21006752 Decision Date: 02/05/21 Archive Date: 02/05/21 DOCKET NO. 15-35 383 DATE: February 5, 2021 ORDER Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is granted. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDING OF FACT Resolving reasonable doubt in favor of the Veteran, his currently diagnosed psychiatric disorder, to include PTSD, is related to service. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder, to include PTSD, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from May 1976 to August 1977. In September 2018, the Board remanded the issues currently on appeal for additional development. In October 2020, a Board hearing was held before the undersigned Veterans Law Judge, and a transcript of the hearing is of record. In November 2020, the Veteran’s representative submitted additional VA treatment records pertaining to the Veteran’s claim for entitlement to service connection for PTSD, and expressly waived initial review of such evidence not previously considered by the agency of original jurisdiction (AOJ). Psychiatric Disorder Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Direct service connection may not be granted without evidence of (1) a current disability; (2) 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. 38 C.F.R. § 3.304; Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Additionally, service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), i.e., a diagnosis conforming to specified diagnostic criteria; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link, or causal nexus, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). If a PTSD claim is based on in-service personal assault, evidence from sources other than service records may corroborate the account of the stressor incident. 38 C.F.R. § 3.304(f)(5). Examples of such evidence include, but are not limited to: records from mental health counseling centers, statements from family members, evidence of behavior changes, and deterioration in work performance. In this case, the Veteran filed a claim for entitlement to service connection for PTSD and depression due to personal trauma in service. See September 2011 VA Form 21-526. As it relates to the Board decision herein, the Veteran asserted that he has PTSD with major depression due to military sexual trauma. See September 2015 VA Form 9. The Veteran reported he was drinking alcohol with other service members in his barrack room, and was sexually assaulted while he was unconscious. See September 2015 VA Form 21-0781a; see also January 2020 VA Form 21-0781a. The Veteran reported he did not seek medical treatment and never told anyone about the incident. The Veteran reported he self-medicated with alcohol and hashish. The Veteran indicated that, at the same time as the sexual assault in service, his father’s health and finances were failing and that he wanted to go back home. The Veteran asserts his request for early discharge from service corroborates his account of military sexual trauma. See October 2020 Board hearing transcript. Service records document that the Veteran’s flight chief relieved the Veteran of duty in March 1977. See Unit Commanders Request for Medical Examination. The Veteran’s commander indicated that there had been no specific behavior change noted until March 1977. The Veteran’s commander reported the Veteran’s father had sold his business due to illness, which adversely affected the Veteran. In March 1977, the Veteran was seen by the Mental Health Clinic and reported his main concerns were related to his job and his family. The Veteran underwent a mental health evaluation in May 1977. The provider indicated the Veteran related feelings of concern over his father’s poor health and business investments, and that the Veteran expressed a lack of job interest and desired discharge. The provider reported there was no evidence of a thought disorder based on psychometric testing and clinical impressions, and the Veteran was not given any mental health diagnosis. However, the provider reported the Veteran exhibited difficulty expressing hostility in a modulated fashion and manifested weak internal controls. In a later service treatment record in May 1977, the provider indicated the Veteran reported he entered service with a good attitude, but at that point, did not care if he received a dishonorable discharge. The provider noted the Veteran had been moved from his room three to four times since being relieved from duty in March 1977. The reason and circumstances for changing rooms was not indicated. The Veteran reported he had thoughts of shooting himself in the leg because of the conditions at work. In August 1977, the Veteran’s request for hardship discharge was approved based on documentation demonstrating the Veteran’s family was experiencing an undue and genuine financial hardship, and a determination that the Veteran’s separation would materially alleviate such conditions. In December 2011 correspondence, the Veteran’s sibling, M.C. reported she observed dramatic changes in the Veteran following his discharge from service. M.C. reported the Veteran appeared withdrawn, depressed, and suicidal. M.C. reported the Veteran’s behavior became increasingly dysfunctional following his separation from service, and that his use of alcohol and drugs escalated. In February 2012 correspondence from another sibling, K.C. indicated that she observed changes in the Veteran’s mental and physical health since returning home from service. K.C. reported the Veteran was unstable in his personal relationships and in his decision-making. Throughout VA treatment records and private treatment records, the Veteran has been diagnosed at various times with psychiatric disorders, including depressive disorders, PTSD, unspecified mood disorder, bipolar disorder, substance use disorders, substance induced mood disorder, generalized anxiety disorder, and personality disorder. See also September 2019 VA medical opinion. Although the Veteran had previously denied military sexual trauma, he reported prior sexual abuse in a June 2011 VA note. See also April 2015 VA psychiatry note (Veteran reported abuse in service that he did not want to discuss at that time); see also September 2015 VA Form 21-0781a (Veteran reported he never told anyone about the sexual assault in service). In a February 2016 VA mental health consult, the Veteran reported he was sexually assaulted in service. Pursuant to the September 2018 Board remand, the Veteran was afforded a VA PTSD examination in September 2019. The examiner reported the Veteran’s claimed stressor of military sexual trauma was adequate to support the diagnosis of PTSD. Although the examiner reported she could find no markers to support the Veteran’s alleged military sexual trauma, she also indicated it was possible that the Veteran’s request for a hardship discharge related to family issues could be considered a marker. The examiner went on to state that she would have to resort to mere speculation to determine whether the sexual assault occurred and/or determine whether the Veteran’s currently reported mental health symptoms were related to the alleged event. The examiner explained that the Veteran’s clinical records documented multiple presentations with varying inconsistent accounts of his past history, and objective evidence of psychological testing demonstrated an over exaggeration of symptoms. In an October 2020 VA note, the psychologist reported that she had worked with the Veteran for approximately four years. The psychologist reported the Veteran had been consistent in experiencing chronic symptoms related to PTSD due to military sexual trauma. In October 2020, VA medical and psychiatric providers reviewed the Veteran’s medical record and determined admission in the Center for Sexual Trauma Services was appropriate for the Veteran. Resolving reasonable doubt in favor of the Veteran, the Board finds the Veteran’s currently diagnosed psychiatric disorder, to include PTSD, is related to service. In this regard, the Board assigns weight to the October 2020 VA treatment records establishing the Veteran’s diagnosis of PTSD is at least as likely as not related to military sexual trauma. Additionally, there is credible evidence of record in support of the Veteran’s report of personal assault in service, including VA mental health treatment records, statements from the Veteran’s family members indicating a change in behavior following service, and documented behavior changes in service. With respect to behavior changes in service, the Veteran’s service records document that, prior to March 1977, the Veteran got along with his peers and superiors, he had no disciplinary problems, and he excelled in his career development course. After March 1977, service records document the Veteran had a poor attitude, was unable to adjust to military life, expressed thoughts of hurting himself, and relocated rooms three to four times for reasons not identified. The Board resolves reasonable doubt in favor of the Veteran in assigning weight to the September 2019 VA examiner’s opinion that it was possible that the Veteran’s request for a hardship discharge related to family issues could be considered a marker of military sexual trauma. In sum, the Board resolves reasonable doubt in favor Veteran in granting his claim for entitlement to service connection for an acquired psychiatric disorder, to include PTSD. REASONS FOR REMAND The Veteran’s claim for entitlement to a TDIU is inextricably intertwined with the initial evaluation to be assigned by the AOJ based on the Board’s decision herein awarding service connection for an acquired psychiatric disorder, to include PTSD. Accordingly, adjudication of the Veteran’s TDIU claim is deferred at this time. The matters are REMANDED for the following action: Readjudicate the issue of entitlement to a TDIU. If the benefit sought remains denied, issue the Veteran and his representative a supplemental statement of the case and inform the Veteran of his appeal options. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Mask, 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.