Citation Nr: 9929281 Decision Date: 10/12/99 Archive Date: 10/21/99 DOCKET NO. 98-00 991 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUE Whether new and material evidence has been submitted to reopen a claim for entitlement to service connection for Post Traumatic Stress Disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARINGS ON APPEAL Appellant; A.R., M.D. ATTORNEY FOR THE BOARD K.L. Salas, Associate Counsel INTRODUCTION The veteran had active military service from March 1981 to March 1985. This appeal arose from March 1997 and July 1997 rating decisions by the Department of Veterans Affairs (VA) Albuquerque, New Mexico Regional Office (RO). The RO determined that the veteran had not submitted new and material evidence to reopen a claim for entitlement to service connection for PTSD. The case has been forwarded to the Board of Veterans' Appeals (Board) for appellate review. The veteran has asserted on a number of occasions that she wishes to have major depression and anxiety service connected as well as PTSD. Claims for these benefits would not be inextricably intertwined with the claim for entitlement to service connection for PTSD. This matter is referred to the RO for appropriate consideration and any necessary action. In September 1997 the veteran filed a claim for entitlement to service connection for headaches and a spine condition. In November 1997 the veteran filed a claim for entitlement to an increased evaluation for a condition of the "feet." These matters are likewise referred to the RO for appropriate consideration and any necessary action. FINDINGS OF FACT 1. In August 1995 the RO found that new and material evidence had been submitted to reopen a claim for entitlement to service connection for PTSD but entitlement to service connection was denied. 2. The veteran was notified of this rating decision at her address of record but did not submit a Notice of Disagreement (NOD) with that decision. 3. The new evidence submitted subsequent to August 1995 consists of additional VA and non-VA medical reports, Board and RO hearing transcripts, and supporting statements. 4. In medical reports or treatment notes dated in March 1994, March 1997, April 1998, May 1998 and August 1998, all received subsequent to August 1995, both psychiatrists and psychologists opine that the veteran suffers from PTSD due to sexual abuse or rape and harassment in service; in February 1999 a VA examiner marginally diagnosed PTSD based on reports of rapes in service. 5. The foregoing evidence was not previously considered and, assuming its credibility, is so significant that it must be considered to decide the merits of the case. 6. The competent evidence of record, assuming its credibility, tends to indicate that the veteran's currently diagnosed PTSD is a result of stressors that occurred in service; therefore, the claim is plausible. CONCLUSIONS OF LAW 1. New and material evidence having been submitted to reopen the claim of entitlement to service connection for PTSD, the January 1968 claim is reopened. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1998). 2. The claim for service connection for PTSD is well grounded. 38 U.S.C.A. § 5107 (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background In 1980, on various enlistment forms, the veteran denied depression, nervous trouble, difficulty sleeping, and any treatment for a mental condition or nervous condition. However on her enlistment history it was noted that she had received prior psychological counseling at age 18 after an offense. In September 1981 the veteran reported fatigue for four months, lower abdominal pain and irregular menses. She had difficulty with a vaginal examination in the past because of a small introitus. She reported one prior pelvis examination at age 16. She was very anxious during the examination. A hymeneal remnant, full circumference was present. The examination was essentially normal. During several days of evaluations in September, the veteran reportedly appeared sad and showed difficulty sleeping and a defeatist attitude. Records from October 1981 indicate that the veteran was having continued trouble sleeping. She worried why a nervous stomach would develop at the time after all the things in her life before. She reported urinary symptoms. It was felt that this was due to anxiety. The veteran underwent a psychological evaluation in October and November 1981. The examiner noted that the veteran reported that when she was 15 she had some trouble with her mother and saw a psychiatrist many times in that period. She wanted greater isolation from her dorm mates in the barracks. Testing was indicative of significant difficulties relating to other individuals and problems with anger and hostility. It was felt that her numerous physical problems could be indicative of a dependency need and sleep disturbance could be a mechanism for isolation. No specific diagnosis was made. In March 1982 the veteran began complaining of headaches. She noted problems at work. The headaches were thought to be vascular or sinus in nature, but there are also assessments that the headaches were probably stress or tension related. There was also a notation indicating that the veteran may have had difficulty with customers at the Non-Commissioned Officers' Club (NCO). She complained of anger and anxiety. The veteran wanted a waiver to eat out of the mess hall in May 1982. She gave scheduling and diet as reasons. In November 1982 the veteran reported pain in her thighs. She attributed this to doing squats. In March 1983 the veteran reported a bump on her labia which was identified as a labia cyst. There was also suspected non specific vaginitis. The veteran reported contact with a partner with nonspecific urethritis. A gynecological examination in August 1983 was normal except for menstrual remnants. It appears that the veteran underwent a test for gonorrhea that month which was negative. The veteran continued to report headaches. In November 1984 there was a notation of vaginitis. The veteran continued to complain of vaginal discharge into 1985. In March 1985 the veteran reported no gynecologic problems aside from vaginal discharge. In May 1985 the veteran underwent a VA examination in connection with a recent claim. The veteran reported some ongoing infection of her cervix and tan-ish red discharge. She also reported headaches. It was noted during the examination that the veteran complained about her service and was dejected. A service clinic record from July 1985 indicated that the veteran had severe cervicitis. The veteran reported that she had taken a "double dose" of medication. In June 1991 the veteran claimed entitlement to service connection for a "nervous condition." In July 1992 entitlement to service connection for a "psychiatric disorder" was denied. A notification letter regarding this rating decision does not appear in the claims folder. In December 1993 the veteran filed a claim for PTSD and a nervous condition. In January 1994 the RO sent a letter to the veteran asking for information in support of her claim. In March 1994 service personnel records from July 1982 to April 1984 were received. A performance appraisal from August 1982 indicates that the veteran needed to separate personal/social concerns from duty. The same concerns were noted in a performance evaluation in December 1982. In July 1983 it was reemphasized that the veteran needed to keep personal problems at home while at work. In a note from November 1983 the veteran was advised that she needed to improve relations with coworkers. It was felt that she needed to disregard gossip, and learn to accept it such. She was advised not to take gossip as a personal attack as this would only intensify the problem. In July 1994 the RO determined that new and material evidence had not been submitted to reopen a claim for entitlement to service connection for PTSD/a nervous condition. A notification letter regarding this rating action was mailed to the veteran's address of record the same month and was not apparently returned as undeliverable. In December 1994 the veteran filed a statement and asked to reopen her claim for entitlement to service connection for PTSD. She stated that she developed stress headaches in 1981 to 1982 and continued to have work and stress related headaches. The veteran also maintained that on her first base, in approximately late 1981/early 1982 an attempt was made to give her an Article 15 for not wearing underclothes while teaching a weight management program. She felt that this caused PTSD. The veteran also reported that in 1982 to 1983 while in Japan, she took 80 pills at one time because she had not had a period in three months and wanted to stop what she felt was a pregnancy. She reported realistic nightmares regarding that incident. The veteran reported that in December 1984 her boyfriend (who apparently she later married) tore her clothes off and in her words, forcefully invaded her sexually despite that she told him no and tried to push him away. She stated that she felt that she was raped by him and later discovered at Charter Hospital in Albuquerque, New Mexico that she "had 'PTSD' from that." She reported that she never told anyone because he was her boyfriend, because he was drunk, and because he expressed regret for his actions. He stated that she had colorful and realistic dreams about the rape. She also claimed that she would get easy (gynecological) infections since discharge from service in March 1985. She pointed to the existence of records from the Philippines and in New Mexico. Finally, she felt that she contended that "guff" that she received in the military caused stomach problems. She stated that doctors told her that she had anxiety attacks. Records from Charter Hospital were received. These records show that the veteran was hospitalized from May 1989 to June 1989 with a diagnosis of schizoaffective disorder. It is noted that the veteran was identified as S. J.W. M. The insurance subscriber was J.R. M. who was listed as her spouse. The veteran was admitted due to complaints of severe depression. She reported that she was having multiple stressors including difficulty finding a good job, and problems in social relationships including her relationship with her boyfriend. She also reported some problems with her ex-husband. She denied past psychiatric problems but reported a "great deal of emotional trauma" in her life. She reported almost continuous headaches since 1982. Her other physical problems were recounted. The hospital report noted multiple somatic complaints. During the hospitalization, the veteran was difficult to deal with because she constantly talked about her own problems. Testing showed a schizophrenic rationing and underlying dependent personality with pendulous ego strength. She reported a difficult childhood and, in the words used in the report, a "somewhat bizarre and sadistic" mother who abused her. She told the examiner that her mother forced her to engage in sexual activity with her mother's boyfriends when she was in junior high school and this reportedly created severe difficulty in her ability to deal with sexual matters. Regarding the service, the veteran reported that she did reasonably well but was not able to reenlist due to a charge of being drunk and disorderly. She reported that she married a service man and spent three years in the Philippines where he was stationed. She stated that this was a very unhappy part of her life because he was irresponsible and she had difficulty finding an appropriate job. The diagnostic impression was major depression. In another report, the veteran reported counseling since age 16. She reported that she had a history of taking approximately 60 pills several years before to try to abort a possible pregnancy. She reported a procedure in 1984 following a possible spontaneous abortion. In August 1995 another rating decision was issued by the RO. The RO determined that new and material evidence had been submitted to reopen a claim for entitlement to service connection for depression and PTSD. However, it was also concluded that service connection was not established. A notification letter was sent to the veteran's address of record the same month. The statement was not returned as undeliverable. In January 1997 the veteran stated that she wanted to file another claim for entitlement to service connection for PTSD. She reported again that she was raped before she was discharged from the military. She stated that the person who raped her was J. R. M. She explained that she did not turn him in because it was "date rape" and she felt that she was to blame. She said that since then she had been unable to date. She reported that she was affected by men who look angry or who attack her in any way. She also reported "awful" color dreams. She stated that her doctors told her that she had PTSD without question. She reported that she was also harassed by other people in service. She specified problems with a "job at the gym." She related that an attempt was made to give her an Article 15 for not wearing undergarments while teaching although statements submitted on her behalf to the effect that she was "not guilty" apparently prevented this from occurring. She stated that she had nightmares from that. She stated that she did not trust anyone and her life was turned upside down. In this statement the veteran reported that things got so bad that she took 80 pills at once; she stated that a friend took her to the hospital to have her stomach pumped. She stated that she started smoking "pot" to make things easier and moved from job to job. The veteran then made a reference to being shot at, beat up and harassed. Numerous VA medical records from 1994 to 1997 were received. These included brief treatment notes and more detailed records. Diagnoses included dysthymia, major depression and PTSD. Additional records from this period were subsequently received, and the most significant of these will be addressed below. In April 1997 the RO sent a letter to the veteran regarding her claim for PTSD secondary to a personal assault. She was asked for additional information and informed as to kinds of information that could be used to support her claim. In June 1997 the veteran submitted a response to the April 1997 RO letter. She recounted the rape as before and noted that it occurred right before discharge from service. She stated that she was rooming with a H.C. at the time but no contact information was provided for this individual. She did add that she received infections from the rape. She then stated that she was raped and abused mentally and verbally in service. On the front of the document she wrote that there were incidents in March 1981 and March 1985. Additional treatment records were received. In a note from March 1994, a staff psychologist indicated that a structured interview was conducted for PTSD. The veteran reported sexual traumas in childhood and adulthood and noted that the first sexual trauma she experienced as an adult was perpetrated by a male friend while she was in the military. She was positive for all three categories of PTSD symptoms to include reexperiencing, avoidance/numbing, and hyperarousal related to the sexual trauma. The assessment was PTSD due to sexual trauma. Psychological testing was invalid because all clinical scales were elevated so that differentiation was not possible. This indicated presence of a great deal of turmoil. The veteran had some relationship difficulties at the time of testing. In a March 1997 note, the veteran reported depression, and anger with "active PTSD" symptoms. The psychiatrist who authored the note stated that the veteran was having anniversary reactions. The veteran strongly felt that she should be service connected for PTSD, and the doctor indicated that he agreed. The assessment was major depression and PTSD. A report of hospitalization from March to April 1997 contained a diagnosis of major depression. The veteran reported sexual abuse by a family friend at age 16. She reported episodes of major depression and one suicide attempt. In April 1997 the RO sent the veteran a letter regarding claims for PTSD secondary to a personal assault. Additional information was requested of her and she was informed about other kinds of evidence that could be helpful in verifying an assault. An August 1997 report from a Dr. L.K. was received. The VA physician stated that he had been the veteran's outpatient psychiatrist for a number of years. He noted that she had been treated for major depression. He felt that her depressive disorder was directly related to "significant sexual harassment and trauma while on active duty." He stated that she was well adjusted and functioned well prior to service but while in the service from 1981 to 1985, she was subjected to various conduct of a sexual nature that was stressful to her, undermined her self-esteem, interfered with her work performance and caused a hostile work environment. He noted that a performance evaluation dated November 8, 1983 [AF Form 77] making a "direct reference to this hostile environment." The doctor noted that in the report the veteran was advised to "disregard gossip and learn to accept it as such" and that the veteran "must not take it as a personal attack, as this attitude only intensifies the problem." The psychiatrist added that the memo confirms the reality of the sexual harassment that the veteran was subjected to and the relative insensitivity of the military to such matters at the time. The psychiatrist felt that blaming the victim contributed to the hostile work environment. In an August 1997 statement the veteran reported that she was a virgin when she entered service. She stated that she was constantly hounded and she did not like the "dirty talk" that went on. She recounted that she was accused of not wearing undergarments to class. She stated that she then got negative performance evaluations from the wife of the Inspector General, who had been involved in the prior incident. She recounted again, without giving detail, about having been driven to take numerous pills in service. She stated that a F.D. would know something about a progress note pertaining to that incident. In her substantive appeal dated in November 1997, the veteran repeated her prior contention of rape and harassment. No dates were given. She added that on one occasion a civilian had shot at her while she was in a car. In April 1998 the veteran submitted several articles about sexual harassment in service. The essence of the articles is that sexual misconduct exists and that victims feared damage to their careers by reporting such conduct. In a follow-up report from April 1998 Dr. L.K. stated that the veteran had been treated at VA and at the University of New Mexico Psychiatry Department for major depression and PTSD. The doctor stated "Well all agree that stress while on active duty played a significant role in her depression and PTSD." The same month, a report was received from D.T.C., Ph.D., a VA staff psychologist at the Albuquerque VAMC. The letter indicates that the veteran was treated for major depression in 1983 and subsequently was evaluated for PTSD "attributable to Sexual Assault and accepted into the Women's Sexual Trauma Support Group." Summary forms from appointments in April 1998 indicate diagnoses of recurrent major depression and PTSD. The primary diagnosis listed was adult sexual abuse. In April 1998 the veteran testified at the RO. She recalled that around Christmas of 1984 her boyfriend raped her. She testified that she told a friend from Hawaii, C. A., about the incident. The veteran also recounted the harassment episode described previously. She did not give an exact date but stated that she was 22 at the time. She then testified that the wife of the Inspector General became her boss and gave her poor performance evaluations. The veteran also described the episode where someone started shooting at her while at a beach; and recounted another occasion when she was beat up on leave in 1982. She reported that a C. L. would have information about the episode. The veteran stated that she would try to contact this individual. The veteran then testified that she stole a note from her chart regarding an overdose of pills in 1983. She stated that a former representative F.D., could provide corroboration. In one other matter, the veteran clarified that she was not raped prior to service but did suffer sexual abuse at the hands of a family friend. In May 1998, the veteran's private psychiatrist at the University of New Mexico, Dr. A.R., issued a report in support of the veteran's claim. She stated that she had followed the veteran since the spring of 1997 and had reviewed VA psychiatric records. According to the psychiatrist, the veteran met the criteria for chronic PTSD, recurrent major depressive disorder in relative remission, and generalized anxiety disorder. She noted that the veteran had experienced relative stability of major depressive symptoms for nine months and anxiety had been manageable with medication. Recurrent distress was felt to be most directly tied in with nightmares, easy startle responses, a sense of being helpless to defend herself from ridicule and taunting, and a generalized sense of being persecuted by others. According to the psychiatrist, the veteran had flip-flopped from avoiding situations that remind her of being teased/tormented to recreating those types of situations unwittingly. Typically her behavior had been impulsive and hurried in assessing others' motivations. The psychiatrist discounted prior assessments of schizophrenia. A June 1998 report was also submitted by a R.P., M.S., a therapist of the veteran. He indicated that he had seen the veteran in individual psychotherapy under doctoral supervision since the summer of 1993. The veteran had reportedly addressed a number of issues, including ongoing symptoms of anxiety, recurrent nightmares, difficulties achieving satisfying interpersonal relationships, issues of trust, and several bouts of major depressive symptomatology. Stress and anxiety were frequently paired with (and appeared to him to contribute to) physical symptomatology as well. According to the therapist, one of the major sources of anxiety for the veteran had been difficulty coping with memories of past traumatic events. Several memories centered around a perception and experience of psychological abuse in different contexts. This included reexperiencing of memories and nightmares of military service, and psychological effects of treatment during this period. The therapist felt that the veteran met the DSM IV criteria for chronic PTSD, major depression in partial remission, and generalized anxiety disorder. A November 1998 report from Dr. A.R. states that the sensitivity with which the veteran experiences others' actions has been heightened in part by her military experience and she continues to meet the criteria for PTSD (waxing and waning severity). According to the report the doctor felt that it had become clear over the last few months her work situation was grossly activating her sensitivity and that tensions in the workplace had increased. The doctor stated that over the past year she had formulated that the veteran's personality style was consistent with borderline character organization in terms of the quick sensitivity to others' attitudes and tendency to jump to conclusions about their motivations. This was felt to be compounded by PTSD. The lack of quick, direct resolution to questions of alleged misconduct was felt to have exacerbated her sense of persecution and amplified criticisms leveled at her. In her physical examination the veteran was anxious about work. She reported sleep disturbance and nightmares (both of her supervisor attacking her and embarrassing her in public and of boot camp and physical education classes with her current supervisor included.) The diagnosis was major depressive disorder in relative remission, generalized anxiety disorder exacerbation, and chronic PTSD in moderate exacerbation. A job reassignment was felt to be imperative in preventing an acute severe psychiatric destabilization. The veteran underwent a VA PTSD examination in February 1999. The examiner reviewed the service medical records. According to the examiner he also spoke with the veteran's current psychiatrist who offered diagnoses of PTSD, major depression and generalized anxiety disorder. The veteran's psychiatrist, Dr. A.R., told the examiner that the veteran had problems with her work situation and work stress that aggravates her sleep and converts to nightmares. The veteran also reportedly was believed to have borderline traits. When the PTSD symptoms flare up, she would become helpless and suicidal. The veteran's psychiatrist told the examiner that the PTSD had to do with an episode in physical training when she was accused of "wrong dressing." From this episode she had nightmares, hypersensitivity and a hyperstartle response. The examiner reviewed the veteran's medical history and noted the veteran's reported history of self abuse. Regarding the veteran's service history, the examiner noted that the veteran served from 1981 to 1985 with a military occupational specialty of personnel. During her tour, she helped to teach a weight-management program. She stated that she had to listen to some program attendees talk about women in a degrading manner. These same individuals reportedly turned her in stating that she had not worn appropriate underwear to class. She reportedly was advised to talk to the students and hammer out differences before, as stated in the report, "it got any larger." The students apparently denied that they had made the statements about her. She was cleared of wrongdoing although according to the veteran she was up for an Article 15. The veteran stated that this was the most traumatic incident that occurred to her and everything snowballed after that. The veteran stated that the Inspector General's wife became her supervisor and ripped her to shreds in her performance appraisal. According to the examiner the veteran stated "I suffered from mental abuse." The veteran also reported that she had to fight off a physical therapist who tried to take off her clothes during a session. She stated that she did not report a lot of these things. The veteran stated that during training in Japan she suffered from verbal and sexual harassment. She was accused of "everything." She reported that she did not hang around with anyone at work. The veteran stated that in 1982-1983 she was raped after a night in the NCO Club. The examiner stated that apparently someone followed her out to her car, convinced her that he would need to stay with her at home, and then raped her. She stated that she was bruised everywhere but she did not "go after him" noting that she felt guilty that she had brought him home. However, she then stated that she did report it because she went to the medic to get treatment for bruises. The veteran stated that she removed the record from her service medical records and later turned it in but that it was now lost. The veteran also reported that while on leave in Hawaii in 1982 to 1983 she and two friends were at a beach when someone pulled a gun on them. According to the report the veteran stated that shots were fired but this event was never reported. The veteran stated that while in Montana, she was raped by her boyfriend but later married the boyfriend and stayed with him for six years. She also reported that she was charged with an assault in an incident in an NCO Club in Montana. She reported that she was drinking at the time and the assault charge resulted from a "misunderstanding." The veteran's post service history was marked by separation from her husband, difficulties at her job, and psychiatric treatment including hospitalizations. The examiner noted several of the veteran's post service psychological treatment records. The veteran reported that she was having continued problems at work and had nightmares about work. The examiner stated that the veteran's psychiatric statements were daily and intense. The veteran reported continued problems with depression, self-abuse, nightmares, anxiety, and weight fluctuation. She stated that she would harm herself to "feel the hurt." She reported that she had done this from seventh or eighth grade until she joined the military. She denied suicide attempts prior to 1997 when she took an overdose of pills. On examination the veteran was a poor historian and could not keep a chronological order. The examiner felt, based on the interview and examination that all diagnostic criteria for PTSD were met, but only marginally. The examiner described associated symptoms including inflexibility with a pervasive pattern of instability of interpersonal relationships, self image and affect, and marked impulsivity beginning in early adulthood. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation was also noted. Impulsivity was shown in at least two areas that are potentially damaging including sex and cutting herself. PTSD was felt to be chronic in nature. The diagnosis was borderline personality disorder and PTSD. In commentary following the diagnosis the examiner stated that borderline personality was the primary diagnosis. When the veteran was asked to explain her major stressor she emphasized false accusations and mistrust instead of the rape that occurred with the man she eventually married. The examiner commented that this sexual harassment was not a life threatening situation; however, the veteran had thrived on the issue and carried it since it occurred. It was noted that the veteran had a long standing psychiatric illness before service. A pattern of unstable and intensive interpersonal relationships, identity disturbance, frantic efforts to avoid real or imagined abandonment, affective instability, chronic feelings of emptiness, inappropriate intense anger or difficulty controlling anger, impulsivity and suicidal threats, gestures or attempts or self mutilating behavior, are all characteristic of borderline personality, and according to the examiner had all been seen in the veteran. It was noted that she was counseled by superiors in the military because of an immature personality but that continued through her career to date. PTSD was marginally diagnosed giving her the benefit of the doubt that she was raped twice and that she could possibly be having nightmares and startle response because of those two incidents. However the veteran minimized those two incidents and maximized the sexual harassment which was not a life threatening attack on her. The examiner stated that the veteran returned after the examination with a rambling note which was supposedly included. However, the Board does not find this note in the claims folder. The veteran and her private psychiatrist testified before the Board in June 1999. The veteran's psychiatrist stated that the veteran had PTSD due to stressors, primarily harassment and rapes in service. She argued that harassment could be as damaging psychologically as assault. She also felt that the veteran was very credible as she had not changed her account of events throughout therapy. The veteran testified that there was only one rape in service, at the hands of the man who later became her husband, although she added that another rape had occurred sometime after service. She testified that she confided in a C.Y., who was a friend, about the inservice rape. She also stated that she also confided in H.C., who was a roommate. She did not know their whereabouts. The veteran also recounted again, in essentially the same fashion, about the harassment she endured in service. Criteria Following notification of an initial review and determination by the RO, an NOD must be filed within one year from the date of mailing of notification; otherwise, the determination becomes final. 38 U.S.C.A. § 7105 (West 1991); 38 C.F.R. §§ 20.302, 20.1103 (1998). A decision, though final as to conclusions based on the evidence of record at that time, may be reopened if new and material evidence is submitted. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. The United States Court of Appeals for Veterans Claims (Court), in Elkins v. West, 12 Vet. App. 209 (1999) (en banc), has held that the Board must perform a three-step analysis when the veteran seeks to reopen a claim. First, the Board must determine whether the appellant has presented new and material evidence. New and material evidence means evidence not previously submitted which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a). See also Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). In determining whether new and material evidence has been submitted, VA must accept proffered evidence as presumptively credible. Justus v. Principi, 3 Vet. App. 510 (1992). For a number of years the governing case law required, in order to reopen a finally denied claim, that there be a reasonable possibility that the new evidence presented, when viewed in the context of all the evidence, both old and new, would change the prior outcome. Manio v. Derwinski, 1 Vet. App. 140 (1991); See also Colvin v. Derwinski, 1 Vet. App. 171, 174 (1991). In Hodge, the Federal Circuit invalidated this standard on the grounds that it could impose a higher burden on a veteran than imposed by 38 C.F.R. § 3.156. The Federal Circuit, in Hodge, noted that 38 C.F.R. § 3.156 emphasizes the importance of a complete evidentiary record for the evaluation of the veteran's claim rather than the effect of new evidence on the outcome. Hodge, 155 F.3d at 1363. Moreover under the regulation, evidence could be material if it provided "a more complete picture of the circumstances surrounding the origin of a veteran's injury or disability, even where it will not eventually convince the Board to alter its rating decision." Id. The Court in Elkins, stated that Hodge effectively decoupled the existing relationship under the Court's case law between determinations of well-groundedness and of new and material evidence to reopen - i.e. that if there was new and material evidence to reopen under Colvin, the claim would necessarily also be well grounded. Hodge implicitly held that new and material evidence can be presented even though a claim is not well grounded. If the Board determines that the claimant has produced new and material evidence, the claim is reopened and the Board must determine whether, based upon all of the evidence of record in support of the claim, presuming its credibility, the reopened claim is well grounded pursuant to 38 U.S.C.A. § 5107(a). Finally, if the claim is well grounded, the Board may then proceed to evaluate the merits of the claim, but only after ensuring that the duty to assist under 38 U.S.C.A. § 5107(b) has been fulfilled. Elkins; see also Winters v. West, 12 Vet. App. 203 (1999) (en banc). Service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed inservice stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed inservice stressor. 38 C.F.R. § 3.304(f)(1998). In Cohen v. Brown, 10 Vet. App. 128 (1997), the Court noted that there are three requisite elements for eligibility for service connection for PTSD. These three elements consist of (1) a current, clear medical diagnosis of PTSD, (2) credible supporting evidence that the claimed in-service stressor actually occurred, and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in- service stressor. See also Gaines v. West, 11 Vet. App. 353, 357. In West v. Brown, 7 Vet. App. 70 (1994), the Court held that the sufficiency of the stressor is a medical determination. See also Cohen. In addition, in Cohen, the Court noted that the VA had adopted a final rule in October 1996, effective November 7, requiring use of the Diagnostic and Statistical Manual for Mental Disorders, fourth edition (DSM-IV) in evaluating mental disorders rather than the third edition (DSM-III) and revised third edition (DSM III-R). The Court found that DSM-IV made the standard for assessing adequacy of a stressor to cause PTSD more subjective. The VA Adjudication Manual M21-1 (M21-1) , Part III, 5.14(c) (February 20, 1996) provides that personal assault, to include rape, is an event of human design that threatens or inflicts harm, and VA recognizes that it is possible that a person could develop PTSD as a result of this type of stressful experience. Moreover, veterans claiming service connection for disability due to an in-service personal assault face unique problems documenting their claims. Because assault is an extremely personal and sensitive issue, many incidents are not officially reported, and victims of this type of in-service trauma may find it difficult to provide evidence to support the occurrence of the stressor. Therefore alternative evidence must be sought. Id. While service connection for PTSD requires credible evidence to support the assertion that the stressful event occurred, this does not mean that the evidence must actually prove that the incident occurred. Rather, the preponderance of the evidence supports the conclusion that it occurred. Id. In such cases, M21-1, Part III, 5.14(c) provides that initial development should include obtaining available service department medical and clinical records, and the service record jacket including complete military personnel records. Other service records that may be needed include reports from the military police, shore patrol, provost marshal's office, or other military law enforcement. Alternative sources that may provide credible evidence of the inservice stressor include medical records from private (civilian) physicians or caregivers who may have treated the veteran either immediately after the incident or sometime later; civilian police reports; reports from crisis intervention centers such as rape crisis centers or centers for domestic abuse; testimonial statements from confidants such as family members, roommates, fellow service members, or clergy; and copies or personal diaries or journals. Furthermore, although the military record may contain no documentation that a personal assault occurred, alternative evidence such as behavior changes at the time of the incident might still establish that an inservice stressor occurred. Examples include visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment; sudden requests for a change of military occupational series or duty assignment without other justification; lay statements indicating increased use or abuse of leave without an apparent reason such as family obligation or family illness; changes in performance and performance evaluations; lay statements describing episodes of depression, panic attacks or anxiety without identifiable reasons for the episodes; increased or decreased use of prescription or over the counter medications; evidence of substance abuse such as alcohol or drugs; increased disregard for military or civilian authority; obsessive behavior such as overeating or undereating; pregnancy tests around the time of the incident; increased interest in tests for HIV or sexually transmitted diseases; unexplained economic or social behavior changes; treatment for physical injuries around the time of the claimed trauma but not reported as a result of the trauma; and breakup of a primary relationship. A sample letter to be sent to the veteran in connection with a claim for an in- service personal assault is included in the M21-1. Id. The M21-1, Part III, 5.14(c) provides that rating boards may rely on a preponderance of the evidence to support their conclusions even if the record does not contain direct contemporary evidence. In personal assault claims, secondary evidence may need an interpretation by a clinician, especially if it involves behavior changes. In YR v. West, 11Vet. App. 393 (1998), the Court vacated and remanded a Board decision denying entitlement to service connection for PTSD, claimed to have been caused by a sexual assault in service. The Court found that PTSD was unequivocally diagnosed several times. It was also clear to the Court that the mental health professionals rendering the diagnoses accepted the veteran's account of an in-service sexual assault as the precipitating cause of her PTSD. Therefore the only remaining issue was whether the veteran had submitted credible evidence to establish that the claimed in service assault actually occurred. Assuming the truth of testimony from the veteran and the veteran's sister that the rape occurred in service, the claim was found to be well grounded. The Court found that as set forth in the M21-1, Part III, 5.14(c) development of alternative sources of information is critical with respect to claims based upon a personal assault, as service records "may be devoid of evidence because many victims of personal assault, especially sexual assault and domestic violence, do not file official reports either with military or civilian authorities." According to the Court there was inadequate discussion of the weight and credibility of statements by the veteran's sister that the veteran had told her of the rape two days after it allegedly occurred and that she had observed that the veteran had injuries on her face and arms, and trouble walking and was in shock. Evidence obtained when the veteran was placed under hypnosis by a licensed social worker was also not adequately addressed. In Patton v. West, 12 Vet. App. 272 (1999) the Court vacated and remanded a Board decision denying entitlement to service connection for PTSD. The Board found that the claim was "based on noncombat-related unverified stressors" concerning alleged in service rape trauma. The Court initially found that the veteran had submitted a well grounded claim for service connection for PTSD. He had provided medical evidence of a current diagnosis of PTSD, his own lay evidence of a sexual assault as the noncombat, inservice stressor, and medical nexus evidence generally linking his PTSD to service. The Court found that the Board did not discuss special evidentiary procedures for PTSD claims based on personal assault in the M21-1, Part III, 5.14(c). Moreover, the Board failed to address various pieces of evidence of record relevant to the factors set forth in the M21-1. The Court stated that because of the unique problems of documenting personal-assault crimes, the RO is responsible for (1) assisting the claimant in gathering, from sources in addition to in-service records, evidence corroborating an inservice stressor, (2) sending a special letter and questionnaire, (3) carefully evaluating that evidence including behavioral changes, and (4) furnishing a clinical evaluation of behavior evidence. By failing to remand the matter so that the RO might assist the appellant in seeking and interpreting such alternative evidence, the Board failed to comply with M21-1, Part III, 5.14(c) and the duty to assist. Section 5107 of Title 38, United States Code unequivocally places an initial burden upon the claimant to produce evidence that his claim is well grounded; that is, that his claim is plausible. Grivois v. Brown, 6 Vet. App. 136, 139 (1994); Grottveit v. Brown, 5 Vet. App. 91, 92 (1993). For a claim for service connection to be well grounded, there must be competent evidence of a current disability in the form of a medical diagnosis, of incurrence or aggravation of disease or injury in service in the form of lay or medical evidence, and of a nexus between in service injury or disease and current disability in the form of medical evidence. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). In addition, in the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Where the determinative issue involves causation or a medical diagnosis, competent medical evidence to the effect that the claim is possible or plausible is required. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The claimant does not meet this burden by merely presenting his lay opinion because she is not a medical health professional and does not constitute competent medical authority. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Lay assertions cannot constitute cognizable evidence, and as cognizable evidence is necessary for a well-grounded claim, Tirpak v. Derwinski, 2 Vet. App. 6-9, 611 (1992), a claim based only on the veteran's lay opinion is not well grounded. In determining whether a claim is well grounded, the claimant's evidentiary assertions are presumed true unless inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). The Court has held that if the veteran fails to submit a well grounded claim, VA is under no duty to assist in any further development of the claim. 38 U.S.C.A. § 5107(a); Gilbert v. Brown, 5 Vet. App. 91, 93 (1993). The Federal Circuit has affirmed this principle. Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997); 38 C.F.R. § 3.159(a) (1998). Analysis As an initial matter, the Board must decide whether new and material evidence has been submitted to reopen the veteran's claim. There was some suggestion that the RO had reopened the veteran's claim in August 1995 but the RO proceeded to deny the claim on the merits. The veteran did not file an NOD from that determination Therefore the claim again became final and new and material evidence is required to reopen the claim before the merits of the underlying claim could again be reached. See 38 U.S.C.A. §§ 5108, 7105(c); 38 C.F.R. §§ 3.156, 20.302, 20.1103. The November 1997 statement of the case (SOC) properly lists the issue as whether new and material has been submitted to reopen the claim for entitlement to service connection for PTSD. However, a March 1999 supplemental statement of the case (SSOC) lists the issue as entitlement to service connection for PTSD. This might suggest that the claim was reopened by the RO, but the Board finds no evidence of record after August 1995 that the RO did so. In any event, it is well-established judicial doctrine that any statutory tribunal must ensure that it has jurisdiction over each case before adjudicating the merits; a potential jurisdictional defect may be raised at any stage in the proceedings, and once apparent such a defect must be addressed. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Therefore, the Board must address whether new and material evidence has been submitted regardless of the actions of the RO. Prior to the August 1995 rating decision, the evidence consisted of private medical records, a VA examination report from May 1985, the veteran's relevant statements and contentions, and service performance evaluations. The veteran's claim was denied because the evidence did not show a confirmed diagnosis of PTSD and the evidence was felt to be inadequate to establish that a stressful experience sufficient to cause PTSD actually occurred. The evidence after the August 1995 rating decision consists of VA and private psychiatric and psychological reports, A VA examination report from February 1999 and the veteran's statements and hearing testimony. The Board is of the opinion that the evidence submitted after the final August 1995 rating decision is new and material and is sufficient to warrant reopening of the veteran's claim so that it can be adjudicated on the merits. Virtually all of the evidence submitted since the last final rating action is new. The veteran's contentions about her stressors tended to be largely cumulative. But importantly, the medical evidence was not. In medical reports or treatment notes dated in March 1994, March 1997, April 1998, May 1998 and August 1998, both psychiatrists and psychologists opine that the veteran suffers from PTSD due to sexual abuse or rape and harassment in service. In February 1999 a VA examiner marginally diagnosed PTSD based on reports of rape in service. The foregoing evidence, assuming its credibility, is so significant that it must be considered to decide the merits of the case. The next step that must be made is to determine whether the claim is well grounded. See Elkins; Winters. In the judgment of the Board, considering all of the evidence of record, the veteran has submitted a well grounded claim. The competent evidence of record, assuming its credibility, indicates that the veteran's currently diagnosed PTSD was incurred as a result of stressors that occurred in service; therefore, the claim is plausible. She has submitted several medical reports containing opinions that the veteran suffers from PTSD due to stressors in service including rape and harassment. There is also a VA examination report containing an opinion that a diagnosis of PTSD was met, albeit marginally, due to rape in service. The critical question is whether the evidence tends to corroborate that the veteran was exposed to the stressors upon which the diagnoses of PTSD were predicated. The Board will address the allegation of harassment in service first. The veteran reported that she was subjected to harassment, including harassment of a sexual nature during service. She stated that this started early in service - sometime in 1981 to 1982 when she was accused falsely of not wearing undergarments to a class she was teaching, and continued in the form of various comments by various people thereafter. She also felt that a supervisor had a vendetta of sorts against her and was intent on giving her negative performance evaluations. The record does not appear to contain complete service personnel records, but the personnel records in the claims folder do make reference to the veteran having trouble getting along with coworkers and others in 1982 into 1983. She was advised to disregard gossip and not to treat gossip as a personal attack as this would only create further problems. This record was identified by the veteran's treating VA psychiatrist, Dr. L.K., as tending to corroborate that the veteran was subjected to the harassment she claimed during service. The Board agrees. It is also noted that in or around October 1981, the veteran told a treatment provider during a psychology consultation that she wanted increased isolation from her barracks mates. This was also the time that the veteran reported anxiety, difficulty sleeping and stomach and urinary symptoms. Headaches, attributed to stress started shortly thereafter. In May 1982, shortly before the first personnel evaluations of record the veteran asked to be excused from eating in mess hall. This evidence, looked at in the light most favorable to the veteran and considering the M21-1 provisions, tends to show that she may have been trying to avoid harassment by others in service. While there has been some concern expressed by the RO that harassment is not sufficient to cause PTSD, and the VA examiner who conducted the February 1999 VA examination would only diagnose PTSD based on rape, case law establishes that sufficiency of a stressor to cause PTSD is a medical determination. Where a diagnosis of PTSD is made based on a history of certain reported stressors, an opinion that those stressors are sufficient to cause PTSD is inherent in the diagnosis. Again, it must be emphasized that credibility is presumed for purposes of well groundedness. The veteran's private psychiatrist and other psychiatrists and psychologists feel that that the veteran has PTSD due at least in part to harassment in service. This presumptively credible opinion is sufficient to establish that PTSD could possibly or plausibly have resulted from harassment in service. On the allegation of rape in service, the Board notes the issue is somewhat convoluted. The veteran initially only reported one rape, occurring close to discharge. However, the VA examiner, who evaluated the veteran in February 1999 recorded a history of two rapes - one in 1982 to 1983 and then later by her boyfriend. The veteran denies two rapes but it is noted that she reported that she took pills to end a pregnancy (she reported another time that this was in the nature of a suicide attempt due to harassment) in early 1983. These appear to be two references to the same sexual contact. The veteran's account, while somewhat confusing, it is not inherently incredible and therefore the veteran's contentions are accepted as credible for the purpose of determining well groundedness only. The Board recognizes that the sexual assaults are traumatic, and are not as likely to be recorded in service records as other types of stressors. This seems especially true given the veteran's explanation that she was subjected to acquaintance or date rape on at least one occasion by a man who later became her husband. The veteran has not submitted any statements from persons she may have spoken to relatively contemporaneously with the reported rape or rapes although she has named two people who she apparently told of the rape by her future husband. However she has submitted some evidence which the Board feels, accepting it as credible for the purpose of well groundedness, tends to support that the claimed stressor existed. Service records showed that around the time the veteran reported that the rape occurred - in late 1984 or early 1985 - she was treated for a question of vaginitis and cervicitis with vaginal discharge. This may or may not be corroborative of a sexual assault in service. This needs further analysis by a mental health professional, but it is evidence of the type listed in the M21-1, Part III, 5.14(c), and tends to establish a plausible factual basis for a finding that PTSD was incurred as a result of rape in service. It is also noted that about the time that the veteran reported the stressor of taking an overdose of pills because of a possible pregnancy in early 1983, service records show some evidence of vaginitis after exposure to a partner with non specific urethritis. She underwent a gonorrhea test which was negative. Again, there is evidence that warrants additional clinical evaluation. For the foregoing reasons, the Board finds that there is new and material evidence to reopen the veteran's claim for service connection for PTSD. ORDER New and material evidence having been submitted, the claim of entitlement to service connection for PTSD has been reopened. REMAND This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board or the Court for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. As previously noted, the claim for entitlement to service connection for PTSD is well grounded. 38 C.F.R. § 3.304(f); YR; Patton. A number of psychiatrists and psychologists feel that the veteran has PTSD and that this is related to harassment and rape in service. There is at least some evidence that harassment occurred in addition to the veteran's contention. There is no direct evidence of rape in service aside from the veteran's account and her willingness to name an individual who assaulted her. However, there is other evidence of record that may be corroborative, and this warrants further consideration. The Board is of the opinion that further development in accordance with the M21-1, Part III, 5.14(c) is warranted prior to making a final determination on the merits of the veteran's claim for entitlement to service connection for PTSD. Because of the unique problems of documenting personal- assault crimes, the RO is responsible for (1) assisting the claimant in gathering, from sources in addition to in-service records, evidence corroborating an inservice stressor, (2) sending a special letter and questionnaire, (3) carefully evaluating that evidence including behavioral changes, and (4) furnishing a clinical evaluation of behavior evidence. Patton. The RO sent the veteran a letter as set forth in the M21-1 telling her what kind of evidence would be beneficial in helping her prove her case. Where the record falls short is with regard to evaluation (to include a clinical evaluation) of evidence of behavioral changes. The RO could also provide more assistance to the veteran in gathering evidence. It does not appear that all service personnel records, to include performance evaluations, have been obtained. The appellant also has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). Therefore, pursuant to VA's duty to assist the appellant in the development of facts pertinent to his claim under 38 U.S.C.A. § 5107(a) (West 1991), and to ensure that she is afforded due process, 38 C.F.R. § 3.103(a) (1998), the Board is deferring adjudication of the issue of entitlement to service connection for PTSD pending a remand to the RO for further development as follows: 1. The RO should obtain all of the veteran's service medical and personnel records from all available sources. Performance appraisals from prior to August 1982 and after November 1983 as well as any records of investigations or disciplinary proceedings should be obtained. 2. The RO should arrange for a VA psychiatric examination to determine whether the veteran has PTSD, the etiology of that PTSD, and whether there is evidence of behavioral changes in service consistent with exposure to harassment or rape. Any indicated special studies should be conducted. The claims file and a separate copy of this remand must be made available to and reviewed by the examiner prior and pursuant to conduction and completion of the examination and the examiner must annotate the claims file in this regard. The examiner must review the veteran's various written statements about her stressors to include the transcripts of her hearings, and histories provided to her medical examiners. The examiner should consider the veteran's preservice history, including a history of sexual assault, her in service history and her post service history. If a diagnosis of PTSD is made, the examiner should address the criteria for a diagnosis of PTSD under the DSM-IV versus the DSM III or DSM III-R and discuss whether PTSD can result from exposure to harassment versus a trauma like rape. The examiner should also be provided with a copy of M21-1, Part III, 5.14(c) so that an opinion can be rendered as to whether there is evidence of behaviors or behavioral changes corroborative of exposure to trauma from harassment or rape. The examiner should comment specifically on the diagnoses made by other examiners - specifically the strengths or weaknesses of those diagnoses. 3. The veteran should be given another opportunity to submit corroborative lay statements or other evidence in support of her claim. 4. Thereafter, the RO should review the claims file to ensure that all of the foregoing requested development has been completed. In particular, the RO should review the requested examination report and required opinions to ensure that they are responsive to and in complete compliance with the directives of this remand and if they are not, the RO should implement corrective procedures. Stegall v. West, 11 Vet. App. 268 (1998). 5. After undertaking any development deemed essential in addition to that specified above, the RO should readjudicate the issue of entitlement to service connection for PTSD with consideration of all applicable laws and regulations. If the benefit requested on appeal is not granted to the veteran's satisfaction, the RO should issue a Supplemental Statement of the Case (SSOC) and the established period of time for response must be provided. Thereafter, the case should be returned to the Board for appellate review if otherwise in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until she is notified by the RO. D. C. Spickler Member, Board of Veterans' Appeals