POSTTRAUMATIC STRESS DISORDER (PTSD)

Summary

The Veteran served from July 2003 to October 2006. The Veteran appealed a September 2019 rating decision, seeking service connection for insomnia, depression, and anxiety. The Board re-characterized the claim to include an acquired psychiatric disability, such as PTSD, based on the medical record. The Veteran reported experiencing military sexual trauma (MST) during service, which she detailed in a March 2019 VA Form 21-0781a. While service treatment records did not show contemporaneous psychiatric treatment, the Board noted that the absence of such records does not preclude service connection. VA treatment records, including a May 2019 VA examination report, confirmed a current diagnosis of PTSD and unspecified insomnia disorder. The Board found the Veteran competent to report her in-service experiences and found her lay statements regarding MST credible, supported by post-service medical records and treatment for a sexually transmitted disease, indicating an in-service MST occurred. Three positive VA nexus opinions from VA psychiatrists/psychologists were also considered, finding the condition related to service and supported by the Veteran's lay statements and medical history. The Board concluded that the Veteran's current psychiatric condition is related to her active service. Service connection for an acquired psychiatric disability, including PTSD and unspecified insomnia disorder, anxiety, and depression, was granted.

Rationale

Medical evidence establishes current psychiatric disability (PTSD, insomnia).; Lay evidence of MST credible and supported by service medical records (STD testing).; Positive VA nexus opinions link condition to service.

Full Decision Text

Citation Nr: A22012312
Decision Date: 06/30/22	Archive Date: 06/30/22

DOCKET NO. 200710-97016
DATE: June 30, 2022

ORDER

Service connection for an acquired psychiatric disability, to include a posttraumatic stress disorder (PTSD) and an unspecified insomnia disorder, is granted.

Service connection for anxiety is granted.

Service connection for depression is granted.

FINDINGS OF FACT

1. The Veteran's acquired psychiatric disability, to include PTSD and an unspecified insomnia disorder, is related to her in-service military sexual trauma (MST).

2. Anxiety and depression are granted as part of the Veteran's now service-connected acquired psychiatric disorder.

CONCLUSIONS OF LAW

1. The criteria for service connection for an acquired psychiatric disability, to include PTSD and an unspecified insomnia disorder, have been met.  38 U.S.C. § 1110, 1131, 5107; 38 C.F.R. § 3.102, 3.303, 3.304.

2. The criteria for service connection for anxiety have been met.  38 U.S.C. 1110, 5103(a), 5103A, 5107; 38 C.F.R. 3.303, 3.310.

3. The criteria for service connection for depression have been met.  38 U.S.C. 1110, 5103(a), 5103A, 5107; 38 C.F.R. 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active-duty service from July 2003 to October 2006.

These matters are on appeal to the Board of Veterans' Appeals (Board) from a September 2019 rating decision.  In July 2020, the Veteran timely appealed the September 2019 rating decision directly to the Board and requested the "direct review" process.  Based on the Veteran's choice to pursue a direct review of his appeal, the Board will only consider evidence received by VA prior to or on the date of the September 2019 rating decision.

The Veteran initially filed a claim for service connection for insomnia, depression, and anxiety.  See July 2019 VA Form 21-526EZ.  However, in Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims clarified how the Board should analyze claims for PTSD and other acquired psychiatric disabilities.  As emphasized in Clemons, a veteran's claim "cannot be limited only to that diagnosis but must rather be considered a claim for any mental disability that may be reasonably encompassed."  Id.  Accordingly, the Board has re-characterized the issue as shown on the title page because the medical record shows multiple psychiatric diagnoses.

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. §§ 1110, 1131.  Service connection may also be granted for disability shown after service, when all the evidence, including that pertinent to service, shows it was incurred in service.  38 C.F.R. § 3.303 (d).

Generally, to establish direct service connection, three elements must be established.  There must be medical, or in certain circumstances, lay evidence of a current disability; medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability.  See 38 C.F.R. § 3.303; see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999).

Specific to claims for posttraumatic stress disorder (PTSD), there must be medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a), 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).

In addition to the regulations cited above, 38 C.F.R. § 3.304 (f)(5) provides if a PTSD claim is based on in-service personal assault, evidence from sources other than the Veteran's service records may corroborate the account of the stressor incident.  Examples of such evidence include, but are not limited
 (PTSD), there must be medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a), 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).

In addition to the regulations cited above, 38 C.F.R. § 3.304 (f)(5) provides if a PTSD claim is based on in-service personal assault, evidence from sources other than the Veteran's service records may corroborate the account of the stressor incident.  Examples of such evidence include, but are not limited to, records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy.  Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources.  Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to, 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.

1. Service connection for an acquired psychiatric disability, to include PTSD and an unspecified insomnia disorder, anxiety and depression, is granted.

The Veteran contends her acquired psychiatric disorder is due to the MST she experienced during her active service.  See March 2019 VA Form 21-0781a.  Her September 2002 Report of Medical Examination on enlistment notes a normal psychiatric examination, and the available service medical records do not reflect treatment for a psychiatric disorder or symptoms.  There does not appear to be a separation examination of record.

The Board notes the absence of contemporaneous records does not preclude granting service connection for a claimed disability.  See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding a lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms").

Here, the Board finds all three elements to establish service connection have been satisfied.  See 38 C.F.R. § 3.303(a); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167-67 (Fed. Cir. 2004).

VA treatment records reflect a diagnosis of and treatment for PTSD.  See e.g., October 2018 Mental Health Note; see also April 2018 PTSD Consult (noting a history of MST with PCL-5 and interview consistent with a new diagnosis of PTSD).  Further, a VA examination report reflects a DSM-V diagnoses of PTSD and an unspecified insomnia disorder.  See e.g., May 2019 Initial PTSD Disability Benefits Questionnaire.  Accordingly, the medical evidence establishes the Veteran has a current acquired psychiatric disability.  See Holton, 557 F.3d at 1366.

Regarding an in-service event, the Veteran recounted her MST in her March 2019 VA Form 21-0781a.  In this regard, the Veteran is competent under the law to describe what she experienced during active service.  See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (holding a veteran is competent to report what occurred during service because they are competent to testify as to factual matters of which they have first-hand knowledge); Barr, 21 Vet. App. at 307-08 (2007) (holding lay testimony is competent to establish the presence of observable symptomatology); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which they have personal knowledge); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson, supra.

The Board notes the Veteran's post-service medical records reflect the same statements regarding her MST, which took place during active service, that she has provided elsewhere in the record throughout the pendency of her claim.  Thus, the Board finds the lay evidence regarding an in-service event, injury, or illness to be credible and sufficient to
) (holding lay testimony is competent to establish the presence of observable symptomatology); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which they have personal knowledge); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson, supra.

The Board notes the Veteran's post-service medical records reflect the same statements regarding her MST, which took place during active service, that she has provided elsewhere in the record throughout the pendency of her claim.  Thus, the Board finds the lay evidence regarding an in-service event, injury, or illness to be credible and sufficient to establish an in-service incurrence.  Finally, service medical records reflect treatment for a sexually transmitted disease, indicating an MST had occurred.  See 38 C.F.R. § 3.304 (f)(5).  Accordingly, the Board finds an in-service injury or incurrence is established.  See Holton, 557 F.3d at 1366.

Finally, as to the third element of the claim, the Board notes there is no negative VA opinion of record.  However, there are three positive VA nexus opinions of record provided by two VA psychiatrists/psychologists.  A review of those opinions reflects, in reaching their conclusions, the examiners highlighted the lay evidence of record, most of it as detailed above and reported by the Veteran in her lay statements where she recalls experiencing an MST during active service.

The Board finds the August 2018 VA licensed physicians' findings to be highly probative because they represent the informed conclusions of professionals and are supported by thorough explanations based on a review of the Veteran's medical history and the symptomatology reflected in the medical and lay evidence of record.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding the probative value of a medical opinion comes from its reasoning); Prejean v. West, 13 Vet. App. 444, 448 (2000) (holding the Board may determine the probative value of medical opinions based on their detail and persuasiveness, and the physicians' access to a Veteran's medical records).  As such, the findings carry significant probative weight in the Board's determination.  See Caluza v. Brown, 7 Vet. App. 498, 506 (1995).

The Board further finds probative the Veteran's service medical records reflect testing for and treatment for a sexually transmitted disease.  38 C.F.R. § 3.304 (f)(5) provides if a PTSD claim is based on in-service personal assault, evidence from sources other than the Veteran's service records may corroborate the account of the stressor incident, and an example of such evidence includes tests for sexually transmitted diseases.

The Board concludes the lay evidence of record, which is supported by the Veteran's service medical records and post-service medical records, indicates the Veteran experienced an MST during her active service and was a changed person after returning home from active service.  The evidence of record reflects she continued to decline and has had a psychiatric condition ever since.  In this regard, the Veteran's available service medical records suggest normal psychiatric health; however, the Veteran's VA medical records reflect mental health diagnoses and treatment related to her active service as she has reported her military-related stressors while seeking treatment.  For example, the three VA opinions reflect the same statements provided by the Veteran regarding her MST during active service, which she has provided elsewhere in the record throughout the pendency of her claim.

Accordingly, given the medical evidence diagnosing a current psychiatric disability related to MST, considering the lay evidence of record that is supported by the Veteran's post-service medical records, in light of the competent evidence of a diagnosis connecting the Veteran's current psychiatric symptomatology with her claimed in-service stressors, the Board finds the evidence reflects her current psychiatric condition is related to her active service.  See 38 C.F.R. § 3.303 (a); Holton, 557 F.3d at 1366; Shedden, 381 F.3d at 1166-67.

(Continued on the next page)

 

Therefore, the Board finds service connection for an acquired psychiatric disability is warranted.  38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). The claims for service connection for anxiety and depression are also granted.

 

 

R. Erdheim

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Buck Denton

The Board's decision in this
 Holton, 557 F.3d at 1366; Shedden, 381 F.3d at 1166-67.

(Continued on the next page)

 

Therefore, the Board finds service connection for an acquired psychiatric disability is warranted.  38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). The claims for service connection for anxiety and depression are also granted.

 

 

R. Erdheim

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Buck Denton

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.