Citation Nr: 0003025 Decision Date: 02/07/00 Archive Date: 02/10/00 DOCKET NO. 98-14 754 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. P. Kennedy, Associate Counsel INTRODUCTION The veteran served on active duty from September 1949 to September 1951. This case comes before the Board of Veterans' Appeals (Board) from an appeal of a rating decision by the Muskogee, Oklahoma, Regional Office (RO) of the Department of Veteran Affairs (VA), in which the RO denied service connection for PTSD. The case is within the jurisdiction of the St. Petersburg, Florida, RO. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the veteran's claim for service connection for PTSD has been developed. 2. The veteran has not presented credible supporting evidence that the claimed inservice stressors actually occurred. CONCLUSION OF LAW The criteria for service connection for PTSD are not met. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303, 3.304(f) (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, the Board finds that the veteran's claim for service connection for PTSD is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991); that is, she has presented a claim that is plausible. See Caluza v. Brown, 7 Vet. App. 498, 506 (1994); Murphy v. Derwinski, 1 Vet. App. 78 (1990). The record contains a report of a January 1997 VA psychiatric examination that contains a diagnosis of PTSD based upon a reported sexual assault during military service. The veteran's statements regarding the alleged inservice stressors -- namely a sexual assault that took place Germany in 1950 and an incident where she was demoted for refusing to date a superior officer -- must be accepted at face value for the purpose of establishing a well grounded claim unless they are inherently incredible. Furthermore, the diagnosis of PTSD appears to have been based on the claimed inservice stressors, thus providing some competent evidence of a nexus between an inservice disease or injury and the diagnosis of PTSD. Thus, the veteran has presented a well grounded claim for PTSD. The elements required to establish service connection for PTSD are 1) a current, clear medical diagnosis of PTSD, which is presumed to include both the adequacy of the PTSD symptomatology and the sufficiency of a claimed inservice stressor; 2) credible supporting evidence that the claimed inservice stressor actually occurred; and 3) competent medical evidence of a causal nexus, or link, between the current symptomatology and the specific claimed inservice stressor. 38 C.F.R. § 3.304(f) (1999); Cohen v. Brown, 10 Vet. App. 128, 138 (1997). The veteran has not alleged that any records of probative value that may be obtained, and which have not been sought by VA or already associated with this claims folder, are available. The Board accordingly finds that all relevant facts have been properly developed, and that the duty to assist her, as mandated by 38 U.S.C.A. § 5107(a) (West 1991), has been satisfied. As indicated above, the veteran essentially contends that she has PTSD due to a sexual assault that occurred during her active duty, and for which service connection should be granted. After a review of the evidence, however, the Board finds that her account of inservice stressors is not supported by additional evidence of their occurrence and that, accordingly, her claim fails. As previously stated, the evidence must show a current, clear medical diagnosis of PTSD, including adequate PTSD symptomatology and sufficient evidence of stressors. The veteran's most recent VA psychiatric examination, in January 1997, revealed that the veteran complained of having trouble making decisions, slept poorly, and attempted suicide once in the past. The examiner found that the veteran had hypervigilance, startle response, mild depression, and occasional nightmares related to an inservice rape by a U.S. serviceman. The examiner also referred to another inservice incident that the veteran recounted in which she was demoted by a superior officer for refusing to date him. The examiner gave the veteran a diagnosis of PTSD. The Board finds no evidence that the veteran's PTSD diagnosis is not in accordance with DSM-IV standards, or that the veteran does not exhibit some PTSD symptomatology based on her account of an inservice sexual assault. The problem with the veteran's service connection claim is that it is lacking credible supporting evidence that the claimed inservice stressors actually occurred. After the veteran filed her initial claim for PTSD in September 1995, VA requested that she submit any additional evidence that could assist VA in deciding her case, such as the unit to which she was assigned at the time, counseling or health clinic records, statements from anyone to whom the veteran confided regarding the incident, request for duty assignment changes, changes in performance evaluations or behavior, increased medication use or substance abuse. The veteran responded with additional information. She also submitted a letter to VA in September 1996 detailing the events of her sexual assault. She did not state in the letter that she ever told anyone about the incident. In fact, she specifically stated that she met with a chaplain and military psychiatrist following the incident, but did not tell them about the assault. The Board notes that VA attempts to obtain further evidence from service medical or personnel records, or military dependent records, of the veteran have been unsuccessful. A May 1997 letter from the Martin Army Community Hospital stated that the hospital did not have any records of the veteran and that any such medical records were retired to the National Personnel Records Center (NPRC). A request for records from the NPRC resulted in an October 1997 reply stating that no records of the veteran were located, and that the records may have been destroyed in the July 1973 NPRC fire. Additionally, in July 1997, the National Archives and Records Administration reported that medical records in their possession dated prior to 1954 were destroyed in accordance with regulations in effect at the time of disposal. The Board also recognizes that the claims file contains additional evidence provided by the veteran relative to her previous service connection claim for a nervous condition. This evidence includes her testimony from an April 1992 RO hearing that also described the inservice incidents now reported as stressors. However, this evidence, like the evidence submitted since her September 1995 PTSD claim, does not include any evidence other than the veteran's own statements regarding the occurrence of her inservice stressors. The Board notes that the record contains a November 1990 statement from the veteran's ex-husband regarding hospital treatment at Fort Benning at some point between 1951 and 1953. However, the statement does not indicate the reason for the treatment. The Board also notes that the veteran's service medical records show that the veteran was treated for "nerves" in June 1951. However, there is no further elaboration on the reason for this inservice treatment, and no indication of any psychiatric problem at the time of her September 1951 service separation physical examination. Following service discharge, the evidence shows that the veteran was treated by VA in 1956 for chronic emotional instability reaction, without any evidence in these VA inpatient records indicating that the treatment was related to an inservice sexual assault. The veteran's December 1998 RO hearing also explained the circumstances of the assault, her inservice treatment for "nerves" and her July 1956 VA inpatient treatment. In reviewing the entire record, the Board must conclude that there is no credible supporting evidence that the claimed inservice stressors actually occurred. In coming to this conclusion, the Board is in no way questioning the veracity of the veteran's account of her inservice stressors. However, the Board is bound by the PTSD service connection prerequisites of 38 C.F.R. § 3.304(f), as previously set forth. Without supporting evidence outside of the veteran's own statements regarding the inservice stressor incidents, her PTSD claim will fail. The Board finds that after weighing the evidence of the veteran's well grounded claim, the record does not contain competent supporting evidence of the occurrence of the claimed inservice stressors. Thus, the preponderance of the evidence is against the claim for service connection for PTSD. Accordingly, the Board must deny her claim. ORDER Entitlement to service connection for PTSD is denied. MARY GALLAGHER Member, Board of Veterans' Appeals