Citation Nr: 1124046 Decision Date: 06/23/11 Archive Date: 06/29/11 DOCKET NO. 08-16 456A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder. 2. Entitlement to service connection for residuals of a head injury, to include headaches. 3. Entitlement to service connection for a gastrointestinal disorder, to include as due to undiagnosed illness. REPRESENTATION Appellant represented by: Kenneth LaVan, Attorney at law WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD G. Jivens-McRae, Counsel INTRODUCTION The Veteran served on active duty from May 1988 to April 1992. He also served on active duty for training (ACDUTRA) from April 1985 to July 1985. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 2001 rating decision of the St. Petersburg, Florida, Regional Office (RO) of the Department of Veterans Affairs (VA). The case was previously before the Board in August 2006, at which time it was remanded for the purpose of scheduling the Veteran for a personal hearing before the Board. In January 2008, the Veteran was afforded a personal hearing at the RO before the undersigned Veterans Law Judge (VLJ). A transcript of the proceeding is record and associated with the claims file. In April 2008, the Board denied the claim for service connection for an acquired psychiatric disorder as well as several other claims for service connection. The Veteran's claim for service connection for residuals of a head injury was reopened and remanded that claim for further development. In addition, the Board remanded for additional development his claim for service connection for a gastrointestinal disability, to include as due to an undiagnosed illness. The Veteran appealed the Board's April 2008 decision to the United States Court of Appeals for Veterans Claims (Court). In May 2009, the parties submitted a Joint Motion for an Order Partially Vacating and Remanding the Board's Decision (JMR), in which the Veteran's attorney indicated that he was appealing only the issue relating to service connection for a psychiatric disorder; the other issues were abandoned on appeal. The record did not reflect that, during the pendency of the Veteran's appeal to the Court, the RO has had an opportunity to work on the two issues that were remanded by the Board in May 2008. Those issues remained in appellate status, and in addition to the issue of service connection for a psychiatric disorder which was the subject of the JMR, were remanded by the Board in March 2010. The issue of service connection for a psychiatric disorder being remanded is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A chronic headache disorder was not shown in service or for many years thereafter and is not shown to be etiologically related to the Veteran's active service, to include an in-service head injury. 2. The Veteran had active duty service in the Southwest Asia theater of operations during the Persian Gulf War. 3. Gastroesophageal reflux disease (GERD) is a diagnosed disability, which was not shown in service or for many years thereafter and it is not shown to be etiologically related to the Veteran's active service. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals head injury, to include headaches, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 2. The criteria for service connection for a gastrointestinal disorder, to include as due to undiagnosed illness, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Assist and Notify As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. As to the claims of service connection, the VCAA duty to notify was satisfied by way of letters sent to the Veteran in February 2001 and May 2007. The letters fully addressed all notice elements and was sent prior to the initial RO decisions in this matter. The letters informed him of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. Under these circumstances, the Board finds that adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). Next, VA has a duty to assist a veteran in the development of the claims. This duty includes assisting him or her in the procurement of service treatment records and other pertinent VA treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2010). The RO associated the Veteran's service treatment records, VA treatment records, records from the Social Security Administration, and identified private treatment records with the claims file. No outstanding evidence has been identified. The Veteran underwent VA examinations in June 2009 and July 2010 for both of the issues regarding a gastroenterology disorder and a neurological disorder related to headaches. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). These examinations were more than adequate, as they were predicated on a full reading of the Veteran's medical records in the Veteran's claims file. All of the pertinent evidence of record was considered, to include the statements of the Veteran, and they provide a rationale for the opinions stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c) (4). Further, in January 2008, the Veteran was provided an opportunity to set forth his contentions during a Travel Board hearing before the undersigned VLJ at the RO. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the January 2008 hearing, the VLJ cited the issue on appeal. See Hearing Transcript (T.) at p. 1. The essential elements for reopening the claim was also discussed. T. at 2. Further, information was solicited regarding the claimed onset of his headache complaints and gastrointestinal disorder. T. at p.8-10. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the Veteran's claims. As such, the Board finds that, consistent with Bryant, the DRO complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. In view of the foregoing, the Board finds no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection The Veteran claims that service connection is warranted for residuals of a head injury to include headaches and a gastrointestinal disorder. He asserts that his head injury occurred in service and occurred after he fell off of a moped and sustained injury to his head. He relates that he now has headaches as a result. As for the issue of service connection for a gastrointestinal disorder, he maintains that this is a result of his Persian Gulf service. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002). Generally, the evidence must show: (1) the existence of a present 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. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004) (citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); Caluza v. Brown, 7 Vet. App. 498, 505 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (table)). If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). However, continuity of symptoms is required where a condition in service is noted but is not, in fact, chronic or where a diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has rejected the view that competent medical evidence is required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. Under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d. 1313 (Fed. Cir. 2009); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102 (2010). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Under the provisions of specific legislation enacted to assist veterans of the Persian Gulf War, service connection may be established for a qualifying chronic disability which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2011. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1)(i). The term "qualifying chronic disability" means a chronic disability resulting from an undiagnosed illness; a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined as a cluster of signs or symptoms; or, any diagnosed illness that VA determines in regulations warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2). Signs or symptoms that may be a manifestation of an undiagnosed illness or a chronic multisymptom illness include: (1) fatigue, (2) unexplained rashes or other dermatological signs or symptoms, (3) headache, (4) muscle pain, (5) joint pain, (6) neurological signs and symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the upper or lower respiratory system, (9) sleep disturbances, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, (12) abnormal weight loss, and (13) menstrual disorders. 38 U.S.C.A. § 1117(g). Among the requirements for service connection for a disability due to an undiagnosed illness is that such disability, by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). There must be no affirmative evidence that relates the undiagnosed illness to a cause other than being in the Southwest Asia theater of operations during the Persian Gulf War. See 38 C.F.R. § 3.317(c). If signs or symptoms have been attributed to a known clinical diagnosis in the particular veteran's case being considered, service connection may not be provided under the specific provisions pertaining to Persian Gulf veterans. See VAOPGCPREC 8-98 at paras. 4-5 (Aug. 3, 1998). Residuals of a head injury Service medical records show that in March 1990, the Veteran was in a motor vehicle accident after he was drinking a few beers. He was driving a moped and was run off of the road by a car. He sustained laceration to his right knee, his head, and sustained a black eye. His left eye was swollen almost shut, but his head only showed a small laceration. No neurological abnormalities were reported. The assessment was motor vehicle accident, laceration of the scalp. A mishap report was filed, his knee was dressed, he was given Motrin for five days, and was told to return the next day for a dressing change. In April 1990, he was seen for an alcohol evaluation. He denied abnormal consumption of alcohol, and indicated he was involved in a moped accident after only having a couple of drinks during suppertime. The assessment was isolated episode of poor judgment in actions during alcohol usage. The examiner reinforced responsibility to the Veteran for his actions. In August 1991, the Veteran was seen in service complaining of chest and head congestion. He had a stuffy nose, sore throat , and cough for three days. He had questionable fever, and occasional headache. The impression was upper respiratory infection. He was prescribed Entex, told to gargle with salt, use Chloraseptic, and return to the clinic if symptoms increase. At the time of his service discharge during his March 1992 separation examination, the Veteran's head was clinically evaluated as normal. On his Report of Medical History, the Veteran specifically denied a history of head injury. The Veteran underwent a VA general examination in February 1993. He related that in 1989, he had a motorcycle accident and fractured his nose. He stated that in 1990, he went to sick bay because of having chest pains. An electrocardiogram was done. He also complained of having sinus-related headaches. His present complaints during examination included a nasal blockage with sinus problem with headaches. The diagnosis did not relate any diagnoses related to a head injury, residuals thereof, or headaches. In August 1995, the Veteran provided a history of sustaining a concussion as a result of an in-service motor vehicle accident. However, in January 2001, he argued that his problems with headaches was the result of an undiagnosed illness. In December 2002, the Veteran was seen by VA in the emergency room indicating that he was having a headache and that he had been getting them lately. He related that the headaches were temporal headaches with pain of 1 on a scale of 1/10, they were localized, intermittent, and worsened with stressful situations at work. He related that they were relieved by Tylenol. He had no chills, fever, nausea, vomiting, visual changes or weakness related to the headaches. He also stated he had not seen his primary care physician regarding the headaches. The assessment was tension headaches. Toradol was ordered, but the pain dissipated on its own. He was told to continue Tylenol as needed and he stated that he was about to change his job so that stressful situations should change. In December 2003, the Veteran underwent a general medical examination. The only central nervous complaint was from frequent frontal headaches for which he was scheduled to have a neurological examination. There was no history of head injury or seizures. Physical examination showed the Veteran's head was of normal contour, his scalp was clear and balding. Neurological findings were within normal limits. The pertinent diagnosis was headache, etiology to be determined. In February 2004, the Veteran was seen by VA in the ophthalmology clinic for an examination with complaints of pulsating daily headaches of one year duration. The headaches were known to respond to Tylenol, were bilateral, and both frontal and occipital. The examiner stated that the headache sounded like tension headache; likely secondary to Veteran's depression. There was no ocular cause of the headache seen. In April 2004, the Veteran was seen by VA with complaints of constant headaches all over which were palpating. He provided a history of headaches for the past two years. The headaches responded to Tylenol. He stated that he had been at two days at most without Tylenol. He noted photophobia with the headaches when they were severe. The pertinent diagnosis was headaches, no temporal association with Wellbutrin, symptoms compatible with migraine headaches with photophobia and throbbing. In July 2004, the Veteran was seen by VA for follow-up for migraine headaches. He stated that he continued to have strong migraine headaches two to three times a week. The character of his headaches had not changed and that Topiramate had been effective in decreasing the intensity of the headaches, with little effect on the frequency. He denied taking over the counter medication for the headaches after he was told to discontinue their use at the last visit. In December 2005, the Veteran was seen by the Florida Department of Health. He related that he had headaches and that they were only occasionally. In January 2008, the Veteran testified at a Travel Board hearing before the undersigned VLJ. He stated that while in service, he was intoxicated and fell off of a moped. He related that it was somewhat his own misconduct, and that since that time, he had migraine headaches, for which VA had been treating him. In June 2009, the Veteran underwent a VA neurology examination. He related a history of migraine headaches since 1995. He related that he fell off of a moped in service and injured his face and had multiple face lacerations, no loss of consciousness, no seizures, and at the time of the accident, he was driving under the influence of alcohol. He stated that since the accident, he continued to have headaches, but there was no documentation of the headaches available from service. At the time of the examination, he was prescribed Verapamil and Tylenol for the headaches. The headaches occurred weekly and were prostrating, lasting for hours. A CT scan was performed in November 2008 which indicated that there were no acute intracranial findings, normal CT of the head and benign cystic fluid lesion of the petrous apex. No further routine imaging was required. The examiner opined that the Veteran's headaches were not caused by or a result of military service. He indicated that the Veteran was involved in a moped accident while in service with no loss of consciousness, no amnesia reported. There was no documentation in the medical records of residuals from this injury while in service, no headaches were documented, and his headaches were diagnosed as migraine headaches and he was diagnosed with this condition after he was discharge from service. The Veteran was seen in January 2010 in the VA neurology clinic. History was provided related to the Veteran's 1990 motorcycle accident and then related that he developed almost frequent daily headaches since that time. No foods were known to trigger his headaches, but he indicated that not eating did trigger the headaches. The assessment was that the Veteran had post-traumatic, post concussive migraine without aura, floral, throbbing with photophobia and phonophobia. No rationale was provided to support the conclusion that the headaches were of a post-traumatic origin. Pursuant to the Board's March 2010 remand, the Veteran underwent a VA neurology examination in July 2010. The findings of the examination were essentially the same as the June 2009 VA neurology findings. The examiner opined that the Veteran's current migraine headache disability was not caused or the result of a moped accident in service. The rationale for the opinion was that the Veteran's service treatment records were silent for any residual effects of the inservice moped accident or any other treatment of any kind which would suggest a migraine disorder. The Veteran reported migraines did not start until 2005, and there was no link to any service related etiology. The Veteran underwent a VA examination in October 2010. It was noted at that time that the Veteran's migraine headaches were under control with medication. A review of the record reveals that the Veteran's claim for residuals, head injury to include headaches has met Shedden element (1). It is not definitive that the Veteran's headaches are indicative of an inservice injury. However, he does have a current disability (chronic headaches) that is satisfied when the claimant has a disability at the time the claim for VA disability compensation is filed or during the pendency of the claim. As to Shedden element (2), the Veteran contends that his headaches were caused by a moped accident in service. The Board wishes to make it clear that it does not disbelieve that the Veteran sustained injury in service when he fell off of his moped. The medical evidence is clear that he sustained a scalp laceration and a left black eye. However, the evidence of record does not support the Veteran's contention that he sustained any residual disability (headaches) thereby. Pertinently, the Veteran's service treatment records show headaches on only one occasion in service, and that was in connection with an upper respiratory infection in 1991. The examiner informed the Veteran to return to the clinic if his symptoms increased, and no other headache complaints were made during his service term. Additionally, the Veteran reported in his Report of Medical History on separation examination in March 1992, denial of head injury. His examination report showed clinical findings of the head as normal. The Veteran's service treatment records are pertinently negative for any head injuries. Any headache the Veteran had during his upper respiratory infection in 1991 resolved without residual disability. Put another way, while the record supports the finding that the Veteran was in a moped accident resulting in a small laceration to the scalp (head injury), there is no objective in-service evidence of chronic residuals stemming from the moped accident, to include chronic headaches. Shedden element (2) has been met to a very limited extent - that the Veteran suffered a head injury. The Board does not concede the presence of a chronic residual of that head injury, to include headaches, in service. Turning to the crucial Shedden element (3), the Board finds that the competent and credible evidence is against the finding that the Veteran presently suffers from any chronic residuals of his in-service head injury, to include his current headaches. The Veteran's July 2010 VA examination indicated that the Veteran's migraine headaches were not the result of his in-service moped accident (head injury) since he had no headaches during service separation, nor did he indicate his headache disorder began until 10 years after service. The examiner also indicated that the service treatment records were silent for any residual effects of the inservice moped accident or any other treatment of any kind that would be suggestive of a migraine disorder. Further, the examiner found no link to any service related etiology. As the examiner had the opportunity to review the complete record and interview and examine the Veteran, the Board assigns significant probative value to the July 2010 examination report. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion). The evidence of record also includes statements from the Veteran that he has experienced chronic headaches since service. The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir.1996) (table); Gabrielson v. Brown, 7 Vet. App. 36, 39- 40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007)). Lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The Board acknowledges that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."). The Federal Circuit recently held in Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010) and in Waters v. Shinseki, 601 F.3d 1274, 1278 (2010) that the Board errs when it suggests that lay evidence can never be sufficient to satisfy the requirement of 38 U.S.C.A. § 5103A(d)(2)(B) that there be a nexus between military service and a claimed condition. In this case, the Veteran is competent to report symptoms of headaches because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. As noted above, he has indicated that he reports having chronic headaches since his documented moped accident that resulted in a head injury. However, the Board finds that the Veteran's reported history of continued symptomatology since active service, while competent, is nonetheless not credible. His reported history of continued symptoms since active service is simply inconsistent with the other evidence of record. Indeed, his assertions of in- service incurrence are inconsistent with the history he provided at the time of his service separation examination, during which time he did not complain of headaches. See Caluza v. Brown, 7 Vet. App. 498 (1995) (in determining whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of a veteran). Moreover, at the time of his moped accident, the Veteran only complained of a small laceration of the head. No findings were made with regard to any chronic residuals, to include headaches. These statements are also inconsistent with post-service treatment records shortly after service, at which time the Veteran expressly reported at his 1993 VA examination that he experienced sinus-related headaches. He made no reference to headaches following the in-service accident. There was no diagnosis of headaches made at that time. Indeed, the first reference to the Veteran complaining of chronic headaches is not until 2002, wherein he reported a history of chronic headaches since 2000. The history provided by the Veteran to his physician is seen as being particularly probative. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Additionally, in this case, the Board emphasizes the multi-year gap between discharge from active duty service and initial report of chronic headaches in 2002, which is nearly 10 years after service separation, despite the fact that he sought treatment for other medical complaints. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (indicating that "evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the [V]eteran's health and medical treatment during and after military service, as evidence of whether a pre-existing condition was aggravated by military service"). The Board simply does not find the Veteran to be a credible historian. The Board has also considered the Veteran's statements asserting a nexus between his complaints of migraine headache disorder and active duty service. The Veteran is again competent to report having symptoms of headaches. However, as he is not a medical expert, he is not deemed competent to present evidence (an opinion) as to the etiology of his post-service diagnosis of migraine headaches. He simply lacks the expertise necessary to relate his headaches to his active service, to include head injury. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). His opinion is also outweighed by medical opinions discussed herein. Additionally, the Board recognizes that a January 2010 neurology clinic note indicates that the Veteran's migraine headache disorder is post-traumatic and post-concussive without aura. That clinic report indicated history of a motorcycle accident and then, development of frequent almost daily occipital headaches. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The Board finds the June 2009 and July 2010 VA examination reports to be more probative than the January 2010 VA neurology clinic note. Both the June 2009 and July 2010 VA examination reports opine that the Veteran's headache disorder is not related to the moped accident in 1990 because the medical evidence at that time is silent for any residuals of the moped injury while in service, and no headaches were documented at service discharge, or prior to 10 years after service discharge, at which time the Veteran stated that he was having the headaches "lately." Both opinions were based on a review of the record and provided supporting rationale. By contrast, the neurology notes merely indicates that the Veteran began having headaches after the moped accident. No rationale was presented. There is also no indication that the examination had the benefit of reviewing the claims file, which would have shown no history of headaches until many years post-service. The January 2010 VA neurology note is therefore not found to be as persuasive as the June 2009 and July 2010 VA examination reports. Based on the evidence of record, the preponderance of the evidence is against the claim of service connection for residuals, head injury to include headaches and here is no doubt to be resolved; therefore, service connection for residuals, head injury to include headaches is not warranted. 38 U.S.C.A. § 5107(b), 38 C.F.R. § 3.102. Gastrointestinal disorder, to include as due to undiagnosed illness. The Veteran's DD Form 214 reflects that he is in receipt of the Southwest Asia Service Medal with two Bronze Service Stars. The Board finds this to be sufficient evidence showing that the Veteran served in the Southwest Asia theatre of operations. 38 C.F.R. § 3.317(d). Service treatment evidence is devoid of findings, treatment, or diagnoses for a gastrointestinal disorder. After service, the Veteran underwent a VA general medical examination in December 2003. A review of the gastrointestinal system revealed the Veteran's weight was stable, his appetite was average. There was no abdominal pain or cramping. He did have occasional indigestion for which he took Zantac as needed. There was no consistent nausea or vomiting and his bowels had been regular. Physical examination revealed the abdomen was soft, there was no mass or tenderness. Bowel sounds were active. No diagnosis related to the gastrointestinal system was made. In May 2007, the Veteran was seen by VA for his depression. He related that he was tried with Zoloft, but it caused him to have diarrhea. In June 2009, the Veteran underwent a VA gastrointestinal examination. The onset of the Veteran's stomach disorder was in 2005. He related that he had heartburn for three years duration. He was prescribed Zantac but no diagnosis was provided. His heartburn took place when eating fatty foods. He had no nausea or vomiting. His course has been stable since the onset and there had been no side effects with his current treatment. There was no history of hospitalization or surgery, trauma, or periods of incapacitation due to stomach or duodenal disease. The diagnosis was gastroesophageal reflux disease (GERD). The examiner opined that GERD was not the result of military service. He developed heartburn after he was discharged from service and there was no documentation in the medical record regarding stomach disorder while on active duty. Pursuant to the Board's March 2010 remand, the Veteran underwent a VA examination in July 2010. The Veteran's problem was noted to be heartburn and the reported onset of the problem was in 2007. The Veteran reported that he had heartburn for 3 years. He reported he had acid reflux which was worse after drinking coffee. He was taking Zantac for this condition. He had been taking this medication for 2 years with mild improvement. The diagnosis was GERD. The examiner indicated that GERD was not caused by a stomach disorder in service. The examiner also stated that the Veteran only reported reflux and heartburn symptoms for 2 to 3 years. There was no objective evidence linking this condition to service. A July 2010 addendum to the Veteran's July 2010 VA gastrointestinal examination was provided. The addendum indicated, in pertinent part, that GERD was a disease with a clear and specific etiology and diagnosis and not related to a specific exposure event in service. As a preliminary matter, among the requirements for service connection for a disability due to an undiagnosed illness is that such disability, by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). There must be no affirmative evidence that relates the undiagnosed illness to a cause other than being in the Southwest Asia theater of operations during the Persian Gulf War. See 38 C.F.R. § 3.317(c). If signs or symptoms have been attributed to a known clinical diagnosis in the particular veteran's case being considered, service connection may not be provided under the specific provisions pertaining to Persian Gulf veterans. See VAOPGCPREC 8-98 at paras. 4-5 (Aug. 3, 1998). As discussed, the Veteran's gastrointestinal problems have been ascribed to GERD. GERD is a clinically diagnosed disorder, which is therefore not subject to the undiagnosed illness provisions. 38 C.F.R. § 3.317(a)(1)(ii). Service connection for a gastrointestinal disorder due to an undiagnosed illness is therefore unwarranted. Consequently, the Board will consider whether the Veteran is entitled to service connection for GERD on a direct basis. As previously indicated, to warrant service connection, the evidence must show (1) the existence of a present 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. Shedden v. Principi. Shedden element (1) is shown as the Veteran has been diagnosed with a present disability of GERD. Shedden element (2), however, is not shown in this case as there was no evidence of GERD in service as the first evidence of GERD or any other chronic stomach symptoms was in 2003, more than 10 years after service. Finally, Shedden element (3) has not been met as there has been no causal relationship between the diagnosed GERD and any stomach symptoms in service. The Board acknowledges the Veteran's Travel Board testimony that he had GERD during the Persian Gulf and was treated for GERD by a doctor. Although the Veteran is competent to report that he was diagnosed with GERD in service and saw a doctor for treatment of the same, the Board does not find his recollection to be credible. In this regard, the Board notes that there are no service treatment records at any point during his service career that indicate GERD, stomach symptoms, or treatment for the condition. Moreover, the Board finds it significant that the Veteran testified in this regard and later went on to indicate that the onset of his condition was in 2005, many years after service discharge. With respect to the Veteran's own contentions, a layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997). See also Bostain v. West, 11 Vet. App. 124, 127 (1998) citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992) (a layperson without the appropriate medical training and expertise is not competent to provide a probative opinion on a medical matter, to include a diagnosis of a specific disability and a determination of the origins of a specific disorder). Lay testimony is competent, however, to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1991). As noted, the Veteran argued that his stomach problems (GERD) had its onset during the Persian Gulf. He is clearly competent to report a history of epigastric symptoms. However, competency does not amount to credibility. Here, the Board does not find that the Veteran's lay statements of experiencing a stomach disorder since service in the Persian Gulf to be incredible. First, as indicated, his service treatment records are silent with respect to this condition. There is also no evidence of post-service treatment for headaches until 11years after discharge. The Board notes that it may, and will, consider in its assessment of a service connection the passage of a lengthy period of time wherein the veteran has not complained of the maladies at issue. See Maxson v. West, 12 Vet. App. 453, 459 (1999). Indeed, the Board places significant weight on treatment records dated in 2003, which is the first instance of stomach complaints documented in the claims file. Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant). Moreover, the fact that the Veteran first filed a claim for service connection for a stomach condition in 2001, 9 years after leaving service, causes the Board to question the Veteran's current assertion that he has experienced a stomach condition since service. The fact that he made no reference of gastrointestinal problems when he first filed his claim for benefits in 1993 also serves as negative evidence. See Shaw v. Principi, 3 Vet. App. 365 (1992) (a veteran's delay in asserting a claim can constitute negative evidence that weighs against the claim). ORDER Service connection for residuals of a head injury, to include headaches is denied. . Service connection for a gastrointestinal disorder, to include as due to undiagnosed illness, is denied. REMAND The Veteran also claims service connection for an acquired psychiatric disorder due to his active service. The March 2010 Board remand requested that the Veteran undergo a VA psychiatric examination and that the examiner provide an opinion whether it is at least as likely as not that any current psychiatric disability had its onset in service or was otherwise caused by the incident during service described by the Veteran when he was charged with sexual assault, followed by the charges being withdrawn. The Veteran underwent a VA psychiatric examination in June 2010. The examiner opined that it is less likely than not that the Veteran's current psychiatric disorders were caused by or a result of withdrawn sexual assault charges in service. However, the examiner did not address the onset of the Veteran's current psychiatric disorder. A remand by the Court or the Board confers on the Veteran or other claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268,271 (1998). Therefore, since this report does not provide sufficient detail, it is incumbent to return the report as inadequate for evaluation purposes. See 38 C.F.R. § 4.2 (2010). Accordingly, the case is REMANDED for the following action: 1. The AMC/RO should contact the VA examiner who examined the Veteran in June 2010 (signed in August 2010) in connection with his claim for service connection for an acquired psychiatric disorder. Have the examiner review the record and provide the answers to the questions indicated in the March 2010 Board remand. If the examiner is unavailable, the Veteran should undergo an additional VA examination with another examiner. In either instance, the examiner should state: Whether it is at least as likely as not (a 50 percent probability or greater) that any current psychiatric disability had its onset in service or is otherwise etiologically related to his active service. The examiner should address whether there is any evidence of continuity of symptomatology of the psychiatric disability since service. He or she should also discuss the September 2009 statement from Dr. Douyon, which expressed the opinion that the Veteran's psychiatric disorder was directly related to his active service. All opinions should be supported by adequate rationale. If the examiner cannot provide an opinion without resorting to mere speculation, such should be stated with rationale. 2. After undertaking the additional development deemed necessary, the AMC/RO should readjudicate the claim. If any such action does not resolve the claim, the AMC/RO shall issue the Veteran a Supplemental Statement of the Case. He and his representative should be given an opportunity to respond. Thereafter, the case should be returned to the Board, if in order. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs