Citation Nr: 1320188 Decision Date: 06/21/13 Archive Date: 07/02/13 DOCKET NO. 06-19 046 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for a brain disorder. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD F. Yankey, Counsel INTRODUCTION The Veteran served on active duty from September 1961 to August 1965. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in August 2005 by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. In a June 2008 decision, the Board denied service connection for a brain disorder. The Veteran appealed the denial to the Court of Appeals for Veterans Claims (Court). In August 2009, the parties (the Secretary of VA and the Veteran) determined that a remand was warranted, and a Joint Motion for Remand was granted by Order of the Court in August 2009. In accordance with the Joint Remand, this case was remanded by the Board in December 2009 for further development by the originating agency. The case was again before the Board in May 2011, at which time, the Board again denied service connection for a brain disorder. The Veteran again appealed the denial to the Court. By July 2012 Order, the Court vacated the Board's May 2011 decision and remanded the matter to the Board for compliance with instructions contained in a July 2012 Joint Motion for Remand of the parties. In accordance with the Joint Remand, the case was remanded by the Board in January 2013 for further development by the originating agency. The case has been returned to the Board for further appellate action. FINDINGS OF FACT 1. A brain disorder, including a brain aneurysm, was not found on examination for entrance onto active duty. 2. Clear and unmistakable evidence does not show that the Veteran had a brain disorder, including a brain aneurysm prior to his enlistment into active service. 3. A current brain disorder, including an aneurysm of the brain and/or brain stem infarct, was not present in service or until years thereafter and is not etiologically related to service. CONCLUSION OF LAW A current brain disorder was not incurred in or aggravated by military service and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1110, 1131, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION 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); 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). When VCAA notice is delinquent or erroneous, the "rule of prejudicial error" applies. See 38 U.S.C.A. § 7261(b)(2). In the event that a VA notice error occurs regarding the information or evidence necessary to substantiate a claim, VA bears the burden to show that the error was harmless. However, the appellant bears the burden of showing harm when not notified whether the necessary information or evidence is expected to be obtained by VA or provided by the appellant. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). 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. Here, the duty to notify was not satisfied prior to the initial unfavorable decision on the claim by the RO. Under such circumstances, VA's duty to notify may not be "satisfied by various post-decisional communications from which a claimant might have been able to infer what evidence the VA found lacking in the claimant's presentation." Rather, such notice errors may instead be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the RO's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the RO); see also 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 SOC or SSOC, is sufficient to cure a timing defect). In this case, although the Veteran was provided a VCAA letter in March 2005 that addressed all four notice elements, he was provided notice of the Dingess requirements subsequent to the initial RO decision by way of a letter sent in March 2006. The letter informed him of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. Therefore, he was "provided the content-complying notice to which he [was] entitled." Pelegrini, 18 Vet. App. at 122. Furthermore, the service connection claim was readjudicated, and a supplemental statement of the case was issued in May 2006. Consequently, the Board finds that the duty to notify has been satisfied. Next, VA has a duty to assist a Veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained service treatment records, VA treatment records, and private treatment records. The Veteran also submitted additional treatment records and written statements in support of his claim. In addition, the Court granted a Joint Motion for Remand in August 2009, finding that the Board failed in its duty to assist the Veteran in developing his claim. Specifically, in May 2006, the Veteran authorized VA to obtain treatment records from Dr. J. R. Fulgham, a physician who had treated his aneurysm and seizures. The Board requested these treatment records, but received no response. The Board informed the Veteran in July 2006 that they had requested these records, but that it was ultimately the Veteran's responsibility to see that VA received them. However, the August 2009 Joint Motion found that VA erred in not making additional requests for Dr. Fulgham's records. In response to the Joint Motion, the Board remanded the case back to the RO in December 2009 with instructions to request that the Veteran submit a current authorization form for the records of Dr. Fulgham and then submit a second request for these records. The RO sent such a letter in January 2010, but the Veteran did not respond with an authorization form to obtain Dr. Fulgham's records. Rather, the Veteran submitted his own copies of Dr. Fulgham's records, along with other treatment records. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Further, the Board recognizes that there is evidence showing that the Veteran is in receipt of Social Security Administration (SSA) disability benefits. Such was discussed in a June 2001 VA examination report and an April 2002 statement from his representative. In Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010), the Court noted that 38 U.S.C.A. § 5103A did not require VA to obtain all medical records or all SSA disability records, only those that are relevant to the Veteran's claim. The Court also stated that VA was not required to obtain records in every case in order to rule out their relevance. Rather, the standard is: as long as a reasonable possibility exists that the records are relevant to the Veteran's claim, VA is required to assist the Veteran in obtaining the identified records. Here, as the April 2002 statement explicitly states that the Veteran's receipt of SSA disability benefits stemmed from a post-service motor vehicle accident that had resulted in a non-service connected back disability, the Board does not find any error in the RO's failure to obtain the Veteran's SSA disability records. As noted above, in accordance with a Joint Motion for Remand granted by the Court in July 2012, the Board remanded the claim in January 2013, to afford the Veteran a VA examination with an opinion on the etiology of any current brain disorder. The Veteran was afforded a VA examination in March 2013. When VA undertakes to provide an examination or obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds the VA examination report to be thorough and adequate upon which to base a decision with regard to the Veteran's claim. Accordingly, the Board finds that the remand instructions were thereby complied with. Stegall v. West, 11 Vet. App. 268 (1998). Based on the foregoing, the Board finds no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. 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). Legal Criteria Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). The theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As coronary artery disease is recognized as chronic under 38 C.F.R. § 3.309(a), the theory of continuity of symptomatology under 38 C.F.R. § 3.303(b) is for application. Id. In relevant part, 38 U.S.C.A. 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (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." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d at 1337 ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). With chronic diseases shown as such in service, or within the presumptive period after service, so as to permit a finding of service connection, subsequent manifestation of the same chronic disease at any later date, however remote, are service-connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, where a Veteran served 90 days or more during a period of war or during peacetime service after December 31, 1946, and brain thrombosis or hemorrhage becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. Providing the benefit to the Veteran, the Board will provide the same presumption to his diagnosed aneurysm. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. § 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2010); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. At 54. Analysis The Veteran's initial contention was that his currently-diagnosed brain aneurysm had its onset in service or is otherwise etiologically related to service. Specifically, he reported that he suffered repeated seizures in service, and that he continued to experience neurological symptoms, such as tremors and blackouts, after he was discharged from service. However, the Veteran has also reported that his aneurysm pre-existed his active service and was aggravated by service. A Veteran is presumed to have been in sound condition when enrolled for service, except for any disease or injury noted at the time of enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). The regulations provide expressly that the term "noted" denotes "[o]nly such conditions as are recorded in examination reports," 38 C.F.R. § 3.304(b), and that "[h]istory of pre- service existence of conditions recorded at the time of examination does not constitute a notation of such conditions." Id at (b)(1); 38 U.S.C.A. §§ 1111, 1137. Generally, a preexisting injury or disease will be considered to have been aggravated by active service where there was an increase in disability during such service, unless there is a specific finding that the increase in disability was due to the natural progress of the disease; however, aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306 (2012). If the disorder becomes worse during service and then improves due to in- service treatment to the point that it was no more disabling than it was at entrance into service, the disorder is not presumed to have been aggravated by service. Verdon v. Brown, 8 Vet. App. 529 (1996). Every Veteran shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence or medical judgment is such as to warrant a finding that the disease or injury existed before acceptance and enrollment, and was not aggravated by such service. 38 U.S.C.A. § 1111. In order to rebut the presumption of sound condition under 38 U.S.C. § 1111, the government must show by clear and unmistakable evidence both that the disease or injury existed prior to service, and that the disease or injury was not aggravated by service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). To satisfy the second requirement for rebutting the presumption of soundness, the government must rebut a statutory presumption of aggravation by showing, by clear and unmistakable evidence, either that (1) there was no increase in disability during service, or (2) any increase in disability was "due to the natural progression" of the condition. Joyce v. Nicholson, 443 F.3d 845, 847 (Fed. Cir. 2006). The clear and unmistakable evidentiary standard applies to the burden to rebut the presumption, but this standard does not require the absence of conflicting evidence. Kent v. Principi, 389 F.3d 1380, 1383 (Fed. Cir. 2004). If the presumption of soundness is not rebutted, the claim is one for service connection rather than compensation based on aggravation. Wagner. No evidence of a brain or neurological disorder was found on the Veteran's service entrance examination. Furthermore, there is no documentary evidence of any pre-service treatment for a brain disorder of record, and the Veteran has not reported any such treatment. The March 2013 VA examiner opined that the Veteran's aneurysm/infarcts did not exist prior to active service or during service. However, the Board notes that as discussed further below, an opinion from the Veteran's private physician, Dr. Wolcott, indicates that the Veteran's brain aneurysm existed since birth, i.e., a congenital defect. However, there is no competent documentary evidence of record to support this contention. Accordingly, the Board finds that the evidence does not clearly and unmistakably show that the Veteran's aneurysm pre-existed his military service. Accordingly, the presumption of soundness is not rebutted, and the claim is one for normal service connection. Wagner. Assuming arguendo that it was affirmatively determined that the Veteran's aneurysm was present since birth, the Board notes that congenital or developmental defects are not considered diseases or injuries for VA compensation purposes. See 38 C.F.R. § 3.303(c), 4.9 (2007); see also Winn v. Brown, 8 Vet. App. 510, 516 (1996). A precedent opinion of the VA General Counsel, VAOPGCPREC 82-90 (July 18, 1990) (a reissue of General Counsel opinion 01-85 (March 5, 1985)) held, in essence, that a disease which is considered by medical authorities to be of familial (or hereditary) origin must, by its very nature, be found to have pre-existed a claimant's military service, but could be granted service connection if manifestations of the disease in service constitute aggravation of the condition. Moreover, congenital or developmental defects, as opposed to diseases, cannot be service-connected because they are not diseases or injuries under the law; however, if superimposed injury or disease occurred, the resultant disability might be service-connected. Id. The Veteran argues that his in-service seizures aggravated his aneurysm. Competent evidence supporting this argument has not been submitted. Moreover, as discussed further below, the record establishes that the Veteran consistently had normal neurological evaluations in service, and that his "seizures" were not true seizures but rather manifestations of his service-connected psychiatric disorder. See March 2013 VA examination report. As such, the Board finds that if it were assumed that the Veteran's aneurysm was congenital and pre-existed service, there is no competent evidence showing an increase of symptomatology or disability and therefore, the provisions of 38 C.F.R. § 3.306 would not apply and service connection based upon aggravation for the Veteran's aneurysm would not be warranted. As noted above, as the evidence does not clearly and unmistakably show that the Veteran's aneurysm pre-existed his military service, the presumption of soundness is not rebutted, and the claim becomes one for normal service connection. Wagner. Service treatment records show that the Veteran was admitted in July 1963 for what was believed to be a seizure disorder. He had been observed to have experienced a 10 to 15 minute episode of tremors of both arms followed by a period of memory loss. He was referred for a neurological evaluation with a diagnosis of seizure disorder of unknown origin. The report of the July 1963 neurological examination, which included an electroencephalogram (EEG) and a 7-day observation period, was essentially negative. A similar seizure-like episode was reported in November 1963. However, a December 1963 neurological consultation was again negative. The examiner opined that it was possible that the Veteran was suffering from some type of hyperventilation syndrome. In June 1965, the Veteran was once again evaluated for symptoms similar to seizures. He was not diagnosed with any neurological disorder. Instead, it was observed that the usual sequence of events involved the Veteran being provoked by his shipmates and, rather than becoming aggressive, he would experience a hyperventilatory episode. The Veteran was not hospitalized, his health was not considered in any danger, and he was considered fit and competent to continue his duties. He was prescribed 10 milligrams of Librium. Significantly, the Veteran's July 1965 separation examination indicated that his neurologic state was within normal limits. The post-service medical evidence of record does not indicate that the Veteran's current brain disorder is related to his active military service. In this regard, the post-service evidence does not reflect neurological symptomatology for many years after service discharge. Immediately following the Veteran's separation from service, he was afforded a VA psychiatric examination in October 1965. The Veteran described his health as "OK" and indicated that he had no further periods of unconsciousness, anxiety, or other neurological difficulties at that time. A neurological evaluation during the same examination found the Veteran's cranial nerves to be intact and normal, with no evidence of neurological diseases. The diagnosis was psychoneurotic disorder, anxiety reaction with episodes of hyperventilation. Parenthetically, the Board notes that service connection for psychoneurotic disorder, anxiety reaction with episodes of hyperventilation, was granted by the RO in a December 1965 rating decision. Following the October 1965 VA psychiatric examination, the claims file is absent of any records or evidence pertaining to a possible brain disorder until the diagnosis of the Veteran's brain aneurysm in August 2002, approximately 37 years after his separation from service. Therefore, the competent evidence does not reflect continuity of symptomatology. During an October 1965 psychiatric evaluation, the examiner determined that the Veteran did not have a neurological disease, but that he suffered from a psychoneurotic disorder, anxiety reaction with episodes of hyperventilation. The examiner observed that the Veteran seemed to accept the fact that he was a nervous type, somewhat willing to accept that he had some type of seizure in service that was related to nervousness but less willing to accept the idea that he could have had epilepsy or some more serious cause of his seizures in service. When the Veteran underwent a VA psychiatric examination in June 2001, he provided a history of experiencing a seizure in service. He described rapid breathing at the time. There was no evidence of an active psychiatric or neurological problem at that time. In an August 2002 private MRI, the examiner noted under "Impression" that the Veteran had multiple lacunar infarcts that "predominantly involved the right pons and basal ganglia." The examiner also noted suspicion of an anterior communicating artery aneurysm. The Veteran underwent a private craniotomy in June 2003 for the clipping of an anterior communicating artery aneurysm. In an April 2005 private noncontrast CAT scan, the examiner noted the present aneurysm clip in the Veteran's anterior cranial fossa. The Veteran was afforded a VA examination in March 2013. The Veteran reported an incident in service in the 1960's, where he experienced what he described as convulsions and was told by the ship doctor that he had a seizure disorder. The Veteran reported further that he was air lifted out to Chelsea Naval Hospital in Boston, where they did not find anything wrong with him. He claimed that he was asked if he wanted a medical discharge and when he replied that he did not, the doctor told him that he would just list his diagnosis as pneumonia. The Veteran claimed that he worked at the hospital for a few weeks and then went back to full duty. The Veteran also reported that he was told that he had anxiety, but he did not believe that to be true, and that no one at the VA would perform any testing on him. The report does not indicate when the Veteran was told that he had anxiety. He claimed that he eventually convinced his doctor to do testing (report does not indicate whether this was a private or VA doctor and when the testing was done) and check him for everything, and the tests showed that he had a brain aneurysm and infarcts, and he underwent surgery for the aneurysm at Henry Ford Hospital in 2003. Finally, the Veteran reported that he "guessed" the aneurysm started in service and that the infarcts were already there because of the one episode in the 1960's. The examiner diagnosed a brain aneurysm and infarcts status post clipping, diagnosed in 2002, and concluded that there was no medical evidence of the Veteran ever having epilepsy or a seizure disorder. He opined that the Veteran's brain disorder, cerebral aneurysm/infarcts, was not at least as likely as not due to active duty military service, and did not have its onset in active duty military service or within one year of service. In rendering his opinion, he noted that the Veteran had a shaking episode in service and some episodes of hyperventilation, but a seizure disorder was ruled out on electroencephalogram (EEG) testing and no neurological condition was found. Furthermore, his discharge physical in July 1965 was normal, and there is no medical evidence of ongoing treatment for a brain disorder after service until 2002, 37 years after his discharge, when the Veteran complained of headaches and was found to have a cerebral aneurysm and infarcts. As such, he concluded that the Veteran's brain condition developed too many years after his active duty service to be considered a causative event. He also noted that the Veteran had risk factors of advancing age, hypertension and smoking. The examiner also concluded that it is undebatable that the Veteran's aneurysm/infarcts did not exist prior to active service or during service, and that instead, it developed years after service. In this regard, he noted that the Veteran was not seen for or treated for an aneurysm while on active duty or immediately after discharge. In fact, there were no symptoms of an aneurysm until 2002, 37 years after discharge, when the Veteran began having headaches and was found at that time, to have a cerebral aneurysm. Finally, the examiner also concluded that the Veteran does not have a brain disorder that is associated but separately related to his service-connected psychiatric disorder, nor does it represent psychomotor epilepsy. In this regard, he noted that the Veteran does not now nor ever did have a seizure disorder, including psychomotor epilepsy, and his cerebral aneurysm and infarcts are not caused by his service-connected psychiatric condition. He noted further that there was no credible medical or scientific literature that states that the psychiatric condition anxiety reaction with hyperventilation causes brain aneurysms and infarcts. There is no other medical evidence of record, VA or private, which indicates that the Veteran's current brain disorder is related to his active military service. The presumption of service connection for a chronic disease diagnosed within one year following discharge from active duty is also not applicable to this case because there is no evidence that the aneurysm manifested within one year of discharge following the first period of service. 38 C.F.R. § 3.307. The Board notes that the Veteran is competent to report his experience and symptoms in service and thereafter, although he is not competent to provide a diagnosis or an etiological opinion. While lay persons are generally not competent to offer evidence which requires medical knowledge, such as opinions regarding medical causation or a diagnosis, they may provide competent testimony as to visible symptoms and manifestations of a disorder. Jones v. Brown, 7 Vet. App. 134, 137 (1994); Layno v. Brown, 6 Vet. App. 465, 469 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). A Veteran can attest to factual matters of which he or she had first-hand knowledge, e.g., experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The United States Court of Appeals for the Federal Circuit has held that lay evidence is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself. The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). In this case, the Board finds that the Veteran is competent to report that he has continued to have neurological symptoms, such as tremors and blackouts since service because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He is not competent, however, to identify symptoms, or link his claimed symptoms to, an aneurysm. Moreover, and more importantly, his assertion of continuity of symptomatology is not deemed credible. In determining whether statements submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board is not required to accept an appellant's uncorroborated account of his active service experiences. Wood v. Derwinski, 1 Vet. App. 190 (1991). In this case, the Board finds that the Veteran's reported history of continued symptomatology since active service, while competent, is nonetheless not credible. In this case, the Board emphasizes that the earliest post-service evidence of record related to symptoms of a brain disorder is in 2002, about 37 years after separation from service. This lengthy period without treatment is evidence against a finding of continuity of symptomatology, and it weighs heavily against the claim. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (service incurrence may be rebutted by the absence of medical treatment of the claimed condition for many years after service). Further, the Board finds that the Veteran's reported history of continued neurological symptomatology since active service is inconsistent with the other evidence of record. Indeed, while he stated that his disorder began in service, the separation examination was absent of any complaints of a neurological disorder. Moreover, the Veteran indicated on his October 1965 VA neuropsychiatric examination that his health was "OK" and that he had no further periods of unconsciousness, anxiety, or other neurological difficulties at that time. Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the Veteran). See also Madden v. Gober, 125 F.3d 1477, 1481 (Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence). That examination also clearly indicated that no neurological diseases were found. Testing of the cranial nerves, motor-sensory innervations, and reflexes were all within normal limits. The Board has weighed the Veteran's statements as to continuity of symptomatology and finds his current recollections and statements made in connection with a claim for benefits to be of lesser probative value. See Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). Therefore, continuity has not here been established, either through the competent evidence or through his statements. Next, service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. The threshold question, therefore, is whether there is sufficient medical evidence to show an etiological link between any current disability of the brain, to include a brain aneurysm or brain stem infarct, and the Veteran's period of active service. The evidence is negative in this respect. Indeed, the Veteran's private neurosurgeon, Dr. W. P. Wolcott, reported, through his nurse in December 2002, that there was no relationship between the Veteran's aneurysm and his military service. He stated that the Veteran's aneurysm was something that he had been born with. The records from Dr. Fulgham indicate that the Veteran was diagnosed with an asymptomatic anterior communicating artery aneurysm in January 2003. Significantly, however, they did not provide an opinion as to the etiology of the Veteran's disorder. There was no discussion with regard to the Veteran's active service. In addition, these records included a June 2004 private treatment note from neurologist D.R. Nair, M.D. Dr. Nair opined that the Veteran had no clear history of ongoing seizures currently, and that the "history of the episode in his 20s is also atypical for seizures." He did not link any alleged in-service seizure episode to his post-service aneurysm. Moreover, a VA examiner in March 2013 provided a competent medical opinion that the Veteran's current brain disorder was not incurred in or due to service. The VA examiner considered the Veteran's lay assertions in forming his medical opinion, but ultimately found that the Veteran's currently diagnosed brain disorder is not related to service. The only medical opinions of record addressing the claimed relationship between the Veteran's brain disorder and service are negative. Simply put, the Veteran has not submitted any competent medical evidence that links any diagnosed disorder of the brain to his active service. The Board has also considered the Veteran's statements asserting a nexus between his currently-diagnosed disorder and active duty service. While the Board reiterates that the Veteran is competent to report symptoms as they come to him through his senses, brain disorders, such as aneurysms, are not the types of disorders that a lay person can provide competent evidence on questions of etiology or diagnosis. See Robinson v. Shinseki, 557 F.3d 1355 (2009). Such competent evidence has been provided by the medical personnel who have examined the Veteran during the current appeal and by service records obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. See Cartright, 2 Vet. App. at 25. When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). 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. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Unlike varicose veins under Barr, a dislocated shoulder under Jandreau, a disorder that was indicated in the medical record to exist years after service, or a finding that one disorder is related to another disorder, is not a condition capable of lay diagnosis. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The issue on appeal does not involve a simple diagnosis. See Jandreau, supra. The Veteran is competent to state that he had headaches/dizziness, but he is not competent to provide more than simple medical observations. He is not competent to provide diagnoses in this case nor is he competent to provide a complex medical opinion regarding the etiology of the claimed disabilities. See Barr, supra. The Veteran's lay assertions regarding the cause of his "seizures" and/or etiology of his brain disorder are not competent or sufficient. Moreover, the Board finds that the Veteran's lay statements are outweighed by the service records, post-service treatment records (indicating a brain disorder that began years after service), and the negative medical opinions from Dr. Wolcott and the March 2013 VA examiner. The Board finds significant probative value in the service treatment records that clearly document that the Veteran's in-service "seizures" were not true seizures but rather manifestations of his service-connected psychiatric disorder, and that he was consistently found to have a normal neurological examination. This conclusion is supported by the June 2004 statement of Dr. Nair, the December 2002 statement from Dr. Wolcott who very clearly indicates that there is no etiological relationship between the Veteran's aneurysm and his military service, and the opinions of the March 2013 VA examiner that (1) there was no medical evidence of the Veteran ever having epilepsy or a seizure disorder, (2) the Veteran does not have a brain disorder that is associated but separately related to his service-connected psychiatric disorder, and (3) that his currently diagnosed cerebral aneurysm and infarcts are not caused by his service-connected psychiatric condition. In sum, the Board finds that the most probative evidence of record points to the Veteran not having suffered an injury or disease of the brain in service. Thus, the Board finds that the medical evidence of record is only against the Veteran's claim. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not applicable. ORDER Service connection for a brain disorder is denied. ____________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs