Citation Nr: 1323886 Decision Date: 07/26/13 Archive Date: 08/06/13 DOCKET NO. 06-06 761 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder. 2. Entitlement to service connection for headaches. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. Nichols, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1965 to January 1966. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The Board issued a decision in February 2010, which, in pertinent part, reopened the previously denied claim for service connection for a psychiatric disorder. The Board also remanded the merits of the claims for service connection for a psychiatric disorder and service connection for headaches. The Board remanded the issues again for further development in December 2011. That development was completed, and the case was returned to the Board for appellate review. In January 2013, the Board requested a medical opinion from a health care professional in the Veterans Health Administration (VHA) for the psychiatric disorder issue. The Board determined that such an opinion was necessary to address the complex medical questions raised by the case. 38 C.F.R. §20.901(a), (d). The Veteran was notified in January 2013 that the Board intended to seek such an opinion. He was later furnished a copy of the medical expert opinion in January 2013, and he was provided 60 days for response. The Veteran, through his representative, responded in April 2013, but did not provide any additional pertinent evidence in support of the appeal. A waiver of RO jurisdiction is not required under such circumstances. See 38 C.F.R. §§ 20.903(a), 20.1304(c). The Veteran's psychiatric disorder claim has been characterized as stated above in order to encompass all acquired psychiatric disorders raised directly by the Veteran or indirectly by the record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). A review of the Virtual VA paperless claims processing system reveals additional evidence, including VA treatment records dated from 2004 to 2012. Some of these records are either duplicative of the evidence of record or are no pertinent to the present appeal. Moreover, to the extent that some of these records are relevant to the issues on appeal, the Board notes that the Veteran has submitted a waiver of the RO's initial consideration of the evidence. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the Veteran's appeal has been obtained. 2. An acquired psychiatric disorder did not manifest in service or within one year thereafter and has not been shown to be causally or etiologically related to the Veteran's military service. 3. The Veteran has not been shown to currently have headaches that manifested in service or that are related to his military service. CONCLUSIONS OF LAW 1. An acquired psychiatric disorder was not incurred in active service, nor may a psychosis be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1154, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 4.125 (2012). 2. Headaches were not incurred in active service. 38 U.S.C.A. §§ 11101, 1110, 1131, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.102, 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). Upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In this case, the RO provided the appellant with notice in May 2004 and July 200. In those letters, the RO informed the Veteran about the information and evidence that is necessary to substantiate his claims for service connection and of the division of responsibilities in obtaining such evidence. A March 2006 letter also explained how disability ratings and effective dates are determined. After the notice was provided, the Veteran's claims were readjudicated in a supplemental statement of the case (SSOC). Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (VA cured failure to afford statutory notice to claimant prior to initial rating decision by issuing notification letter after decision and readjudicating the claim and notifying claimant of such readjudication in the statement of the case). In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records are in the claims file and were reviewed by both the RO and the Board in connection with his claims. As previously noted, these claims have also been remanded twice for further development, to include affording the Veteran VA examinations and requesting that he identify his treatment providers. To date, the Veteran has not identified any other outstanding records that are pertinent his claims being decided herein. Furthermore, the Veteran was afforded VA examinations in March 2007, June 2010, and December 2011 in connection with his claims. The Board also requested the Board requested a VHA medical opinion on the psychiatric issue in January 2013. 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). With regard to headaches, the Board finds that the December 2011 VA examination is adequate, as the examiner reviewed the claims file and considered the Veteran's statements and medical history. She also provided a complete rationale for the opinions stated, relying on and citing to the records reviewed. In fact, the examiner specifically addressed the Veteran's symptomatology in June 1965 of diffuse upper respiratory tract infection with headaches, vertigo, and cough, a requested in the December 2011 VA examination. The Board also finds that the January 2013 VHA medical opinion is adequate. The opinion is predicated on a full reading of the Veteran's claims file, and the VHA psychologist considered all of the pertinent evidence of record. She provided an adequate rationale for her opinion stated, relying on and citing to the records reviewed and various medical principles. Indeed, she specifically referenced various documents in the file, including the Veteran's service treatment records, lay statements, and post-service medical records. She also reiterated the exact directives of the opinion request and gave complete answers with fully supported rationale. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the psychiatric disorder issue has been met. 38 C.F.R. § 3.159(c)(4). For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of his claims of service connection. 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). Law and Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain diseases, such as psychoses, may be also be established on a presumptive basis by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). As to presumptive service connection, the term "psychosis" means any of the following disorders listed in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, of the American Psychiatric Association (DSM-IV-TR): (a) Brief Psychotic Disorder; (b) Delusional Disorder; (c) Psychotic Disorder Due to General Medical Condition; (d) Psychotic Disorder Not Otherwise Specified; (e) Schizoaffective Disorder; (f) Schizophrenia; (g) Schizophreniform Disorder; (h) Shared Psychotic Disorder; and (i) Substance-Induced Psychotic Disorder. 38 C.F.R. § 3.384 (2012). In determining whether service connection is warranted, the Board shall consider the benefit-of-the-doubt doctrine. 38 U.S.C.A. 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1991). I. Acquired Psychiatric Disorder In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for an acquired psychiatric disorder. The Veteran's service treatment records show that he underwent a neuropsychiatric consultation in November 1965 pursuant to his request for discharge as a conscientious objector. A psychiatric examination revealed no evidence of neurosis or psychosis; however, the examining physician noted that the Veteran alienated himself from others and had religious preoccupations and fantasies that were near delusional. The Veteran was diagnosed with a schizoid personality. As a result, he was considered unsuitable to continue with service and was recommended for discharge. The Veteran contends that he was never offered treatment by the military for the schizoid personality disorder and that his current psychiatric condition has stemmed from his psychological problems in service. Post-service private and VA treatment records reveal a history of psychiatric problems over the course of 30 years. Private medical records show that the Veteran was treated for an acute anxiety condition related to stress in 1983 and 1984. In 1987, he was hospitalized and treated as a result of overdosing on medication, which was considered a suicide gesture. In the late 1990s, the Veteran sought psychiatric treatment because of a reported increase in stress due to financial and familial problems. A June 1998 psychiatric progress note from the Dallas VA Medical Center revealed an Axis I diagnosis of depression related to life stressors. Saginaw VA medical center records dated from 2002 to 2011 reveal a multitude of assessments and diagnoses of psychiatric disorders. In 2002, the Veteran was diagnosed with depression and anxiety. In 2003 and 2004, reports of symptomatology showed an increase in financial and familial stressors, and the Veteran was diagnosed with dysthymia due to partner relational problems. In 2004, the Veteran sought anger management treatment. An August 2004 psychodiagnostic evaluation was administered to rule out a psychotic disorder based on the Veteran's indication that he was diagnosed with acute schizophrenia upon discharge from service. The examining psychiatrist observed no hallucinations and no evidence of any current signs of schizophrenia. The psychiatrist noted a theme of consistent depression and opined that it is likely related to feelings that the Veteran has not utilized his life well. A dissociative disorder was ruled out. The examiner listed a diagnosis of "dysthymia versus depression" and psychotic disorder, not otherwise specified (NOS). Treatment records dated in 2005 show various diagnoses of bipolar disorder, NOS; adjustment disorder; and psychotic disorder, NOS. A VA examination in March 2007 revealed a diagnosis of major depression, recurrent, NOS. The examiner noted the Veteran's history and reports of stressors related to financial and familial problems and opined that his symptoms of depression are not related to any service-related problems. However, he did not provide a complete rationale for his opinion. Thus, the Board finds that March 2007 examiner's opinion to be of limited probative value. Treatment records covering 2008 and 2009 reveal the Veteran's mental health progress with a social worker. He was diagnosed with a mood disorder, NOS. The Veteran was afforded another VA examination in June 2010, which revealed a diagnosis of a mood disorder, NOS. The examiner specifically commented that there was no evidence of any symptoms at present that would suggest a psychotic disorder, and therefore, stated that it was not likely that the Veteran's mental disorder was caused by any service-related experiences. However, he did not address whether the symptoms in service could have been manifestations of a disorder other than a schizoid personality. Therefore, the Board also finds that June 2010 VA examiner's opinion to be of limited probative value. Treatment records dated in 2011 show an Axis I diagnosis of depression and Axis II notation of a personality disorder. In January 2013, the Board requested a VHA medical opinion. The Board specifically asked that the medical expert (1) identify the Veteran's current acquired psychiatric disorder(s); (2) provide an etiological opinion relating such disorder(s) to military service, to include the Veteran's in-service symptomatology and diagnosis of a schizoid personality disorder; and (3) provide an opinion as to whether the Veteran had any additional psychiatric disorders superimposed on his schizoid personality disorder in service. A VHA medical opinion was subsequently rendered in January 2013. The VHA psychologist considered the Veteran's in-service psychiatric history, to include the psychiatric evaluation dated in November 1965. The report noted that the Veteran became preoccupied with apocalyptic views. Due to his characterization of the Navy environment as being antithetical to his religious beliefs, the Veteran was noted to have become more withdrawn in the military. Upon mental status examination, there was no evidence of neurosis or psychosis noted, although his religious preoccupations and fantasies were considered "near delusional." It was noted that the Veteran was diagnosed with severe schizoid personality disorder and was deemed unsuitable for military retention. The VHA psychologist observed that the Veteran had no documented history of psychiatric treatment until 1983, when he saw a psychologist for a short period of time and was hospitalized for four days for anxiety and gastritis. Since that time, the Veteran was documented as having intermittent periods of psychiatric treatment, including hospitalizations. The VHA psychologist explained that none of the Veteran's psychiatric treatment records since 1983 have provided a diagnosis of a schizoid personality disorder. She indicated that, in retrospect, it appears that the Veteran's schizoid personality disorder in the military was not accurate because personality disorders are considered to be enduring emotional and behavioral patterns. Rather, his symptoms in service appeared to have been related to his conservative religious beliefs and his poor fit with the military's philosophy. The VHA psychologist based her opinion on the fact that, at the time of the Veteran's initial psychiatric evaluation in 1965, the DSM-I was in effect, which did not delineate specific diagnostic criteria, but rather provided a general description of symptoms. She stated that the Veteran's religious preoccupations and difficulty with social relationships in the military likely contributed significantly to his schizoid personality disorder diagnosis at the time. She also commented that the Veteran does not appear to have met the diagnostic criteria for such a disorder since beginning treatment in 1983. The VHA psychologist noted that the DSM-III and subsequent editions since 1983 have included specific diagnostic criteria rather than a general description of emotions and behavior. She pointed to the 2010 VA examination findings and an August 2004 psychological evaluation to support her opinion that the Veteran did not have an actual diagnosis of schizoid personality disorder because the treatment records since 1983 supports this opinion. The VHA psychologist also addressed the question of whether there was any other psychotic disorder. She noted that the Veteran's initial psychiatric examination in 1965 noted an absence of psychotic symptoms. An April 2003 treatment note and the March 2007 VA examination also did not contain the presence of psychotic symptoms, and the Veteran denied having such symptoms. An August 2004 treatment note did document a diagnosis of a psychotic disorder, NOS. However, upon review of the report, the VHA psychologist concluded that the diagnosis of psychotic disorder NOS appeared to be based only on the Veteran's poor concentration and difficulty maintaining mental focus, which is also consistent with his symptoms of anxiety and depression related to situational factors. She noted that the documented absence of hallucinations, delusions, and a thought disorder provides evidence against a psychotic disorder diagnosis and commented that there is insufficient evidence of psychotic symptoms in the report to support such a diagnosis. In addition, the VHA psychologist clarified that, overall, there is no reliable documentation of any psychotic symptoms in the Veteran's records to support any psychotic disorder diagnosis, to include schizophrenia. Moreover, the VHA psychologist indicated that a review of the Veteran's treatment records note significant anxiety and depression related to specific psychosocial issues, mainly financial concerns and family conflict. She noted that the Veteran's previous suicide attempts have also been related to the same psychosocial problems. She addressed the diagnoses of recurrent major depressive disorder, dysthymia, and mood disorder, NOS. Based on the evidence, however, she ruled out dysthymia and mood disorder, NOS. Ultimately, based on the totality of the evidence, the VHA psychologist opined that a diagnosis of major depressive disorder, recurrent, appears most likely. With respect to linking such a disorder to military service, the VHA psychologist opined that the totality of the Veteran's records do not support any psychiatric disorder beginning during his military service, and she stated that is less likely as not that the Veteran's military service is casually or etiologically related to any post-military psychiatric problems. She supported her conclusion by reviewing his history of interpersonal problems prior to and during service. She observed that the Veteran's ongoing difficulties in life adaptation appear to be related to his beliefs and personality style rather than attributable to any psychiatric diagnosis, including a personality disorder. His strong and rigid religious beliefs have continued to contribute to his life stressors since the military, as exhibited by the problems he has had with his family and his church. Lastly, the VHA psychologist commented on whether the Veteran had any additional psychiatric disorder superimposed on his schizoid personality disorder in service. She reiterated that the Veteran's post-military history and more definitive symptom specificity in newer editions of the DSM indicate that the Veteran does not meet the criteria for a schizoid personality disorder. She explained that it is not likely that the Veteran experienced a remission in symptoms of schizoid personality disorder subsequent to the military, indicating that his original psychiatric diagnosis of such was not accurate. In so doing, she noted personality disorders are considered to be enduring patterns of emotional and behavioral responsiveness. She pointed to the fact that his initial psychiatric evaluation in November 1965 noted that there was no evidence of neuroses or psychosis, and his treatment in 1983 was related to depression secondary to psychosocial stressors, which has been a consistent pattern for the Veteran since that time. Finally, she concluded that there is no evidence that the Veteran's psychiatric symptoms or diagnoses subsequent to the military were related to any factors during military service. The law is clear that it is the Board's duty to assess the credibility and probative value of evidence, and provided that it offers an adequate statement of reasons and bases, the Board may favor one medical opinion over another. Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wray v. Brown, 7 Vet. App. 488 (1995) (the Board may adopt a particular independent medical expert's opinion for its reasons and bases where the expert has fairly considered the material evidence of record). The Board, of course, is not free to reject medical evidence on the basis of its own unsubstantiated medical conclusions. Flash v. Brown, 8 Vet. App. 332 (1995). After weighing the medical evidence, the Board finds the January 2013 VHA psychologist's opinion to be most probative. She reviewed and carefully summarized all of the pertinent evidence and provided a helpful and detailed rationale, as discussed above. The value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). Based on the foregoing, the Board attaches the greatest probative weight to the opinion of the VA medical expert who had the benefit and review of all pertinent medical records and who provided a thorough rationale supported by the record. In summary, the January 2013 VHA psychologist has opined that the Veteran did not have a schizoid personality disorder in service and has not been diagnosed with any other pscyhoses. She also stated that the evidence does not support a finding that any psychiatric disorder began in service or is otherwise related thereo. Moreover, there is no other medical opinion of record that supports the Veteran's claim. The Board recognizes that the Veteran is competent to report his experience and symptoms in service. 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). A veteran can attest to factual matters of which he has or 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 Federal Circuit has held that lay evidence is one type of evidence that must be considered, if submitted, when a Veteran seeks disability benefits, and competent lay evidence can be sufficient in and of itself for proving the existence of a chronic disease. See Buchanan, 451 F.3d at 1335; 38 C.F.R. §§ 3.303(a), 3.307(b). The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. Buchanan, 451 F.3d at 1336. 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 Veteran appears to have alleged a continuity of symptomatology since his military service. In various statements, he has asserted that his mental health disorder stemmed from his psychological problems in service and has continuously affected his life. In so doing, he has also contended that he received poor psychological counseling and treatment during service. Nevertheless, as discussed above, the preponderance of the evidence shows that the Veteran has not had a psychotic disorder or psychoses. The theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic as listed in 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Thus, service connection is not warranted based on continuity of symptomatology. Moreover, to the extent that the Veteran and his wife have attested to a relationship between a current psychiatric disorder and his military service, the Board notes such lay evidence is outweighed by the highly probative opinion of the January 2013 VHA psychologist. She considered the Veteran's own reported medical history and his treatment records and relied on her medical expertise in applying the DSM criteria and providing a medical opinion. Her opinion is supported by a clear and thorough rationale. The Board also acknowledges that, in June 2004, the Veteran submitted written material obtained from an online source regarding the connection between schizophrenia and sleep apnea. However, the Board notes that the Veteran is not service-connected for sleep apnea. Moreover, this evidence is general in nature, and no examiner has specifically related the information contained therein to the Veteran. See Sacks v. West, 11 Vet. App. 314, 317 (1998) ("This is not to say that medical article and treatise evidence are irrelevant or unimportant; they can provide important support when combined with an opinion of a medical professional."). In addition, considering that the preponderance of the evidence shows that the Veteran did not and currently does not have schizophrenia or a psychotic disorder, this article is not particularly relevant. Thus, the Board finds that the medical literature has no probative value in this case. Based on the foregoing, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for an acquired psychiatric disorder. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt provision does not apply. Accordingly, the Board concludes that service connection for an acquired psychiatric disorder is not warranted. II. Headaches In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for headaches. The Veteran's service treatment records, to include his entrance and separation examinations, do not reflect any diagnosis or treatment of chronic headaches or migraines. However, in June 1965, the Veteran was seen for a diffuse upper respiratory tract infection with headaches, vertigo, and cough listed as accompanying symptoms. Post-service VA treatment records first indicate that the Veteran suffered from headaches in May 1998 and June of 1998. They were noted to be stress headaches (in the context of psychological evaluation). In May 1998, a CT scan of the Veteran's head revealed normal results. VA medical records dated from 2002 also show that the Veteran complained of headaches in the context of receiving psychiatric treatment; however, a 2003 mental health note indicates that the Veteran denied having headaches or any visual changes. At the March 2007 VA examination for mental disorders, the Veteran reported that he was receiving treatment for migraine headaches. The Veteran was afforded a VA neurological examination in June 2010 during which he reported that he has been experiencing headaches for the last 12 years (late 1990s). For the last three years or so, he had been taking medications regularly to control the frequency of the headaches. He indicated that most of the headaches are bitemporal and in the vertex area, and he noted that the headaches are associated with some vague blurring of the vision and nausea on some occasions. The Veteran also stated that stress causes headaches and no other precipitating factors. The VA examiner diagnosed the Veteran with migraine headaches (a 12 year history) and opined that the disorder is not likely related to the Veteran's active military service. In his rationale, he referred to the body of the VA examination report, which contained discussions of the Veteran's military and medical history. The Veteran was afforded another VA examination in December 2011 at which time the examiner reviewed the Veteran's military history, including his service treatment records. Notes from the examination show that the Veteran indicated that he experienced occasional headaches with one episode of transient loss of vision. The Veteran did not have prostrating and prolonged attacks of migraine headache pain, and the headaches do not impact his ability to work. The examiner noted that the Veteran's current reported migraine headache symptoms are head "discomfort" and opined that such headaches are not caused by or a result of military service. He specifically commented on the 1965 notation of headache symptoms in connection with the in-service respiratory tract infection and stated that such symptoms 46 years ago were acute and transitory with no residual functional deficit. The examiner indicated that there is no medical nexus to establish causation of current complaints of head "discomfort" and military service. He also added that the separation examination in January 1966 evidenced a normal examination and noted that the Veteran's military service was eight months in duration. Based on the foregoing evidence, the Board finds that headaches did not manifest in service. The Veteran's service treatment records did not document any diagnosis. While he was noted to have headaches accompanying a respiratory infection, such headaches appear to have been acute and transitory, as there was no indication of any headaches at the time of his separation examination. Moreover, the December 2011 VA examiner even opined that the headaches in 1965 were acute and transitory with no residual function. Moreover, the Veteran and his representative have not asserted that his current headaches manifested in service and that there has been continuity of symptomatology. With regard to the decades-long evidentiary gap in this case between active service and the earliest manifestations of headaches, the Board notes that a prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board must consider all the evidence including the availability of medical records, the nature and course of the disease or disability, the amount of time that elapsed since military service, and any other relevant facts in considering a claim for service connection. Id.; cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000) (holding that the absence of medical records during combat conditions does not establish absence of disability and thus suggesting that the absence of medical evidence may establish the absence of disability in other circumstances). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). In addition to the lack of evidence showing that headaches manifested during active duty service or within close proximity thereto, the evidence of record does not link any current diagnosis to the Veteran's military service. The December 2011 VA examiner reviewed the pertinent medical evidence of record, considered the Veteran's reports of symptomatology, performed a physical examination, and provided an etiological opinion that is consistent with the evidence of record. Furthermore, the VA examiner addressed the report of headache symptoms in the 1965 service treatment record and provided an adequate rationale as to why such symptoms were not related to the Veteran's current migraine headaches. Thus, as the VA examiner provided an adequate supporting rationale, the Board finds this VA examination to be the most probative. The record does include any medical opinions otherwise supporting the Veteran's claim. Moreover, to the extent that the Veteran has attested to a relationship between his current headaches and his military service, the Board notes such lay evidence is outweighed by the more probative opinion of the December 2011 VA examiner. He considered the Veteran's own reported medical history and his medical records, including his service treatment records. The examiner relied on his medical expertise in providing a medical opinion, which is supported by a clear and thorough rationale. Based on the foregoing, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for an acquired psychiatric disorder. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt provision does not apply. Accordingly, the Board concludes that service connection for an acquired psychiatric disorder is not warranted. ORDER Service connection for an acquired psychiatric disorder is denied. Service connection for headaches is denied. ____________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs