Citation Nr: 1326359 Decision Date: 08/19/13 Archive Date: 08/26/13 DOCKET NO. 11-23 808 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUES 1. Entitlement to service connection for a chronic neurological disability, to include stroke with vision loss due to thiamine deficiency, to include as secondary to service-connected gastroesophageal reflux disease (GERD). 2. Entitlement to service connection for an acquired psychiatric disability, to include depression and adjustment disorder, to include as secondary to service-connected disabilities. ATTORNEY FOR THE BOARD S. Grabia, Counsel INTRODUCTION The Veteran had active service in the United States Air Force, to include as an active member of the reserves, from November 1980 to November 1990, January 1991 to April 1991, and September 1991 to August 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from May 2008 and June 2009 rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO), in San Diego, California, and Albuquerque, New Mexico, respectively. The Veteran resides in the jurisdiction of the Albuquerque RO. This matter was previously before the Board in January 2013 at which time it was remanded for additional development. It is now returned to the Board. As will be discussed further herein, the Board finds that the agency of original jurisdiction (AOJ) substantially complied with the remand orders and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a) (2) (West 2002). FINDINGS OF FACT 1. The preponderance of the competent and credible evidence regarding the contended causal or aggravating nexus between service-connected GERD and a chronic neurological disability, to include stroke with vision loss due to thiamine deficiency is against the alleged relationship. 2. The Veteran does not have a chronic neurological disability, to include stroke with vision loss due to thiamine deficiency which had its onset in active service or manifest to a compensable degree within one year after discharge from active service and is not the result of a service-connected disease or injury or associated surgical treatment. 3. The preponderance of the competent and credible evidence regarding the contended causal or aggravating nexus between the service-connected disabilities and an acquired psychiatric disability, to include depression and adjustment disorder is against the alleged relationship. 4. The Veteran does not have an acquired psychiatric disability, to include depression and adjustment disorder which had its onset in active service or manifest to a compensable degree within one year after discharge from active service and is not the result of service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for a chronic neurological disability, to include stroke with vision loss due to thiamine deficiency, to include as secondary to service-connected GERD, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. The criteria for service connection for an acquired psychiatric disability, to include depression and adjustment disorder, to include as secondary to service-connected disabilities, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist 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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). 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. 38 C.F.R. § 3.159(b) (1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim. Accordingly, 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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA 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). Where complete notice is not timely accomplished, such error may 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); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent letters in February 2008 (prior to the initial adjudication of the acquired psychiatric condition claim in May 2008) and January, February, and June 2009 (prior to the initial adjudication of the neurological condition claim in June 2009), and August 2010 (subsequent to the adjudication of the neurological condition claim in June 2009) that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. The letters also explained what type of information and evidence was needed to establish a disability rating and effective date. The Board acknowledges that complete notice was not issued to the Veteran prior to the adverse determinations on appeal. However, fully compliant notice was issued later, and the claims were thereafter readjudicated most recently in an April 2013 Supplemental Statement of the Case. Thus, any timing deficiency has here been appropriately cured. Mayfield, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was represented by the Disabled American Veterans (DAV) and subsequent to the January 2013 Board remand, in May 2013 revoked DAV's representation. He has proceeded since that time without representation. The Board notes that DAV is presumed to have knowledge of what is necessary to substantiate a claim for service connection. Neither the Veteran nor his prior representative has pled prejudicial error with respect to the content or timing of VCAA notice during the appeal period. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Even if the Veteran was not notified with regard to the degree of disability and the effective date, because the Board has concluded that the preponderance of the evidence weighs against the claims for service connection, any questions as to the appropriate disability rating or effective date to be assigned are rendered moot, and no further notice is needed. See Mayfield v. Nicholson, 19 Vet. App. 103, 115 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Accordingly, the duty to notify has been satisfied. See Dingess/Hartman, 19 Vet. App. at 484; 38 C.F.R. § 3.159. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him/her in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. 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 Board further observes that this case was remanded in January 2013 in order to obtain outstanding treatment records and afford the Veteran a VA examination. Thereafter, additional relevant treatment records were associated with the claims file, and the Veteran was afforded the requested VA examination. The Board has carefully reviewed such records and concludes that no additional available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. Also, the Veteran was afforded VA examinations, most recently in September 2010 (neurological disorder) and February 2013 (psychiatric disorder). The Board finds that the VA examinations are adequate because, as shown below, they were based upon consideration of the pertinent medical history, lay assertions and current complaints, and because they describe the Veteran's disabilities and symptomatology in detail sufficient to allow the Board to make fully informed determinations. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994). The Board accordingly finds no reason to remand for further examinations. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran 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). Service connection Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). In order to prevail on the issue of service connection for any particular disability, there must be evidence of a current disability; evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence, or in certain circumstances, lay evidence, of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). Service connection for certain chronic diseases may also be established based upon a legal "presumption" 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 U.S.C.A. § 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (rejecting the argument that continuity of symptomatology in § 3.303(b) has any role other than to afford an alternative route to service connection for specific chronic diseases). In addition, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) (2012); Allen v. Brown, 7 Vet. App. 439 (1995). VA has amended 38 C.F.R. § 3.310 to explicitly incorporate the holding in Allen, except that it will not concede aggravation unless a baseline for the claimed disability can be established with evidence created prior to any aggravation. 38 C.F.R. § 3.310(b). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. The Veteran asserts that he developed a chronic neurological disability, to include stroke with vision loss due to thiamine deficiency, to include as secondary to service-connected GERD. In addition he asserts that he developed an acquired psychiatric disability, to include depression and adjustment disorder, to include as secondary to service-connected disabilities. The Board recognizes the Veteran's contentions that he has a chronic neurological disability; and an acquired psychiatric disability, to include depression and adjustment disorder. 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. See Jandreau, 492 F.3d 1372, 1377 (Fed. Cir. 2007). It, however, would require medical or scientific expertise to say that a chronic neurological disability, to include stroke with vision loss due to thiamine deficiency was related to the Veteran's GERD or the surgical treatment he underwent for GERD; or that an acquired psychiatric disability, to include depression and adjustment disorder was caused by service or was secondary to the Veteran's service connected disabilities. These are not matters that are subject to lay observation. There is no indication that the Veteran possesses the requisite medical knowledge or education to render a probative opinion involving medical diagnosis or medical causation. See Jandreau, 492 F.3d at 1377. Chronic neurological disability, to include stroke with vision loss due to thiamine deficiency, to include as secondary to service-connected GERD The service treatment records are absent for any complaint, treatment, or diagnosis of any neurological disability, a stroke, vision problems, or thiamine deficiency during service, and the Veteran does not contend that there was an onset in active service. In a March 2008 private medical record, David Poor, MD, noted that he was the Veteran's primary care physician. He noted that the Veteran had an unusual collection of symptoms to include short term memory loss, vision abnormalities, cognitive impairment, and nerve damage. He had seen several neurologists and an ophthalmologist and had several tests done, which show some abnormalities but the underlying causes remained unknown. Specialists believe he may have had some kind of small stroke which could account for his symptoms, but this was not definitely established. The file contains numerous private medical records including; A November 2007 treatment record from Dr. Poor, which notes the Veteran, "may have had a TIA (transient cerebral ischemic attack), however, no diagnosis was given. A Jordan Valley Hospital treatment record notes, no acute intracranial hemorrhage, hematoma, mass or mass effect, no demyelization, no acute ischemic infarct, and a normal magnetic resonance imaging (MRI) study of the brain. A December 2007 treatment record describes memory problems beginning around January 1, 2004. These were daily, moderate to severe, and possibly from electrocution injury when a car the Veteran was working on was struck by lightning and he were thrown 12 feet. However, no white matter was found. A clinician noted partial seizures may account for the memory difficulties. A January 2008 treatment report notes the November 2007 MRI was normal showing no evidence of white matter disease, strokes, or atrophy. Dr. Poor noted two electroencephalograms (EEG 's) had been performed due to concern of seizures. A treatment report in March 2008 noted that a neurologist and ophthalmologist felt the Veteran may have had some kind of small stroke but that has not been definitively established yet. An April 2008 treatment report showed thiamine deficiency, in which, he prescribed vitamin B for control. A December 2008 neurology consult revealed a normal MRI of the brain and the Veteran was admitted to the telemetry unit for observation with orders for TIA and stroke protocol. Imaging studies were performed and came back nondiagnostic. The treating physician was not convinced that this was a TIA or stroke. Private treatment records also show blindness in the right eye and vision loss in the left eye. However, there was no evidence this condition was related to military service. The service treatment records and the post service treatment records do not contain a clear diagnosis or clinical findings of a stroke. The Veteran was afforded a VA examination in June 2009. The examiner noted that he reviewed the VA treatment records; the claims file was not available. He noted that the Veteran reported being diagnosed with GERD in 1985. Symptoms were initially minor and became worse requiring surgery in 2005. This resulted in malabsorption syndrome with vitamin B12, B6, B1 deficit, resulting in two strokes due to hyper coagubility. The Veteran reported being hospitalized in December 2008 for observation for stroke; and May 2009 for observation for migraine. The examiner noted that the Veteran reported loss of work in the past 12 months due to a stroke in December 2009. The diagnosis was left inguinal hernia with secondary hypercoagubility state leading to CVA 2007 and 2008 due to malabsorption after surgery. The examiner noted no clear diagnosis or clinical finding of a stroke. This examination was deemed inadequate for rating purposes and a new examination was requested. The Veteran was afforded a VA examination in September 2010. The examiner noted he reviewed the claims file and VA treatment records. The Veteran reported vision loss as secondary to GERD surgery or vitamin deficiency. The examiner noted that an August 2009 neurological consult noted a two year history of cognitive issues including difficulty focusing and thinking. He was easily distracted and was unable to recall short term events. He also reported being unable to perform basic math calculations. He was also unable to read big paragraphs and even with small paragraphs needed to read them three to four times. His symptoms began in mid-2007 when he blacked out at work. He consulted a neurologist and was determined to be vitamin B deficient. In December 2008 he had sudden left arm pain and severe headaches. He went to bed and woke up with sudden loss of vision in his right eye and worsening cognitive function. He continued to see a neurologist but MRIs, MRAs, MRBs, and other studies were all normal. The examiner noted that the Veteran had multiple neurological signs and symptoms of unknown origin, and that he had extensive work ups with normal results. The examiner noted that, "At this point it's difficult to understand the origin of his clinical picture." The examiner noted that the claimed stroke with vision loss was not secondary to GERD surgery or vitamin deficiency. The rationale given was that the initial evaluation of cognitive and visual complaints was in Utah and indicates the changes can be dated back to an event in which the Veteran was struck or near struck by lightning in 2004- a date the Veteran confirmed as valid. In the history provided by the Veteran he felt he had no residuals or acute problems from the lightning event and did not seek medical attention until weeks later when his primary care provider did a work up and found him to be "OK." It was 18 months after GERD surgery when he first consulted his primary care provider regarding cognitive changes and was found through a neurologist to have multi-vitamin B deficiencies. Neurology changes appeared to predate the gastrointestinal surgery in 2005. It was also pointed out by numerous consultants that the evaluations for neurological deficits have not yielded evidence as to cause. There was no clear evidence of a stroke. A TIA which the Veteran felt was his diagnosis was defined as a transient condition and would not be appropriate in this setting. An August 2009 neurological consultation presented a detailed account of the history of events leading up to the evaluation and noted no physical explanation for the Veteran's findings. The Veteran's current primary care provider did not list neurologic deficits or stroke as historical diagnoses and did not address further evaluation of that condition. The September 2010 opinion is based on the examiner's medical knowledge, and is a subject on which the examiner, as a physician, is competent to address. With regard to the Veteran's contentions, all that is forwarded is his own personal belief that a neurological condition, to include stroke with vision loss due to thiamine deficiency had some etiological relationship to his post-surgical GERD. He is competent to describe his history of symptoms. See Layno v. Brown, 6 Vet. App. 465, 469; Jandreau, 492 F.3d at 1377. In limited instances where an etiology is readily capable of lay observation, he is also competent to provide a nexus opinion. See id. However, there is no other medical opinion, private or VA, which is supportive of the Veteran's contention. Quite the opposite, the VA examiner explained that the contended relationship is not logical as a medical proposition. The determination on whether such is related to service or an intercurrent cause is a medical question. Id. The Veteran is not shown to be a medical professional and is not competent to express an opinion on such an issue. See Jandreau, 492 F.3d at 1376-1377; see also Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010); King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Thus, his assertions are not competent evidence to show a nexus to service and in this regard, have no probative value. Id; see Davidson, 581 F.3d at 1316. In the 2010 opinion, the VA examiner noted that an August 2009 neurological consult noted no physical explanation for the Veteran's findings, and his current primary care provider did not list neurologic deficits or stroke as historical diagnoses or addressed further evaluation of that condition. By "competent medical evidence" is meant in part that which is provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a). The VA medical opinions cited above are plausible, consistent with the record, and uncontroverted by any additional medical opinion. They are accompanied by a detailed medical explanation with specific considerations to the Veteran's lay reports and service-connected disabilities. The Board considers the VA medical examination opinions to be highly probative, and they weigh against the claim. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also King, 700 F.3d at 1345. In other words, the preponderance of the evidence is against finding a nexus to service, including a secondary relationship to a service-connected disability. Accordingly, the Board must find that the preponderance of the evidence does not support the contended relationship, and the claim will be denied. The Board further notes that in the absence of any medical diagnosis of an underlying disability, the Board finds that the evidence of record demonstrates that the Veteran does not have disabilities which correspond to this claim for VA purposes. Degmetich v. Brown, 104 F. 3d 1328 (1997). A threshold requirement for the granting of service connection is evidence of a current disability. In the absence of evidence of a current disability, i.e. stroke, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see McClain v. Nicholson, 21Vet. App. 319 (2007)(finding that the requirement for a current disability is satisfied if the claimant has a disability at the time a claim was filed or at any time during the pendency of the appeal, even if the disability resolves prior to the Secretary's adjudication of the claim). In reaching this determination, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran's claim. 38 U.S.C.A. § 5107(b) (West 2002); see also Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Acquired psychiatric disability, to include depression and adjustment disorder, to include as secondary to service-connected disabilities The service treatment records are absent for any complaint, treatment, or diagnosis of an acquired psychiatric disability, to include depression and adjustment disorder during service. The Veteran was afforded a VA examination in September 2010. The examiner reviewed the claims file and VA treatment records and noted that the Veteran had been treated since August 2009 for an undifferentiated somatoform disorder. Psychological testing revealed that the Veteran reported severe depressive symptoms including loss of pleasure, agitation, loss of interest, indecisiveness, change in sleep pattern, irritability, concentration difficulty, sadness, pessimism, tiredness, fatigue. The examiner noted the Veteran was cooperative, clean, casually and appropriately dressed. He was lethargic and his speech was slow and clear. Affect was blunted, and mood was depressed and dysphonic. Intelligence was average and memory normal. There were no hallucinations, inappropriate, obsessive or ritualistic behavior, panic attacks, homicidal or suicidal thoughts, or episodes of violence. The examiner noted the Veteran had been treated in the past with an anti-depressant, "primarily for sleep and secondarily for mood." A University of Utah report noted that this was due to the Veteran's sleep being disturbed by pain in his leg. The Veteran had been treated for undifferentiated somatoform disorder. His initial assessment noted that, "patient does not report any significant prior history of depression preceding his recent cognitive deficits. He however does report having various trials of flouxetine (an antidepressant) for chronic pain issues....." Records further indicate, "Recent cognitive decline creating severe financial and social stressors that ultimately have led to worsening depression." The examiner opined that the Veteran's current claimed major depressive disorder was less likely as not caused by or as a result of the claimed depression as related to his service connected hamstring muscle. The rationale was that in a colloquial use of the word having a chronic illness or injury may be "depressing," but this was different from a diagnosis of major depressive disorder. Upon initial diagnosis and treatment of the Veteran's injury he was given anti-depressive medications though the treating physician states the treatment was, "primarily for sleep and secondarily for mood." Considering that mood was a secondary consideration in the case at the time it seems more likely than not that the Veteran may have been experiencing some depressive symptoms at the time that were judged to be a reaction to a diagnostically separate disorder. This notion was supported by psychological evaluations from 2009 indicating that he did not have an ongoing history of depression but began experiencing depressive symptoms secondary to job loss, financial hardship, and increased marital strife. The Veteran was afforded a VA examination in February 2013. The examiner reviewed the claims file and VA treatment records. A thorough review of the Veteran's records revealed a history of an undifferentiated somatization disorder as diagnosed by multiple providers. The Veteran endorsed numerous medical complaints over the years including physical and cognitive complaints that after appropriate investigation could not be fully explained by any known medical condition or the direct effect of a substance, (i.e. drug abuse, medication abuse). In addition the physical and cognitive complaints and resulting social and occupational impairment were in excess of what would be expected from the history and other findings. The disorder was first diagnosed in 2009. The examiner opined that the Veteran did not meet the criteria for a depressive disorder. His mood was described as feelings of anger, resentment, and betrayal which the Veteran used to define his depression. His reports were said not to coincide with the standard definition of depression; or of a depressed mood (feeling sad or empty; or observations of tearfulness). The Veteran's reported depressive symptoms were not consistent with a clinical depressive disorder. The VA examiner in September 2010 commented that the colloquial use of the word "depression" by the Veteran was different than a diagnosis of major depression (or other DSM-IV defined depressive disorders) and the examiner agreed with this comment. The VA examiner opined that the claimed acquired psychiatric disorder, diagnosed as undifferentiated somatoform disorder, was less likely than not proximately due to or the result of the Veteran's service-connected conditions. The examiner explained that the diagnosis of undifferentiated somatoform disorder was less likely than not aggravated by any service-connected disability. Also, it was less likely than not that the Veteran's psychiatric diagnosis had causal origins in active service. While the VA examiner noted that a clinician in the pain clinic prescribed an anti-depressant (largely for a sleep disturbance, and only secondarily for symptoms of depression), there was no information that met DSM-IV diagnostic criteria for any depressive disorder at that time. The VA examiner explained that persons can experience depressive symptoms without meeting diagnostic criteria for a depressive disorder. Multiple providers over the years of treatment made no mention about any connection between events in the military and current psychological symptoms. Furthermore, multiple providers indicated etiology and onset occurred in approximately 2004 or 2006 and were related to occupational problems, cognitive complaints (by contrast neuropsychology showed intact cognitive functioning), and other life stressors (i.e. divorce, selling business with family member). The Veteran was seen by a psychologist over a 10 month period in 2009-2010 for a total of 22 sessions, and the psychologist noted that the Veteran denied any history of depression prior to the reported onset of cognitive deficits. The psychologist's notes do not provide any indication that any service connected disability was related to the Veteran's psychological symptoms, nor that any of his psychological symptoms had causal origin in active duty. The VA examiner opined that the depressive symptoms the Veteran endorsed were secondary to job problems, subsequent job loss, financial hardship, and marital conflict with subsequent divorce. The medical evidence and opinions are based on the examiners' medical knowledge, and is a subject on which the examiners, as physicians are competent to address. There is no other medical opinion, private or VA, which is supportive of the Veteran's contention that he incurred an acquired psychiatric disability, to include depression and adjustment disorder, to include as secondary to service-connected disabilities. The Veteran is competent to report on what comes to them through their senses, and in some cases, they are competent to report on simple medical conditions. See Jandreau, 492 F.3d at 1377. With respect to something as complicated as a nexus opinion addressing the potential relationship between an acquired psychiatric disability, to include depression and adjustment disorder, to include as secondary to service-connected disabilities and the onset of an acquired psychiatric disability, however, the Board must conclude that the Veteran lacks the requisite medical credentials to opine as to something so complicated. Id. Thus, his assertions are not competent evidence to show a nexus to service and in this regard, have no probative value. Id; see Davidson, 581 F.3d at 1316. By "competent medical evidence" is meant in part that which is provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a). The VA medical opinions cited above are plausible, consistent with the record, and uncontroverted by any additional medical opinion. They are accompanied by a detailed medical explanation with specific considerations to the Veteran's lay reports and service-connected disabilities. The Board considers the VA medical examination opinions to be highly probative, a they weigh against the claim. See Nieves-Rodriguez, 22 Vet. App. at 304; see also King, 700 F.3d at 1345. In other words, the preponderance of the evidence is against finding a nexus to service, including a secondary relationship to a service-connected disability. Accordingly, the Board must find that the preponderance of the evidence does not support the contended relationship, and the claim will be denied. In reaching this determination, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran's claim. 38 U.S.C.A. § 5107(b) (West 2002); see also Ortiz, 274 F.3d at 1365; Gilbert, 1 Vet. App. at 55. ORDER Service connection for a chronic neurological disability, to include stroke with vision loss due to thiamine deficiency, to include as secondary to service-connected GERD, is denied. Service connection for an acquired psychiatric disability, to include depression and adjustment disorder, to include as secondary to service-connected disabilities, is denied. ____________________________________________ DEMETRIOS G. ORFANOUDIS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs