Citation Nr: 1338329 Decision Date: 11/21/13 Archive Date: 12/06/13 DOCKET NO. 05-04 353 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for residuals of a head injury, other than headaches. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD N. Snyder, Counsel INTRODUCTION The Veteran served on active duty from August 1973 to April 1975 and from May 1975 to May 1981. This appeal comes to the Board of Veterans' Appeals (Board) from a June 2004 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. When this claim was most recently before the Board in May 2013, it was remanded for further development. The Veteran and his wife presented testimony at a videoconference hearing before the undersigned Veterans Law Judge in May 2006. A transcript of the hearing is of record. The record before the Board consists of the Veteran's paper claims files and an electronic file known as Virtual VA. FINDING OF FACT No residuals of an in-service head injury, other than the already service-connected headaches, have been present during the period of this claim. CONCLUSION OF LAW The criteria for service connection for residuals of head injury, other than headaches, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2013), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided 'at the time' that or 'immediately after' VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The record reflects that the Veteran was provided all required notice in letters mailed in April 2004 and March 2006. Although complete notice was not provided until after the initial adjudication of the claim, the Board finds that there is no prejudice to the Veteran in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the Board notes that following the provision of the required notice and the receipt of all pertinent evidence, the originating agency readjudicated the claim. There is no indication or reason to believe that the ultimate decision of the originating agency on the merits of the claim would have been different had complete VCAA notice been provided at an earlier time. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006) (A timing error may be cured by a new VCAA notification followed by a readjudication of the claim). The record reflects that all service treatment records (STRs) and all available post-service medical evidence identified by the Veteran have been obtained. The Board acknowledges that the record indicates that an EEG was ordered in October 2005 but the record does not include the results of the ordered EEG. It does not appear that the EEG was performed, however: all available VA medical records, including all test results, have been obtained and they do not suggest that the EEG scheduled for October 2005 was ever performed. Furthermore, neither the Veteran nor his representative has alleged that there is an outstanding EEG report or that any other evidence is outstanding. The Board notes that although the record does not include the records associated with the Veteran's award of Social Security Administration (SSA) disability benefits, it does not appear that SSA has any records pertinent to the issue on appeal. In this regard, the Board notes that the SSA benefits were awarded based on an unrelated low back disability and neither the Veteran nor his representative has alleged that the SSA has any records pertinent to the issue on appeal. Moreover, neither the Veteran nor his representative has alleged that there are any other, existing evidence that could be obtained to substantiate the claim. The Board is also unaware of any such evidence. The Veteran was afforded appropriate VA examinations and probative opinions (i.e. opinions supported by a detailed rationale) have been obtained with respect to the claimed residuals of an in-service head injury. The Board acknowledges that the Veteran has contended that the September 2004 VA examination record is not probative because the examination was not conducted by a neurologist. It is not necessary that VA examinations be conducted by a specialist in the particular field of the Veteran's claimed disability; VA satisfies its duty to assist the Veteran when it provides a medical examination performed by a person who is qualified through education, training, or experience to offer medical diagnosis, statements, or opinions, regardless of whether the person is a doctor, nurse practitioner or physician's assistant. Cox v. Nicholson, 20 Vet. App. 563 (2007). In this case, there is no evidence that would tend to show the examiner, a physician, was not competent and qualified to examine the Veteran and provide an opinion. Accordingly, the Board finds that the examination and opinion are adequate. Furthermore, there has been substantial compliance with the Board's remand directives with respect to the issue decided herein. Accordingly, the Board will address the merits of the Veteran's claim. Legal Criteria Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests epilepsy to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as opposed to merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service (or during any applicable presumptive period) is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). 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 a 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 (2012); 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. Factual Background and Analysis An April 1976 treatment record indicates that the Veteran presented for treatment with a history of minor head injury five days earlier. The record notes that the head injury was not associated with loss of consciousness, retrograde amnesia, or focal neurological symptoms. The Veteran reported intermittent bifrontal headaches after the accident and three episodes of loss of consciousness, without apparent warning. The Veteran added that the episodes lasted a few seconds and were not associated with definite tonic-clonic movement, incontinence, or tongue biting. The episodes were followed by questionable, brief (less than three minutes) confusion but no lethargy. The Veteran denied a history of previous loss of consciousness or other neurological symptoms. After examination, the Veteran was assessed with "probable hyperventilatory syncope or so-called 'post-concussional' syndrome, rather than post-traumatic seizures," although it was noted that seizures could not be ruled out. An April 1976 electroencephalogram (EEG) was normal. Subsequent medical records indicate a diagnosis of probable seizures in January 1977 and treatment with Dilantin. In January 1978, it was noted that the Veteran reported four episodes of loss of consciousness during the past year. Examination was within normal limits. The examiner suspected seizures though it was "difficult to say for certain." In a November 1980 report of medical history for dental treatment, the Veteran reported a history of epilepsy or fits and indicated that he was currently taking medication for epilepsy. A November 1981 authorization for a medical tag warning reflects "convulsive disorder." On the May 1981 separation examination, the Veteran was noted to have had a normal clinical evaluation of the head, neurologic system, and psychiatric system, and no blackout spells, loss of consciousness, or seizure disorder was noted. Service records also indicate that the Veteran received limited duty assignments due to the head injury and seizure disorder. Such records indicate that the Veteran was prohibited from assignments where sudden loss of consciousness could be dangerous to himself or others. There is no indication in the post-service medical evidence of complaints of or treatment for blackout spells, loss of consciousness, or a seizure disorder from the time of the Veteran's May 1981 separation from service until September 2004. In June 2004, the Veteran's wife submitted a statement indicating that she had been married to the Veteran for 20 years. The Veteran's wife stated that during the early years of their relationship she was unaware of his condition, but that, about ten years ago, she noticed that he started having problems with headaches and blackouts. The statement furthermore indicate that there were times that the Veteran would occasionally pass out without warning and that, because they did not have health insurance, the Veteran did not receive any treatment for this condition. The Veteran's wife also stated that the Veteran suffered from blackouts once or twice every three months. The Veteran was afforded a VA examination in September 2004. At the time of the examination, the Veteran reported that following his in-service motor vehicle accident in 1976, he began having abnormal episodes, which he described as seizures, and that he continued to have these episodes about every three months. He also reported that on discharge from the military, his medications were dropped due to lack of medical care or attention and that at this point he did not notice any change in the recurrence pattern of these episodes. The Veteran further reported that he currently experienced one of these episodes about every three months, during which he passed out and awoke with someone standing over him asking if he was all right. He reported that witnesses had said that he was not experiencing any overt seizure activity but was simply unconscious for a few minutes. The Veteran denied seeking recent medical care for this condition. The VA examiner stated that the current examination and review of the military medical records failed to reveal a definitive diagnosis of a seizure disorder and that EEG and computed tomography (CT) scan were still pending but otherwise the allegation of this diagnosis was supported only by the Veteran's verbal history. The examiner added that the fact that the Veteran failed to seek any medical care for this condition in the last 23 years cast significant doubt on the validity of the diagnosis. Post-service medical records beginning in September 2004 indicate treatment related to complaints of seizures, episodes of syncope, and recurrent headaches. A September 2004 CT scan of the head was unremarkable. In October 2004, the Veteran reported approximately a 20-year history of headaches following a car accident. He also reported a history of episodes of syncope since 1976 but indicated that his family did not report any shaking or seizure activity. A December 2004 EEG report indicates that the Veteran reported having one seizure every three months. The EEG was normal for age in the awake, drowsy and sleep states. VA treatment records dated from October 2004 indicate diagnoses of chronic headaches, migraine headaches, and syncopal episodes. Such records indicate that the Veteran reported experiencing approximately 10 to 15 syncopal episodes per year, which were blackouts typically preceded by dizziness and increased headache pain followed by loss of consciousness for two to five minutes. An October 2005 treatment record notes that the Veteran had spells of passing and a "distant history of possible seizures," and the Veteran was ordered testing including an EEG. A November 2005 VA treatment record reflects a cardiology resident's determination that the reported syncopal symptoms did not seem cardiac-related. The resident stated that the loose associate with being "upset" could point towards vasovagal as an etiology, but the timing of when the episodes began, after a motor vehicle accident, suggested that it was somehow related to neurologic injuries. The resident added that neither the Veteran nor his wife described typical tonic-clonic seizure activity during the episodes. In an addendum, a cardiologist added that the Veteran was a poor historian. The cardiologist noted that the episodes did not sound cardiac and that the length of their duration made them unlikely to be related to a significant life-threatening cardiac etiology. A February 2006 VA treatment record reveals the Veteran's history of taking Dilantin and Phenobarbital for presumed seizure disorder in service through 1981 and then not taking prescribed medications again until 2003. He and his wife denied any other history of head trauma. The examiner indicated that it was concerning that the Veteran reported occasional loss of consciousness approximately three times in the previous year as well as blurry vision with some headaches. It was also noted that he had been seen by mental health for depression "some time ago." A May 2006 VA treatment record reflects the Veteran's history of depression for several months. The record reveals assessments of alcohol abuse versus dependence, marijuana dependence, nicotine dependence, and likely substance-induced depressive disorder. During the Veteran's May 2006 Board hearing, the Veteran testified that he began experiencing symptoms of a seizure disorder following his in-service automobile accident, including blackout spells and bad headaches, which continued following his discharge from service in May 1981. He also testified that he presently had symptoms of a seizure disorder including blackouts, headaches, and convulsions. The Veteran's wife testified that she had witnessed the Veteran's convulsions. A December 2006 MRI of the brain revealed microangiopathic disease and an otherwise unremarkable brain. A January 2007 VA treatment record reflects the Veteran's history that his depression "seem[ed] to be resolving." In a February 2007 addendum to the September 2004 VA examination report, the VA examiner noted that a September 2004 CT scan and a December 2004 EEG were normal and that the Veteran had had subsequent neurology evaluations for migraines and syncope, but that there was no mention of a seizure disorder in the notes of these evaluations. The examiner opined that, given the negative studies, and lack of attention to this previously alleged disorder, the Veteran had no current seizure disorder. The examiner noted that there was mention in the neurology notes of infrequent syncope, but that this was never the issue for which he had been evaluated, and there was no definite cause given for the syncopal episodes. The examiner further stated that recent neurology evaluations were all focused on recurrent headaches and that at the most recent evaluation in January 2007 the Veteran reported no loss of consciousness. The examiner noted that February 2006 VA notes indicate complaints of loss of consciousness, estimated to have occurred three times in the past twelve months. However, the examiner also noted that the Veteran's neurological examinations had been consistently normal and that his only current neurological diagnosis listed in the neurology evaluations during the past year was recurrent migraine headaches. The examiner concluded that the Veteran had no seizure disorder. A January 2008 VA treatment record indicates that the Veteran had a history of "syncope versus seizures." A February 2008 VA neurology record reflects that the Veteran reported a history of episodes of loss of consciousness with complete loss of muscle tone. He denied tonic/clonic like activity or urinary incontinence but reported biting his tongue once during an episode. The record notes that a 2004 EEG was normal and that an echocardiogram and Holter monitor were normal. It was determined that the episodes did not sound like seizures and that the normal EEG and the fact that the Veteran reported episodes while on Phenobarbital and Dilantin supported this finding. It was believed the episodes might be related to overmedication. A May 2008 treatment record indicates that the episodes had resolved. A December 2008 VA treatment record reflects diagnoses of polysubstance dependence and rule out substance-induced mood disorder. January and February 2009 VA treatment records reveal diagnoses of polysubstance dependence. February 2010 VA inpatient records indicate that the Veteran had a traumatic brain injury. The record also reflects that the Veteran was found to have no neurologic disease. A November 2011 VA treatment record reflects the Veteran's history of syncopal episodes. The neurology resident noted that Army documentation brought by the Veteran showed that he has a diagnosis of seizure disorder but an October 2004 EEG did not show definite evidence of a seizure disorder. The Veteran was assessed with syncopal episodes with previous diagnosis of seizures. A March 2012 VA examination record indicates that the Veteran was being examined to rule out a seizure disorder. After review of the claims file and examination of the Veteran, the examiner found it less likely than not that any alleged history of seizures was related to the Veteran's service. The examiner, a neurologist, found no credible evidence to actually indicate the existence of a seizure disorder. A June 2012 VA neurology record indicates that the Veteran had a history of blackouts questionably secondary to seizures. The Veteran reported intermittent blackouts. The Veteran indicated that he was unclear as to any trigger or provocative factors; he reported that he did not have any warning that these events were forthcoming. He added that he did not bite his tongue or lose bowel/bladder control, though he reported losing tone and becoming difficult to arouse, with some period of confusion afterward. His wife was unable to give specific details of what the Veteran did during these events but did believe the episodes were related to stress. The Veteran denied a history of febrile seizures as a child or major childhood illnesses but reported a history of head trauma in the 70s (inciting event), and a family history of seizures. The neurologist reviewed the Veteran's chart back to 2005, when the Veteran was initially seen. The neurologist noted that the Veteran was given a diagnosis of seizures/epilepsy after his motor vehicle accident in the 70s and was on Phenobarbital and Dilantin. The neurologist added that the Veteran has not had any change in the frequency of his events since those medications were discontinued in 1981 or with the addition of Topamax/neurontin and that the Veteran had a full cardiac work up that was unremarkable for cardiac cause of his episodes. The examiner added that the Veteran reportedly had an EEG that was "unrevealing," but the neurologist was unable to locate this report. The neurologist noted that the Veteran recently had an MRI of the "brain (12/2011) that [per the neurologist's read] showed microangiopathic changes without any acute (or other chronic) abnormalities (formal read states area of restricted diffusion in right frontal lobe, [which the neurologist was] unable to visualize; also reports areas of confluent white matter disease and to rule out [multiple sclerosis] - there are no changes on TI, believe these are simply representative of leukoariosis/microangiopathy from small vessel disease)." The Veteran was assessed with "Spells not otherwise specified - syncope vs. seizure vs. NEEs vs. ?- The history is unclear in terms of his spells, and it appears that he has had an extensive cardiac work up and reportedly a neurologic work up, although data is incomplete." A June 2012 VA psychiatric record reflects the Veteran's history of symptoms, including nightmares related to events when he was stationed in Korea. The record notes that the motor vehicle accident occurred while the Veteran was stationed stateside. The examiner noted that the Veteran met the DSM-IV criteria for posttraumatic stress disorder (PTSD), which has not previously been diagnosed. "This may relate to alcohol abuse/dependence, depression and increased irritability, sleep disturbance and other [symptoms] noted above." The Veteran was diagnosed with major depressive disorder and PTSD. An August 2012 EEG was clinically normal in the "awake state." The record notes that the absence of epileptiform abnormalities does not preclude a clinical diagnosis of seizures." A September 2012 VA treatment record reflects the Veteran's history that his spells had decreased since beginning medication for his PTSD. A November 2012 VA examination record reflects the examiner's notation that the Veteran was recently diagnosed with PTSD. The record suggests the examiner believed the Veteran's non-epileptic "spells" were associated with the PTSD. The examiner reported that neurological examination was normal and there was no focal cranial pathology. A February 2013 VA treatment records notes that the Veteran had had a cardiac and neurology work-up for blackout spells and that it did not appear that they were epileptic activity. March 2013 VA psychiatric examination records reflect diagnoses of PTSD and major depressive disorder. The examiner found that the Veteran did not have a diagnosed TBI. The examiner explained that although the term "head injury" was seen in the records, there was no diagnosis of TBI. The Veteran reported stressors involving events while he was stationed in Korea. The examiner determined that PTSD was not related to the head injury. The examiner explained that although the Veteran did mention a 1976 motor vehicle accident, he never made statements relating the motor vehicle accident to his PTSD symptoms. The examiner added that the Veteran reported that the car accident was "not that bad." The examiner also determined that the major depressive disorder was not related to the head injury. A June 2013 addendum opinion reiterates that the Veteran did not relate his PTSD to a head injury and that the Veteran only mentioned his head injury in passing. The examiner added that he could not provide an opinion as to the relationship between major depression and substance abuse disorder without resorting to speculation because the examiner had not examined the Veteran regarding head trauma. The examiner noted that a TBI examination had not been conducted. A June 2013 TBI examination record reflects the examiner's determination that the Veteran did not have and had never had a TBI or any residuals thereof. The examiner noted that the Veteran hit his head on the dashboard as a result of a car accident. The examiner also noted that contrary to the Veteran's current history of loss of consciousness associated with the accident, the April 1976 record reflects a finding of no loss of consciousness. The examiner reiterated that there was no documented evidence of alteration or loss of consciousness beyond the current verbal report of the Veteran. The examiner noted that the Veteran currently reported a history of blackouts/seizures since the accident. The examiner indicated that there was no consensus among treatment providers regarding the seizure disorder as a cause for the blackouts or whether the blackouts were a residual symptom of the head trauma during service. After examination, the examiner determined that the Veteran did not have a traumatic brain injury (TBI). The examiner noted that although the Veteran had a head injury, there was no loss of consciousness. The examiner explained that by definition, traumatic brain injury diagnosis requires a period of altered consciousness, amnesia, alteration of mental state at the time of the injury (dazed, disoriented, or confused) or focal neurological deficits. The examiner added that although the Veteran reported the onset of intermittent unexplained loss of consciousness within five days of the accident, these have not been diagnosed as seizures and did not respond to treatment with anticonvulsants. The examiner found the etiology of the blackout spells was unclear. The examiner added that although the Veteran and his spouse currently reported a history of urinary incontinence during several of the spells and fecal incontinence on a couple of occasions, these histories were not noted in the service treatment records. The examiner also noted that the symptoms were reported to have improved after initiation of treatment for PTSD. Based on interview and review of the records, the examiner found the required diagnostic feature of alteration of consciousness or loss of consciousness following the motor vehicle accident has not been documented. Based on the information available, the examiner found the head injury did not meet the criteria for a diagnosis of TBI and that none of his current symptoms should be considered residuals of a TBI. Furthermore, the examiner noted that testing revealed memory impairment which raised some concern over the reliability of the Veteran's reported history of recent events. A July 2013 VA psychiatric examination record reflects the examiner's determination that the Veteran did not incur a TBI during service and that none of the presenting psychiatric diagnoses were due to head injury. The examiner explained that the Veteran reported no loss of consciousness at the time of the accident, the EEG and CT scans had been negative, and the headaches began after the reported head injury. The examiner found the Veteran did not meet the criteria for a TBI and therefore would not have any residual. After reviewing the record, the Board finds a preponderance of the evidence to be against the Veteran's claim of entitlement to service connection for residuals of head trauma. With respect to the claimed condition of a seizure disorder, the record does not reflect competent evidence of the existence of a seizure disorder when the Veteran filed this claim or thereafter. Although service treatment records document some evidence suggestive of a seizure disorder, no evidence of a seizure disorder was found on the examination for discharge, and there is no post-service medical evidence showing that he has been diagnosed with a seizure disorder. Moreover, multiple VA examiners, including a neurologist, have consistently determined that the Veteran does not have a current seizure disorder. Such opinions were based on examination of the Veteran, review of the military medical records and current medical records, as well as testing, all of which failed to reveal a seizure disorder. The Board acknowledges that some service records reflect diagnoses of "seizure disorder" and convulsive disorder and that the Veteran reports having continuity of symptomatology since the motor vehicle accident. The associated medical records do not corroborate the diagnoses of seizure/convulsive disorder, however. They only reflect findings of possible or suspected seizure disorder. In the absence of evidence that the diagnoses reported on the August 1980 limited profile report and November 1981 authorization were based on medical evaluation and were recorded by a competent person, the Board finds the service medical records are more probative and that the service treatment records do not establish the existence of a chronic disorder in service. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Furthermore, the medical evidence dated during the claim clearly and consistently reports findings that the Veteran does not have a seizure disorder. As discussed above, these findings are based on objective testing and evaluation, and the Board finds them more probative than the in-service diagnose as to the existence of a current seizure disorder, particularly because the in-service diagnoses were not corroborated by medical testing. With respect to the claimed residuals of a TBI, the record does not reflect competent evidence of the existence of a TBI or residual thereof. Although the record clearly shows head injury during service, the competent evidence does not indicate that the head trauma resulted in a TBI. The associated treatment records reflect negative histories as to amnesia, loss of consciousness, or neurological symptoms, and VA examiners have provided probative opinions that a TBI did not result from the motor vehicle accident. There is no contrary medical opinion of record. The Board acknowledges that the Veteran currently reports loss of consciousness after the 1976 motor vehicle accident. The Veteran's current history is not credible, however, as it is contradicted by the history provided by the Veteran soon after the accident. With regard to the claimed residual psychiatric symptoms, the associated disabilities, i.e. major depressive disorder and PTSD, have not been shown to be etiologically related to the Veteran's in-service head trauma. The records do not suggest, and the Veteran has never alleged, that his PTSD is related the in-service motor vehicle accident; rather, the evidence consistently indicates that the diagnosis is based on unrelated stressors. The evidence also does not suggest that the major depressive disrober is related to the head trauma. There are no reported symptoms or findings indicative of psychiatric symptoms until many years after the head injury, and a VA examiner has opined that the Veteran's psychiatric symptoms are not related to the head injury. There is no contrary medical opinion of record. Finally, with respect to the Veteran's claimed blackout spells and loss of consciousness, the record does not reflect a diagnosed condition manifested by the reported episodes and does not otherwise indicate that the episodes are related to the head trauma. The Board acknowledges that service treatment records reveal histories of episodes of loss of consciousness and that the Veteran reports episodes since the motor vehicle accident during service. The record does not include any diagnosed condition manifested by the reported blackouts, however. Except in circumstances not applicable here, service connection will not be granted for symptoms such as episodic blackouts; there must be a diagnosed or identifiable underlying malady or condition. Sanchez-Benitez v. West, 13 Vet. App. 283, 285 (1999). Moreover, even assuming the spells were a service-connectable disability, the record does not include any competent medical evidence linking the reported spells to the in-service head trauma. In this case, the medical evidence demonstrates that the etiology of the reported spells is unknown, though medical professionals have determined that they are not attributable to a seizure disability, a TBI, or a cardiac disability. The Board is mindful that competent medical evidence is not necessarily required where the determinative issue in a case involves the existence of a disability. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); see also Barr v. Nicholson, 21 Vet. App. 303 (2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). However, the Veteran is not providing statements related to the diagnosis of a simple disorder but is instead rendering an opinion as to the existence of a seizure disability, the incurrence of a TBI, and the etiology of a disability manifested by loss of consciousness. These are matters that require medical expertise, which the Veteran lacks. Therefore, his lay opinions concerning these matters are of no probative value. Accordingly, service connection is not warranted for the claimed residuals of head injury, other than the already service-connected headaches. In reaching this decision, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. ORDER Service connection for residuals of a head injury, other than headaches, is denied. ____________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs