Citation Nr: 1331527 Decision Date: 09/30/13 Archive Date: 10/02/13 DOCKET NO. 04-42 962 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to service connection for hepatitis C. 2. Entitlement to service connection for schizoaffective disorder, alternatively diagnosed as posttraumatic stress disorder (PTSD), and depression. 3. Entitlement to service connection for an acquired psychiatric disorder other than schizoaffective disorder, alternative diagnosed as PTSD, and depression, to include body dysmorphic disorder. 4. Entitlement to service connection for headaches. 5. Entitlement to service connection for residuals of a head injury. REPRESENTATION Appellant represented by: New York State Division of Veterans' Affairs WITNESSES AT HEARINGS ON APPEAL The Veteran and T.B. ATTORNEY FOR THE BOARD S. Mishalanie, Counsel INTRODUCTION The Veteran served on active duty from August 1973 to August 1977 and from August 1984 to June 1987. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from August 2002 and January 2004 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. In July 2004, the Veteran testified before a Hearing Officer at the RO. In January 2011, the Veteran and a friend (T.B.) testified at a Travel Board hearing before the undersigned Veterans Law Judge. Transcripts of both hearings are of record. In May 2012, the Board remanded the claims for additional development. The Board has recharacterized the Veteran's claims as styled on the title page to ensure that all diagnoses reasonably encompassed by his reported symptoms are considered. See, e.g., Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). FINDINGS OF FACT 1. The evidence is at least in relative equipoise on the question of whether the Veteran's hepatitis C was incurred in service. 2. The evidence is at least in relative equipoise on the question of whether the Veteran's schizoaffective disorder, alternatively diagnosed as PTSD, and depression are related to service and/or service-connected hepatitis C. 3. The preponderance of the evidence is against finding that body dysmorphic disorder is related to the Veteran's service, to include a head injury therein. 4. The evidence of record demonstrates that the Veteran's headaches are related to treatment for service-connected hepatitis C and psychiatric disorder. 5. Residuals of a head injury have not been demonstrated. CONCLUSIONS OF LAW 1. Hepatitis C was incurred in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.301, 3.303 (2012). 2. Schizoaffective disorder, alternatively diagnosed as PTSD, and depression were incurred in service or are proximately due to treatment for service-connected hepatitis C. 38 U.S.C.A. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). 3. Body dysmorphic disorder was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303. 4. The Veteran's headaches are proximately due to treatment for his service-connected hepatitis C and psychiatric disorder. 38 U.S.C.A. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.310 (2012). 5. Residuals of a head injury were not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). With regard to service connection for hepatitis C, schizoaffective disorder, alternatively diagnosed as PTSD, and depression, and headaches, given the favorable outcome detailed below, an assessment of VA's duties under the VCAA is not necessary for these particular issues. Regarding the remaining issues of service connection, the requirements of 38 U.S.C.A. § 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or the completeness of the application. VA notified the Veteran in September 2005 of the information and evidence needed to substantiate and complete the claims, to include notice of what part of that evidence is to be provided by the claimant, and what part VA will attempt to obtain. In March 2006, VA provided notice as to how disability ratings and effective dates are determined. The claims were readjudicated most recently in a December 2012 supplemental statement of the case. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate the claims, and as warranted by law, affording VA examinations. Regarding the Veteran's claimed residuals of a head injury and psychiatric disability, the reports of these examinations are adequate as they reflect that the examiners interviewed and examined the Veteran, reviewed the claims file, and reported the clinical findings in detail. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (finding that VA must provide an examination that is adequate for rating purposes). While the VA psychiatry examiner indicated that he could not determine the etiology of the Veteran's body dysmorphic disorder without resorting to speculation, he discussed and considered the relevant evidence in the claims file. Furthermore, as will be discussed in greater detail below, the VA neurology examiner made clinical findings suggesting a source unrelated to service for the body dysmorphic disorder. Therefore, the Board finds that the VA examinations and opinions, when considered together, are adequate for rating purposes. In May 2012, the Board remanded the claims for additional development. As the agency of original jurisdiction (AOJ) notified the Veteran of the types of alternative evidence he could submit to corroborate his account of an in-service personal assault, and obtained the requested VA examinations and medical opinions, the Board finds that VA has substantially complied with the prior remand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with). The Veteran was also provided an opportunity to set forth his contentions regarding hepatitis C at hearing before a Hearing Officer at the RO in July 2004 and regarding all his claims at a hearing before the undersigned Veterans Law Judge in January 2011. The record reflects that at these hearings the Hearing Officer and undersigned Veterans Law Judge set forth the issues to be discussed, focused on the elements necessary to substantiate the claims for service connection, and sought to identify any further development that was required to help substantiate the claims. These actions satisfied the duties a Hearing Officer and Veterans Law Judge have to explain fully the issue and to suggest the submission of evidence that may have been overlooked. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010) (holding that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board). Notably, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) , nor have they identified any prejudice in the conduct of the hearings. In sum, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. 38 C.F.R. § 3.159(c). Legal Criteria Service connection is established where a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498 (1995). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including psychoses, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). Where there is a chronic disease shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). When a condition noted during service is not shown to be chronic, or the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013) (noting that the continuity of symptomatology provisions apply only to the chronic disorders as listed in 38 C.F.R. § 3.309(a)). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, service connection may be granted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). 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. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Analysis Hepatitis C The Veteran claims that he was infected with hepatitis C during service. He has reported the following in-service risk factors: sexual activity, air gun inoculations, shared tooth brushes and razors, hernia surgery, and dental work. The Veteran also has a history of cocaine use. Although treatment records note a history of intranasal cocaine use (a recognized risk factor for hepatitis C), the Veteran has disputed these reports. In more recent statements, he has denied any intranasal cocaine use, claiming that his drug of choice was alcohol and that he only smoked crack cocaine on a very limited and occasional basis. VA treatment records reflect that the Veteran currently has a confirmed diagnosis of hepatitis C. Regarding the reported risk factors for hepatitis C, as a lay person, he is competent to report what he has personally experienced. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). To the extent his statements are consistent with the underlying record, the Board finds him credible. Significantly, his service treatment records reflect that he was treated for gonorrhea in 1973, 1975, and 1985. The only remaining question is whether there is a relationship between his current hepatitis C and any of the in-service risk factors. In this regard, the Board finds the evidence in relative equipoise. In July 2004, a VA nurse (L.M.) noted that the Veteran was treated several times for sexually transmitted diseases in service and that was "as likely as not also the source of his hepatitic C infection." It is unclear, however, whether the nurse considered all of the Veteran's potential risk factors when rendering this opinion. A VA examination was also conducted in November 2004. The examiner initially opined that the Veteran's hepatitis C was "more likely than not service related due to high sexual activity during the service, piercing of the ear lobe and sniffing and smoking cocaine." In an addendum, the examiner seemed to change his opinion, stating that there was "less than a 50% probability that the cause of Hepatitis C is gonorrhea in service." However, the rationale provided was confusing - "[the Veteran] could have been infected with gonorrhea and Hepatitis C at the same time because gonorrhea and Hepatitis C are two different diseases." Hence, it appears that the examiner was explaining that although gonorrhea itself was not the cause of hepatitis C, he could have been infected with both diseases during sexual activity in service. Another VA examination was conducted in August 2012. The examiner listed the Veteran's risk factors in order of the likelihood to cause hepatitis C infection: (1) intranasal cocaine use; (2) sexual activity with an infected individual. The examiner noted that the sharing of toothbrushes and the use of air gun inoculations posed a slight or small risk. Given the Veteran's history, the examiner indicated that she could not provide an opinion as to when the Veteran became infected without resorting to speculation. The Board notes that the medical opinions provided do not definitively relate the Veteran's hepatitis C infection to service; however, they do relay a definite link between sexual activity and hepatitis C. The Veteran reportedly had multiple sexual partners in service and was treated on multiple occasions for gonorrhea. Notably, the residuals of venereal disease incurred in service are not considered the result of willful misconduct, and hence, not a bar to service connection. 38 C.F.R. § 3.301(c)(1). While other risk factors during civilian life are possibly present, the Board finds that the evidence is at least in relative equipoise as to whether the hepatitis C infection was incurred in service. Accordingly, resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for hepatitis C are met. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Acquired Psychiatric Disorder The Veteran asserts that his current psychiatric disorder is related to stressful events that occurred in service. Specifically, he testified that being in the demilitarized zone (DMZ) in Korea was stressful, that there was a firefight on his first day in Korea and he saw soldiers being taken to receive medical help, and that he was the victim of an unprovoked assault. Board Hearing Tr., pgs 8-11. He has reported similar stressors to VA treatment providers. In addition, the Veteran and some of his family members submitted lay statements reporting that he has had nightmares since returning from service. He also reported having paranoia, anxiety, and depression since returning from Korea. A lay person is generally competent to report what he or she has personally experienced, including events in service, and psychiatric symptoms such as nightmares, paranoia, anxiety, and depression. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Veteran's service treatment records are unremarkable for any complaints, treatment, or diagnoses related to a psychiatric disorder. At his March 1987 separation examination, his psychiatric evaluation was normal. Post service, the first documented report of psychiatric symptoms was in December 1996. The Veteran reported having nightmares and increased stress at home with a newborn and depressed wife. The impression was PTSD. In April 2002, VA treatment records reflect that the Veteran was treated for alcohol and cocaine dependence; he described his mental state as tense, depressed, forgetful, sad, worried, fearful, angry, unenthusiastic, and regretful. The Veteran's Social Security Administration (SSA) records include an October 2002 psychiatric evaluation. The Veteran reported feeling depressed, having difficulty concentrating, and experiencing sleep disturbances. The diagnosis was major depression. A February 2003 VA psychiatric intake note reflects that the Veteran was referred for depression and reported being worried about his hepatitis C treatment. The social worker indicated that she did not get the impression of PTSD and noted that it was unclear whether the Veteran's depression was caused by hepatitis C or exacerbated by it. The differential diagnosis was dysthymia versus adjustment reaction to illness. A note was made to rule out psychotic depression and PTSD. In March 2003, he reported having nightmares of being attacked, replaying the events of an assault while in Korea. The psychologist indicated that the Veteran seemed to be suffering from PTSD from repeated incidents of unexpected violence against himself echoing childhood abuse he had suffered. The diagnoses were major depressive disorder and PTSD. In April 2003, a note was made to rule out schizoaffective disorder. In June 2006, a VA physician (Dr. K.C.) completed a psychiatric evaluation for the Veteran for the purposes of obtaining SSA benefits. The physician diagnosed the Veteran with schizoaffective disorder, depressive type, body dysmorphic disorder, and possible PTSD. His primary symptoms were "ideas of reference, thought broadcasting, and nightmares." A January 2007 VA infectious diseases note reflects that the Veteran had been diagnosed with schizoaffective disorder, depression type. It was noted that he also had nightmares and a questionable diagnosis of PTSD. In February 2007, it was noted that he had PTSD, schizoaffective disorder, and body dysmorphic disorder. A June 2010 VA mental health evaluation reflects that the Veteran returned to treatment after a long hiatus. He was diagnosed with schizoaffective disorder, depressive type, body dysmorphic disorder, and PTSD by history. Regarding body dysmorphic disorder, the Veteran reported that he did not leave his home because he believed his head was too large and wanted to avoid people looking at him. VA treatment records dated from January 2011 to September 2012 reflect that the Veteran's psychiatrist (Dr. K.C.) diagnosed PTSD, body dysmorphic disorder, and possible schizoaffective disorder. Regarding body dysmorphic disorder, the Veteran complained about the size and shape of his head. In June 2012, he complained of a lump on his skull, which the examiner indicated was not obvious. In May 2012, the Board remanded the claim, in part, to obtain a VA examination and medical opinion regarding the nature and etiology of the Veteran's psychiatric disability. A VA examination was conducted in August 2012. The examiner, a clinical psychologist, diagnosed the Veteran with schizoaffective disorder and body dysmorphic disorder. The examiner explained that the Veteran did not meet the full criteria for PTSD, but that his experiences in Korea contributed to some of his current symptoms (e.g., nightmares, hypervigilance, and paranoia). Hence, the examiner opined that the Veteran's schizoaffective disorder was "at least as likely as not due to the stressful incidents [the Veteran] experienced while deployed in Korea." The examiner indicated that the Veteran's depressive symptoms were independent and resulted from his hepatitis C diagnosis. Regarding whether the body dysmorphic disorder was related to the reported head injury in service, the examiner stated that he could not make a determination without resorting to speculation. The Board finds that the VA examiner's opinion relating the Veteran's schizoaffective disorder to his military service is probative and persuasive based on the psychologist's thorough and detailed evaluation of the Veteran, comprehensive review of the claims file, adequate rationale, and consideration of the Veteran's lay statements in regards to his symptoms. In addition, there are no contrary competent medical opinions of record. Although the Board is not required to accept medical authority supporting a claim, VA must provide reasons for rejecting that evidence and, more importantly, must provide a medical basis other than its own unsubstantiated conclusions in support of a determination. Jones v. Principi, 16 Vet. App. 219 (2002); Smith v. Brown, 8 Vet. App. 546 (1996); Colvin v. Derwinski, 1 Vet. App. 171 (1991). Here, because the only medical opinion regarding nexus supports the Veteran's claim, the Board finds that service connection for schizoaffective disorder is warranted. VA should not seek an additional medical opinion where favorable evidence in the record is unrefuted. Mariano v. Principi, 17 Vet. App. 305 (2003). The Board also points out that the Veteran's symptoms of nightmares, hypervigilance, and paranoia have been alternatively and sometimes jointly diagnosed as schizoaffective disorder and PTSD. Furthermore, the Veteran's symptoms of depression have been diagnosed as major depressive disorder and schizoaffective disorder, depressive type. The Veteran's depressive symptoms have been linked to his diagnosis and treatment of hepatitis C. See 38 C.F.R. § 3.310. Therefore, resolving the benefit of the doubt in the Veteran's favor and in order to ensure consideration of all of the Veteran's service-related psychiatric symptoms, the Board finds that service connection is warranted for schizoaffective disorder, alternatively diagnosed as PTSD, and depression. Regarding the diagnosis of body dysmorphic disorder, this disorder is characterized as a preoccupation with an imagined defect in appearance or, if a slight physical anomaly is present, the person's concern is markedly excessive. See American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) 225 (4th ed. 1994). The preoccupation causes clinically significant distress and is not better accounted for by another mental disorder. Id. In this case, treatment records reflect that the Veteran believes his head is too big, misshapen, or that he has an abnormally large lump on it. He believes he is stigmatized as a result and avoids leaving his home. The August 2012 VA psychiatry examiner indicated that he could not make a determination as to the etiology of the dysmorphic disorder without resorting to speculation. As discussed further below, the August 2012 VA neurology examiner noted that the Veteran has a lipoma on the right side of his head that is unrelated to service, including any head injury therein. A lipoma is a benign neoplasm of adipose tissue, composed of mature fat cells. See Stedman's Medical Dictionary 1021 (27th ed.2000). To the extent that the Veteran's body dysmorphic disorder is partially related to the existence of the lipoma, the preponderance of the evidence is against a finding of service connection because the lipoma is unrelated to service, as specifically noted by the August 2012 neurology opinion, as well as absence of any evidence of record that this condition manifested for many years after service. Moreover, to the extent that the body dysmorphic disorder is manifested by the Veteran's subjective complaints of self-consciousness about the size and shape of his head, the Board finds that such complaints are encompassed in the Veteran's acquired psychiatric disorder, to include schizoaffective disorder (alternatively diagnosed as PTSD), which is granted in this decision, based on the psychiatric examination reports of record dated in June 2006, February 2007, June 2010, and August 2012. In other words, in these mental health examinations, along with mental health treatment records, the Veteran was diagnosed with varying psychiatric disorders, as well as body dysmorphic disorder. The Board does not find that the evidence in this case warrants a separate finding of service connection for body dysmorphic disorder, as the evidence indicates that this condition is intertwined with the psychiatric disability that is being allowed in this decision. For the foregoing reasons, the Board finds that the preponderance of the evidence is against entitlement to service connection for body dysmorphic disorder. The benefit of the doubt doctrine is not for application, and the claim is denied. See 38 C.F.R. § 3.102. Headaches and Residuals of a Head Injury The Veteran asserts that he has residuals from an in-service head injury. In January 2005, he stated that he collapsed in formation and suffered a "bloody head wound." He said he "currently suffer from headaches and have large lump and cyst on my head from this injury." In a November 2005 statement, he said that he also suffered trauma to the forehead in a flag football game, was treated with ice, given pain medication, and released from emergency. He also reported that he collapsed in formation, hit his head, and was treated for dehydration. He indicated that he had a scar and cyst on the right side of his head, and experienced soreness and numbness, headaches, and insomnia. During the Board hearing, he testified said that he still had a lump or cyst on his head from the head injury, which he found embarrassing. He also described having headaches and numbness on the side of his head with a history of Bell's Palsy. Board Hearing Tr., pgs. 12-13. The Veteran's service treatment records reflect that at his February 1977 separation examination, he reported having had a head injury in a football game in 1976. It was noted that he had no loss of consciousness and that no treatment was sought or required. The examiner indicated that there were no complications or sequelae. For his second period of service, a separation examination was conducted in March 1987, which showed that his head was normal. In May 1987, the Veteran complained of dizziness and reported that he had passed out while standing in first call formation. He also complained of a headache and reported that he had not taken in much fluid over the last week. A lab stick showed that he was greatly dehydrated. His pupils were equal accommodation and reactive to light and his ears were clear without redness. The assessment was dehydration; he was treated with IV fluids. It was also reported that the Veteran had a large lump on the back of his head. A skull series was recommended to rule out other problems. He was told to increase his fluids and return if the problems continued. The Veteran separated from service in June 1987; there is no record that a skull series was conducted. An October 2000 note from a physician at the New York VA Medical Center indicates the Veteran was seen in the emergency room and dermatology for a scalp lesion and headaches. VA treatment records reflect that the Veteran underwent Interferon treatment for his hepatitis C; in June 2004, it was noted that he had headaches as a side effect. He had a cyst removed from his back in August 2010; there was no mention of any cyst on his head. A February 2011 VA psychiatric treatment record notes the Veteran's complaints of occasional headaches and morning lightheadedness; these symptoms were thought to be secondary to Prazosin, a medication prescribed to treat his psychiatric symptoms. VA treatment records thereafter note headaches on the Veteran's active problem list. As mentioned above, VA psychiatric records indicate that the Veteran has been diagnosed with body dysmorphic disorder manifested by concerns about the size and shape of his head. He also reported having a lump on his head, which was not observed. His concerns in this regard have been described as a "near delusional conviction." In May 2012, the Board remanded the claim, in part, to obtain a VA examination and medical opinion as to whether there were any current residuals of the head injury the Veteran sustained in service. A VA neurology examination was conducted in August 2012. The Veteran reported that he began getting headaches and experiencing numbness on the top of his head after the head injury. He said he grew his hair to disguise a lump on the back of the head, which the examiner said felt like a lipoma. He also reported that he had Bell's Palsy in 2002 for six months. The examiner indicated that the Veteran had a lipoma on the post right aspect of his skull and that light touch was diminished on the right side of his face, but not related to distribution of trigeminal nerve. The examiner opined that the Veteran's headaches were as likely as not due to head trauma in service, but noted that the features were more consistent with a tension type headache. Regarding the lump, the examiner opined that this was unrelated to the fall. Although the Veteran reported having a scar, there was no scar observed. Furthermore, the examiner opined that the numbness on the face was unlikely to be related to service. After reviewing the claims file, the examiner provided an addendum opinion. She opined that there was no evidence in the claims file that the Veteran suffered headaches following his reported collapse in 1987 and that his current headaches were not due to this event. She indicated that headaches were reported only secondary to hepatitis C therapy. The Board finds that the evidence preponderates in favor of service connection for headaches. Although the Veteran believes that his headaches are related to the in-service head injury, the medical evidence reflects that his headaches have been attributed to treatment for his service-connected psychiatric disorder and hepatitis C. Hence, service connection for headaches is warranted on a secondary basis. See 38 C.F.R. § 3.310. The preponderance of the evidence is against finding service connection for any other claimed residual of the head injury. In this regard, the August 2012 VA examiner concluded that the lipoma, numbness, and Bell's Palsy were unrelated to service. Although the examiner was not provided the claims file until after the examination, she did not change her opinion with respect to any of these conditions. Hence, the Board finds the VA examiner's opinion to be highly probative. As the examiner reviewed the claims file, considered the Veteran's assertions and medical history and conducted a clinical examination, the opinion is adequate for the adjudication of this claim and is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The Board has considered the Veteran's lay contentions that the lump on his head, numbness of the face, and Bell's Palsy are related to service. Although lay persons are competent to provide opinions on some medical issues, Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the etiology of various neurological complaints, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." The question of etiology in this case goes beyond a simple and immediately observable cause-and-effect relationship. Moreover, even assuming the Veteran's lay assertions regarding etiology were competent, the Board nevertheless finds the VA examiner's opinion to be more probative, as it is based on a review of the record and her medical expertise. For the foregoing reasons, the Board finds that the preponderance of the evidence is against the claim of entitlement to service connection for residuals of a head injury. The benefit of the doubt doctrine is not for application, and the claim is denied. See 38 C.F.R. § 3.102. ORDER Entitlement to service connection for hepatitis C is granted. Entitlement to service connection for schizoaffective disorder, alternatively diagnosed as PTSD and depression, is granted. Entitlement to service connection for an acquired psychiatric disorder other than schizoaffective disorder, alternatively diagnosed as PTSD, and depression, to include body dysmorphic disorder, is denied. Entitlement to service connection for headaches is granted. Entitlement to service connection for residuals of a head injury is denied. ____________________________________________ LAURA H. ESKENAZI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs