Citation Nr: 1801439 Decision Date: 01/09/18 Archive Date: 01/19/18 DOCKET NO. 13-17 200 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for schizophrenia. 2. Entitlement to service connection for fatigue. REPRESENTATION Veteran represented by: Robin M. Webb, Attorney ATTORNEY FOR THE BOARD S. Schick, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1990 to September 1994. This appeal comes to the Board of Veterans' Appeals (Board) from September 2004 (fatigue) and April 2011 (schizophrenia) rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In an August 2017 Statement in Support of Claim, the Veteran's representative requested that the 90 day waiting period before a decision would rendered should be extended until Monday, November 27, 2017. The Board notes the requested deadline has expired. The Board previously remanded these issues in April 2015 and December 2016 and they have been returned for appellate review. The record reflects that after the final Supplemental Statement of the Case (SSOC) additional relevant evidence has been associated with the claims file. No subsequent SSOC was issued, but this is not necessary because the Veteran waived initial review of the evidence by the agency of original jurisdiction in accordance with 38 C.F.R. § 20.1304 (2017). See November 2017 Statement in Support of Claim. FINDINGS OF FACT 1. Schizophrenia was first manifested many years after service, and the preponderance of the evidence is against a finding that it is related to service. 2. The Veteran does not have a diagnosis of a separate and distinct fatigue disability that is related to service or a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for schizophrenia have not been met. 38 U.S.C. §§ 1101, 1131, 5107 (2012); 38 C.F.R. § 3.303, 3.307, 3.309 (2017). 2. The criteria for service connection for fatigue have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The VCAA, codified in part at 38 U.S.C. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claim. VA afforded the Veteran appropriate VA medical examinations in July 2012 and August 2015, and an April 2017 VA addendum opinion has been obtained. The Board acknowledges the Veteran's representative's contention that because the VA examiner's August 2015 and April 2017 opinions found no markers in the record about symptoms of mental health, they are based on a factually inaccurate premise because of "SPRs that reflect [the Veteran's] performance deterioration and early separation." See November 2017 Statement in Support of Claim. Additionally, the Veteran's representative argues that the April 2017 VA examiner's addendum opinion default to "without resort to speculation" rationale is neither evidence for or against the claim. Id. First, the Board points out that the April 2017 opinion explains that the Veteran's first documented diagnosis of schizophrenia was in January 2006 and there was no treatment for mental illness in the military from a review of his claims file. The examiner indicated that it was approximately 12 years after service that the Veteran received mental health treatment for his symptoms and that he said he functioned well while in the military, although he said he had paranoid ideation at times. The examiner determined that although he has the diagnosis of schizophrenia there are no markers in his record that he found of it manifesting during active service or developed due to an aspect of service. The examiner went on to explain that he could not change his opinion based on the above rationale without speculation because without any markers found in the record about the Veteran's symptoms of mental health problems while in service and based on his previous evaluation, he could not change his opinion without resorting to speculation. The examiner provides a thorough and supporting rationale for his opinion. Accordingly, as explained in more detail below, the opinion is adequate and probative. Further, the Board notes that in his April 2017 VA Addendum, the examiner indicated that he reviewed the claims file. Thus, by incorporation his opinion is based on a review of the complete record, to include service personnel records. The Board observes that it is within the province of a qualified professional to determine the significance of evidence, which the VA examiner did in this case, concluding that there were no markers in the Veteran's service records. Cf. 38 C.F.R. § 3.304(f)(5). As such, the examiner's opinion is not based on an inaccurate factual basis and for reasons explained in more detailed below is adequate. The Board finds that together, the July 2012, August 2015, and April 2017 VA examination reports and opinions provide adequate bases upon which to make a decision. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Accordingly, the Board will address the merits of the claims. II. Service Connection Legal Criteria Service connection may be granted for disability or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show (1) the existence of a current disability; (2) the existence of the disease or injury in service; and (3) a relationship or nexus between the current disability and any injury or disease during service. See Cuevas v. Principi, 3 Vet. App. 542 (1992). 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 distinguished from merely isolated findings or a diagnosis including the word chronic. When the disease identity is established, there is no requirement of evidentiary showing of continuity. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. For certain disabilities, such as schizophrenia, service connection may be presumed when such disability is shown to a degree of 10 percent or more within one year of a veteran's discharge from active duty. 38 C.F.R. §§ 3.307, 3.309. Such a presumption is rebuttable by affirmative evidence to the contrary. Id. The applicable law and regulations also permit service connection 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). Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Board must determine, as a question of fact, both the weight and credibility of the evidence. Equal weight is not accorded to each piece of evidence contained in a record; every item does not have the same probative value. The Board must account for the evidence which it finds to be persuasive or unpersuasive, analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, and provide the reasons for its rejection of any such evidence. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164, 169 (1991). The Veteran's credibility affects the weight to be given to his testimony and lay statements, and it is the Board's responsibility to determine the appropriate weight. See Washington, 19 Vet. App. at 368. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and 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. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Analysis Schizophrenia The Veteran has a current diagnosis of schizophrenia. See August 2015 VA examination report. He contends that his current schizophrenia is a result of service. See February 2006 VA 21-4138 Statement in Support of Claim. Thus, the first element necessary to establish service connection is met. With regard to the second and third elements of service connection, the Board notes there are competing opinions of record. Regarding element two, the existence of the disease or injury in service, service treatment records (STRs) were silent for mental health diagnoses, complaints, and treatment. There is conflicting evidence as to what was reflected in the service personnel records (SPRs), as will be discussed below. Turning to element three, nexus, in a February 2009 Correspondence from Dr. R.L.H. she indicated that she knew the Veteran since September 2006 and he had a long history (probably since late teens/early 20s) of paranoid delusions, ideas of reference, and occasional auditory hallucinations. Dr. R.L.H. indicated the Veteran was psychiatrically hospitalized three times in 2006 when he burned his family home due to delusional thinking. She noted that when taking his medications regularly, the Veteran is only vaguely paranoid and is able to function at work and when he is not overtly delusional, his ability to interact appropriately with peers and adapt to changes in his situation is only fair. She indicated that the Veteran is often noncompliant with his medication and his prognosis depended on his anti-psychotic medication compliance. The Board affords Dr. R.L.H.'s conclusions that the Veteran has had a long a history since late teens/early 20s of paranoid delusions, ideas of reference, and auditory hallucinations reduced probative weight because she failed to provide a rationale and supporting explanation of how the record supports these symptoms were present in his late teens/early 20s. Instead, she indicated that she started treating the Veteran in 2006 and only cited evidence that supports his symptoms have been present since 2006, but failed to include evidence prior to 2006 or adequately explain her basis for relating his 2006 symptoms as beginning in the 1990s (his late teens/early 20s). The Board notes that the Veteran was afforded a July 2012 VA examination and the examiner opined that there is certainly the possibility of a lengthy and slow prodromal onset that could have been during this active duty years as this would be the most common onset age. The examiner also noted only possible markers described by the Veteran are uncharacteristic conduct problems and disrespect during service. The Board affords this opinion decreased probative weight as service connection may not be based on a resort to speculation or mere possibility. See 38 C.F.R. § 3.102. In an August 2015 VA mental disorders examination report, the examiner opined that the Veteran's schizophrenia, paranoid type was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that his first documented diagnosis of schizophrenia in the claims file was in January 2005, there was no treatment for mental illness in the military from his claims files that was reviewed, and it was approximately 12 years later that he received mental health treatment for his symptoms. The examiner further explained that the Veteran said he functioned well while in the military, although he said he had paranoid ideation at times and although he has a diagnosis of schizophrenia there were no markers in his claims file found of it manifesting during active service or developed due to an aspect of service. Following the August 2015 VA mental disorder examination, additional service records were associated with the claims file and in an April 2017 VA addendum opinion, the August 2015 VA examiner reasserted his August 2015 opinion that the Veteran's schizophrenia, paranoid type was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness and the examiner reasserted his August 2015 rationale. The examiner added that he did not feel he could change his opinion based on his rationale without speculation. Without any markers he could find in the claims file about his symptoms of mental health problems while in service, based on his previous evaluation he did not feel he could change his opinion without speculation. The Board finds the August 2015 VA examiner competent and credible and together, affords the examination reports probative weight as the examiner reviewed the complete claims file in April 2017, noted the Veteran's reports regarding the onset of his symptoms, and explained how there were no markers in the record to support that his currently diagnosed schizophrenia had its onset in service or was a result of service. In a September 2017 Correspondence, Dr. R.L.H. indicated that the Veteran was under her care from September 2006 until September 2012. She indicated that he was treated for persistent psychotic symptoms that are consistent with paranoid schizophrenia. She noted that she reviewed the Veteran's records in their entirety from his previous treatment under her care as well as select service records. She also reviewed the August 2015 VA examination report and the addendum opinion of April 2017 in which the examiner said that he could not change his previous opinion without resorting to speculation. Dr. R.L.H. indicated that following the August 2015 VA examination of the Veteran, she saw him October 2015 for reassessment regarding a VA disability determination appeal. Dr. R.L.H. indicated that from her treatment records there were several documents/notations that indicated an onset of symptoms in the early to mid-1990s. She noted that when he was evaluated in 2006, questions were asked trying to discern the onset of his symptoms. She indicated that at his first appointment in September 2006, he indicated that he had paranoia when he left the military in 1994. She indicated that in a note on November 2006, he indicated problems with his thinking and coming to weird conclusions starting in 1994-95 and she noted that paperwork completed for a FMLA absence in 2009 reflected that his condition began in the early to mid-1990s. Dr. R.L.H. indicated that she stated in paperwork completed for SSA Disability in 2009 that he experienced paranoid delusions, ideas of reference, and auditory hallucinations probably since his late/teens early 20s. She noted that these examples of her documentation regarding the Veteran's symptom onset were prior to claims being made to VA regarding chronology of his illness and being in the service. Dr. R.L.H. indicated that when she met with the Veteran in October 2015, he described very similar baseline symptoms as when he was last seen in 2012. Dr. R.L.H. also indicated that even when medicated, the Veteran experiences vague paranoia and ideas of reference meaning that he misinterprets ordinary events to have very specific and personal relevance to him. She noted that regarding his enlistment, the Veteran served in the Air Force from October 1990 until September 1994. Dr. R.L.H. indicated that the first two years the Veteran stated he felt well and did not feel stressed or uncomfortable during this time. She explained that however, he described the latter two years as being a time he "didn't feel right in the head." Dr. R.L.H. indicated an example of things not feeling right was the Veteran repeatedly trying to give away his guns to an army chaplain who would visit the base on Sundays; he felt uncomfortable having weapons and did not want them. She noted that the Veteran also mentioned that while in Saudi Arabia, a Saudi soldier invited him home for a meal with his family. She also noted that there was something about his words that led the Veteran to think the soldier was inviting him to his house so that he could have sex with the Saudi soldier's wife. She also noted that when the Veteran asked him if that was what he meant, the soldier told him that he would pretend that he did not hear what he said and they never spoke again. Dr. R.L.H. indicated that the Veteran described much of his latter two years in service as not going well, and he was discharged early and upon leaving the military it was then that the Veteran recalls his first auditory hallucination which continued upon his return to Tennessee. Dr. R.L.H. indicated that the Veteran got married in 1995 to a woman he only knew for about six months. They had three children and the Veteran worked pretty consistently. She indicated that throughout this time he continued to experience paranoia, auditory hallucinations, and ideas of reference which he largely ignored. Dr. R.L.H. indicated that when asked how he dealt with the voices and bad thoughts for all those years, the Veteran said "It wasn't hard to ignore. It got worse when I was under a lot of stress. I started working two jobs and things started to unravel. I wasn't sleeping much and that had an effect in my ability to deal with everything." Dr. R.L.H explained that this period is when his psychosis led to behaviors that resulted in his first treatment (medication in 2005) and first hospitalization (in 2006 after he burned down his house). She noted that this event was precipitated when he thought some of his wife's hand gestures meant that she wanted him to burn the home. She noted that his wife noticed paranoia for several years prior to that with fears that she was trying to poison him and that the CIA was bothering him. She indicated that the Veteran was discharged from the Air Force in September 1994 at age 22. Dr. R.L.H. indicated that in 1994 and 1995, the Veteran was experiencing symptoms of schizophrenia such as being paranoid, coming to bizarre conclusions, experiencing auditory hallucinations, and using poor judgment. Dr. R.L.H. indicated that he fulfilled DSM-5 criteria of schizophrenia as he experienced delusions and hallucinations, was deficient in several major areas such as occupational and social functioning (poor judgment and irresponsible behaviors, failed out of college four times and interpersonal difficulties), symptoms were continuous for greater than six months, there were no mood or drug/alcohol contribution to his symptoms, and there is not a history of a developmental disorder that could account for his symptoms. Dr. R.L.H. indicated that the VA examiner's report is correct in that there is no service or VA history of mental health treatment or the diagnosis of schizophrenia prior to 2006. She explained that, however, the Veteran's service personnel records do indicate deterioration in his performance. She noted that in July 1992, he was awarded The Air Force Achievement Medal for meritorious service. Dr. R.L.H. indicated that in September 1993 his flight sergeant did not find him ready for promotion and said the Veteran has not progressed in his job qualification and his Certificate of Release or Discharge from Active Duty states in 1994, "Member ([Veteran]) has not completed first full term of service." Dr. R.L.H. indicated that the prodrome (early symptoms indicating the onset of a disease or illness) of schizophrenia can last several years and the following excerpts are from the article "Early signs diagnosis and therapeutics of the prodromal phase of schizophrenia and related psychotic disorders." "Researchers have also attempted to describe the course of the prodrome. Evidence suggests that the following course is typically observed. First, individuals commonly experience negative or nonspecific clinical symptoms, such as depression, anxiety symptoms, social isolation and school/occupational failure. This is often followed by the emergence of basic symptoms, attenuated positive symptoms (APS) or brief, intermittent APS of moderate intensity. Most proximal to psychosis, individuals commonly exhibit more serious APS that remain subpsychotic in terms of frequency (once or twice a month), duration (often lasting for only a few minutes and usually less than a day), and intensity (skepticism as to the veracity of hallucinations or delusions can still be induced). During this final high risk period individuals often exhibit predelusional unusual thoughts, prehallucinatory perceptual abnormalities or prethought disordered speech disturbances." "Prodromal individuals are often adolescents and young adults experiencing mild or moderate disturbances in perception, cognition, language motor function, will, initiative level of energy and stress tolerance. This period of prepsychotic disturbance in which attenuated or subthreshold psychotic features begin to manifest, differs from frank psychotic features in intensity, frequency, and/or duration. The threshold albeit relatively subjective and arbitrary, is based on symptom severity and the presence of frank psychotic symptoms which would warrant immediate antipsychotic medication treatment, signifying the endpoint of the prodromal period. Although the prodrome has been viewed traditionally as a retrospective construct, efforts are now underway to identify and characterize the prodromal period prospectively." Dr. R.L.H. noted that the VA examiner's report wherein the examiner recorded the Veteran's statements that his "symptoms of paranoia began when he was in Saudi Arabia. He never talked about it to anyone. He began fearing using a gun while in the military. He did not share this info with anyone while in the military." Dr. R.L.H. indicated that she has found it to be most common for individuals to be very cautious about sharing paranoid thoughts or hallucinations, especially to those in authority. She noted that the Veteran reported to the VA examiner that he experienced paranoia and irrational fears while in the service and showed a record of not being able to complete college course work during and post service. She indicated that all of which are consistent with early stages of schizophrenia. Dr. R.L.H. disagrees with the VA examiner's conclusion that the Veteran's schizophrenia did not begin in service (or within one year after separation). Dr. R.L.H. explained that the VA examiner apparently requires documented symptomatology and/or treatment of the Veteran's schizophrenia while in service yet, as literature shows it is not uncommon for prodromal behavior to be unreported so it is not unusual or in any way telling that the Veteran's service records do not reflect this kind of documentation. Dr. R.L.H. also explained that the VA examiner's opinion fails to take into account the typical course this disease runs with what can be years between symptom onset and diagnosis. She noted that the VA examiner does not account for the Veteran's in-service performance deterioration and early discharge. She indicated that the examiner's opinion illustrates the exception and not the norm as to onset if one were to look to 2006 as the baseline. Dr. R.L.H. opined that there is no doubt of the Veteran's schizophrenia diagnosis. She explained that the Veteran describes prodromal as well as overt psychotic symptoms during the latter two years of service and immediately following his discharge to civilian life. She opined that between the Veteran's symptoms that began while in the service and continued to intensify following his discharge and the well-documented age of symptom onset in males being in their early 20s (years 18 to 25 have the highest incidence), it is as at least as likely as not that his disease onset coincides with the time he was in service or within one year after his separation from service. The Board finds Dr. R.H.L. competent; however, her September 2017 opinion and treatment notes are afforded reduced probative weight as they relied on the Veteran's subjective complaints and the Board notes that the record on appeal contains indications that the Veteran is an unreliable historian. See Gardin v. Shinseki, 613 F.3d 1374, 1379 (Fed. Cir. 2010); Caluza, 7 Vet. App. at 510-511 (the Board can use inconsistent statements, among other factors, to impeach the credibility of a witness). Although the Veteran is certainly capable of providing statements regarding his in-service events and symptoms, the Board does not find those statements to be entirely credible. Barr v. Nicholson, 21 Vet. App. 303 (2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency, a legal concept determining whether testimony may be heard and considered, and credibility, a factual determination going to the probative value of the evidence to be made after the evidence has been admitted). As noted above, the Veteran's STRs are negative for complaints, treatment, or diagnosis of schizophrenia in service and Dr. R.L.H. conceded that there is no service or VA history of mental health treatment or the diagnosis of schizophrenia prior to 2006. Significantly, Dr. R.L.H. indicated that from her treatment records there were several documents/notations that indicated an onset of symptoms in the early to mid-1990s and in a note on November 2006, the Veteran reported problems with his thinking and coming to weird conclusions starting in 1994-95. The Board takes notice of the cited literature by Dr. R.L.H. and acknowledges her treatment notes; however, these notes were admittedly based on the Veteran's subjective complaints when his treatment began with her in September 2006. Most importantly, the Veteran's reports in his treatment records with Dr. R.L.H. are contradicted by earlier treatment records created before the Veteran sought treatment from Dr. R.L.H. For example, a January 2006 VA psychiatric discharge summary indicated that the Veteran was "without an established hx of any psychiatric illness" and the history (hx) was obtained by talking to the Veteran, reviewing treatment notes, and current acceptance notes. It was noted that, his "problems might have started about a year ago" and around "About Xmas his symptoms started getting acutely worse." Moreover, his wife and sister endorsed the Veteran's episodes of paranoia and non-bizarre delusions in the last couple of months. Additionally, his January 2006 VA treatment notes highlighted inconsistencies in the Veteran's reported symptoms, including that the Veteran initially endorsed a recent history of command auditory hallucinations and later the Veteran denied ever hearing voices or conversations that are not real. The Board finds it significant that the January 2006 records reflect that the Veteran, his spouse, and his sister indicated that his symptoms of paranoia began shortly before his hospitalization, as opposed to beginning in service or shortly thereafter. Thus, these January 2006 records are inconsistent with the Veteran's later contentions, made in the context of a claim for monetary benefits. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that the contemporaneous evidence has greater probative value than history as reported by a Veteran). With regard to the service personnel records, the August 2015 VA examiner indicated that there were no markers in the claims file to indicate schizophrenia manifesting during active service or developing due to an aspect of service. In fact, the Veteran's private doctor, Dr. R.L.H., indicated that the VA examiner's report was correct in that there is no service or VA history of mental health treatment or the diagnosis of schizophrenia prior to 2006. However, Dr. R.L.H. asserted that the Veteran's service personnel records do indicate deterioration in his performance. She noted that in July 1992, he was awarded The Air Force Achievement Medal for meritorious service. Dr. R.L.H. indicated that in September 1993 the Veteran's flight sergeant did not find him ready for promotion and stated the Veteran has not progressed in his job qualification and his Certificate of Release or Discharge from Active Duty stated in 1994, "Member ([Veteran]) has not completed first full term of service." However, the Board finds that Dr. R.L.H.'s conclusion is not supported by the remainder of the Veteran's service personnel records. The Board notes that within the same September 1993 personnel record, the Veteran's performance evaluation for the period from January 1991 to September 1993, also indicated the Veteran was absolutely superior in all areas of performing assigned duties; excelled in knowledge of related positions and mastered all duties in primary duties; set the example for others in complying with standards; exemplified the standard of conduct on and off duty; was highly effective in his ability to supervise/lead; complied with all training requirements; and was highly skilled writer and communicator. Accordingly, Dr. R.L.H.'s characterization of performance "deterioration" does not appear consistent with his performance evaluation. Moreover, there is no indication that the Veteran left military service early as the result of any onset of mental illness. The Board observes that his DD 214 reflects that he served four years and was discharged to the Reserve. It was noted that he was subject to active duty and/or annual records screening, which is inconsistent with a conclusion that he was removed from service due to his mental health. Additionally, the Board notes Dr. R.L.H.'s indication that the Veteran reported examples of things not feeling right including the Veteran repeatedly trying to give away his guns, and his report that he felt a soldier was inviting him to his house so that he could have sex with the Saudi soldier's wife. However, as acknowledged by Dr. R.L.H., he admittedly did not make these reports during service as they are not documented in his records. Moreover, at his August 2015 VA examination, the Veteran reported that his paranoia symptoms and fearing using a gun began while he was in the military; however, he did not report the invitation to a meal by a soldier to the August 2015 VA examiner. With regard to Dr. R.L.H.'s indication that upon leaving the military it was then that the Veteran recalls his first auditory hallucination which continued upon his return to Tennessee, as noted above, January 2006 VA treatment notes highlighted inconsistencies in the Veteran's reported symptoms. Specifically, the Veteran initially endorsed a recent history of command auditory hallucinations and later the Veteran denied ever hearing voices or conversations that are not real. Moreover, Dr. R.L.H. indicated that she stated in paperwork completed for SSA disability benefits in 2009 that the Veteran experienced paranoid delusions, ideas of reference, and auditory hallucinations probably since his late teens/early 20's. She noted that these examples of her documentation regarding the Veteran's symptom onset were prior to claims being made to VA regarding chronology of his illness and being in the service. The Board acknowledges Dr. R.H.L.'s treatment records noted "since back (94-95)." However, the Board notes her examples of documentation regarding the Veteran's symptoms onset were not prior to his claims being made to VA as her treatment began in September 2006 and the Veteran filed a February 2006 claim for service connection for schizophrenia. See February 2006 VA 21-4138 Statement in Support of Claim. Moreover, a February 2009 SSA Disability Report-Field office Form SSA-3367 indicated the Veteran had a prior claim for SSA disability benefits in June 2006 that was denied. As such, Dr. R.L.H.'s documentations were not prior to his claims for VA and SSA monetary benefits. Based on the foregoing, the Board concludes that Dr. R.L.H.'s opinions are based on an inaccurate factual premise, to include the Veteran's unreliable reports of the onset of his symptomatology. They are therefore afforded little probative value. Accordingly, the Board finds that the preponderance of the competent and credible evidence is against a finding that the Veteran's schizophrenia had its onset in service or is otherwise related to service. Because the preponderance of the evidence is against the claim, the benefit of the doubt provision does not apply. Accordingly, the Board concludes that service connection for schizophrenia is not warranted. Fatigue The Veteran contends that his fatigue is related to service, to include as due to an undiagnosed illness and as secondary to his schizophrenia. STRs are silent with respect to any complaints, findings, or diagnoses pertaining to fatigue. The Veteran's Form DD 214 indicates that he had service in support of Operation Desert Shield/Storm/Calm from October 1990 to September 1994. With regard to the first element of service connection, current disability, the record contains competing opinions as to whether the Veteran has a diagnosed fatigue disability. In an April 2004 Correspondence, the Veteran's private doctor, Dr. S.C. indicated the Veteran has been fatigued since his experience in the Middle East. Dr. S.C. indicated that during his time in the Middle East, the Veteran had exposure to mycoplasma which may have contributed to his fatigue and was probably obtained during his experience in the Middle East. The Board affords reduced probative value to Dr. S.C.'s opinion as it lacks a thorough rationale for her loose conclusions that mycoplasma "may have contributed" to fatigue which was "probably" obtained during his experience. The Veteran was afforded an August 2015 VA fatigue syndrome examination and the examination report indicated that the Veteran does not now have, nor has he ever been, diagnosed with chronic fatigue syndrome. The examiner opined that the fatigue the Veteran reports is less likely than not (50 percent or less probability) associated with his Southwest Asia experience and more likely associated with his mental illness diagnosis. The examiner explained that the Veteran's description of fatigue is not congruent with the characteristics of chronic fatigue syndrome. The examiner indicated the Veteran believes that the positive mycoplasma antibody test in March 2004 diagnosed him with chronic fatigue syndrome. However, the examiner opined that the test did not confirm such a diagnosis. The examiner explained that she reviewed the documentation from Dr. S.C. of April 2004 wherein it was noted that the rash and fatigue was probably obtained in the Middle East, but there was no documentation that could be found to base such a statement. The examiner further indicated that it was noted that the Veteran was sleeping six to seven hours and exercising without difficulty and this is not consistent with a chronic fatigue syndrome. Further, the examiner explained that specific etiologies have also been ascribed to the CFS/SEID. The proposed diagnosis was chronic brucellosis from the 1930s to the 1950s and hypoglycemia from the 1950s to the 1970s. Other hypotheses have included chronic Epstein-Barr virus (EBV) infection [11-13], purported chronic Lyme disease, total allergy syndrome, multiple chemical sensitivity syndrome [14], chronic candidiasis [15], and xenotropic murine leukemia virus-related virus (XMRV) and related retroviruses, such as murine leukemia virus (MLV) [16,17]. None of these etiologic agents have been scientifically linked to the CFS/SEID. Other terms that have been used for CFS/SEID to reflect postulated etiologies include "myalgic encephalomyelitis" (in the United Kingdom) and "chronic fatigue and immune dysfunction syndrome" (CFIDS, in the United States) [18]. The Board notes that the VA examiner indicated the Veteran's fatigue is not consistent with chronic fatigue syndrome and opined that the Veteran's fatigue is less likely than not (50 percent or less probability) associated with his Southwest Asia experience and more likely than not associated with his mental diagnosis. The Board finds the VA examiner competent and credible and affords the opinion probative weight as it was supported by a thorough rationale. In short, the Veteran's fatigue has been attributed to many factors including his schizophrenia diagnosis. His fatigue has not been diagnosed as a separate and distinct disorder such as chronic fatigue syndrome. A threshold factor in establishing service connection is the existence of a current disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). This requirement is satisfied when a veteran has a disability at the time he or she files a claim for service connection or during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (holding that the requirement of a current disability is satisfied when a claimant has a disability at any time during the pendency of the claim); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (requirement of a current disability may be satisfied if there is a recent diagnosis of a disability prior to the claim). In the absence of medical evidence of a diagnosis of the claimed fatigue disability, service connection must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Insofar as the Veteran reports that he has a fatigue disability secondary to schizophrenia, in addition to having no diagnosed fatigue disorder, the Veteran is not service connected for schizophrenia. Secondary service connection cannot be established if the underlying (primary) disability basis for the secondary service connection is not itself service connected. 38 C.F.R. § 3.310. Absent a diagnosed fatigue disability and absent service connection for schizophrenia, the preponderance of the evidence is also against the claim for service connection for fatigue, to include as secondary to schizophrenia. ORDER Entitlement to service connection for schizophrenia is denied. Entitlement to service connection for fatigue is denied. ____________________________________________ S. HENEKS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs