Citation Nr: 18150109 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 14-28 742A DATE: November 14, 2018 ORDER Entitlement to service connection for residuals of a traumatic brain injury (TBI) is granted. FINDING OF FACT The evidence is evenly balanced as to whether TBI residuals originated during active service. CONCLUSION OF LAW Resolving reasonable doubt in favor of the Veteran, the criteria for establishing service connection for TBI residuals have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a veteran must show: “(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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran in this case claims entitlement to service connection for TBI. She has described an April 2005 incident where she hit her head after falling off of a ladder. She has also reported being in proximity to multiple improvised explosive device (IED) explosions during her deployment to Iraq. Her DD-214 indicates that she served in Iraq from January 2005 to January 2006 and that she served in a designated imminent danger pay area. There is conflicting medical evidence as to whether she currently suffers from residuals of a TBI. In December 2016, the Veteran underwent a VA Polytrauma/TBI consult. The examiner, a VA staff physician, noted that the Veteran reported that in April 2005, while deployed to Iraq, she fell off of a three-foot ladder without a helmet on and hit her head. She reported that this resulted in loss of consciousness lasting about five minutes and then about 30 minutes of disorientation. The Veteran added that following the injury, people told her that she was acting differently. She reported that in the last month, she almost always experienced anxiety, depression, irritability, and poor frustration tolerance; frequently experienced poor concentration, fatigue, and difficulty falling/staying asleep; often experienced dizziness, poor coordination, vision problems, hearing difficulty, noise sensitivity, numbness or tingling in body parts, changes in appetite, forgetfulness, difficulty making decisions, and slowed thinking; and occasionally experienced loss of balance. The examiner noted that there was some question as to whether she lost consciousness or not but she has had some ringing in her ear and some difficulty with concentration. The examiner also noted that she was also involved in multiple IED explosions that went off near her and that she reported posttraumatic stress disorder (PTSD) due to sexual trauma during deployment, depression, anxiety and migraine headaches and that during service she was hospitalized for suicide attempts. (The Veteran is service connected for, inter alia, depressive disorder with anxiety and migraine headaches.) Following an examination of the Veteran, the examiner indicated that based on the history of the injury and the course of clinical symptoms, it was his opinion that the Veteran sustained a TBI during deployment to Iraq and that in his clinical judgment, the symptom presentation was most consistent with a combination of Iraq deployment-related TBI and behavioral health conditions. In May 2017, the Veteran was referred to a VA neuropsychology consult by the December 2016 physician to assess cognitive and psychological functioning as part of a comprehensive traumatic brain injury evaluation. Following an evaluation, the examiner’s impression was that the Veteran’s mild inefficiencies (such as processing speed) and day-to-day cognitive difficulties most likely reflected a combination of mood/psychological issues, pain and poor sleep rather than residual effects of remote mild TBI. The examiner noted that these factors are well known to inhibit several cognitive functions such as difficulties with attention and concentration, learning and memory, processing speed, and executive functioning. In sum, the Board finds that the evidence in this case is evenly balanced as to whether the Veteran currently suffers from residuals of a TBI incurred in service. The Veteran is competent to report falling off of a ladder and being near IED explosions and her service in Iraq in a designated imminent danger pay area is consistent with exposure to IEDs. While there is no record of her having fallen off a ladder, service treatment records show multiple psychological symptoms, including hospitalization for a suicide attempt. Post-service treatment record show that such symptoms continued after service. Whether these symptoms are partly the result of a TBI is debated. While the December 2016 examiner concluded that the Veteran suffered a TBI during service and that her clinical presentation was consistent with a combination of TBI residuals and behavioral health conditions, the May 2017 examiner attributed all of her current symptoms to non-TBI-related psychological and physical causes. Both examiners have the requisite training and experience in order to offer such an opinion and both appear to have had an accurate understanding of her medical history, which is complex. In short, therefore, the evidence is in relative equipoise. As such, the Veteran is entitled to the benefit of the doubt. 38 U.S.C. § 5107. The appeal is granted. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Matthew Schlickenmaier, Counsel