Citation Nr: 18158077 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 06-11 243A DATE: December 14, 2018 ORDER Entitlement to service connection for fatigue disorder is denied. FINDING OF FACT The Veteran does not have a fatigue disorder. CONCLUSION OF LAW The criteria for service connection for fatigue disorder have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service as a weather observer in the United States Army from July 1958 to June 1973. This case comes before the Board of Veterans’ Appeals (Board) on appeal of a November 1996 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Board notes that this case has a long and complex procedural history which is described extensively in the Board’s October 2012 Decision. At a December 2017 hearing, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. The Board has recharacterized the issue as fatigue disorder to address the Veteran’s symptoms, regardless of how those symptoms are diagnosed or labeled. See Clemons v. Shinseki, 23 Vet App. 1, 5 (2009). Service Connection Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). A layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997). See also Bostain v. West, 11 Vet. App. 124, 127 (1998). If the evidence is competent, the Board must then determine if the evidence is credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In order to establish service connection on a direct basis, the record must contain competent evidence of: (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). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The service record evidence does not show that the Veteran had active service in the Southwest Asia theater of operations, therefore the provisions of 38 C.F.R. § 3.317 (a)(1) concerning chronic fatigue syndrome are not for application in this case. Chronic Fatigue Disorder The Veteran contends that he has a “separate” or stand-alone fatigue disorder, which was incurred in, or otherwise related etiologically, to his active service. The Veteran contends that fatigue is a manifestation of a chronic disability and not a symptom (or symptoms) of his other disabilities. See December 2017 hearing transcript, p.11. The Board has reviewed the record of evidence comprehensively. Although the Board has an obligation to provide reasons and bases to support a decision, there is no requirement to discuss, in detail, all the evidence submitted by or on behalf of a Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and the most relevant evidence—about what this evidence shows, or fails to show, about the issue on appeal. The Veteran must not assume that the Board has overlooked pieces of evidence that are not discussed explicitly. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). A review of service treatment records (STRs) reveals November 1971 documentation of dyspnea on exertion with fatigue and resultant hyperventilation. In a July 1996 VA general examination, an examiner diagnosed “fatigue,” and referred the Veteran for psychiatric evaluation. The examiner who conducted the subsequent August 1996 VA mental health examination reported that the Veteran had no diagnosable psychiatric disability. In May 2001, the Veteran stated that he had been depressed for the past 4 years; has felt fatigued; and has lost motivation and interest in activities. Upon VA psychiatric examination in April 2004, an examiner provided a diagnosis of dysthymic disorder; associated symptomatology included insomnia, low energy, poor concentration, and feelings of helplessness during bouts of depressed mood. Upon VA examination in February 2013, an examiner opined that the Veteran did not have chronic fatigue syndrome and that his fatigue is more likely as not related to age, medication, activity level, deconditioning, and body habitus. In an October 2013 addendum opinion, an examiner indicated that the Veteran took a beta blocker which has the possibility of causing fatigue. This examiner did take note of the 1971 report of fatigue in the Veteran’s STRs, prior to taking a beta blocker; however, the examiner indicated that the Veteran had other disorders, treatment protocols, and factors which could contribute to fatigue—morbid obesity, sleep apnea, intermittent use of antihistamines, depression, and advanced age. As to whether the Veteran’s fatigue was a symptom of the Veteran’s service-connected depression or whether a “separate” fatigue disorder was caused by, or aggravated by, depression, this examiner declined to provide an opinion, underscoring that this would need to be answered by a mental health professional. Upon psychological evaluation in April 2016, a VA examiner diagnosed the Veteran’s disorder as recurrent mild-stable major depressive disorder (MDD). As to the question of whether a disorder characterized by fatigue was caused by, or aggravated by, MDD, she opined that “fatigue” is not a recognized psychiatric disorder. At the December hearing, the Veteran testified that episodes of fatigue occurred, among other times, when he drives and when he watches television. In the case of the former, he stated that he must pull off the road to take a little nap. In the case of the latter, he stated that when he begins watching a program, he quickly falls asleep. See December 2017 hearing transcript, p.3. Upon consideration of the divergent VA opinions concerning both the characterization and etiology of the Veteran’s manifestations of fatigue, the Board sought an independent medical opinion from an expert associated with the Veterans Health Administration (VHA) in May 2018. In July 2018, Dr. P., a board-certified physician in Internal Medicine, provided an opinion responsive to the Board’s requests. Dr. P. opined that it is not as likely as not that the Veteran at any has had a separate disorder characterized by fatigue. However, it is likely that the Veteran’s reported episodes of fatigue are related to the Veteran’s obstructive sleep apnea (OSA), depression, atrial fibrillation, and medications taken to treat these disabilities. As a rationale for his opinions, Dr. P. provided a comprehensive discussion of the Veteran’s medical history, extensive roster of prescribed medications, and recent medical and psychiatric treatment. Considering these variables, he concluded by opining that the Veteran has multiple, chronic medical problems including MDD; diabetes mellitus, type 2; chronic atrial fibrillation; benign hypertension; OSA, morbid obesity; and chronic low back pain. Hence, it is likely that the Veteran’s reported episodes of fatigue are related to multiple underlying disorders. The Board also observes that Dr. P. referenced a medical publication entitled “Approach to the Adult Patient with Fatigue.” (Continued on the next page)   The Veteran has advanced that he has a separate or stand-alone fatigue disorder. While the Board finds the Veteran competent to report his discernable symptoms (such as feelings of fatigue and tiredness), he is not competent to provide a specialized medical opinion differentiating between fatigue symptoms attributable to other disabilities and a stand-alone fatigue disorder. See Jandreau; Routen, both supra. Here, the Board ascribes considerable probative weight to Dr. P.’s July 2018 opinion, which considered the evidence of record within the framework of specialized medical knowledge. Dr. P. resolved divergent VA opinions, with especial emphasis upon the fatigue symptoms associated with the Veteran’s multiple disabilities and roster of prescribed medications. Moreover, Dr. P. provided a rationale for his opinion, which included reference to medical literature on point. Therefore, the Board finds that service connection for fatigue disorder is not warranted. The preponderance of evidence is against the Veteran’s claim and there is no doubt to be resolved. See 38 U.S.C. § 5107(b); Gilbert, supra. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. J. Komins, Associate Counsel