Citation Nr: 1808602 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 12-03 366 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for residuals of a traumatic brain injury (TBI). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Smith, Associate Counsel INTRODUCTION The Veteran served honorably on active duty in the U.S. Army from August 1968 to August 1971, for which he is in receipt of an Air Medal with "V" device, and a Purple Heart Medal. This matter comes to the Board of Veterans' (Board) on appeal from a February 2010 rating action of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Jurisdiction now resides with the Atlanta, Georgia RO. In October 2015, the Veteran testified at a hearing before the undersigned Veterans Law Judge at the Atlanta RO. A transcript of that proceeding has been associated with the claims file. The Board remanded this matter in March 2016 and April 2017, and has since been returned for further appellate review. FINDING OF FACT The Veteran does not have TBI residuals related to his period of active duty service. CONCLUSION OF LAW The criteria for service connection for residuals of a TBI are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist VA's duty to notify was satisfied by letter dated November 2009. 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017); Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records (STRs), as well as all identified and available post-service medical records, including available VA treatment records, are associated with the claims file. The record indicates the Veteran received treatment for a head injury at a private hospital in December 2010, and the Veteran reported to the VA TBI clinic in September 2011 that he received injections for his headaches from a private neurologist. In connection with this appeal, VA has repeatedly requested that the Veteran identify any outstanding private treatment records and provided him with the necessary authorization forms to allow VA to obtain those records on his behalf. See July 2016 and April 2017 VA development letters. The Veteran was also informed that he could directly submit any outstanding, relevant evidence. The Veteran's treating physician also repeatedly requested the Veteran bring copies of the records from the Veteran's private neurologist, but the Veteran did not provide them. See July 2011 VA treatment record. A veteran pursuing a claim has some responsibility to cooperate in the development of all facts pertinent to his claims, and the duty to assist is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190 (1991). Thus, the Board finds that VA has fulfilled the duty to assist with obtaining relevant VA and private treatment records. The Board finds that there has been compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The prior remands directed the AOJ to afford the Veteran another TBI examination, which was then afforded to the Veteran in August 2017. The Veteran also offered testimony before the undersigned Veterans Law Judge (VLJ) at a Board hearing in October 2015. The Board finds that all requirements for hearing officers have been met. 38 C.F.R. § 3.103 (c)(2) (2017); Bryant v. Shinseki, 23 Vet. App. 488 (2010). To the extent that any evidentiary deficiency was noted, the Board finds that it has been cured on remand. Thus, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. There is no error or issue that precludes the Board from addressing the merits of this appeal. Service Connection: TBI The Veteran seeks entitlement to service connection for residuals of a TBI that he asserts are etiologically related to an in-service event where his weapon exploded in his face. He initially only reported symptoms of tinnitus and headaches, but during the pendency of the appeal also alleged that he had ongoing chronic symptoms of loss of vision, dizziness, fainting, difficulty concentrating, and memory problems since the in-service accident. At the outset, the Board notes the Veteran is already service-connected for tinnitus. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303(a) (2017). To establish a right to compensation for a present disability, 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 - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge 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). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). For example, a layperson would be competent to identify a simple condition such as a broken leg, but not competent to provide evidence as to a more complex medical question such as a form of cancer. Id. at n. 4. Also, non-expert witnesses are competent to report that which they have observed with their own senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Non-expert nexus opinion evidence may not be categorically rejected. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The complexity of the question and whether a nexus opinion or diagnosis could be rendered based on personal observation are factors in determining whether a non-expert nexus opinion or diagnosis is competent evidence. In sum, whether non-expert (lay) diagnoses or nexus opinions are competent evidence depends on the on the question at issue and the particular facts of the case. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence of the record; every item of evidence does not have the same probative value. When there is an approximate balance of evidence for and against the issue, reasonable doubt will be resolved in the Veteran's favor. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Here, the Veteran's STRs are silent for a head injury or complaints thereof. In February 1970 following an incident where the Veteran's weapon overheated and exploded in his face during combat, the Veteran was treated for a shrapnel wound to the right upper arm and was assigned light duty for two weeks. The Veteran was seen in sick call multiple times throughout his period of service for treatment, but only one STR documents a complaint of a headache in January 1969. He also had a sore throat and fever at that time and was assessed as having an upper respiratory infection. None of the STRs mention dizziness, loss of vision, chronic headaches, or memory problems. The Veteran's separation exam is illegible. At a June 2002 VA medical appointment, the Veteran denied chronic or recurrent headaches. There are no VA treatment records prior to 2002 showing complaints of chronic headaches. A November 2002 VA treatment record documented the Veteran reported being involved in a fight in October 2002, and he reported pain in his head and neck since then. At a March 2005 VA appointment, the Veteran asked for a medication to treat headaches he had been having for the prior year. An October 2007 VA mental health note documented the Veteran recently fell backwards down a flight of stairs and had been experiencing headaches since that time. A July 2008 VA treatment record documented the Veteran continued to have complaints of neck pain and headaches. At a July 2008 VA mental health appointment, the Veteran attributed his headaches to a neck whiplash injury. Another July 2008 VA hospital record documented the Veteran had a history of getting in fights and was beaten badly in 2006. The Veteran reported that he was kicked in the head at that time, and had headaches ever since. The Veteran was afforded a CT scan of the head to assess his headaches complaint, and the results showed no acute intracranial pathology. In October 2008 the Veteran first presented as a self-referral to the VA TBI clinic because he wanted to find out whether he was having residual problems from an in-service concussion. The Veteran reported that in-service his weapon overheated and exploded in his face. He endorsed complaints of dizziness, loss of balance, daily headaches, vision problems, tinnitus, numbness and tingling in fingers and hands, poor concentration, forgetfulness, sleep difficulty, irritability, anxiety, depression, and neck and back pain. Following examination, the nurse practitioner assessed the Veteran as having a history of a concussion due to the machine gun explosion. It was difficult to determine whether the Veteran's current symptoms were residuals of that event. She reported that the Veteran's primary difficulties were related to his mental health diagnoses. November 2008 MRI studies of the brain showed two small foci of T2 prolongation within bounds of normal for a patient of the Veteran's age and otherwise unremarkable MRI of the brain. An EEG of the brain was also normal. A January 2009 VA neurology consultation report documented the Veteran had a sudden loss of consciousness in October 2008 after he had been running and felt dizzy and fell to the ground. The Veteran gave a history of daily headaches that worsened with anger or anxiety. The neurologist noted that these symptoms began since the Veteran stopped taking a certain medication after his October 2008 fainting episode. The Veteran also reported chronic ringing in his ears since the explosion in Vietnam. Following exam and review of the 2008 MRI studies, the physician assessed the Veteran as having a syncopal episode in October 2008 rather than a seizure. An April 2009 VA attending follow up note documented the Veteran presented with several complaints that he attributed to his military service. It was noted the Veteran had already been to the TBI clinic but felt that he should go back to see a neurologist due to chronic headaches and memory problems. The physician noted the Veteran's brain MRI was normal. The physician documented a history of exposure to an explosion 30 years prior, and stated that there was a question of rebound headaches due to chronic pain medication use. The Veteran was referred to the VA TBI clinic in July 2009 following the April 2009 positive TBI screen. The Veteran reported that in Vietnam his weapon overheated and exploded in his face and that he was blinded for a while and had ringing in his ears. He stated that he was disoriented thereafter for several days, and was in the hospital. He had no loss of consciousness. He reported that since then he had headaches, tinnitus, and numbness and tingling in his arms. He also reported that he fell down a flight of stairs in 2008 and injured his neck. The Veteran also had a sudden loss of consciousness after he had been running and then felt dizzy in October 2008. He denied any similar episodes after. On mental status examination it was noted the Veteran sometimes contradicted himself and the smell of alcohol was detectable. Following examination, the assessment was mild TBI by history. The Veteran's effort on exam was so poor with regards to testing of thinking and memory, the Veteran was not referred for neuropsychological testing. The Veteran was advised of rebound headache phenomenon. The Veteran underwent a VA speech pathology consult in relation to the positive TBI screen in August 2009. At that time the Veteran complained of memory difficulties since service. Examination showed cognitive impairment across several areas, and the examiner reported the diagnoses of PTSD and TBI made it difficult to highlight contributing factors relating to complaints given by the Veteran related to memory function. A September 2009 VA audiology consultation notes the Veteran had perceived left ear hearing loss since an incident in service where his weapon exploded in his face. The Veteran complained of having memory problems since separation from service. Another TBI screening was performed that noted the Veteran had difficulty remembering medical appointments, to take medications, things that had been said to him 5 minutes earlier, to complete tasks, to pay bills, difficulty completing more than one thing at a time, and difficulty planning and organizing things. The composite severity rating showed the Veteran to be moderately impaired. The assessment was that the Veteran was a functional verbal communicator and reported a history of difficulty with functional memory. He scored in the mildly impaired range on executive function, moderately impaired on attention, language, and visual/spatial skills, and severely impaired range for memory. The Veteran had difficulty with auditory memory and had a flat/blunted affect with lack of eye contact. The Veteran had diagnoses of PTSD and bipolar disorder. The diagnoses of PTSD and TBI made it difficult to highlight contributing factors related to memory function. In his original October 2009 claim, the Veteran wrote that he believed he had a traumatic brain TBI suffered from chronic headaches. He reported being treated at the VA for a TBI. In a November 2009 statement the Veteran wrote that his "problems with [TBI] dates back to 1972 when I was granted 10 percent for tinnitus due to explosion in my face." He reported problems of constant and reoccurring headaches and tinnitus off and on since separation. He noted that he had been assessed by the VA TBI clinic who would not say conclusively whether or not he had a TBI in service. In his April 2010 notice of disagreement, the Veteran wrote that he did not complain previously about the ringing or headaches because of frustration over "our involvement in Vietnam and Cambodia." A January 2010 TBI consultation documented the Veteran was seen in the TBI clinic in July 2009 when he was diagnosed with mild TBI by history. Currently, the Veteran endorsed ongoing memory problems but did not mention headaches. Neurologic testing was again administered with indecisive and at times seemingly capricious answers. The assessment was mild TBI by history, however the Veteran's current complaints were more consistent with PTSD and sleep problems rather than a TBI. A July 2010 VA audiology report documented the Veteran reported tinnitus associated with ringing and headaches. During exam it was noted the Veteran exaggerated his voice levels when responding to questions as if to imply hearing impairment. The Veteran had to be tested repeatedly due to inability or unwillingness to provide valid responses. August 2010 VA emergency department records document the Veteran fell in the bathroom and hit his head. He complained of headache and neck pain and was assessed as having a concussion. The Veteran underwent a CT scan of the head that showed no acute skull fracture or intracranial abnormality. The findings were most consistent with a small, thin hematoma within the scalp in the right frontal region anterolaterally. A September 2010 VA progress note documented the Veteran had suffered a head injury three weeks prior when he slipped in the bathroom and hit his head on the toilet. He reported his TBI symptoms were now worse. The assessment was recent head trauma. September 2010 VA MRI studies of the brain showed no evidence of acute hemorrhage or infarct. There was minimal nonspecific ischemic changes within the subcortical white matter of both frontal and parietal lobes that was grossly unchanged when compared to the prior study. Those findings were assessed as likely secondary to chronic small vessel atherosclerotic ischemic changes. An October 2010 VA TBI note documented the Veteran had a history of a mild TBI who presented to the clinic for follow-up of a concussion he suffered in August 2010 after he fell backwards in the shower and lost consciousness. He suffered a contusion on his right temple. Since that injury, he reported worsening of pre-existing memory problems. He also reported headaches in the right temporal area that spread to the left temple. He reported that his memory and headache problems had returned to their baseline. The impression was recurrent mild TBI, with the Veteran back at his abnormal baseline. December 2010 VA psychiatry records document the Veteran was involved in a motor vehicle accident in 2010 and hit his head and sustained a whiplash injury to his neck. He was reportedly assessed at Gwinnett Medical Center after sustaining the trauma, and reported that since the accident his head did "not feel the same." A June 2011 VA psychiatry record documented the Veteran had concerns of worsening neurological and cognitive problems after an accident in December 2010. The Veteran had been involved in a motor vehicle accident and hit his head, and sustained a whiplash injury to his neck. The Veteran was taken to Gwinnett Medical Center and had imaging studies completed. The Veteran reported that he believed his TBI was worse after the accident. He reported memory deficit, stuttering, ongoing headaches, and photosensitivity. The assessment was history of TBI and now memory loss. Another June 2011 VA treatment record documented the Veteran reported receiving treatment from an outside neurologist who wanted to give him "shots in the head" to improve his headaches. A July 2011 VA treatment record documented the Veteran reported headaches since a concussion in December 2010. The record documented that the Veteran's physician had requested records from the Veteran's private neurologist, however the Veteran had not provided those records. In an addendum note, the Veteran's physician wrote that the Veteran had a neck MRI 4 months prior and a brain MRI within the past year. The physician requested that the Veteran be contacted again to request those private neurology records. A September 2011 VA TBI note documented that the Veteran was seen in TBI clinic in October 2010 and found to be returned to baseline but returned for reevaluation following a head injury while riding a bus. He reported that the bus he was riding in hit a car, and his head collided with another passenger's head on the right temple area. The Veteran reported receiving treatment with an outside neurologist but had quit because he disagreed with the headache treatment. He also reported memory difficulty that began two months after the accident. The assessment was new incident of likely mild TBI. His cognitive complaints were assessed as likely related to multifactorial issues such as: pain increase, lack of sleep, and chronic PTSD. It was possible that the mild TBI contributed to the symptoms as well. The Veteran's headaches were assessed as being related to many factors, including neck pain, back pain, poor sleep, stress, and chronic use of pain medication. The nurse practitioner stated the Veteran was not likely to bring in the scans from Gwinnett Medical Center, so a brain MRI was reordered. November 2011 VA MRI studies of the brain showed few tiny, punctate foci of likely small vessel ischemic changes scattered throughout the subcortical white matter, otherwise unremarkable study. There was no acute intracranial process, significant TBI, or intracranial hemorrhage. There were minimal nonspecific ischemic changes that were likely secondary to chronic small vessel atherosclerotic ischemic changes. The Veteran underwent neuropsychological testing in November 2011, at which time the psychologist noted that documented that the head CT scan following the December 2010 injury was normal, and the September 2010 MRI revealed no evidence of acute hemorrhage or infarct. The minimal nonspecific ischemic changes were likely secondary to chronic small vessel atherosclerotic ischemic changes. The Veteran reported that he had been improving from his initial head injury when he was reinjured in the motor vehicle accident. He reported ongoing headaches, and cognitive difficulties related to memory, thought process, organization, and attention. The psychologist reported that the test was invalid due to significant discrepancies between test performance and actual functioning, and the examiner felt the Veteran did not give his best effort on the evaluation. His performance on measures of symptom validity and effort fell far below expectation even for individuals with severe neurological dysfunction such as dementia. While there may be legitimate cognitive deficits, the examiner was unable to accurately quantify them in light of his variable effort on testing. The examiner stated that there were several reasons why a person may do poorly on neuropsychological measures, including emotional distress, chronic pain, poor motivation, and deliberate exaggeration. Overall, the severity of the deficits the Veteran reported was highly inconsistent with the relatively mild injury he sustained and it was believed that other factors than a concussion accounted for those difficulties, such as chronic pain, medical effects and emotional distress. No diagnosis of TBI was advanced. Rather, the examiner diagnosed rule out somatoform pain disorder versus conversion disorder, questionable abuse of alcohol, PTSD, and depressive disorder not otherwise specified. The Veteran was discontinued from the TBI clinic and referred to his physician for follow-up treatment. A February 2012 VA physical medicine note documented the Veteran returned for follow up of neck pain, and one of the impressions made was TBI. In an attending progress note that same month, it was documented the Veteran had a history of chronic headaches. The assessment was history of TBI that had already been evaluated in the TBI clinic, and improved memory problems. A May 2012 VA PTSD examination report documented the Veteran had chronic headaches, tinnitus, and light sensitivity related to a TBI, and the examiner noted the Veteran self-reported the TBI diagnosis. A November 2012 VA TBI headache clinic note documented the Veteran had been discharged from the TBI clinic in January 2012. The Veteran reported headaches since a bus accident in 2010, described as occurring in the right temporal area and spreading to the left temple. The assessment was headaches. A February 2015 VA ophthalmology note reported the Veteran had a TBI in Vietnam 40 years prior and had ongoing sensitivity to light. At the October 2015 Board hearing, the Veteran wrote that after his gun exploded in his face he was stunned and shocked for a period of time that he could not account for. The Veteran also reported being in a helicopter crash where they landed so hard he was thrown from the helicopter. He reported ongoing headaches and tinnitus since service. The representative argued that the Veteran's TBI was recurring, as evidenced by his fall in 2008. A November 2016 VA neurology consultation report documented the Veteran had neck pain, headache, right shoulder pain, and tingling in right hand since a motor vehicle accident in 2014. It was noted the Veteran had going to a non-VA surgeon who offered to perform neck surgery. The assessment was neck pain and headache since 2014 motor vehicle accident. The Veteran underwent a VA TBI examination in August 2017 conducted by a psychiatrist. The Veteran reported that the onset of his TBI was when his weapon exploded in his face in service which resulted in loss of vision, ringing of the ears, memory loss, and dizziness. The Veteran reported gradually worsening symptoms since that time. The examiner determined the Veteran did not have nor had ever had a TBI or residuals of a TBI. The examiner noted that the Veteran had a complaint of mild memory loss about recalling conversation, or remembering names or belongings. He also said he chose not to remember certain events due to his down mood, and he could not differentiate between whether he chose not to remember things or whether he had a memory deficit. The claimant scored 1/5 in the delayed memory section of the MOCA which indicated a decline from normal. However, the examiner noted that the Veteran made little effort when taking the examination. Thus, the examiner concluded that a direct causal link between the reported traumatic incident and cognitive deficits could not be confirmed. Also, the Veteran's memory symptoms were not specific to a particular etiology and could be attributable to his PTSD diagnosis. Regarding judgment, the examiner identified that the Veteran had moderately-severely impaired judgment. The Veteran had a history of multiple DUIs, physical altercations, and fights that have caused legal trouble or termination of employment. The examiner again noted that anger and irritable behavior could be attributed to the PTSD diagnosis. The examiner documented the Veteran's social interaction was inappropriate most of the time as evidenced by irritability, use of profanity, and using short responses to answer questions. The Veteran did not have impairment related to orientation, and was always oriented to person, time, place, and situation. His motor activity was also normal. The Veteran's visual spatial orientation was mildly impaired, however the examiner again noted the Veteran did not exert full effort during the visual spatial section of the MOCA exam so a direct causal link between the reported TBI and resulting cognitive deficit could not be confirmed. Also, those symptoms could be attributable to metabolic problems, psychiatric problems, or systemic factors. The Veteran reported additional subjective symptoms of tinnitus, dizziness, and headaches. The examiner did not identify any communication difficulty, or altered consciousness. The examiner noted that imaging studies in 2010 following the Veteran's December 2010 injury had been normal. In sum, the examiner suspected lack of effort by the Veteran during examination and concluded that for the claimed condition of TBI there was no diagnosis because there was no pathology to render a diagnosis. Instead, the examiner stated the Veteran's symptoms could be attributable to the Veteran's PTSD diagnosis. In a September 2017 statement, the Veteran asserted that he had a TBI from the in-service concussive blast. He wrote that his current main problems related to his TBI were loss of vision in his left eye and ringing in his ears. The Board finds that based on the foregoing, entitlement to service connection for residuals of a TBI are not met as the most probative evidence of record demonstrates that the Veteran did not have a TBI with residuals as a result of his in-service injury. Regarding the Veteran's reports of TBI residuals in-service and thereafter, the Board does not find his testimony to be credible. STRs do not show complaints of such symptoms in service although the Veteran sought treatment for various other complaints throughout service. The Veteran also received treatment for other injuries related to the weapon explosion, but no mention of TBI residual symptoms was made by the Veteran or medical providers in service. He denied headaches prior to 2002, and had several head injuries from 2002 onward, after which he reported experiencing headaches. Specifically, the evidence demonstrates that the Veteran was in a fight in October 2002 after which he began to report headaches, that he fell down a flight of stairs in October 2007, that he was in another fight in 2006 and reported being kicked in the head, that he had an October 2008 syncopal episode, that he fell again and hit his head in August 2010, and that he was involved in motor vehicle accidents in December 2010 and 2014. While the Veteran has at times testified that he experienced chronic headaches since the in-service explosion, this is contradicted by other statements he has made to his treatment providers as documented in the medical evidence. Further, medical examiners have repeatedly assessed the Veteran as exaggerating his symptoms of failing to apply appropriate effort during testing. While the Veteran has stated that he did not previously complain about his tinnitus and headaches because of frustration over US involvement in the Vietnam War, he complained of other symptoms during and shortly after separation, including other residuals from the weapon explosion injuries. Due to these inconsistencies, the Board finds the Veteran's testimony regarding his in-service TBI symptoms and continuity of symptoms to not be credible. Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that the credibility of a witness may be impeached by a showing of interest, bias, inconsistent statements, consistency with other evidence), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The most probative medical evidence also does not show that the Veteran had an in-service TBI with residuals. The Board acknowledges the Veteran was diagnosed by various VA practitioners as having a TBI by history in relation to his reported in-service incident. The "by history" diagnosis was based on the Veteran's reported symptoms of the time, and the treatment providers who gave the by history TBI diagnoses also did not review the Veteran's STRs. The Board does not find the Veteran's reports of in-service symptoms related to the TBI to be credible, and thus a diagnosis based on this history is afforded less weight. While the Board notes that the Veteran was diagnosed with a concussion and then recurrent mild TBI during the pendency of this appeal, this was after the August 2010 fall and the medical evidence did not relate any symptoms or residuals of the 2010 injury to service. Further, following neurological assessment in November 2011 no diagnosis of TBI was advanced, and the Veteran was discontinued from the TBI clinic. Also, repeated diagnostic testing failed to show any brain abnormality except minimal nonspecific ischemic changes secondary to chronic small vessel atherosclerotic ischemic changes, which was not noted until September 2010. The earliest available CT scans from July 2008 showed no intracranial pathology, November 2008 MRI studies showed results within the bounds of normal and a contemporaneous EEG of the brain was also normal. Upon review of all relevant medical evidence, interview, and neurologic testing, the August 2017 VA examiner determined the Veteran did not have nor ever had a TBI. The Board has also considered the Veteran's lay assertions that he has residuals of a TBI due to his in-service injury. While the Veteran is competent to report symptoms, the Board has not found his reports of in-service symptoms and continuity of symptoms to be credible. Also, he has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that he received any special training or acquired any medical expertise. Therefore, his lay statement that he has a TBI due to his period of service lacks competency. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The record also shows that the Veteran's memory and cognition problems could be attributable to his service-connected PTSD. See October 2008 TBI clinic report; see August 2009 VA speech pathology consultation; see September 2009 VA audiology consultation; see January 2010 TBI consultation; November 2011 neurological assessment; see August 2017 VA examination. The Veteran's headaches have also been assessed as being related to neck pain, back pain, poor sleep, stress, and chronic use of pain medication. See September 2011 VA TBI clinic note. Based on the foregoing, the Board finds that the weight of the competent and credible evidence shows that at no time during the current appeal has the Veteran been diagnosed with residuals of a TBI related to the in-service incident. Thus, his claim for service connection for residuals of a TBI must be denied. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit-of-the-doubt doctrine is not helpful to a claimant where, as here, the preponderance of the evidence is against the claim. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Entitlement to service connection for residuals of a TBI denied. ____________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs