Citation Nr: 21003085 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 14-30 810 DATE: January 19, 2021 ORDER Service connection for an acquired psychiatric disorder is denied. Service connection for sleep apnea is denied. Service connection for a headache disorder is denied. FINDINGS OF FACT 1. An acquired psychiatric disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service and a psychosis did not manifest to a compensable degree within one year of discharge from active duty. 2. Sleep apnea is not caused or aggravated by a service-connected disability. 3. A headache disorder is not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder have not been met. 38U.S.C.§§1101,1112,1131, 1137, 5107; 38C.F.R.§§3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for sleep apnea have not been met. 38 U.S.C.§§1131, 5107; 38C.F.R.§§3.102, 3.303, 3.310. 3. The criteria for service connection for a headache disorder have not been met. 38 U.S.C.§§1131, 5107; 38C.F.R.§§3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1976 to November 1977. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a rating decisions issued in February 2013 and April 2015 by a Department of Veterans Affairs (VA) Regional Office. In December 2017, the Board remanded the claim for service connection for an acquired psychiatric disorder. In a July 2019 Board decision, the Board denied service connection for an acquired psychiatric disorder, sleep apnea and a headache disorder. The Veteran appealed that decision to the U.S. Court of Appeals for Veterans Claims (Court). In August 2020, the Court issued an Order that vacated the Board's July 2019 decision based on findings that the Board’s analysis of the Veteran’s acquired psychiatric disorder claim was inadequate, and remanded the matter on appeal for adjudication consistent with the instructions outlined in the August 2020 Joint Motion for Remand by the parties. Of note, the JMR found that, because the issues of service connection for sleep apnea and a headache disorder were inextricably intertwined with the Veteran’s psychiatric disorder claim, they too should be remanded by the Court. The August 2020 remanded the issues in accordance with the JMR. While those issues are before the Board for consideration following re-consideration of the Veteran’s psychiatric disorder claim in accordance with the JMR, the analyses have not changed for those issues due to the fact that the Board’s conclusion, that an acquired psychiatric disorder is not due to service, remains the same. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may also be granted for any disease 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). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38C.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) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection may not be established on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38C.F.R.§3.310(b). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. See 38U.S.C.§1111; 38C.F.R.§3.304(b). In Smith v. Shinseki, 24 Vet. App. 40, 45 (2010), it was clarified that the presumption applies when a veteran has been “examined, accepted, and enrolled for service,” and where that examination revealed no “defects, infirmities, or disorders.” 38 U.S.C.§1111. Plainly, the statute requires that there be an examination prior to entry into the period of service on which the claim is based. See Crowe v. Brown, 7 Vet. App. 238, 245 (1994) (holding that the presumption of sound condition “attaches only where there has been an induction examination in which the later-complained-of disability was not detected” (citing Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991)). Only such conditions recorded in examination reports are considered as noted. 38C.F.R.§3.304(b). History of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions but will be considered together with all other material evidence in determinations as to inception. 38 C.F.R.§3.304 (b)(1). Therefore, where there is evidence showing that a disorder manifested or was incurred in service, and this disorder is not noted on the veteran’s entrance examination report, this presumption of soundness operates to shield the veteran from any finding that the unnoted disease or injury preexisted service. See Gilbert v. Shinseki, 26 Vet. App. 48 (2012); Bagby, 1 Vet. App.at 227; 38C.F.R.§3.304(b). Such presumption is only rebutted where the evidence clearly and unmistakably shows that the veteran’s disability (1) existed before acceptance and enrollment into service and (2) was not aggravated by service. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Bagby, 1Vet. App.at 227; VAOPGCPREC 3-2003 (July 16, 2003). The two parts of this rebuttal standard are referred to as the “preexistence prong” and the “aggravation prong.” Horn v. Shinseki, 25 Vet. App. 231, 234 (2012). To satisfy this second-prong requirement for rebutting the presumption of soundness, the government must show by clear and unmistakable evidence either that there was no increase in disability during service or that any increase in disability was “due to the natural progression” of the condition. Joyce v. Nicholson, 443 F.3d 845, 847 (Fed. Cir. 2006). Additionally, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as psychosis, 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.§§1101, 1112, 1137; 38C.F.R.§§3.307, 3.309. Alternatively, when a disease at 38C.F.R.§3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38C.F.R.§3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R.§3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38U.S.C.§5107; 38C.F.R.§3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). As noted above, in July 2019, the Board denied service connection for an acquired psychiatric disorder. Thereafter, the Veteran appealed this decision to the Court. In a Joint Motion to Remand, the parties found that the July 2019 Board decision was inadequate citing a failure to provide adequate statement of reasons and bases to support negative treatment of January 2017 and February 2019 private opinions. Further, the parties noted that on remand, the Board should address the credibility of lay statements that the appellant experienced psychiatric symptoms in and since service. The motion for partial remand was granted in an August 2020 Court Order. As such, in the decision immediately below, the Board seeks to address the stated inadequacies cited by the Court. As much of the evidence and analysis is the same as that discussed in July 2019 decision, much of the decision below is identical to it. Entitlement to Service Connection for an Acquired Psychiatric Disorder Factual Background The Veteran’s service treatment records reveal that, in his September 1976 Report of Medical History completed at the time of his enlistment, he reported that he had or was then having nervous trouble of any sort. The Veteran’s contemporaneous September 1976 Report of Medical Examination reflect that his clinical psychiatric evaluation was normal, and no diagnoses or defects related to an acquired psychiatric disorder were noted. The Veteran’s November 1977 report of medical examination for separation shows a normal psychiatric and skin evaluation. The “notes” section of the examination form states, “physically fit.” The Veteran’s service treatment records demonstrate service in California. The Veteran’s DD 214 reflects that he served for one year and fifteen days with no foreign service. The Veteran received an honorable discharge. Post-service treatment records include a May 1978 letter from Kennedy-King College which noted that the Veteran had unsatisfactory academic progress as of the end of the Spring 1978 term. The Veteran stated that he wanted VA counseling. In an August 1978 note from the Veteran explaining an overpayment due to withdrawal, the Veteran stated that when he enrolled in school at Kennedy-King, he was not working. The Veteran stated that he then took a full-time job and realized he could not manage a full-time job and a full-time course schedule, leading him to withdraw from some of his schoolwork which caused the overpayment. In a January 1979 application for compensation or pension, the Veteran filed a claim for a skin disease and no other disorder. The Veteran stated that he tried to re-enlist but he was denied re-enlistment due to a skin disorder. Post-service treatment records reflect a normal head CT in September 1992 and no prior head trauma was noted in August 2000. At such time, the Veteran reported experiencing depression for the prior three years since his father passed away. The Veteran also reported anxiety attacks. The Veteran reported having a few beers each night and twelve or more beers per weekend. A February 2001 urgent care nursing note states that the Veteran presented with complaints of a bloodshot, painful left eye. The Veteran stated that he was in a fight when he was intoxicated and sustained several blows to the left face and shoulders. He stated he was taken to jail after the fight and refused emergency room treatment offered to him at that time. In December 2001, the Veteran submitted a claim for service connection for a head injury. The Veteran stated that in May 1977 he was hit in the head with flying debris from a helicopter blade. He stated that he was unconscious and had a memory problem. The Veteran was referred to VA psychiatry in 2003 after experiencing crying spells following the loss of his job. The Veteran was next seen in 2008 at which time he reported memory problems and frequent tearfulness. In October 2008, the Veteran reported an in-service TBI, as well as numerous post-service TBIs during his employment (however, he subsequently denied any post-service TBIs in December 2008). Due to his current cognitive impairment, he was noted to be an unreliable historian. The Veteran reported experiencing anhedonia since 2000. In an October 2008 neuropsychology evaluation report, it was noted that the Veteran was referred by his psychiatrist for neuropsychological testing due to memory problems and crying unexpectedly following a head trauma in the military when he served in Vietnam. Background information included that the Veteran was a fifty-year-old man who served in Vietnam for six months and then was discharged after a severe head injury. The Veteran reported that he had been unemployed since June of 2007 and that since leaving the military he had been employed on and off in construction and manual labor but that he rarely kept a job for more than a year. It was noted that currently the Veteran was trying to obtain disability benefits. It was noted that the Veteran still drove, reported no speeding tickets, accidents or anything of the like. The examiner stated, however, that the record indicated at least one DUI. It was noted that the Veteran was an unreliable reporter of history which may be due to cognitive impairments. The psychologist noted that the Veteran reported that, in 2007, he was convicted of an assault by an employment agency staff person. The Veteran stated that the person fell out of his chair while he tried to take back his resume. The Veteran described an incident during service where he was hit by a metal object when trying to land a helicopter which rendered him unconscious. It was noted that the Veteran had several other incidents while employed where heavy objects had fallen on his head. It was noted that the Veteran had a history of anxiety and depressive symptoms, and that the Veteran’s chart indicated that he experienced panic disorder symptoms after the death of his father and that he struggled with depression. It was noted that the Veteran reported drinking heavily when he was 18-30 years old but that he abstained from alcohol for the last twenty years except on special occasions. The examiner stated that the Veteran requested that he not contact the Veteran’s mother who he thought was trying to make him look crazy. The examiner stated that the Veteran did not appear to be an accurate historian as he could not recall or did not want to reveal his DUI. The examining psychologist concluded that the Veteran sustained a severe head injury during active duty and several subsequent insults to the head while working in construction. It was noted that the Veteran’s test results, when taken together, demonstrated widespread cognitive deficits in multiple domains of functioning which was consistent with the blow to the head he reported in Vietnam but "may have further been exacerbated by his remote chronic alcohol abuse and subsequent head injuries.” The Veteran had a mental health initial evaluation in December 2008. It was noted that the Veteran had difficulty keeping jobs and a history of excessive drinking between the ages of 18-30, and that he currently drank occasionally. The Veteran reported that he used to enjoy going to museums, playing the drums and going to see friends but of late had been watching television and staying home. It was noted that the Veteran’s speech was somewhat slurred. A summary of findings stated that the Veteran reported a head injury while on active duty and that allegedly he was a changed man since according to a letter sent from his mother. It was noted that the Veteran presented with a picture of severe memory impairment and took a long time to answer questions and that the information given was of questionable reliability. The psychologist noted that he was somewhat surprised that the Veteran was able to drive and navigate despite his visio-spatial impairment and that at the end of the session he asked someone to take him to the bus station. The examining psychiatrist stated “it is interesting to note that by the end [the Veteran] asked me to fill a questionnaire given [to him] by his lawyer. When told that he can get a copy of my eval [sic], he became quite vocal, spoke fluently, showed no speech impediment and insisted getting the questionnaire filled out adding that he needed and[sic] income and that the report given to him from Neuropsych was not enough. He appeared to show reasonably intact executive functions or at least some aspects of it, and he has no difficulty remembering the lawyers[sic] instructions and asking the examiner for a time to pick up the questionnaire. This did not appear to jive with his assumable level of impairment.” In a March 2009 treatment note from the Veteran’s social worker, a history of alcohol abuse was noted, the Veteran was shown to state that he only drank socially now. In an August 2010 psychiatry attending record, it was noted that the report was from a first appointment with the Veteran whose history was significant for reported head injury, depression, anxiety, lability and alcohol problems. The examining doctor stated that the Veteran was difficult to interview. It was noted that he was “slowed, concrete, vague and [that the Veteran] changes his story from five minutes to five minutes.” The treating physician noted that the Veteran took out a form from Housing and Urban Development-VA Supporting Housing (HUD/VASH) form at the end of his visit in an organized fashion, spoke rapidly and coherently when he wanted to know about transportation money at the end of the appointment. It was noted that after receiving his labs the Veteran returned thirty minutes later and was able to speak in a much more coherent, faster and more organized manner, again looking for transportation funds and that he remembered the tasks he had to do in between his appointment and returning later. The examining doctor stated that from the interview it was not clear what the Veteran’s level of impairment was. It was noted that there was repeated charted history of a bad injury in service. An addendum to these findings later in August 2010 noted that a review of the Veteran’s chart showed that “the same discrepancies between his presentations prior to asking for something and after occurred in 12/31/2008 mental health eval” regarding his lawyer’s papers. Treatment reports include the Veteran’s report that he sustained multiple TBIs in a November 2010 social work assessment and a November 2013 treatment note associated with case management A psychology progress note dated in November 2012 noted that the Veteran had requested a concise statement of his condition. Dr. J.Y. stated that the Veteran sustained a serious head injury during service and that his records did not indicate that his injury received proper attention at the time. Dr. J.Y. stated that it was apparent that the Veteran had sustained a serious traumatic brain injury that resulted in long term negative cognitive and emotional changes and that the Veteran had a distinct pattern of PTSD symptoms related to his trauma. In a November 2012 statement, the Veteran’s mother, M.B., stated that the Veteran was injured somewhere in the jungle but did not know where he was and that he had flown many hours to get there and that he was injured in the head by a helicopter sling donut. She stated that the Veteran was flown by helicopter to a hospital tent and later back to the United States. She stated that he had written to her that he was asked if he wanted to go home and he said yes and was discharged. M.B. stated that before the Veteran entered the service, he was an active, vibrant, sweet, and caring young man and was not the same when he left service. She stated that the Veteran’s memory was affected, and his joy was gone that he went from city to city and could not seem to hold on to a job. She stated that his tongue became sharp and he could at any moment become a different person. She stated that there were times she did not see the Veteran for as many as four years with little contact and that she had to support him many times. The Veteran’s friend, D.A., also submitted a statement in support of the Veteran’s claim in November 2012. In his statement, D.A. stated that the Veteran was a very good friend of his and was a school classmate. D.A. stated that before entering the military the Veteran was involved in martial arts and that he was a drummer and bass player in the band. D.A. stated that he attended amusements parks and concerts but that after he returned from service from an accident, he was not the same person. D.A. stated that he would appear afraid or bothered by things from time to time and had trouble remembering things and was sometimes unable to hold a conversation or would get angry and believed someone was trying to harm him. D.A. stated that the Veteran would burst out crying for no reason. D.A. stated that the Veteran wrote him in 1977 of a helicopter injury to his head. The Veteran submitted a statement in support of his claim in November 2012. In his statement he stated that he had a disability which was the direct result of an injury during active duty. The Veteran stated that he would have applied for compensation soon after being discharged, but that he was young and was unaware that his injury would catch up with him. The Veteran stated that he sustained an injury while on an operation sometime between the summer and fall of 1977. He stated that once he returned after his injury, he was not functioning well and that he was discharged with an honorable discharge but should have been discharged with a medical discharge. The Veteran stated that he was put in front of a board of medics and officers and asked how he felt and that he told them about the sharp pain that “comes and goes from my brain and neck area” and that he panicked at the sound of helicopters. He stated that he was on light duty due to his injury and was discharged thereafter. The Veteran stated that he was knocked unconscious and there was blood everywhere when he woke up. He explained that he was trying to hook up a water buffalo tank while the aircraft was descending with staff rope that had a donut ring hooked at the end and the was struck by the donut above his left eye in the head. He stated that he was taken by a first aid helicopter to a medical tent away from the landing zone where he was tested and given stiches. The Veteran stated that he no longer remembered where he was located when he was injured. The Veteran stated that he was unable to hold a job and received social security due to his injury. Records demonstrate that the Veteran received benefits from the Social Security Administration due to organic mental disorder. In an April 2013 treatment record, the Veteran’s PTSD clinic psychologist noted that the Veteran was seen in a PTSD consultation session for thirty minutes for a PTSD diagnosis. It was noted that the Veteran remained confused, perplexed and anxious because he could not remember certain details of his trauma which the psychologist stated was a head injury from a helicopter hoist block. The psychologist, Dr. J.Y., stated that it was more likely than not that the Veteran had severe enough brain injury that he could not remember those details and that his claim should not be denied for that reason and that clinically it was completely consistent with PTSD based on this kind of injury. A November 2013 report conducted in conjunction with case management services noted that the Veteran reported to have suffered multiple TBIs. He stated that his memory was impaired at times. In April 2015, the Veteran’s mother, M.B., stated that the Veteran was a very well-behaved child but that he changed suddenly when he was in the Marines. M.B. noted that the Veteran wrote letters talking about how much he wanted to come home and that he came home a changed man. She stated that he came home suddenly with an honorable discharge but never wanted to talk about his time in the service and in fact didn’t want to talk much at all. She stated that he suddenly had unusual mood swings, outbursts of anger and strange temperament as well as crying spells. She noted that he would say mean things when he was angry and would lie and deny that any of the bad things he had done occurred. She noted that things had not improved with time and that the Veteran struggled to hold jobs, was careless and accident prone and had mood swings. In July 2015 the Veteran’s friend, R.T. submitted a statement in support of the Veteran’s claim. In his statement, he noted that he had known the Veteran since high school and that the Veteran liked to joke around and was very social prior to his military service. R.T. stated that when the Veteran was discharged from service, he noticed the first time he saw him that he was different from high school. R.T. stated that the Veteran was violent and volatile and that he still had to censor himself around the Veteran because of his violence. In an August 2015 statement from the Veteran’s friend, T.M., T.M. stated that he had known the Veteran since third grade and that he had no issues going into the service. T.M. stated that he saw the Veteran a few times on leave and noticed his memory loss issues and that he struggled with remembering the people he grew up with. T.M. stated that immediately after service the Veteran’s memory loss was worse and that more recently he had to remind the Veteran of his last name. A March 2016 mental health intake assessment noted that the Veteran had not been treated since 2014 and had a TBI with cognitive impairment presenting for panic attacks, nightmares and repeated crying spells. The Veteran endorsed a twenty-plus year history of anxiety. The treating physician noted that the Veteran denied traumatizing events in service but that he did have a TBI in service which prompted an honorable discharge. An April 2016 head CT suggested mild cerebral and cerebellar atrophy, which was noted to possibly represent mild medial wall blowout fracture of the right and left orbits. Pursuant to the December 2017 remand, the Veteran was afforded a VA examination in August 2018. At such time, the examiner noted diagnoses of generalized anxiety disorder (GAD) and depression, and rendered several opinions. Specifically, he opined that the Veteran’s acquired psychiatric disorder, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury event, or illness. The examiner also opined that the Veteran’s acquired psychiatric disorder was at least as likely as not proximately due to or the result of his service connected TBI. In support thereof, the examiner noted that the Veteran had documented evidence of depression, GAD, and unspecified anxiety disorder. Thus, he concluded that it was more likely than not that his current acquired psychiatric disorders were service-connected and secondary to his sustained TBI. The examiner further opined that the Veteran’s acquired psychiatric disorder was at least as likely as not incurred in or was caused by the claimed in-service injury, event, or illness. He reasoned that, due to a documented service connected TBI, the Veteran’s conditions of anxiety and depression were likely attributed to such TBI. He also noted that the Veteran’s anxiety and depression were related to and caused in part by his TBI and exacerbated by post-military life stressors. However, as the Veteran has not been service-connected for a TBI, nor has it been found that he had an in-service TBI, an addendum opinion was requested, and such was obtained in November 2018. At such time, the examiner explained that October 2008 and August 2010 treatment records noted that the Veteran had cognitive impairments likely due to a TBI. However, he concluded that, while such records documented TBI, they did not sufficiently document that his multiple psychological conditions were a direct result of this TBI. As the examiner did not provide a rationale for his now negative opinion, the Veteran was afforded another VA examination in December 2018. At such time, the examiner noted diagnoses of mild neurocognitive disorder due to multiple etiologies with behavioral disturbance and a panic disorder. She also observed that a TBI has been noted by multiple providers, but she could not locate any documentation about the indexed injury. The examiner opined that it was not at least as likely as not that the Veteran’s mental disorder was incurred in or was caused by his military service. In support thereof, she reasoned that, while the Veteran reported a head injury in 1977, had been consistent in describing the event, and there was no reason to doubt his credibility, there was no supporting documentation of any in-service treatment for a head injury. She also explained that a CT scan in 1992 was normal and the Veteran did not present with mental health complaints, including memory complaints, until 2000 despite having other interactions with VA medical providers. Thus, she concluded the 20-plus year interval between the initial injury and the first report of symptoms indicated no causal nexus between the reported in-service injury and the Veteran’s current mental health complaints. Private opinions relating the Veteran’s acquired psychiatric disorder to service were obtained from Dr. H.H.in January 2017. In a disability benefits questionnaire, Dr. H.H. noted that the Veteran’s claims file had been reviewed and a mental status examination conducted. Dr. H.H. reported the Veteran’s symptoms to include depressed mood, anxiety, suspiciousness, memory loss, disturbance of motivation and mood and persistent delusions or hallucinations. Suicidal ideation was not noted. Dr. H.H. noted that the Veteran admitted self-medicating with alcohol in the past. The Veteran was noted to report having various jobs over the years with none lasting more than a year. Dr. H.H.’s report further noted that the Veteran and his family and friends endorsed anxiety symptoms being related to military service and that they had exacerbated since, noting that the Veteran was happy and outgoing prior to service and changed during service and thereafter into a different person. Dr. H.H. opined that the Veteran had an unspecified anxiety disorder that more likely than not began in military service and continued uninterrupted to the present. Dr. H.H. noted in a section of her report entitled “Medical Journal Articles Supporting the Veteran’s Claim” that there was a body of literature which found that active military service impacted depression, anxiety and quality of life satisfaction. Dr. H.H. stated that guilt was a feature in mental health diagnosis and that research indicated that some psychiatric diagnoses led to occupational dysfunction. The articles cited in support of Dr. H.H.’s findings were submitted in support of those findings. One of the three articles entitled “The Effect of Depression on the Association between Military Service and Life Satisfaction” notes that there was reason to believe that military service had a positive or neutral impact on life satisfaction, but that this might be different for men with psychiatric conditions. In the Results portion of the report the authors stated that “the interaction between a history of military service and depression was significant…indicating that depression influenced the association between military service and life satisfaction.” A second article cited by Dr. H.H. entitled “Guilt, Shame, and Suicidal Ideation in Military Outpatient Clinical Sample” discussed the relationship between guilt, shame and suicidal ideation in military personnel. It was noted that “the primary aim of the current study was therefore to explore the associations of guilt and shame with suicidal ideation in a general clinical sample of military personnel receiving outpatient mental health treatment.” The final article cited by Dr. H.H., entitled “The Civilian Labor Market Experience of Vietnam Era Veterans” found that PTSD and depression lowered the likelihood of employment and hourly wages based on a 1980s survey of Veterans on active duty during the Vietnam War. A February 2019 private examination report was submitted in support of the Veteran’s claim wherein Dr. H.H. stated that she could not find medical records to document the Veteran’s claimed TBI during service. In this regard, she noted that the Veteran had repeatedly stated that he had a TBI in service and she had little doubt he believed that he sustained a TBI therein. In this regard, Dr. H.H. observed that head traumas were not taken seriously during the time period the Veteran was in service (1976-1977); rather, they were told to “shake it off” and no treatment was given. She concluded that she did not think it was totally possible to determine if the Veteran did in fact sustain a TBI in service. However, she noted that there did not seem to be any doubt that the Veteran did develop an anxiety disorder during service based on the observations from people that knew him before and after service, her interview with the Veteran, and all the records that clearly supported it. Dr. H.H. explained that it was not unusual when a person developed a mental health problem to try and find a physical explanation for the mental illness. She found that what the Veteran’s explanation did tell her was the time frame for when his mental illness first manifested itself, which was clearly during service. Dr. H.H. stated that in light of the newly reviewed information it was highly likely that the Veteran’s anxiety disorder started in service. In an April 2019 statement in support of his claim, the Veteran reported that he had sustained many accidents and that the worst accident was an in-service injury and that the second was when a tractor lawn mower fell on top of his body. The Veteran described not being able to hold a job, feelings of worthlessness, trouble concentrating, remembering, making decisions and that he thought of death. Analysis The Board concludes that the evidence weighs against a finding of service connection. As noted above, service connection requires an in-service event, injury or disease, a current disorder, and a link between the two. Here, it is clear that the Veteran has an acquired psychiatric disorder. The Board must determine, then, whether the evidence is at least in equipoise as to whether a psychiatric disorder began in service and that his current psychiatric disorder is related thereto. I. Presumption of Soundness The Veteran is presumed sound at service entrance. 38U.S.C.§1111. Additionally, while the Veteran notes in his September 1976 report of medical history that he had or had had nervous trouble, his service treatment records, to include a contemporaneous examination which reflected a normal psychiatric evaluation, treatment records during service and his November 1977 separation examination, are otherwise negative for any complaints, treatment, or diagnoses referable to an acquired psychiatric disorder or a head injury. While the Veteran’s August 2018 VA examiner found that the Veteran’s acquired psychiatric disorder clearly and unmistakably existed prior to service, his rationale supports a finding that the Veteran’s acquired psychiatric disorder did not clearly and unmistakably exist prior to service as he reasoned that there was no evidence in the records nor by self-reports from the Veteran that he received psychological treatment prior to entry into the military. Therefore, the Veteran is presumed to have been in sound condition upon enlistment. II. The Evidence Does Not Demonstrate an In-Service Head Injury Much of the evidence in favor of a finding that the Veteran’s psychiatric symptoms were due to service is based upon the Veteran’s unsubstantiated claim that he sustained a traumatic brain injury in service. The preponderance of the evidence is against a finding that the Veteran sustained a head injury as he describes. Initially, the Veteran’s service treatment records are silent as to any head injury. The Veteran is shown to have reported that he was knocked unconscious and placed on light duty following a head injury, in some statements he further describes that there was “blood everywhere” and that he was discharged due to that head injury. It stands to reason that the Veteran’s report of medical examination would note a severe head injury or the residuals thereof. Of note, Dr. H.H. noted that often traumatic brain injuries were not taken seriously in service, and this may be the case, however, Dr. H.H. also notes that it is not possible to make a determination that such an injury occurred in service and noted that often one may attribute a mental disorder to a physical injury to explain their symptoms. Beyond the lack of evidence in the Veteran’s service treatment records of a head injury, the Veteran is shown to have made a claim for a skin disorder in 1978 for which he explained that he was discharged due to a skin disorder. It stands to reason that the Veteran would mention a traumatic head injury and the residuals thereof in a claim for service connection. The Veteran later explains in a statement that he did not realize that his symptoms would catch up with him upon his discharge because he was young. Further, treatment records demonstrate that a September 1992 head CT was normal, and no prior head trauma was noted in August 2000. The Veteran was seen in the urgent care unit in February 2001, after sustaining blows to the left side of the head around his left eye and he claimed service connection for a traumatic head injury only thereafter, in December 2001, but associated his symptoms with a head injury which occurred over a decade earlier. As treatment records do not demonstrate a head injury in service or thereafter for over twenty years, the weight of the issue as to whether the Veteran sustained a head injury in service, relies upon the Veteran’s own testimony that such occurred. The Board finds, however, that, for the reasons stated below, the Veteran lacks credibility. As the issue as to whether the Veteran sustained a head injury in service is not demonstrated by service treatment records, or for years thereafter, and only following the Veteran’s claim for service connection, and the Veteran is not shown to be credible, the Board finds against concluding that the Veteran sustained a head injury in service. III. Credibility Credibility determinations are multifaceted and require consideration of factors such as: bias; inconsistent statements; bad character; internal inconsistency; facial plausibility; self-interest; consistency with other evidence of record; malingering; desire for monetary gain; and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board’s role as factfinder is to determine the credibility of evidence and then consider that lay evidence against the other evidence of record. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The Veteran is presumed credible, unless the evidence demonstrates otherwise. The absence of evidence of the claimed in-service head injury is insufficient to determine that the Veteran’s statements are not credible, however, when considered alongside the totality of the evidence, it may go towards a negative credibility determination. The Veteran is found to lack credibility in part due to inconsistent reporting. The Veteran’s treatment records demonstrate many varied reports regarding his criminal history, his history of substance abuse and intake, and the severity of his condition. On multiple occasions, many cited above, the Veteran is reported to be an unreliable historian. The Veteran is shown to have had some degree of memory loss, which could account for differing reports, as stated by Dr. J.Y., however, some accounts in treatment notes suggest that the Veteran exaggerated his symptoms. The Board finds significant findings in December 2008 and August 2010 by two different doctors that the Veteran’s symptoms were found to be presented as far more severe during evaluation than later when the Veteran was seeking benefits, housing in one case and transportation in another. The Veteran’s August 2010 examining physician noted this specifically: “the same discrepancies between his presentations prior to asking for something and after occurred in 12/31/2008 mental health eval” regarding lawyer’s papers. Further, the December 2008 treating physician noted that the Veteran’s speech was somewhat slurred and that the Veteran lacked focus during evaluation but not when he was asking that documents be filled out for housing benefits. Additionally, the Veteran’s treating physicians note that the Veteran’s testing results demonstrated far more incapacitation than the Veteran showed in visits. The exaggeration of symptoms suggested in the Veteran’s treatment reports, coupled with the Veteran’s 1978 claim for service connection for a skin disorder wherein he states that he was discharged due to such further indicate that a desire for monetary gain influenced his reporting. Further, the changes in the Veteran’s attribution to his symptoms from the death of his father and loss of his job to a traumatic brain injury are shown to coincide with the Veteran’s claim for service connection. Moreover, even in statements in support of the Veteran’s claim, the Veteran’s mother is shown to report that the Veteran had lied to her about things he had done and in her first statement in support of the Veteran’s claim, she retells the Veteran’s history of his claimed in-service head injury as occurring in the jungle and noted that he had been helicoptered to the United States, despite the fact that the Veteran is shown to have no foreign service and to have served in California. The Board is cognizant that the Veteran’s December 2018 VA examiner states that there was no reason to doubt the Veteran’s credibility and Dr. H.H.’s apparent reliance on the Veteran’s claims and reports. However, given the multiple occasions in which the Veteran is found by treating physicians to be an unreliable historian, and given the many varied reports of the Veteran’s accidents, to include the number of head injuries he had sustained, and varied reports of the severity of the Veteran’s symptoms, the Board finds that the overwhelming majority of the Veteran’s record supports its finding that the Veteran lacks credibility. The Veteran is found to lack credibility in his assertions. Accordingly, findings that rely upon his reporting will be afforded less probative weight. IV. Lay Evidence in Support of the Veteran’s Claim The Board has considered the lay statements of the Veteran’s mother, M.B. and his friends D.A., R.T. and T.M. in support of his claim and has considered their credibility and probative value. In as much as the lay statements in support of the Veteran’s claim report what the Veteran told them about service and his claimed head injury, for the reasons described above, as these statements rely upon the Veteran who is found to lack credibility, those statements are afforded little probative value. Lay evidence may support a later diagnosis in that symptoms observed may demonstrate that the Veteran’s disorder, shown later, began prior to a formal diagnosis. The Board finds lay statements regarding the Veteran’s changes in behavior to be credible. Of note, however, statements in support of the Veteran’s claim were submitted, at their earliest in 2012, decades after the Veteran’s service, it stands to reason those making statements in support of the Veteran’s claim would have a diminished recollection of observations made decades prior. Moreover, while the Veteran’s mother and T.M. note that the Veteran was different in and immediately after service, it is unclear when D.A. and R.T. first saw the Veteran following discharge, and the Veteran’s mother indicates that the Veteran wandered around in the years following service and that at one point she did not see him for four years, negating the idea that she observed a continuous change in the Veteran’s behavior. Most significantly, however, while the Veteran’s mother and friends are competent to report observed behavior of the Veteran during and following service, they are not shown to have the required medical expertise to make a determination as to the cause of such behavior. This is especially so under circumstances such as this where the evidence demonstrates alcohol abuse between the ages of 18 and 30, as reported by the Veteran prior to his claim for service connection, and as demonstrated by reports of DUIs, and findings by the Veteran’s physicians, where such may have also influenced his behavior, as is shown when the Veteran is arrested for a fight while intoxicated. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The disability at issue is not a condition that is readily amenable to lay diagnosis or probative comment regarding etiology. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Nothing in the record demonstrates that the Veteran, his mother or his friends received any special training or acquired any medical expertise. King v. Shineski, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Where the cause of the Veteran’s observed changes in behavior may be attributed to a number of sources as shown by treatment records, and the lay statements are shown to rely in part on the incredible statements of the Veteran, the statements in support of the Veteran’s claim are afforded only limited weight. V. Examinations and Medical Evidence The Board notes that, in November 2012 and April 2013, Dr. J.Y. states that the Veteran has PTSD due to a traumatic brain injury in service. Significantly, however, such conclusions are based in great part on the Veteran’s reports and a finding that such an injury occurred. As the Board has found, above, that the evidence was against finding that the Veteran sustained a severe head injury in-service and that the Veteran lacks credibility, Dr. J.Y.’s conclusions are afforded no probative value. The Board affords great probative weight to the December 2018 VA examiner’s opinion that the Veteran’s acquired psychiatric disorder is less likely than not related to service, as such considered all of the pertinent evidence of record and provided a complete rationale, relying on and citing to the records reviewed. Significantly, the examiner noted that while a TBI was noted in treatment records, she could not find documentation of such. The examiner explained that supporting her finding that the Veteran’s psychiatric disorder was less likely than not related to service was a normal 1992 CT and the fact that while the Veteran had interactions with VA medical providers, he did not report memory complains or mental health complaints until 2000. She noted that the interval of twenty plus years went against a finding of a causal nexus between the Veteran’s claimed injury and his current disorder. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). Furthermore, her opinion is consistent with the contemporaneous evidence of record. Regarding the January 2017 and February 2019 findings of Dr. H.H. initially, the Board notes that much of Dr. H.H.’s conclusions rely upon the Veteran’s statements which are found to lack credibility. In her February 2019 concluding opinion, Dr. H.H. states that it is not unusual for a person who develops a mental health problem to try to find a physical explanation for it and states “what the Veteran’s explanation does tell us is the time frame when his mental illness first manifested itself and that is clearly in service.” Dr. H.H., thus, is shown to rely directly on the Veteran’s report of symptoms first manifesting in service, despite simultaneously noting that the Veteran may have falsely attributed his symptoms to an event that may not have occurred. She does not reconcile this seeming contradiction. Moreover, the Board notes that Dr. H.H. made no mention of the Veteran’s inconsistent statements or substance abuse, which is noted throughout the Veteran’s treatment records. Dr. H.H. only notes that the Veteran reported that he self-medicated with alcohol and takes such at face value without further discussion. She states that “all the records clearly support” a finding that the Veteran developed an anxiety disorder in service, despite no record of such in treatment records, and many inconsistencies, as described above, in the Veteran’s record. Dr. H.H. further reasoned that the August 2018 and December 2018 VA examiners indicated the Veteran was normal before service, but had continuous problems ever since discharge, which was documented by the fact that he “kept getting fired for panic attacks” after service. However, such rationale indicates that the Veteran developed an acquired psychiatric disorder after service not during service, which is not in dispute. Moreover, the Veteran had a normal head CT in September 1992, and no prior head trauma was noted in August 2000. Further, at such time, the Veteran reported experiencing depression for the prior three years since his father passed away and, in October 2008, reported experiencing anhedonia only since 2000. Consequently, the contemporaneous objective evidence of record contradicts Dr. H.H.’s conclusion that the Veteran’s acquired psychiatric disorder had its onset in service. Dr. H.H. is shown to have reviewed the statements in support of the Veteran’s claim and to have found that these, combined with her interview with the Veteran and his treatment records clearly supported a finding that the Veteran’s anxiety disorder began in service. In so doing, Dr. H.H. is shown to have relied upon evidence of limited probative value without making, again, any note whatsoever as to records which contradict these findings. Insofar as Dr. H.H. cites medical articles to support her findings, the Board notes that, under some circumstances medical treatise when supported by the findings of a medical professional may support a claim of service connection. Here, Dr. H.H. indicates that the articles cited support a finding that the Veteran’s psychiatric disorder is due related to service. The articles do not support such a finding. Dr. H.H. states that three articles support the Veteran’s claim. Dr. H.H. notes that these articles find that military service impacts certain psychiatric disorders and quality of life satisfaction, that guilt is a salient feature in mental health diagnoses of active duty military personnel and that service can impact gainful employment. The Board may not make medical determinations. The Board’s role is instead to determine the probative weight of evidence. In so doing, while the Board may not make medical deductions from articles provided in support of the Veteran’s claim, the Board may determine whether medical findings speak to the issue of service connection. The first article cited by Dr. H.H., “The Effect of Depression on the Association between Military Service and Life Satisfaction” is not shown to support the Veteran’s claim for service connection. The article states, in part, that there was reason to believe that there is a positive or neutral relationship between military service and life satisfaction, but that the relationship “may be different for men with psychiatric conditions.” The article’s results section noted that its findings “indicat[ed] that depression influenced the association between military service and life satisfaction.” This does not speak to whether depression is related to service. Instead the article speaks only to the impact on life satisfaction that depression has and the article finds that “depressed men with a history of military service were just as likely to be satisfied with life as depressed men without a military history.” This does not speak to depression being caused by service at all, but only speaks to life satisfaction in already depressed men with prior military service. Moreover, the article states that “covariates that were associated with lower odds of life satisfaction included ages 35-54…smoking and heavy drinking.” Dr. H.H. makes no note of this finding whatsoever despite the Veteran’s age, and history of smoking and heavy drinking. The second article cited by Dr. H.H. “Guilt, Shame, and Suicidal Ideation in a Military Outpatient Clinical Sample” speaks to an “association between suicidal ideation with certain forms of combat exposure…the primary aim of the current study was…to explore the associations of guilt and shame with suicidal ideation.” Again, this does not speak to whether the Veteran’s psychiatric disorders are related to service. Moreover, in her own report, Dr. H.H. notes that the Veteran does not have suicidal ideation. Thus, the article does not relate to the facts of this case. The last article cited by Dr. H.H. “The Civilian Labor Market Experience of Vietnam Era Veterans” similarly does not speak to a relationship between service and the Veteran’s psychiatric disorders or onset of such but instead to the affect PTSD and depression had on Veterans of the Vietnam War. In her report, Dr. H.H. uses these articles in support of her opinion that the Veteran had an unspecified anxiety disorder which more likely than not began in military service. Dr. H.H. does not state how these articles support her conclusion, she only states that they do. In this case, where a simple reading of the cited articles clearly demonstrates that they do not relate to the issue of service connection but instead to the impact of depression, guilt, shame, and suicidal ideation, and to Vietnam Veterans’ ability to maintain work, reliance on such articles makes Dr. H.H.’s conclusions less probative. VI. Conclusion For the reasons described above, the evidence weighs against a finding that the Veteran sustained an in-service head injury. Moreover, the probative evidence weighs against a finding of service connection, to include on the basis of continuity of symptomology. In so finding, the Board notes the November 1977 Report of Medical Examination at the time of separation from service demonstrating that his clinical psychiatric evaluation was normal, the normal CT scan in 1992, the fact that the Veteran did not present with mental health complaints, including memory difficulties, until 2000 despite having other interactions with VA medical providers and the findings of the December 2018 VA examiner. Further, while the Veteran’s mother and friends noted changes in behavior, not all observations were made immediately after service and, given the Veteran’s complex medical history, the Veteran’s mother and friends are not found to be competent to attest to the cause of the Veteran’s change in behavior. Consequently, presumptive service connection, to include on the basis of a continuity of symptomatology, is not warranted. 38U.S.C.§§1101, 1112, 1137; 38C.F.R.§§3.307, 3.309; Walker, supra. Additionally, the Board has also considered whether service connection for psychosis is warranted on a presumptive basis, to include on the basis of continuity of symptomatology. In this regard, a May 1978 notification from Kennedy Kind College indicated the Veteran had unsatisfactory academic progress and he desired VA counseling regarding the issue, however the Veteran is shown to have explained in August 1978 that he had an overpayment because he could not attend school and work full time simultaneously. Such does not demonstrate psychosis within a year of service. Therefore, the Board finds that the Veteran’s acquired psychiatric disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, and psychosis did not manifest to a compensable degree within one year of discharge from active duty. Consequently, service connection for such disorder is not warranted. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for service connection for an acquired psychiatric disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38U.S.C.§5107; 38C.F.R.§3.102; Gilbert, supra. Entitlement to service connection for sleep apnea as secondary to an acquired psychiatric disorder. Entitlement to service connection for a headache disorder as secondary to an acquired psychiatric disorder. The Veteran contends that he has sleep apnea and a headache disorder that is secondary to his acquired psychiatric disorder. The Veteran does not allege, and the record does not show, that sleep apnea and a headache disorder are directly or presumptively related to his military service. Robinson v. Shinseki, 557 F.3d 1355, 1361 (2008). In regard to the secondary aspect of the Veteran’s claims, April 2017 disability benefit questionnaires from Dr. M.B. were received indicating that he had a current diagnosis of obstructive sleep apnea and tension headaches. Dr. M.B. opined that it was as likely as not that the Veteran’s anxiety disorder aided in the development of, and permanently aggravated, his obstructive sleep apnea. She also opined that it was as likely as not that the Veteran’s headaches were caused by his anxiety disorder. However, as the Board herein determined that service connection for an acquired psychiatric disorder is not warranted, he lacks legal grounds to establish entitlement to service connection for sleep apnea and a headache disorder as secondary to such disorder. See Sabonis v. Brown, 6 Vet. App. 426 (1994). As there is no legal entitlement, the claims of entitlement to service connection for sleep apnea and a headache disorder are without legal merit. Id. Consequently, the Board must find that sleep apnea and a headache disorder is not caused or aggravated by a service-connected disability. Therefore, service connection for such disorders is not warranted. In reaching the foregoing determinations, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claims for service connection for sleep apnea and a headache disorder. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied.38U.S.C.§5107;38C.F.R.§3.102; Gilbert, supra. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Slovick, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.