Citation Nr: 21063365 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 01-09 827A DATE: October 14, 2021 ORDER Entitlement to service connection for a psychiatric disorder is denied. Entitlement to service connection for an anterior communicating artery (ACA) aneurysm status post craniotomy is denied. Entitlement to service connection for cognitive deficits and dementia, claimed as due to an ACA aneurysm status post craniotomy, is denied. Entitlement to service connection for a headache disorder is denied. Entitlement to service connection for obstructive sleep apnea (OSA) is denied. FINDINGS OF FACT 1. A psychiatric disability, cognitive disorder, dementia, ACA aneurysm and/or headaches, did not have their onset in service, they did not manifest to a compensable degree within one year of discharge, and they are not shown to be causally or etiologically related to any disease, injury, or incident in service. 2. The preponderance of the evidence is against finding that OSA began during active service or for many years thereafter, and OSA is not otherwise shown to be related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for a psychiatric disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 2. The criteria for service connection for ACA aneurysm status post craniotomy have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 3. The criteria for service connection for cognitive deficits and dementia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 4. The criteria for service connection for a headache disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 5. The criteria for service connection for OSA have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1974 to February 1987. He died in February 2016. Prior to his death, he had been adjudicated incompetent for Department of Veterans Affairs (VA) purposes, and his spouse was appointed as his fiduciary. Upon the Veteran's death, in February 2016, the Veteran's surviving spouse requested to be substituted as the appellant for purposes of processing the pending appeals to completion. See 38 U.S.C. § 5121A; 38C.F.R. §3.1010. She has been properly substituted as the appellant in this case. This matter comes before the Board of Veterans' Appeals (Board) from a September 2000 rating decision, which denied service connection for an aneurysm status post craniotomy; an October 2001 rating decision, which denied service connection for dementia and implicitly denied service connection for headaches; and a May 2003 rating decision, which denied service connection for a psychiatric disorder and obstructive sleep apnea. In March 2008, the appellant testified at a Board hearing. In December 2009, the Board remanded the appeal to the agency of original jurisdiction (AOJ) for additional development. The Board remanded the appeal again in November 2011 because the appellant elected to testify at a new hearing after being notified that the Veterans Law Judge who conducted the March 2008 hearing was no longer with the Board. In March 2012, the Veteran and appellant testified at another Board hearing. Transcripts of both hearings are associated with the claims file. The remaining issues on appeal were again remanded for additional development in November 2012, August 2017, July 2020 and March 2021. Based on the history of extensive development of this appeal expanding over 20 years, and the fact that with each prior remand additional development has provided overall negative evidence against the claims addressed herein, the Board finds there has been substantial compliance with prior remand directives such that that a seventh remand for more development would likely not be productive of evidence beneficial to the appellant's claims. Further remands are not warranted. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability, there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Shedden, 381 F.3d at 1167; Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Certain evidentiary presumptions - such as the presumption of service incurrence for certain diseases, which manifest themselves to a degree of disability of 10 percent or more within a specified time after separation from service - are provided by law to assist Veterans in establishing service connection for a disability or disabilities. 38 U.S.C. §§ 101, 1112; 38 C.F.R. § 3.304 (b), 3.306, 3.307, 3.309. When a chronic disease is shown in service, sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303 (b). To be "shown in service," the disease identity must be established and the diagnosis must not be subject to legitimate question. Walker v. Shinseki, 708 F.3d 1331, 1335 (Fed. Cir. 2013); see also 38 C.F.R. § 3.303 (b). There is no "nexus" requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease. Walker, 708 F.3d at 1336. Service connection may also be granted on a secondary basis for a condition that is not directly caused by the Veteran's service. 38 C.F.R. § 3.310. In order to prevail under a theory of secondary service connection, the evidence must demonstrate an etiological relationship between (1) a service-connected disability or disabilities and (2) the condition said to be proximately due to the service-connected disability or disabilities. Buckley v. West, 12 Vet. App. 76, 84 (1998); see also Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition, secondary service connection may also be found in certain instances when a service-connected disability aggravates another condition. See Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310(b). 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. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for a psychiatric disorder 2. Entitlement to service connection for an ACA aneurysm status post craniotomy 3. Entitlement to service connection for cognitive deficits and dementia 4. Entitlement to service connection for a headache disorder The appellant is seeking service connection for a psychiatric disability, an ACA aneurysm, cognitive disorder and dementia, as well as a headache disorder. The evidence establishes that in May 1993, after service discharge, the Veteran underwent a craniotomy to clip a large ACA aneurysm. In correspondence in July 2000, the appellant reported that since the Veteran's May 1993 craniotomy to repair a ruptured aneurysm, he had suffered from chronic headaches, memory loss, blank spells, and more recently mood swings, irritability and problems with concentration. In January 2001 correspondence signed by the Veteran and appellant, the appellant reported the Veteran had been evaluated by psychiatrists during service, who told him he was violent and had violent tendencies. The appellant believed the Veteran had psychiatric and headache symptoms in service that were "indications that an underlying condition existed previously to the actual aneurysm presenting itself." In a statement in November 2001, the Veteran asserted that his headaches had onset in service and were a manifestation of his aneurysm before it ruptured in May 1993. In March 2004 correspondence, the Veteran's sister, B.P., who identified herself as a licensed practical nurse (LPN), reported that since 1974, the Veteran had complained of severe headaches and had increasingly become more forgetful with moderate to severe mood swings. She believed his "aneurysm started then." In support of the claim, the Veteran submitted an April 2001 statement from a fellow servicemember who reportedly served with the Veteran from 1984 to 1987, and saw him using aspirin for headaches. In March 2005, the appellant and/or Veteran asserted that service connection was warranted for a mental disorder superimposed upon a personality disorder, citing a service treatment record in which an examiner from a mental health clinic could not rule out a personality disorder. The service treatment records show that in October 1977, the Veteran was seen for complaints of fever, cough and headache, associated with strep pharyngitis. He was seen again in April 1980 for complaints of headaches, chest cold, productive cough and runny nose, associated with an upper respiratory infection. In August 1982 the Veteran reported headaches, nasal congestion, malaise, myalgia, mild chills and mild dizziness, attributed to a viral syndrome with sinus congestion. In October 1982, the Veteran reported headache, sore throat and fever. The clinician noted upper respiratory infection, rule out strep throat. The Veteran's service treatment records reflect he was unable to attend an appointment in March 1978 at the mental health clinic; however, his wife (the appellant) attended. In January 1979, the mental health clinic administered a standard battery of psychiatric tests, which were "suggestive of defensiveness, rebelliousness, and impulsivity." The examiner could not rule out personality disorder. A record several days later indicated that a mental health clinician agreed not to enter the Veteran into a rehabilitation program because he stated he would not "be involved in this sort of incident again." In May 1979, a clinical psychologist evaluated the Veteran at the request of the Veteran's commander and reported that the evaluation indicated no psychiatric disorder. "Nor was there sufficient evidence warranting a C&B [diagnosis]." Finally, social worker notes from January and February 1984 indicate that the Veteran's mental status was within normal limits, that "DWI school should be sufficient," and that the Veteran was seen for a "domestic incident" described as an "isolated incident." On separation examination in October 1986 the Veteran denied a history of frequent or severe headaches, head injury, frequent trouble sleeping, depression or excessive worry, loss of memory or amnesia, nervous trouble of any sort, or periods of unconsciousness. The Veteran's psychiatric and neurological systems were clinically evaluated as normal. In May 1993 the Veteran presented to the emergency room with complaints of worsening headache and lethargy. He described feeling something pop, then he developed a headache and became weak. There was no history of head trauma or similar symptoms. A CT brain scan showed marked subarachnoid hemorrhage and streak hemorrhage in the right subfrontal area suggestive of an intracranial aneurysm. In May 1993, the Veteran underwent a craniotomy to clip a large anterior communicating artery aneurysm. In June 1993, the Veteran complained of a headache. In November 1999, the Veteran reported a five year history of headaches after he underwent surgery to treat an aneurysm. The clinician diagnosed vascular headaches. On neurological consultation in December 1999, the Veteran reported headaches having onset after surgery to repair aneurysm at age 37. Thereafter, he experienced almost daily headaches in the occipital parietal area on the left. In March 2000, the Veteran reported daily headaches after the surgery to repair aneurysm. In April 2000, the Veteran reported daily headaches since surgery. A CT scan of the head in May 2000, showed findings suggestive of underlying structural disease and could be consistent with the patient's history of neurosurgical procedure. A clinician in August 2000, noted ACA aneurysm status post craniotomy in 1993, with related problems with memory and concentration. Neuropsychiatric testing showed cognitive deficits. The clinician diagnosed a mental disorder due to general medical condition, aneurysm. In January 2001, the Veteran reported onset of headaches after the May 1993 surgery. He stated that he noticed impaired memory and attention within one year of surgery for ACA aneurysm. In a medical statement in February 2001, Dr. R.T. indicated that the Veteran was disabled indefinitely due to cerebrovascular disease and aneurysm resulting in cognitive impairment. Thus, there is no evidence of psychosis or a neurological disorder in service or within one year following discharge from service. On the contrary, the Veteran was evaluated at least three times for a mental health disability and while a personality disorder was not ruled out, neither a personality disorder nor a neurological or psychiatric disability was diagnosed. In fact, the Veteran's mental status was consistently found to be within normal limits. Similarly, a chronic headache disability was not shown in service, or within one year of discharge from service. Rather, the Veteran's headache complaints noted in the service treatment records appear to have been transient, associated with viral illness and to have resolved with treatment. Therefore, the Board finds that the service treatment records do not support a finding of a chronic psychiatric and/or neurologic condition. Moreover, the Veteran's post service treatment records attribute his mental health symptoms, cognitive deficits, dementia and headaches to his post-service ACA aneurysm status post craniotomy. Thus, the Veteran was not shown to have a psychiatric or neurological disability in service or within one year following discharge from service, as such, service connection cannot be established for the claimed disabilities on a presumptive basis. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. Based on the above, the Board must conclude that a chronic psychiatric disability, an ACA aneurysm, a cognitive disorder, dementia, or a headache disorder, did not have its onset during service and has not been continuous since that time. Owens v. Brown, 7 Vet. App. 429, 433 (1995). In so noting, the Board recognizes that the mere absence of medical records is not dispositive as to the question of continuity; the lay evidence must be considered as well. See Buchanan v. Nicholson, 451 F.3d at1335. If, however, it is determined based on reliable evidence, that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). To the extent the appellant and the Veteran have asserted continuity of symptomatology from service, the Board finds such statements inconsistent with the overall record, to include the service treatment records and post-service treatment records, which fail to document any related complaints until after six years discharge from service, associated with the May 1993 ACA aneurysm status post craniotomy. See Owens, supra. In reaching the above conclusion, the Board does not rely solely on the absence of contemporaneous evidence corroborating the Veteran and appellant's reports of continuity. Instead, there is evidence in the October 1986 report of medical history, where the Veteran, himself, affirmatively denied the presence of headaches, depression or excessive worry, loss of memory or amnesia, or nervous trouble of any. It is also noteworthy that prior to filing of a claim for VA benefits in 2000, in statements rendered in connection with treatment the Veteran reported onset of mental health symptoms, cognitive deficits and headaches, after the May 1993 ACA aneurysm. See White v. Illinois, 502 U.S. 346, 355-56 (1991) (holding that statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment). Similarly, in correspondence in July 2000, the appellant reported onset of chronic headaches, memory loss, blank spells, mood swings, irritability and problems with concentration since the Veteran's May 1993 craniotomy. The Board places greater evidentiary weight on the affirmative denials issued by the Veteran many years prior to the filing of his service connection claims, than later statements alleging continuity of symptoms since service, which may be influenced by pecuniary interest in obtaining VA benefits. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) (pecuniary interest may affect the credibility of testimony); see also Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the testimony). Therefore, the Board finds that the most probative evidence of record shows that the Veteran did not have continued problems with a mental health disability, cognitive deficits, dementia, a neurological disability or a headache disorder in and since service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(b). It is important for the appellant to understand that the post-service record provides significant evidence against the claims. Even assuming, without conceding, for discussion purposes, the credibility of the Veteran and the appellant's account of in-service symptoms, the record is insufficient to link the Veteran's psychiatric disability, cognitive deficits, dementia or headaches to any aspect of the Veteran's service. On the question of a nexus between the Veteran's psychiatric disability, cognitive deficits, dementia, ACA aneurysm and/or headaches, initially noted many years after service, and service, the evidence weighs against the claims. In June 2001 the Veteran underwent a mental health disorders examination. The examiner noted that there was no description consistent with a mental disorder in the Veteran's service records. Additionally, the evidence failed to disclose that any previous examining psychiatrist or psychologist diagnosed mental disorders or conditions unrelated to the Veteran's history of post-aneurysm hemorrhage. The examiner determined that the Veteran's symptoms, including irritability, mood lability, hypersomnia and polydipsia were consistent with a mental health disorder due to intracranial aneurysm, as opposed to major depressive disorder. The examiner diagnosed moderate dementia due to a general medical condition. In November 2002, Dr. F.S. noted that hypertension had been recorded in the Veteran's medical chart on a few occasions dating back to 1979. Dr. F.S. opined that hypertension could be considered a contributing factor for progression of obstructive coronary disease and if this was the case also a contributing factor - although not the sole contributing factor, to weakening of the aneurysmal vessel wall. Dr. F.S. noted that unfortunately, the Veteran continued to smoke, which was a contributing factor to his aneurysm. In a March 2005 statement, a VA Nurse Practitioner opined, having reviewed the service records, that it was as likely as not that the Veteran's aneurysm and craniotomy resulting in dementia was related to his military service due to hypertension. No rationale in support of the opinion was provided. A VA examiner in October 2017, following a review of the claims file, opined that the Veteran's headaches were less likely than not incurred in or caused by the claimed in-service injury, event or illness. In support of the opinion, the examiner noted that there were only a few references to headaches in the service treatment records, and these were associated with cold and rhinitis symptoms. The examiner explained that upper respiratory infections commonly were symptomatic for headaches. The evidence failed to show a chronic headache disability in service. Additionally, despite allegations that headaches had onset in service, there was no medical documentation from any medical source showing that the Veteran sought medical treatment for headaches from 1987 to 1993, when headaches were initially noted due to a ruptured ACA aneurysm. Consistent with this finding, subsequent treatment records associated the Veteran's headaches with the 1993 aneurysm repair. Moreover, the examiner also noted that lay statements asserting onset of headaches in service were provided more than 15 years after service discharge. Concerning the Veteran's aneurysm, the examiner opined that the condition was less likely than not proximately due to or the result of the Veteran's service. The examiner explained that the reason that aneurysms were so dangerous was that they usually presented no symptoms until they leaked or ruptured. Risk factors for developing an aneurism included cigarette smoking, alcohol consumption and hypercholesterolemia. The examiner noted that smokers with hypertension had a 15-fold increase in the risk of subarachnoid hemorrhage from an aneurysm. The Veteran had all the above risk factors, and notably he had a 2ppd smoking habit for more than 50 years. In July 2021, following a review of the claims file, a VA examiner opined that the claimed psychiatric disorder, cognitive deficits and dementia were less likely than not incurred in or caused by in-service injury, event or illness, or was otherwise superimposed by upon a personality disorder. The examiner noted that the service records were unremarkable for a mental health disorder. Entrance and separation examination reports during service also recorded no mental health issues. While the Veteran was seen in mental health clinic for psychiatric evaluations per social action referral due to his smoking marijuana in 1979 and alcohol in 1984, examinations failed to disclose any evidence of psychosis or neurosis and the Veteran was found to be fully qualified and fully fit for all duties. Personality testing suggested some defensiveness and impulsivity, however, the Veteran did not meet the criteria for a personality disorder or other mental health disorder. The examiner also noted that after service, the Veteran did not express any mental health concerns within 12 months post discharge until he suffered a cerebral aneurysm in 1993. He was eventually diagnosed with dementia due to general medical condition (cerebral aneurysm). (DSM 5 diagnosis major vascular neurocognitive disorder). The Veteran's neuropsychiatric symptoms were associated with his dementia. In support of the opinion, the examiner noted that the service treatment records and post-service treatment records failed to document any mental health disorder, cognitive problems, psychosis or neurosis, until he suffered a cerebral aneurysm in 1993. Therefore, the absence of a diagnosis of a psychiatric disorder in service, as well as the lack of mental health problems prior to 1993, failed to support a finding of a nexus between his diagnosis of dementia and his military service. The examiner found significant that treatment reports post ACA aneurysm recorded complaints of memory and attentional difficulties that the Veteran reportedly noticed within a year after his surgery. On examination at that time, the Veteran endorsed mild depression and while his performance on cognitive screening did not suggest overt cognitive deficits, mild difficulty was noted with organization, planning, shifting attention and processing speed. Subsequent treatment notes showed severe cognitive dysfunction affecting primarily memory and conceptualization, as well as moodiness, irritability, restlessness, inappropriate behaviors, aggression, low frustration tolerance, depression, sleep problems, agitation, low motivation and apathy, which were common neuropsychiatric symptoms found in dementia. The examiner concluded, given the absence of a diagnosed mental health disorder, cognitive disability or dementia during service, the absence continuity of cognitive or neuropsychiatric symptoms prior to his ACA aneurysm in 1993, and the fact that dementia was a progressive disease leading to loss of mental abilities, decline in physical abilities and eventual death usually caused by a stroke and/or heart attack, that it was less likely than not that the Veteran's non-service connected dementia and associated neuropsychiatric symptoms were aggravated beyond their natural progression by his service connected conditions. Concerning the Veteran's ACA aneurysm and headaches, the examiner opined that the conditions were less likely than not incurred in or caused by in-service injury, event or illness. The examiner noted that the service treatment records showed no evidence of a diagnosis, treatment or symptoms suggestive of ACA aneurysm or chronic headache disorder while on active duty or within one year of separation from military service. The Board finds the VA examiners' opinion to be highly probative. The opinions were based on a thorough review of the claims file, including the service treatment records and post-service treatment records. The examiners cited to the service and post-service treatment records that documented treatment for a situation adjustment disorder, and the opinions are internally consistent and consistent with other evidence of record. Moreover, the examiners provided adequate rationale for the opinions provided and cited to medical literature in support of the opinions. Accordingly, the VA examiners' opinion are entitled to great probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). Significantly, there is no competent medical opinion of record linking the Veteran's psychiatric disability, cognitive deficits, dementia, ACA aneurysm and/or headaches to service or a service-connected disability. The Board has considered the statements from the Veteran and the appellant asserting that his psychiatric disability, cognitive deficits, dementia, ACA aneurysm and/or headaches, had onset during active duty service. The Veteran and appellant are certainly competent to report as to the observable symptoms the Veteran experienced and their history, but they cannot self-diagnose because of the medically complex nature of such a diagnosis. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). The ultimate questions in this case are related to an internal medical process which extends beyond an immediately observable cause and effect relationship. Id. Moreover, whether the symptoms the Veteran experienced in service or following service are in any way related to service or a service is a matter that requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the Veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). The Board finds that the specific, reasoned opinion of the VA examiners of greater probative weight than the more general lay assertions in this regard. The examiners have training, knowledge, and expertise on which they relied to form the opinion, and the examiners provided rationale for the conclusions reached. The Board also acknowledges the statement from the Veteran's sister who identified herself as an LPN, in which she stated that the Veteran's headaches and cognitive problems had onset in service and were an early manifestation his ACA aneurysm. Although the Board recognizes her credentials as an LPN could render her competent to opine on certain medical matters, an LPN has generally completed a 12- to 14-month post-high-school education course that focuses on basic nursing care. See Sue C. Delaune & Patricia K. Ladner, Fundamentals of Nursing: Standards and Practice 41 (2d ed. 2002). Based on general certification requirements, an LPN does not have the kind of medical knowledge and training that a certified registered nurse practitioner is required to obtain and must generally work under the guidance of a licensed provider such as a registered nurse. See DeLaune & Ladner, supra. Stated more directly, an LPN does not possess the medical expertise to diagnose a complex neurological disorder and symptomatology of ACA aneurysm, especially 11 years after the reported occurrence. In any event, the Board has given this medical opinion some probative weight, but the Board cannot ignore the evidence of the VA examiners which the Board finds has more probative weight than this opinion. Finally, to the extent the appellant has asserted, and some medical providers determined, that the Veteran's aneurysm was caused by hypertension, as service connection for hypertension has not been established, there is no legal basis upon which to award service connection on a secondary basis. 38 C.F.R. § 3.310. Simply stated, both the best medical evidence in this case, and the facts of this case, provide highly probative evidence against the claims, indicating a problem than began several years after service ended in 1987. Based on the foregoing, the Board finds the preponderance of the probative and persuasive evidence against a finding that a psychiatric disability, cognitive deficits, dementia, ACA aneurysm and/or a headache disorder, arose in service or are etiologically related to service or any incidents therein. Moreover, a psychosis or neurological disability was not shown within one year following discharge from service, and the provisions regarding continuity are not for application. See Walker, 708 F.3d at 1340 (holding that only conditions listed as chronic diseases in 38 C.F.R. § 3.309 (a) may be considered for service connection under 38 C.F.R. § 3.303 (b). As the preponderance of the evidence weighs against the Veteran's claims, there is no reasonable doubt to be resolved, and the claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55. 5. Entitlement to service connection for OSA The appellant asserts that the Veteran had sleep apnea throughout his military service, stating he "was always snoring and snorting so loud." In an April 2001 buddy statement, D.O., who served with the Veteran from 1984 to 1987, recalled that the Veteran "would take a lot of naps." He stated that he kept in touch with the Veteran over the years, had seen a decline in his ability to function, and he was taking "a lot more naps than he did before." He did not describe any other observations of the Veteran sleeping. The Veteran's service treatment records were silent for complaints, diagnosis, or treatment for sleep apnea or sleep problems generally. In fact, in a report of medical history in October 1986, the Veteran denied a history of frequent trouble sleeping. Additionally, there is no evidence contemporaneous with service showing complaints or findings consistent with impaired sleep or a diagnosis of OSA. Among post-service private and VA treatment records, the Veteran reported having increased sleep periods of up to 11 hours per day during March 2000 VA mental health visits. The examining psychologist attributed his increased sleeping to symptoms of depression. In January 2001, he complained, "All I do is eat and sleep." A June 2001 psychiatry note reflects the appellant's report that "maybe that Modafinil was working because all [the Veteran] does is sleep now." The psychiatrist ordered a sleep study referral for symptoms that sounded like OSA. A November 2001 sleep study confirmed the Veteran had OSA. His weight at that time was recorded as 208 pounds and other contemporaneous records noted he was obese. In comparison, an October 1996 private treatment note recorded his weight as 158 pounds, representing a 50-pound weight gain in five years. The Board notes that the first documented evidence of OSA is more than two decades after the Veteran's discharge from active duty service. In so noting, the Board recognizes that the mere absence of medical records is not dispositive as to the question of continuity; the lay evidence must be considered as well. See Buchanan, 451 F.3d at 1336; see also Maxson at 1333. To the extent the Veteran and the appellant have asserted continuity of symptomatology from service, the Board finds such statements inconsistent with the overall record, to include the service and post-service treatment records. Thus, the appellant has not adequately shown that the Veteran's OSA had onset in service and continued since active duty service. Accordingly, competent evidence linking the current claimed disorder to service is needed to substantiate the claim. On the question of a nexus between the Veteran's OSA, initially noted many years after service, and service, there is evidence both for and against the claim. In October 2020, a fee-basis physician reviewed the Veteran's claims file and opined that it was at least as likely as not that the Veteran's obstructive sleep apnea, which was diagnosed in November 2001, was incurred in or caused by his military service. In support of the conclusion, the physician noted that an April 2001 buddy statement attested to the Veteran taking lots of naps from 1984 to 1987; subsequent treatment records dated in March 2000 demonstrated increased sleepiness; and a November 2001 sleep study demonstrated sleep apnea. Based on these facts, the reviewing examiner believed that OSA diagnosed in 2001 likely represented a continuation of the same disease process. Unfortunately, the reviewing examiner did not provide an explanation or rationale as to how the Veteran's in-service naps represented a disease process or address other risk factors for OSA documented in the record such as the Veteran's smoking history, uncontrolled hypertension, or 50-pound weight gain in the five years preceding the November 2001 diagnosis of sleep apnea. Accordingly, the opinion is afforded little probative value. In contrast, in July 2021, following a review of the claims file, a VA examiner opined that the Veteran's OSA was less likely than not incurred in or caused by in-service injury, event or illness. In support of the opinion, the examiner noted that the service treatment records failed to document any evidence of a diagnosis, treatment or findings consistent with OSA. The examiner addressed the lay statements asserting onset of OSA in service, and indicated that observed snoring, unrestful sleep, gasping, trouble sleeping, shallow breathing, and insomnia were not pathognomonic for sleep apnea. The examiner explained that OSA was diagnosed by polysomnography, apnea/hypoxia index (AHI or PRDI), which was the diagnostic standard for OSA. An AHI >5 or PRDI >15 was indicative of OSA. People often would have episodes of gasping or brief times of stopping breathing, however, < 5/hour (AHI) or <15/hour (PRDI) was considered normal. Insomnia (sometimes erroneously referred to as "non-organic circadian rhythm sleep disorder) was not a sign of OSA and the two were mutually exclusive. Insomnia was a sleep disorder where people experienced trouble sleeping, such as difficulty falling asleep, or staying asleep as long as desired. Insomnia was typically followed by daytime sleepiness, low energy, irritability, and a depressed mood. In contrast people with OSA had no trouble falling or staying asleep. The examiner cited to the medical literature noting that risk factors for OSA included obesity, craniofacial abnormalities and upper airway soft tissue abnormalities. Obesity was the best documented risk factor for OSA. The prevalence of OSA progressively increased as the body mass index and associated markers, such as neck circumference and waist-to-hip ratio, increased. Craniofacial and upper airway soft tissue abnormalities each increased the likelihood of having or developing OSA. Examples of such abnormalities included an abnormal maxillary or short mandibular size, a wide craniofacial base, tonsillar hypertrophy, and adenoid hypertrophy. The Board finds the opinion of the VA examiner in July 2021 to be highly persuasive and probative in finding that the evidence does not support a conclusion that the Veteran incurred OSA in service. The examiner's findings were based on a review of the evidence, including the service and post-service treatment records , which did not substantiate a finding that the Veteran's OSA initially manifested in service. The examiner considered the complete record and the appellant and the Veteran's contentions and prior statements, and provided an explanation as to why the evidence does not support a finding that the Veteran's OSA, which was not shown in service, and was initially noted in 2001, was not related to service. The examiner cited to the medical literature and specifically addressed lay statements submitted in support of the claim and explained why observed snoring or napping did not support a diagnosis of OSA. The opinion contains an internal logic consistent with the known facts, as well as with other evidence of record. The Board finds this opinion highly probative. Consequently, the Board finds the July 2021 VA medical opinion report more probative and outweighs the findings of the opinion of the VA examiner in October 2020. See Nieves-Rodriguez, 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"). The Board has considered the statements from the Veteran and the appellant asserting that OSA had onset during active duty service. The Veteran and appellant are certainly competent to report as to the observable symptoms, experiences and their history, but the ultimate questions in this case are related to an internal medical process which extends beyond an immediately observable cause and effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Therefore, while the Veteran may have had sleep and snoring problems during active duty service, neither the Veteran nor the appellant have been shown to be competent to state that these were symptoms of OSA. The Board finds that the specific, reasoned opinion of the VA examiner in July 2021 is of greater probative weight than the more general lay assertions in this regard. The examiner has training, knowledge, and expertise on which she relied to form the opinion, and the examiner provided a rationale for the conclusion reached. For the reasons set forth above, the Board finds that the most probative evidence weighs against a finding that the Veteran's OSA is related to service. Thus, service connection for OSA is denied. As such, the benefit of the doubt rule does not apply. See 38 U.S.C. § 5107(b). John J. Crowley Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Azizi, T. 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.