Citation Nr: 21065155 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 16-39 720 DATE: October 25, 2021 ORDER Entitlement to service connection for obstructive sleep apnea, to include as secondary to posttraumatic stress disorder (PTSD), is denied. Entitlement to service connection for chronic fatigue syndrome, to include as due to Gulf War Illness, is denied. FINDINGS OF FACT 1. A sleep apnea disability was not manifest during active service, or until many years after service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 2. A sleep apnea disability is not shown to be related by causation or aggravation to a service-connected disability, including PTSD. 3. A chronic fatigue syndrome disability was not manifest during active service, or until many years after service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a sleep apnea disability, to include as due to service-connected PTSD have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.317 (2021). 2. The criteria for service connection for a chronic fatigue syndrome disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1118, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.317 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1990 to June 1991, with qualified active service in the Southwest Asia theater of operations in the Persian Gulf with his deployment to Operations Desert Shield and Storm from December 1990 to May 1991. This case is before the Board of Veterans' Appeals (Board) on appeal from a December 2013 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA) in Winston Salem, North Carolina. The Board remanded the issues on appeal for additional development in December 2018 and September 2020. The directives having been substantially complied with, the matter again is before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). This appeal was originally certified to the Board with additional issues: entitlement to service connection for painful and swollen joints, irritable bowel syndrome, headaches, eczema, and depressive disorder. However, in multiple rating decisions in September 2016, January 2021, June 2021, and July 2021, the RO granted entitlement to service connection for those listed claims. As such, the issues are no longer in appellate status before the Board. Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2021). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert. denied, U.S.C. Oct. 3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection Legal Criteria for Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or the result of service-connected disease or injury, or that service-connected disease or injury has chronically worsened the nonservice-connected disability for which service connection is sought. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). For those chronic diseases listed, most must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3). Service connection can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. For chronic diseases shown as such in service or within the applicable presumptive period, subsequent manifestations of the same chronic disease at any later date are service-connected unless attributable to an intercurrent cause. 38 C.F.R. § 3.303(b). For a chronic disease to be considered to have been "shown in service," there must be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Id. When the condition noted in service or within the presumptive period is not a chronic disease, a showing of continuity of symptomatology after discharge is required. Id. Service connection may be established on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2026, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). In claims based on undiagnosed illness, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Notably, laypersons are competent to report objective signs of illness. Id. For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117 and 38 C.F.R. § 3.117, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. See Gutierrez v. Principi, 19 Vet. App. at 8-9. Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A "medically unexplained chronic multi symptom illness" means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. See 38 C.F.R. § 3.317(a)(2)(ii). There are currently no diagnosed illnesses that have been determined by the Secretary to warrant a presumption of service connection under 38 C.F.R. § 3.317(a)(2)(C), with the exception of asthma, rhinitis, and sinusitis, which are pertinent to an August 2021 interim final rule related to particulate exposure for Gulf War Veterans. "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. See 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi symptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. See 38 C.F.R. § 3.317(b). For purposes of section 38 C.F.R. § 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. See 38 C.F.R. § 3.317(a)(4). Where the evidence does not warrant presumptive service connection for Gulf War Illness, a veteran is not precluded from establishing service connection for disability with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1041 (Fed. Cir. 1994). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Proof of a current disability is a threshold to establishing service-connection for any claimed disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). To be a present as a current disability, there must be evidence of the condition at some time during the appeals period. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Evidence and Analysis The Veteran served in the National Guard from 1988 to 1994, to include a period of active duty from November 1990 to June 1991, most of which was served in the Persian Gulf during Operations Desert Shield and Storm, and thus the Veteran qualifies as a Gulf War Veteran for the purposes of 38 C.F.R. § 3.317. The Veteran received a separation examination in April 1991 when redeploying from the theater that indicated the Veteran had no complaints regarding obstructive sleep apnea or chronic fatigue syndrome. 1. Entitlement to service connection for obstructive sleep apnea The first medical record of any sort related to the Veteran's claimed sleep apnea is a VA general medical examination in May 2001. The examiner noted the Veteran's statement that he had sleep apnea and problems sleeping "for the last two or three years." The Veteran discussed his sleep problems in the context of a complaint of chronic tension headaches. No opinion for service connection or further discussion of etiology was made. The Veteran received a September 2011 sleep study from a VA medical center in response to his statements that he was noted to snore heavily at night and that he believed he had sleep apnea. This study diagnosed obstructive sleep apnea. No opinion as to etiology was noted. The Veteran received a private medical examination for multiple issues, to include sleep apnea, in April 2016, uploaded to the claims file in May 2016. This private physician, who conducted a telephone interview with the Veteran, diagnosed severe obstructive sleep apnea and that also noted that a CPAP machine had been prescribed. This examiner provided a positive opinion for service connection in conjunction with a telephonic diagnosis of a psychiatric disorder, and produced copies of medical literature that indicate general conclusions that individuals with depression also had sleep apnea. The Veteran received a VA examination in June 2016 for his sleep apnea as part of a VA Gulf War medical examination. This examiner diagnosed sleep apnea based on the September 2011 sleep study noted previously, and also that the Veteran was not currently using his CPAP machine. The examiner noted the Veteran's statements that he was diagnosed with sleep apnea in 1997 and again in 2002, though without any medical record of those diagnoses. The Veteran received another VA examination for his sleep apnea in October 2020. The examiner repeated the earlier diagnoses of obstructive sleep apnea and that CPAP use was required. No medication or other assistance device was required. This examiner noted a negative opinion for direct service connection, saying it was less likely than not, less than 50 percent probability, that the Veteran's diagnosed sleep apnea was incurred in or caused by the claimed in-service event, injury, or illness. The examiner's rationale was that there were no complaints of sleep problems during active service. There was no evidence of a sleep condition on the redeployment physical examination and there is no evidence of chronicity of care since service. The Veteran received an addendum VA medical opinion from a VA physician in August 2021 regarding the possibility of secondary service connection for his sleep apnea, to include as due to his service-connected PTSD. The examiner noted her review of the Veteran's claims file, to include the service and post-service history of a lack of complaints about sleep issues until 1997 or diagnosis regarding sleep apnea until 2011. The examiner noted the Veteran's excessive body weight from the medical record as well, as a known precursor to sleep apnea. The examiner concurred with the negative nexus opinion from October 2020 regarding direct service connection, and added that the Veteran's claimed sleep apnea disability is less likely than not (less than 50 percent probability) caused by or aggravated by service-connected PTSD or other service-connected disability. The examiner noted that while there are studies in the medical literature where PTSD and sleep apnea are co-morbidities, that there are no medical studies that establish that one causes the other. This examiner noted the Veteran's PTSD and how his examiners and treatment providers have documented sleep issues, to include chronic impairment. This October 2020 examiner took care to distinguish the documented sleep issues from the Veteran's PTSD from the claimed sleep apnea, in that the Veteran has multiple and significant sleep apnea risk factors unrelated to service, to include male gender, progressive weight gain since active service, and advancing age. See Mittleider v. West, 11 Vet. App. 181 (1998). The examiner noted that PTSD patients frequently have insomnia, difficulty falling asleep or staying asleep, and often have nightmares resulting from their PTSD stressors. The examiner continued, noting that those displayed sleep problems are not "synergistic" with obstructive sleep apnea, and that while it is possible for PTSD and sleep apnea to occur together, that coincidence and correlation are not equivalent to causation or even aggravation from one to the other. The examiner continued, noting that sleep apnea is a disorder characterized by obstructive apneas and hypopneas caused by repetitive collapse of the upper airway during sleep, which is a different type of display than the sleep issues described in the Veteran's PTSD examinations and treatment notes. This examiner also further discussed how the risk factors of gender, increasing body weight, and craniofacial or upper airway soft tissue abnormalities increase the incidence of sleep apnea. The Board finds the VA examination reports and opinions to be of great probative value, along with both the VA treatment notes and private treatment regarding the Veteran's claimed sleep apnea disability. Indeed, the VA examiners considered the Veteran's contention, the claims file, and clinical medical evidence before providing a negative opinion for both direct and secondary service connection. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The examiners' negative opinions were supported by a sufficiently clear and well-reasoned medical rationale and was consistent with the verifiable facts regarding the Veteran's contentions. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). Additionally, the second VA opinion writer distinguished the sleep impairment symptoms of the Veteran's PTSD from his claimed symptoms of his sleep apnea. See Mittleider v. West, 11 Vet. App. 181 (1998). Significantly, the opinion also offered the non-service-related factors believed to be responsible for the disability at issue. The Board acknowledges that the Veteran is competent to testify as to his beliefs that his disabilities are related to service. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). In order for lay evidence to be competent, the individual must have personal knowledge, derived from his/her own senses, of what is being attested; "[c]ompetent testimony is thus limited to that which the witness has actually observed, and is within the realm of his personal knowledge." Layno v. Brown, 6 Vet. App. 465, 471 (1994). Here, the Veteran, along with his spouse's statement, are competent to testify about his symptoms relating to his claimed sleep apnea condition. However, there is nothing in the record to suggest that the Veteran or his spouse have the appropriate training, experience, or expertise to render a medical opinion regarding etiology of his sleep apnea, especially in light of his PTSD diagnosis and its associated sleep problems. See 38 C.F.R. § 3.159(a)(1) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). While the Veteran is competent to report what he has experienced, he is not competent to ascertain the etiology of any current condition, as the causative factors for such are not readily subject to lay observation. See Layno v. Brown, 6 Vet. App. 465 (1994); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, his assertions to that effect are of no probative value. The Board acknowledges the Veteran's statements that his sleep apnea could be related to service. However, the Board notes that the Veteran's service treatment records, to include reports of medical history, are silent for any treatment or complaint of any sleep condition or distress during active service and up until August 2011, over 20 years after active service ended. A negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Even the Veteran's statement that his sleep apnea began around 1997 places that event approximately six years after active service. The Board notes the private medical statement from April 2016 in favor of a possible nexus to service, but also considers that opinion to be of no probative value. The conclusory statement that the Veteran's sleep apnea resulted from a co-morbidity with a diagnosed psychiatric condition has no rationale or discussion beyond the submission of general medical literature that does not indicate causation of one for the other, and there is no indication that the private physician actually had access to the Veteran's service medical records or history. While treatise evidence can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of the specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. See Wallin v. West, 11 Vet. App. 509, 514 (1998); Sacks v. West, 11 Vet. App. 314, 317 (1998); Stadin v. Brown, 8 Vet. App. 280, 284 (1995). Here, however, the supplied medical treatises do not indicate a causal relationship between PTSD or other psychiatric condition and sleep apnea. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). A bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 18, 22 (2007). When assessing the probative value of a medical opinion, the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical opinion that contains only data and conclusions is not entitled to any weight. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Upon review of the record, the Board concludes that entitlement to service connection for sleep apnea is not warranted, either via direct or secondary service connection. The Board notes a current diagnosis of the sleep apnea disability in September 2015, and thus the requirement for a current disability is shown. The Veteran is currently service-connected for PTSD. The Board acknowledges the Veteran's contentions, and the Veteran's post-service statements are noted, along with that of his buddies. However, the Veteran's service medical records, to include all examinations, are silent for any existing sleep or related condition at the time of separation, and, and there is no competent evidence to tie the current assertion to any in-service disease or injury. Two VA examiners have extensively discussed all of the Veteran's sleep apnea disability and symptoms, to include secondary service connection via the diagnosed PTSD, and all possible risk factors raised by the record, and opined that sleep apnea is not related back to active service or caused or aggravated by any service-connected disability. The Board thus finds the Veteran fails the third prong of the test for entitlement to direct service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed sleep apnea disability was not incurred in service, or was caused or aggravated by service-connected disability. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a sleep apnea disability, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for chronic fatigue syndrome, to include as due to Gulf War Illness The first medical record of any sort related to the Veteran's claimed chronic fatigue syndrome is a VA general medical examination in May 2001. The examiner noted the Veteran's statement that he had chronic fatigue syndrome because of his problems sleeping "for the last two or three years." The examiner noted the Veteran's fatigue was due to his sleep problems, and specifically declined to make a diagnosis of chronic fatigue syndrome because of the lack of symptoms in the Veteran that might otherwise enable such a diagnosis. No opinion for service connection or further discussion of etiology was made. The Veteran received a VA examination in July 2016 for his claimed chronic fatigue syndrome as part of a VA Gulf War medical examination. This examiner declined to diagnose chronic fatigue syndrome or any other fatigue-related illness. The examiner noted the Veteran's statements of his chronic fatigue, but also noted that the Veteran's reported symptoms did not comport with the diagnostic profiles of those with chronic fatigue syndrome, and that his fatigue symptoms were due to his sleep problems. The Veteran received another VA examination for his chronic fatigue syndrome in October 2020. The examiner repeated the negative diagnosis of chronic fatigue syndrome. The examiner's rationale was that the Veteran doesn't meet the symptomatic criteria for chronic fatigue syndrome or any other fatigue condition, and that his sleep impairment problems are related to his diagnosed PTSD. The Veteran was also evaluated for fibromyalgia based on his statement regarding joint pains. The examiner noted the Veteran had never been evaluated by a rheumatologist or any other medical treatment provider regarding complaints that might relate to fibromyalgia. The Veteran had no symptoms beyond that already described, and the examiner declined to make a diagnosis of fibromyalgia. The Board also notes that the Veteran's upper extremity hands and finger digits are now service-connected for swelling and weakness. The Veteran received an addendum VA medical opinion from a VA physician in June 2021 regarding his chronic fatigue syndrome claim. The examiner noted her review of the Veteran's claims file, to include the service and post-service history of a lack of complaints about fatigue issues until 1997, when the Veteran made complaints of fatigue later determined to be related to his sleep apnea and his psychiatric disorder. The examiner specifically stated that the Veteran had never had a diagnosis of chronic fatigue syndrome or fibromyalgia. The examiner further remarked that the Veteran has no unexplained pain, and that he has a specific diagnosis for each of his complaints that are related to fatigue. The Board finds the July 2016, October 2020, and June 2021 VA examination reports and opinions to be of great probative value. Indeed, the examiner considered the Veteran's contention, the claims file, and clinical medical evidence before providing a negative opinion in each instance. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The examiner's negative opinion was supported by a sufficiently clear and well-reasoned medical rationale and was consistent with the verifiable facts regarding the Veteran's contentions. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). The Board acknowledges that the Veteran is competent to testify as to his beliefs that his disabilities are related to service. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). In order for lay evidence to be competent, the individual must have personal knowledge, derived from his/her own senses, of what is being attested; "[c]ompetent testimony is thus limited to that which the witness has actually observed, and is within the realm of his personal knowledge." Layno v. Brown, 6 Vet. App. 465, 471 (1994). Here, the Veteran is competent to testify about his symptoms relating to his claimed fatigue condition. However, there is nothing in the record to suggest that the Veteran has the appropriate training, experience, or expertise to render a medical opinion regarding etiology of a fatigue syndrome or related injury. See 38 C.F.R. § 3.159 (a)(1) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). While the Veteran is competent to report what he has experienced, he is not competent to ascertain the etiology of any current condition, as the causative factors for such are not readily subject to lay observation. See Layno v. Brown, 6 Vet. App. 465 (1994); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, his assertions to that effect are of no probative value. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, there is no valid diagnosis of a current disability of chronic fatigue syndrome or a related fatigue illness. The service treatment records are completely silent for any specific symptoms or presentation of chronic fatigue syndrome. The Veteran did not cite any complaints about any fatigue disability in his VA examinations prior to 1997. The Veteran has not reported symptoms of chronic fatigue syndrome to his VA primary care physician or other health care providers since the beginning of his VA medical care in 2011. Thus, the Veteran's claim does not meet the first prong of service connection, the requirement of a current disability. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. With regard to the possibility of service connection pursuant to 38 C.F.R. § 3.317 and Gulf War Illness claims, the Board notes the Veteran does meet the service requirements and concedes the Veteran is a "Persian Gulf Veteran" under the definitions provided in the law. However, the Board notes the Veteran fails the second prong of the test, in that he does not exhibit objective indications of chronic disability or infectious disease during such service or to a degree of 10 percent or more not later than December 31, 2026, as noted by VA examiners. 38 C.F.R. § 3.317(c); Stankevich v. Nicholson, 19 Vet. App. 470 (2006). In addition, a multisymptom condition is not a medically unexplained illness when both the etiology and the pathophysiology are at least partially understood. 38 C.F.R. § 3.317(a); Stewart v. Wilkie, 30 Vet. App. 383 (2018); see Goodman v. Shulkin, 870 F.3d 1383, 1387 (Fed. Cir. 2017). The Board also notes that the Veteran's symptoms of fatigue are accounted for in his service-connected PTSD and his diagnosed but non-service-connected sleep apnea. Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed fatigue syndrome was not incurred in service. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for chronic fatigue syndrome, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Setter, 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.