Citation Nr: 21022780 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 17-25 026 DATE: April 19, 2021 ORDER Entitlement to service connection for a headache disability is denied. Entitlement to service connection for a gastrointestinal (GI) disability is denied. FINDINGS OF FACT 1. The Veteran’s current headache disability is not shown to be related to an in-service event, injury, or disease. 2. The Veteran’s current GI disability is not shown to be related to an in-service event, injury, or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for a headache disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a GI disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1991 to February 2005. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). These matters were remanded several times to include most recently in December 2020. Service Connection Generally, to prevail on a claim for service connection, there must be competent evidence of (1) current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence or other competent evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). Certain chronic disabilities, such as arthritis and organic diseases of the nervous system, if manifest to a degree of 10 percent or more within one year after separation from active duty, are presumed to have been incurred in active service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). In adjudicating a claim, the Board must assess the competence and credibility of the claimant. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362 (2005). The Board also has a duty to assess the credibility and weight given to evidence and it must provide reasons or bases for favoring one opinion over another. Winsett v. West, 11 Vet. App. 420 (1998). Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997); Wensch v. Principi, 15 Vet. App. 362 (2001). Competency of evidence must be distinguished from weight and credibility, which are factual determinations in determining the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67 (1997). Although interest may affect the credibility of testimony, it does not affect competency to testify. Cartright v. Derwinski, 2 Vet. App. 24 (1991). If all the evidence is in relative equipoise, reasonable doubt shall be resolved in the Veteran’s favor, and the claim should be granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. If the preponderance of the evidence is against the claim, the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for a headache disability The Veteran asserts that his current headache disability is due to an in-service event, illness, or injury. The Veteran asserts that his headaches began in service, and have persisted since, but that he did not seek treatment until 2007. Indeed, he states that his headaches are due to medication taken during service. The Veteran’s service treatment records (STRs) document several headache complaints. The Board notes, however, there is no indication of a chronic headache disability during service. A December 2013 buddy statement asserts (in relevant part) that the Veteran’s headache symptoms were related to ongoing use of Mefloquine (brand name Lariam). A December 2013 headache Disability Benefits Questionnaire (DBQ) diagnosed unspecified cephalgia headaches. In an April 2017 addendum opinion, the examiner opined that the Veteran’s headaches are unrelated to service since he had stated they began in 1997, and not during his service in Lagos (as noted above, his active service extended from August 1991 to February 2005). A February 2019 private headache DBQ notes a diagnosis of migraine headaches and opines that it is at least as likely as not that the Veteran’s headaches are related to service; further rationale was not provided. On December 2019 examination, the examiner opined that it was less likely than not that the Veteran’s headaches (described as cephalgia MOH- medication overuse headache) are related to service. In December 2020, the Board found the examination/opinions were not wholly adequate for rating purposes and that remand was warranted for an adequate opinion. Pursuant to the December 2020 Board remand, an opinion was obtained in January 2021. The examiner noted that the Veteran’s claim was that his headache disability was secondary to Lariam exposure. He diagnosed migraine headaches and MOH secondary to a headache disability. He stated that the current headache disability is not due to the noted in-service headaches. The examiner indicated that headaches are a side effect of this anti-malarial drug, however they tend to resolve within weeks of stopping this medication. The Veteran is no longer on Lariam. He indicated that the Veteran’s STRs are silent for the complaint, diagnosis or treatment of headache not associated with an underlying acute illness. He found that no other environmental hazards in Lagos have been found to be associated with this complaint long term. The Board concludes that, although the Veteran has a diagnosis of headaches, the preponderance of the evidence is against finding that such began during active service, or is otherwise related to an in-service injury, event, or disease. Indeed, the probative evidence shows the current disability is not related to the noted in-service headache complaints. In fact, the most recent VA examiner indicated that that headaches are a side effect of the anti-malaria medication the Veteran was taking while in service and once the medication is discontinued, the headaches resolve. The Board observes the positive February 2019 private headache DBQ that notes a diagnosis of migraine headaches and opines that it is at least as likely as not that the Veteran’s headaches are related to service; however, further rationale was not provided. The opinion is conclusory and inadequate for rating purposes. Although the Veteran is competent to describe his history of headache pain, the cause of any neurological change involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and effect relationship, he is not competent to render such a complex medical opinion regarding etiology of a degenerative disorder. As such, the question of etiology in this case may not be competently addressed by lay evidence. Therefore, the most probative evidence of record indicates that the Veteran’s current headache disability is not etiologically related to service, to include noted in-service headache complaints. With no adequate probative evidence to the contrary, the Board finds that service connection for a headache disability is not warranted. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for a GI disability The Veteran asserts that his current GI disability is due to an in-service event, illness, or injury. Indeed, he contends that he has a GI disability related to environmental exposures while stationed in Lagos, Nigeria; or in the alternative he has a GI disability that is a permanent side effect of taking Lariam while stationed in Lagos, Nigeria. The Veteran’s STRs document he was seen on several occasions for complaints of stomach cramps, nausea, and vomiting. The records do not document a chronic GI disability during service. In several statements, the Veteran asserts that he has experienced continuous GI symptomatology since service. He also submitted buddy statements that reiterated his assertions. A May 2012 correspondence from T.E.B, the Assistant General Counsel of the Defense Intelligence Agency documents that the Veteran’s current disability may have a causal connection to his military service in Nigeria ten years ago. He stated, however, that competent medical authorities at the VA must make that determination in consultation with the Department of State medical officer who is responsible for treatment of personnel and family members serving at the U.S. Embassy, including those assigned to the Defense Attache Office. In September 2013, the Veteran was hospitalized with suspected colitis. During December 2013 VA examination, the examiner indicated that the file was reviewed and stated that the Veteran’s GI disability had resolved. The VA examiner stated that this condition was an acute and transient viral gastroenteritis. The Veteran was examined again in December 2019. The Board found in its December 2020 remand that the December 2019 examiner failed to adequately address the Veteran’s subjective complaints as well as buddy statements indicating the Veteran experienced GI symptoms in service and since. The Board concluded that the failure to adequately consider the Veteran’s lay statements rendered the negative nexus opinion provided inadequate for rating purposes. Pursuant to the December 2020 remand, an addendum opinion was obtained in January 2021. The examiner reviewed all the evidence in the file. He opined that gastrointestinal side effects of Lariam are noted in the medical literature, however, they tend to resolve with discontinuation of the medication, and do not show a propensity for chronicity. It would further not be uncommon for gastrointestinal upset to be acutely present on overseas deployment related to food, water, stress, lack of sleep or other factors associated with changes in habits. These have not been shown to persist long term following resolution of the offending activity. No other environmental hazards in Lagos have been found to be associated with this complaint long term. The examiner reviewed the Discharge Summary from Sacred Heart Hospital dated September 28, 2013 and noted that it provided a discharge diagnoses of Sepsis, Clostridium difficile (C. difficile) colitis and chronic renal insufficiency, Stage 4. The examiner noted that an infection with C. difficile and its resultant colitis is sudden, severe, overwhelming, and acute. Although there may be residuals associated with this infection, it almost certainly was not present for very long prior to hospital admission, and certainly not present as far back as active military service. The examiner concluded that the Veteran’s current diagnosis documented on the January 2020 VA examination report of rapid bowel transit is more likely than not a residual of his September 2013 diagnosis and treatment of acute C. difficile colitis and sepsis, and less likely than not caused by, related to, or aggravated beyond natural progression by military service, environmental exposures or Lariam treatment while in service. Based on the foregoing, the Board finds that the preponderance of the evidence is against the Veteran’s claim. Although the evidence of record shows that the Veteran has diagnoses of current GI disorders, the probative evidence demonstrates that they are not related to service. In this regard, the Board places great probative weight on the most recent January 2021 VA examiner’s opinion as it sets out clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. The Board acknowledges the Veteran’s contentions, as well as the May 2012 correspondence from T.E.B. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts that they have observed and are within the realm of their personal knowledge, but are not competent to establish that which would require specialized knowledge or training, such as medical expertise. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). The Board observes that T.E.B. indicates that the Veteran’s current disability may be due to his service in Nigeria; however, he acknowledges that the VA should definitely make that determination. In the instant case, the Board finds that questions regarding the potential relationship between the Veteran’s GI disability and any instance of service to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more comp1ex medical questions). Thus, although the Veteran is competent to describe the manifestations of his GI disability, the Board must accord his statements regarding the etiology of his disorders little probative value. Based on the above, the Board must find that the Veteran’s current GI disability is not shown to be causally or etiologically related to any disease, injury, or incident during service, to include service in Nigeria as well as any medication taken during service. (Continued on the next page)   Therefore, the most probative evidence of record indicates that the Veteran’s current GI disability is not etiologically related to service, to include noted in-service GI complaints. With no adequate probative evidence to the contrary, the Board finds that service connection for a GI disability is not warranted. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. L. ANDERSEN Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. McPhaull, 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.