Citation Nr: 21030147 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 15-23 974 DATE: May 18, 2021 ORDER Entitlement to service connection for chronic fatigue syndrome, to include as due to Gulf War Illness, is denied. Entitlement to service connection for irritable bowel syndrome, to include as due to Gulf War Illness, is denied. Entitlement to service connection for headaches, to include as due to Gulf War Illness, is denied. FINDINGS OF FACT 1. 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. 2. An irritable bowel 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. 3. A headaches 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 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 (2020). 2. The criteria for service connection for an irritable bowel 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 (2020). 3. The criteria for service connection for a headaches 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 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1990 to May 1991, with an additional period of active duty for training (ACDUTRA) in June 1993. The Veteran has 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 April 1991. This case is before the Board of Veterans' Appeals (Board) on appeal from a November 2012 rating decision by the St. Petersburg, Florida Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran, with his spouse, testified at a November 2018 travel Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is of record. The Board remanded the issues on appeal for additional development in May 2019. 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). 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) (2020). 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). 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 arthritis, the disease 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, 2021, 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). "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 As a threshold matter, service personnel records reflect that the Veteran had active military service in the Southwest Asia theater of operations during the Persian Gulf War, pursuant to 38 C.F.R. § 3.317. The law and regulations pertaining to undiagnosed illness incurred due to Persian Gulf service, discussed above, are thus applicable in this case. In addition, the Board notes the Veteran's combat service as part of Operation Desert Storm in that active duty period, which ended in April 1991. The Veteran's last period of active duty for training occurred in June 1993 while he was still a serving reservist. VA provided a Gulf War General medical examination to the Veteran in December 2019 that was uploaded to the claims file in January 2020. The list of identified areas includes the three claims discussed in this appeal before the Board and others that are not part of this appeal. This examiner noted of the conditions identified, which includes chronic fatigue syndrome, headaches, and irritable bowel syndrome on appeal here, that none of the conditions are diagnosed illnesses for which no etiology was established. 1. Entitlement to service connection for chronic fatigue syndrome, to include as due to Gulf War Illness. VA provided a September 2012 Gulf War medical examination which included an examination for chronic fatigue, and the examiner at the time noted a history of anxiety. In the general comments, this examiner noted there was no objective evidence of chronic fatigue, and that the Veteran's tiredness and sleep impairment is associated with anxiety and not with Gulf War Illness. VA provided an examination for the Veteran's chronic fatigue syndrome in December 2019 that was uploaded to the claims file in January 2020. This examiner declined to make a diagnosis of chronic fatigue syndrome or any other fatigue-related illness or condition. The Veteran described symptoms of joint pains with consistent low energy plus headaches. There was no acute onset noted and the Veteran takes no medication for his claimed condition. Any debilitating fatigue did not required reduction in activity levels to less than 50 percent of pre-illness levels. The examiner explicitly noted that the Veteran has none of the potential symptoms and findings related to chronic fatigue syndrome. 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 examiner provided a negative opinion for service connection, saying it was less likely than not, less than 50 percent probability, that the claimed chronic fatigue syndrome was incurred in or caused by the claimed in-service event, injury, or illness. The examiner's rationale was that complaints of fatigue in service were acute and resolved by the end of active service. There was no evidence of a fatigue condition on the redeployment physical examination and there is no evidence of chronicity of care since service. The examiner noted there was no objective findings for a diagnosis, and there are no medical records during or since service that contain any notation of any fatigue condition. The examiner also noted that complaints of fatigue are documented in the medical records for the Veteran's service-connected posttraumatic stress disorder (PTSD), and that it would be impossible to distinguish the symptoms of fatigue between the PTSD and a claimed chronic fatigue condition. The Board finds both the September 2012 and December 2019 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 2012. 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 September 2002. 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, 2021, 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. 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. 2. Entitlement to service connection for irritable bowel syndrome, to include as due to Gulf War Illness. VA provided a September 2012 Gulf War medical examination which included an examination for intestinal diseases, and the examiner at the time noted a history of diverticulitis, for which the Veteran had a previous outpatient treatment in a hospital in in 2006 hospitalization. This examination did not address the Veteran's claim for irritable bowel syndrome. VA provided an intestinal conditions examination for the Veteran's claim of irritable bowel syndrome, to include as due to Gulf War Illness, in December 2019, which was uploaded to the claims file in January 2020. The examiner noted a historical diagnosis of diverticulitis that the Veteran insisted was actually irritable bowel syndrome in 2006, but did not make any other diagnoses of any intestinal or related condition. The examiner noted symptoms beginning as abdominal cramping and urgency, and since the onset, persistent symptoms consistent with irritable bowel syndrome. Frequent episodes of loose stools and frequent bowel movements were noted, up to four a day. Rare episodes of constipation were also noted. Continuous medication was not required, and there were no episodes of exacerbation of bowel disturbances with abdominal distress. There was no functional impact of the Veteran's irritable bowel disease. This examiner provided a negative opinion for service connection, saying it was less likely than not, less than 50 percent probability, that the Veteran's claimed irritable bowel syndrome was incurred in or caused by the claimed inservice injury, event, or illness. The examiner's rationale was that any symptoms of the irritable bowel syndrome did not begin until approximately after 13 years after the end of active military service. There was no objective findings for any intestinal diagnosis at the time of this examination, and the examiner pointed out that while there may be current symptoms of an intestinal condition, that there was no indication that these symptoms occurred in any proximity to the Veteran's active service which ended in 1993, and not until approximately 13 years after the end of active service. This examiner also pointed out that the Veteran's symptoms do not establish any objective evidence of a chronic condition, and that there is no nexus between any observed pertinent symptoms and active service. The Board finds both the September 2012 and December 2019 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 irritable bowel syndrome 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 irritable bowel 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. Upon review of the record, the Board concludes that entitlement to service connection for irritable bowel syndrome is not warranted. The Board acknowledges the Veteran's contentions, and the Veteran's post-service complaints are noted. However, the earliest manifestation of any possible functional gastrointestinal illness was in 2006, 13 years after active service, when the Veteran was treated on an outpatient basis for what was diagnosed then as diverticulitis. A colonoscopy was performed with no abnormal findings and the Veteran's condition was treated with a high-fiber diet. The more recent December 2019 VA examination noted irritable bowel syndrome but with only mild, transient symptoms. Moderate symptoms of frequent episodes of abdominal distress, which would otherwise warrant a compensable evaluation, have never been noted by any medical treatment provider. Thus, the Veteran's claim does not meet the third prong of 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. 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 irritable bowel syndrome or related disease during such service or to a degree of 10 percent or more not later than December 31, 2021, 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). Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed irritable bowel 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 irritable bowel 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. 3. Entitlement to service connection for headaches, to include as due to Gulf War Illness. VA provided a September 2012 Gulf War medical examination which included an examination for headaches, and the examiner at the time noted a history of anxiety. In the general comments, this examiner noted there was no objective evidence of chronic headaches, and that the Veteran's headaches were associated with anxiety and not with Gulf War Illness. VA provided a headaches examination for the Veteran's claim, to include as due to Gulf War Illness, in December 2019, which was uploaded to the claims file in January 2020. The examiner noted a 1991 diagnosis of acute tension headaches from the service medical records, but that there was no further mention of that condition in service, and the redeployment physical examination was silent for any mention of headaches. Since service, the examiner noted the Veteran complains of periodic headaches but has never had a formal evaluation, diagnosis, or treatment. The Veteran self-medicates with over-the-counter analgesics when necessary. There were no other symptoms besides head pain during his headaches. The headaches were not considered prostrating. This examiner provided a negative opinion for service connection, saying it was less likely than not, less than 50 percent probability, that the Veteran's headaches condition was incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale is that while the Veteran has periodic tension headaches of an acute nature, that there is no chronic headaches condition and therefore no current disability. The examiner stated he found no objective evidence for any chronic headaches pathology, and the earliest records regarding any headaches complaints date from 2012, well after active service. The examiner also noted that the Veteran's complaints of headaches are addressed as a symptom of his service-connected posttraumatic stress disorder (PTSD), which is not on appeal here. The Board finds both the September 2012 and December 2019 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 headaches 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 headaches condition 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 a chronic headaches condition or a related illness. The service treatment records are completely silent for any specific symptoms or presentation of chronic headaches or related injury or illness. The Veteran did not cite any complaints about any headaches disability in his VA examinations prior to 2015. The Veteran has not reported symptoms of chronic headaches to his VA primary care physician or other health care providers since the beginning of his VA medical care in September 2002. 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, 2021, 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 headaches are accounted for in his service-connected PTSD. Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed headaches condition 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 headaches, 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.