Citation Nr: 21031532 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 16-24 942A DATE: May 24, 2021 ORDER A compensable rating for hypertension is denied. Service connection for a traumatic brain injury (TBI) is denied. Service connection for an acquired psychiatric disorder is denied. Service connection for headaches is granted. Service connection for a disability manifested by frequent loss of balance is denied. Service connection for a respiratory disorder is denied. FINDINGS OF FACT 1. The Veteran served on active duty from July 1978 to September 1986. 2. Hypertension requires continuous medication for control but diastolic pressures are not predominantly 100 or more and systolic pressure are not predominantly 160 or more. 3. TBI has not been shown during the appeal period. 4. An acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), was not shown in service and is not causally or etiologically related to service, nor is it secondary to service-connected disability. 5. Headaches are secondary to service-connected tinnitus. 6. A disability manifested by frequent loss of balance was not shown in service, is not causally or etiologically related to service, and is not secondary to service-connected disability. 7. A respiratory disorder, to include sleep apnea, was not shown in service, is not causally or etiologically related to service, and is not secondary to service-connected disability. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for hypertension have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.104, Diagnostic Code (DC) 7101 (2020). 2. TBI was not incurred in service. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). 3. An acquired psychiatric disorder was not incurred in service, nor is it proximately due to, aggravated by, or the result of a service-connected disability. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2020). 4. Headaches have been found to be proximately due to or the result of a service-connected disability. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). 5. A disability manifested by frequent loss of balance disorder was not incurred in service, nor is it proximately due to, aggravated by, or the result of a service-connected disability. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2020). 6. A respiratory disorder, to include sleep apnea, was not incurred in service, nor is it proximately due to, aggravated by, or the result of a service-connected disability. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In April 2019, the Board remanded the appeal for additional development. There has been substantial compliance with the remand's directives pertaining to the claims decided herein, and the Board will proceed with the appeal. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). Increased Rating for Hypertension Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Hypertension is rated as noncompensable pursuant to DC 7101, which provides a 10 percent rating where diastolic blood pressure is predominantly 100 or more, or systolic blood pressure is predominantly 160 or more, or when an individual with a history of diastolic blood pressure predominantly 100 or more requires continuous medication for control. Turning to the medical evidence, an October 2012 VA examination report indicated that the Veteran's treatment plan did not require taking continuous medication for hypertension. The examiner opined that the Veteran did not have a history of a diastolic blood pressure elevation to predominantly 100 or more. Blood pressure readings were 139/85, 138/87, and 148/96. The examiner stated that the Veteran's hypertension did not affect his ability to work. Clinical records reflect blood pressure readings in the 120s-140s/70s-80s range to 181/108 at the highest on one occasion in April 2016. Specifically, in May 2015 it was 125/70, October 2015 134/75, January 2016 126/81, March 2016 132/80, 135/89 151/85, 152/87, 142/110, 129/74, and 145/89, April 2016 142/88, 150/83, 135/93, 181/108, 144/80, 170/74. VA treatment records from 2015 and 2016 reflect that the Veteran was on continuous medication (Prazosin) for hypertension. A February 2020 VA examiner related that the Veteran did not take continuous medication for hypertension. It was also indicated that he did not have a history of diastolic blood pressure elevation to predominately 100 or more. It was reflected that December 2019 blood pressure readings were 146/78, 138/82, and 120/78. The examiner stated that hypertension impacted his ability to work in that he sometimes got headaches and felt lightheaded and dizzy due to hypertension and must rest and wait until the lightheadedness, headache or dizziness resolves. Based on the above, the medical evidence does not support a compensable rating for hypertension. In this regard, the Veteran's diastolic pressure is not and has not historically been predominantly 100 or more. Notably, although there is a single blood pressure reading containing diastolic pressure of 110 in March 2016, this was an isolated finding not representative of the overall disability picture and importantly, both the October 2012 and February 2020 examination reports specifically noted that it had not been predominantly 100 or more. Additionally, the evidence of record demonstrates that the systolic blood pressure was never predominantly 160 or more. Therefore, the medical evidence does not support a higher rating. The Board has also considered the Veteran's lay statements that his disability is worse. While he is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's hypertension has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which this disability is evaluated. Moreover, as the examiners have the requisite medical expertise to render medical opinions regarding the degree of impairment caused by the disability and had sufficient facts and data on which to base the conclusion, the Board affords the medical opinions great probative value. As such, these records are more probative than the Veteran's subjective complaints of increased symptomatology. In sum, after a careful review of the evidence of record, the benefit of the doubt rule is not applicable and the appeal is denied. Service Connection Claims Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection may be granted on a presumptive basis for diseases listed in 38 C.F.R. § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C. § 1110; Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). "In the absence of proof of a present disability there can be no valid claim." See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Residuals of TBI The Veteran maintains that service connection is warranted for TBI because it is related to service. Specifically, he alleges that he had head injuries in service that caused his current disorder. The Veteran filed his claim for service connection for TBI August 2013. During the appeal period, TBI has not been shown. Specifically, an August 2012 VA TBI examination report stated that the Veteran did not have a diagnosis of TBI, a January 2015 VA psychiatric examination report noted that he was not diagnosed with TBI, a July 2016 private disability benefits questionnaire (DBQ) reflected that he did not have a TBI, a February 2020 VA examination report reflected that he did not meet the criteria for a current diagnosis of TBI, and there is no other medical evidence that shows he has a current diagnosis of TBI. The February 2020 VA examiner, a neurologist, conducted neuropsychological testing, took a full history from the Veteran and reviewed the claims file. The examiner concluded that although the Veteran experienced head injuries in service in January 1981 (he was seen for complaint of left temporal pain for three days following a basketball collision) and September 1993 (he was seen for head trauma; there was no loss of consciousness, but he initially complained of light-headedness and slight headache), these mild conditions in service resolved without residuals attributable to TBI. In March 2021 the Veteran argued that the February 2020 VA opinion supported the appeal; however, a review of this report clarified that the opinion was only relevant to whether the Veteran's sustained a TBI/head injuries in service, but did not address nexus. This opinion was authored by the same examiner (a neurologist) who provided the above noted February 2020 etiology opinion. Specifically, the opinion cited by the Veteran as supporting the claim for TBI stated that the claimed condition was at least as likely as not incurred in or caused by the claimed inservice injury, event, or illness. The examiner went on to explain that the Veteran likely sustained trauma to the head/mild TBI on at least two occasions during service when he was evaluated after a basketball injury and on another occasion when he was struck in the head and felt light-headed. Therefore, while this opinion at first glance seems in favor of the claim, when read in its entirety and when considered along with the subsequent February 2020 clarifying opinion described above, it is insufficient to support the claim because it only acknowledged the Veteran experienced head trauma in service. It did not address whether the Veteran currently had a current diagnosis of TBI. This deficiency prompted the RO to obtain the clarifying February 2020 medical opinion, which weighs against the claim. This opinion is consistent with the service treatment records (STRs) which do not reflect continuing complaints related to the head or any residuals consistent with a TBI after the January 1981 and September 1983 head injuries. Further, the Veteran denied head injury and periods of unconsciousness on the September 1982 Report of Medical History, the September 1982 reenlistment examination report noted normal clinical evaluation of the head, he denied head injury and periods of unconsciousness on the September 1986 separation Report of Medical History and the September 1986 separation examination report noted normal clinical evaluation of the head. These denials and normal medical findings in service at separation/after the head injuries, coupled with the lack of complaints or findings in the post-service medical evidence as well as the above-listed opinions stating that the Veteran did not have a current diagnosis of TBI all weigh heavily against the claim. There is no contradictory medical opinion finding a current diagnosis of TBI which is etiologically related to service (including related to the head injuries noted in service). The Board places significant probative value on the August 2012, January 2015 and February 2020 VA opinions, the July 2016 private DBQ, and the clinical records. The VA examinations were adequate for evaluation purposes. The February 2020 VA examiner conducted a neuropsychological examination of the Veteran, reviewed the claims file, and determined that the Veteran did not have a current diagnosis of TBI despite experiencing mild head injuries in 1981 and 1983 in service. Importantly, the Veteran's private July 2016 DBQ authored by Dr. H-G indicated that the Veteran did not currently have a TBI diagnosis. Further, the VA treatment records do not reflect any diagnosis of TBI. Therefore, the medical evidence does not reflect a current diagnosis of TBI, and no such diagnosis has been rendered at any time during the pendency of this appeal. See McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). While the Veteran sought treatment during service for two head injuries, which the February 2020 VA examiner concluded were mild TBIs in service, evidence of an in-service injury does not alleviate the requirement for a current disability in a claim for service connection. The Veteran has not provided any medical evidence showing that he has a currently-diagnosed TBI. The Board acknowledges that, as noted below, a February 2021 private psychological examination report from Dr. G. stated that, based on review of the claims file, including review of the February 2020 VA examination, the Veteran has a diagnosis of neurocognitive disorder due to TBI. However, this finding is based on an inaccurate reading of the February 2020 VA examination reports because as discussed above, the February 2020 VA examination reports together reflect that the Veteran had mild TBIs in service only and that he did not currently have a diagnosis of TBI. Dr. G. did not do any neuropsychiatric testing and did not diagnose TBI on her own. As such, this opinion is afforded lesser probative value with respect to this claim. Thus, the evidence weighs against a finding that he has a current diagnosis of a TBI. In sum, the February 2020 examination report and clinical records are of great probative value and the medical evidence weighs against the claim. Acquired Psychiatric Disorder The Veteran claims that he has an acquired psychiatric disorder, to include a major depressive disorder (MDD), anxiety, and PTSD, which is related to service, began in service and has been ongoing since, and/or was caused or aggravated by his service-connected disabilities (including tinnitus and/or right knee disability). With respect to whether the Veteran has a current diagnosis of an acquired psychiatric disorder, the medical evidence includes a January 2015 VA examination report which diagnosed an adjustment disorder with mixed anxiety and depressed mood, a September 2015 letter from his treating social worker which diagnosed PTSD and depressive disorder, and VA treatment records dated in 2014, 2015, and 2016 which noted diagnoses of MDD, PTSD, and generalized anxiety disorder. Further, a July 2016 private DBQ from Dr. H-G noted a diagnosis of adjustment disorder, a December 2019 VA examiner diagnosed an adjustment disorder with mixed disturbance of emotions and conduct, and a February 2021 private clinician diagnosed PTSD, possible bipolar, depressive disorder, generalized anxiety disorder (GAD), conversion disorder, and adjustment disorder. With specific regard to PTSD claims, three elements must be present: (1) a current medical diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a); (2) medical evidence of a causal nexus between current symptomatology and a claimed in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128 (1997). As to in-service incurrence, there are no psychiatric complaints or findings in service, there is no psychiatric diagnosis in service, the separation examination noted normal psychiatric examination, and the Report of Medical History for separation purposes indicated that the Veteran denied nervous trouble of any sort, frequent trouble sleeping, and depression or excessive worry. As such, the STRs do not reflect a chronic acquired psychiatric disorder. The post-service medical evidence includes a May 1995 treatment note which indicated that the Veteran reported left leg pain and a history of right leg osteomyelitis. The assessment included anxiety. A February 1996 psychological screening test was negative. A March 2000 VA treatment record noted that he reported feeling depressed. He mentioned nothing about service or any ongoing symptoms since service. Another March 2000 VA treatment record contained in the Social Security Administration (SSA) disability records indicated that the Veteran related that he had had depression off and on since the previous year and was hospitalized after an overdose of pills in December 1999. He did not relate anything to service; instead, depression was noted to be associated with his right ankle disability for which he was on SSA disability benefits. An October 2002 VA treatment record noted a prior history of alcohol abuse and syncopal episodes, and also drug abuse. The Veteran reported that he was currently clean. There was no psychiatric diagnosis listed. A March 2003 VA treatment record noted a diagnosis of manic depression. It was noted that he was on prescription medication for depression. A December 2004 VA treatment record noted a medical history of manic depression. A June 2014 VA treatment record reflected that the Veteran reported being depressed and unable to sleep for the past year. He was reportedly taking care of his wife and mother and it was overwhelming for him. A January 2015 VA treatment record indicated diagnoses of PTSD and depressive disorder NOS. It was reflected that the Veteran was diagnosed with anxiety and depression in 2001, as well as bipolar II disorder. It was also indicated that he had a significant trauma history involving an accident that resulted in loss of limb and later surgeries to save it. He had been hospitalized many times due to an infection following rejoining his limb with titanium plates, requiring in-home intravenous antibiotic treatment. His psychiatric symptoms were exacerbated by physical issues and pain in the past 3-4 years. He had recurrent, involuntary and intrusive distressing memories of the traumatic event. A March 2015 VA treatment record noted that the Veteran was seeking help with pain management and depression issues. It was noted that he was diagnosed with bipolar disorder II in 2001, and recently it was listed as being in total remission. He indicated that his health, pain, and financial situation cause increased depression and anxiety, in addition to having endured emotional child abuse. He did not mention military service or any service stressors. A May 2016 VA treatment record noted a diagnosis of conversion disorder with mood dysregulation, associated transient cognitive impairment in the context of somatoform spectrum disorder, history of affective dysregulation with cluster b personality traits versus disorder. The Veteran spent the session expressing that he had a secret he had not told his wife and he was afraid if he told her she would leave him. He declined psychiatric therapy and preferred to speak alone to his wife at home. He did not describe any incidents in the military or ongoing symptoms since service. Based on the above, although the Veteran has reported and been treated for various psychiatric disorders, the contemporaneous medical evidence does not establish a relationship to service. Specifically, when anxiety was first noted in 1995, he did not indicate that the symptoms were related to service; rather, the suggestion throughout the post-service treatment records were that his psychiatric complaints were related to a serious post-service injury. Such histories reported by the Veteran for treatment purposes are of more probative value than the more recent assertions and histories given for VA disability compensation purposes. The lay statements that his psychiatric disorders were associated with a post-service injury when medical treatment was being rendered is afforded greater probative value as statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care. Therefore, this evidence does not support a finding that the psychiatric complaints were related to service. As to a medical nexus, the Veteran contends that his psychiatric disorder(s) are related to the following in-service stressors: witnessing a fellow service member being cut in half, witnessing a fellow service member be sucked into a jet engine, witnessing a fellow service member being mangled on the flight deck, and getting his hand trapped under a plane's wheels. He submitted a lay statement from his sister which stated that he changed after service and was no longer the happy guy she always knew; he became distant, unhappy, short-tempered, and unmotivated. Thus, the requirement of in-service incurrence has been met. A January 2015 VA examination report noted a diagnosis of adjustment disorder. The examiner opined that the Veteran's emotional problems were primarily due to his reaction to his post-service ankle injury and subsequent development of osteomyelitis, as this was the topic he focused on during the examination, discussing his history with this problem in detail and blaming the VA hospitals where he had treatment for poor infection control. While the Veteran recalled having his hands trapped under the nose wheel of the plane while he was in service, the examiner opined that this experience was clearly quite minor in comparison with his subsequent ankle problem, which happened after service. Therefore, the examiner concluded that it is far less likely than not that the Veteran's emotional problems were due to the wheel running over his hand(s) while in service. A September 2015 letter from a VA social worker indicated that the Veteran had a diagnosis of PTSD pursuant to DSM-V criteria and depressive disorder. It was noted that he had a history of military traumas, including sustaining injury to his hands when they were trapped under the wheels of an airplane on the flight deck. He was also noted to have other stressors including chronic pain, post-military trauma, financial difficulties, disabled spouse, and childhood abuse. It was further indicated that the Social Worker hoped his service claim would be approved and he should apply for service connection for PTSD due to the military trauma including the hand injuries, observing someone get sucked into the intake of an aircraft/was cut in half, another person get sucked into the intake of an aircraft who survived but was badly mangled, and observing another man die when he jumped off a roof at Andrews Air Force Base. A July 2016 private DBQ noted a diagnosis of adjustment disorder. The private psychologist, Dr. H-G indicated that the Veteran's records were reviewed and a mental status examination was conducted. Dr. H-G diagnosed an adjustment disorder with depressed mood which more likely than not began in service, continued uninterrupted to the present, and was aggravated by tinnitus, hypertension, headaches, ankle and back problems. Dr. H-G reasoned that due to the complex overlap of endorsed symptoms, it was inconceivable to differentiate specific causation for the disability. Therefore, Dr. H-G noted that the disease pattern could not be attributable to one particular condition; rather, all conditions may indeed contribute to the overall decompensation and disability of the Veteran. December 2019 VA examination reports noted a diagnosis of adjustment disorder. The examiner reviewed the claims file and examined the Veteran. The examiner indicated that the Veteran specifically attributed his anxiety and depression to his right ankle osteomyelitis. It was also noted that the Veteran reported having a temper after service and having difficulty with alcohol in service and after service. The examiner indicated that the Veteran reported he was having increasing difficulty speaking and when the examiner inquired further, the Veteran began mumbling and engaged in circumlocution. The examiner opined that the Veteran demonstrated a high level of vocabulary and provided additional situational cues which suggested that he was functioning at a more advanced intellectual level than which he was attempting to convey. His degree of effort put forth during psychological testing was waxing and waning. The examiner noted that the Veteran had historically been noncompliant with treatment and during the examination appeared to be exhibiting malingering behavior. The examiner opined that the adjustment disorder was related to the post-service physical condition (right ankle disability/infection) and his mental health conditions were not aggravated by his service-connected conditions. The examiner reasoned that the medical records showed that the Veteran was not compliant with medical treatment, did not provide a rational and relevant basis for any conditions reported (he completely failed to report in-service stressors previously reported such as his hands being pinned under a nose wheel, etc.), and had displayed a pattern of beginning to mumble and present himself as not lucid when asked to provide specific circumstances regarding his symptoms. For example, the Veteran was reportedly proficient in his preaching at church, but was unable to articulate symptoms and circumstances under which many events occurred. The examiner also noted specifically that the Veteran reported that his anxiety and depression symptoms were related to his nonservice-connected right ankle disability. Next, a February 2021 private medical opinion stated that a single diagnosis of adjustment disorder is insufficient. The private examiner, Dr. G., diagnosed the Veteran with PTSD, possible bipolar, depressive disorder, GAD, conversion disorder, and adjustment disorder. Dr. G. opined that that it is more likely than not that the Veteran's mental health symptoms began during service and have been aggravated by his service-connected disabilities. The Veteran described a long history of mental health symptoms and was tearful when discussing in-service stressors including being trapped under a nose wheel and witnessing fellow service members become mangled, die, or sucked into an engine intake on the flight deck. He indicated that his mental health symptoms began during service due to stressful working conditions. He worked as an aviation mechanic engineer which required him to be in a constant state of high alert and to work with volatile elements which could explode at any moment. He stated that he became emotionally numb as a result of these experiences and after service he had a temper and trouble adjusting emotionally with his family. Dr. G. reviewed the claims file and recited numerous prior medical records, including VA and private examination report findings. The diagnoses were noted to include major depression with anxious distress, functional neurological symptom disorder, and neurocognitive disorder due to TBI. Dr. G. opined that all of these mental health diagnoses have considerable symptom overlap and the symptoms have mutually exacerbated each other. Further, it was determined that his military stressors and poor coping skills triggered mood, somatic, and anxiety symptoms, all of which have been complicated by medical problems; therefore, Dr. G. opined that it was reasonable to assert that the in-service stressors triggered one or more of these diagnoses and they have been complicated and exacerbated by medical issues over the years. Dr. G. cited to medical literature which finds a link between chronic pain and depression. She concluded that the Veteran's mental health symptoms more likely than not began during service and have been aggravated by service-connected conditions. After review, the weight of the competent medical evidence does not support the claim. In rendering this decision, the Board acknowledges that the September 2015 letter from a VA social worker essentially (but not directly) opined that the Veteran's PTSD was related to inservice stressors including his hand injury (being crushed under a nose wheel), the July 2016 private opinion from Dr. H-G stated that the Veteran's adjustment disorder began during service, has been present since service, and was caused/aggravated by tinnitus, hypertension, headaches, ankle and back problems, and Dr. G. opined that the Veteran's mental health symptoms more likely than not began during service and have been aggravated by service-connected conditions. However, the Board affords lesser probative value to these opinions. In this regard, a mere conclusory opinion is insufficient to allow the Board to make an informed decision as to the weight to assign to the opinion. Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007). The probative value of a medical opinion is also generally based on the scope of the examination or review, as well as the relative merits of the analytical findings; the probative weight of a medical opinion may be reduced if the physician fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). Furthermore, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008). Here, Dr. H-G did not provide any basis for the opinion that the adjustment disorder began in service, continued uninterrupted to the present, and was aggravated by tinnitus, hypertension, headaches, ankle and back problems apart from stating that it was inconceivable to differentiate specific causation for the disability and as such, all conditions may indeed contribute to the overall decompensation and disability of the Veteran. Dr. H-G did not point to any current treatment or findings which supported the opinion. Moreover, Dr. G., Dr. H-G, and the VA social worker failed to acknowledge or account for the fact that there were no mental health complaints or findings in service, including at service separation in 1986, when the Veteran specifically denied depression, excessive worry, etc. Further, the private opinions did not address or account for in their conclusions the numerous post-service treatment records which do not reflect any ongoing mental health symptoms since service or relation of mental health complaints to any incident of service, but instead overwhelmingly relate the psychiatric complaints and symptoms to the post-service right ankle injury, childhood trauma, and other life stressors such as finances, ankle pain, and caring for his wife and mother. Dr. G. specifically did not address how the Veteran's right ankle, the most significant source of physical pain in his life, related to/impacted depression and mental health symptoms, and seemed to bypass that significant nonservice-connected medical condition (right ankle) in favor of an opinion that the service-connected disabilities aggravated the psychiatric conditions without explanation or reconciliation of this discrepancy. Given the fact that the medical literature she cited to specifically indicated that pain is related to depression, the fact that his depression began in the 1990s after his ankle injury and complications, and the fact that other examination reports contain the clear opinion that the PTSD and other mental health conditions were more likely than not related to the serious ankle problems, not any inservice stressor, as the Veteran clearly spent more time discussing the ankle stressor than any other stressor, Dr. G.'s opinion is afforded lesser probative value. She does not adequately account for these factors, nor does she address the numerous findings of malingering in other examination reports. It is also noted that Dr. H-G cited to medical literature which showed that active duty impacted depression, anxiety and quality of life satisfaction in that active duty military personnel become disillusioned with their personal and professional identities as a result of the chronic guilt and shame associated with their service identities, and have more mental health events than civilians. However, the Veteran is not currently active military personnel and this research is not specific to him. Also cited by Dr. H-G was medical literature showing that "neural circuits are activated in both depression and tinnitus." However, this research does not address causation/etiology nor does Dr. H-G address how it specifically relates to this Veteran. As alluded to above, the VA social worker did not address the stressor involving the right ankle injury and subsequent infection/osteomyelitis, which according to the bulk of the post-service treatment records, and the January 2015 VA examiner, is the Veteran's major stressor and source of pain, and serves as the basis for the PTSD diagnosis. Finally, Dr. H-G and Dr. G. both cited to the correlation between pain and depression, but glossed over the fact that the nonservice-connected ankle injury was the Veteran's greatest source of pain, and the service-connected knee disability was not a significant source of pain or treatment. Dr. G. further provided no rationale or basis on which to conclude that tinnitus caused or aggravated this Veteran's mental health disorders and as noted above, Dr. H-G's medical literature regarding neural circuits being activated in both depression and tinnitus did not support causation in this regard. Therefore, the opinions are assigned lesser probative value. In sum, there were no mental health complaints in service (the Veteran specifically denied mental health symptoms at service separation) or thereafter until 1995 (when anxiety related to the ankle was incidentally noted), which is more than a decade after service. Further, there is no evidence of a diagnosis of any mental health disorder until over a decade after service, and nothing to relate any mental health symptoms to service over the subsequent years or until the VA social worker's opinion in 2015. Moreover, the preponderance of the evidence links the PTSD diagnosis to the post-service right ankle injury and subsequent medical complications rather than to any incident of service, and the majority of the medical evidence links the psychiatric symptoms other than PTSD to ankle pain, other post-service stressors, and not to any service-connected disability. As indicated and for the reasons listed above, the private opinions are afforded lesser probative value. As such, the weight of the medical evidence is against the claim. Headache The Veteran claims that service connection is warranted for headaches secondary to service connected tinnitus. He has also alleged that headaches were present in service and have continued ever since. As to a current diagnosis, an August 2012 examination report noted non-migraine headaches more than once a month and a June 2016 private DBQ noted a diagnosis of tension headaches. While there are various individual VA treatment records which noted that the Veteran denied experiencing headaches, there are other VA treatment records noting persistent, chronic headaches. As such, a diagnosis of a headache disorder has been shown. With respect to medical nexus, there are opinions both in favor and against the claim. At an August 2012 VA audiology examination, the Veteran reported that tinnitus was associated with headaches. Further, a December 2019 VA examiner opined that the Veteran's headaches were at least as likely as not proximately due to or the result of his service-connected tinnitus. The examiner referenced medical literature which noted a connection between tinnitus and headaches. Next, a June 2016 private clinician found that it was at least as likely as not that the Veteran's headaches were caused by his service-connected tinnitus. The private physician cited to medical literature which found that damage to the auditory system resulting in tinnitus could also cause headaches. This evidence all weighs in support of the appeal. On the other hand, the February 2020 VA examiner opined that the Veteran's headaches were not post-traumatic/related to any head injury because they did not begin after the head injuries in service. Instead, it was opined that the headaches are more likely related to other medical conditions such as cervical spine disease and untreated sleep apnea. Further, the examiner determined that they were not related to tinnitus because tinnitus was not a significant cause for primary headaches. After review, the medical evidence is at least in equipoise as to whether headaches were caused or aggravated by tinnitus. In this regard, it is not relevant to this particular Veteran's case whether tinnitus is a major factor in causing primary headaches in general; the question here is whether it is at least as likely as not that the Veteran's headaches are caused or aggravated by service-connected tinnitus, and the February 2020 examiner did not provide an opinion as to whether the headache disability is aggravated by the tinnitus. In sum, there are two medical opinions in favor of the Veteran's claim, which are supported by medical literature and there is evidence at the initial August 2012 VA audiology examination that the Veteran reported that tinnitus was associated with headaches. As such, and in giving the Veteran the benefit of the doubt, service connection is warranted for headaches. Disability Manifested by Frequent Loss of Balance The Veteran claims that service connection is warranted for a disability manifested by frequent loss of balance due to tinnitus. While numerous VA treatment records dating from 2010 to March 2020 include notations that he denied dizziness, poor balance, and weakness, a December 2019 VA examination report reflected a diagnosis of a disability manifested by frequent loss of balance and a clarifying February 2020 VA opinion did not dispute that he experienced loss of balance. Based on examination of the Veteran, review of the claims file, and the Veteran's noise exposure during service, the December 2019 examiner, a nurse practitioner, opined that it was at least as likely as not that the loss of balance had its onset during service or was otherwise etiologically related to service. The examiner reasoned that prior to service, the Veteran did not have any loss of balance and now he experienced loss of balance. Also cited as rationale by the examiner was an August 2011 treatment record, which noted that the Veteran presented with dizziness, syncope, difficulty ambulating, lightheadedness, vertigo, faintness, and loss off balance, which had begun two months earlier. It also noted that associated symptoms did not include tinnitus. It was further noted by the examiner that the Veteran did not have hearing loss for VA purposes. The December 2019 VA examiner also opined that it is at least as likely as not that the Veteran's disability manifested by loss of balance was aggravated by the service-connected tinnitus. The examiner cited to medical literature showing that tinnitus could lead to loss of balance. In February 2020, a clarifying VA examination and opinion was obtained. The February 2020 VA examiner, a neurologist, examined the Veteran, reviewed the claims file, and opined that the Veteran's loss of balance was more likely related to musculoskeletal causes (his chronic foot and ankle pain, and chronic osteomyelitis). The specialist noted that the Veteran's gait was antalgic but he did not have an ataxic appearance as would be expected from a neurogenic etiology. After review, the Board affords greater probative value to the February 2020 clarifying VA opinion report than the December 2019 VA opinion. The February 2020 opinion report was authored by a neurologist who reviewed the claims file, examined the Veteran, and provided an opinion with a thorough rationale supported by medical examination findings specific to the Veteran. The December 2019 VA examiner, a nurse practitioner, on the other hand, reasoned that the Veteran did not have loss of balance before service and had it after service. This observation in no way supports causation/an etiological connection between service and the current loss of balance. The December 2019 VA examiner also supported the direct service connection opinion by citing to an August 2011 treatment record which only indicated that the dizziness and loss of balance had been present for two months, which in no way supports a connection to service. Moreover, the August 2011 treatment record indicated that the Veteran did not have hearing loss for VA purposes and did not reference tinnitus whatsoever, yet the December 2019 cited noise exposure as a reason for the current loss of balance being related to service without reconciliation of the factual disconnect. In addition, the December 2019 VA examiner supported the secondary service connection opinion with general medical literature not specific to this Veteran. Importantly, the December 2019 VA examiner did not account for the Veteran's antalgic gait or lack of ataxic appearance in rendering the opinion. As such, the preponderance of the medical evidence does not support the claim for service connection for a disability manifested by frequent loss of balance on any basis. Instead, the competent, credible medical evidence shows that the loss of balance is related to the nonservice-connected musculoskeletal conditions. Respiratory Disorder The Veteran has claimed that service connection is warranted for a respiratory disorder, to include sleep apnea, as due to a psychiatric disorder. In the alternative, he has argued that sleep apnea is due to obesity which resulted from his service-connected right knee disability. The VA treatment records reflect a current diagnosis of sleep apnea diagnosed by sleep study in 2014. As such, a current disability has been shown. The Veteran does not contend, and the evidence does not reflect, that sleep apnea was present in service or is otherwise causally or etiologically related to service. As such, the evidence does not support service connection on a direct basis. Rather, a November 2016 private medical opinion report from Dr. S. stated that the Veteran's adjustment disorder more likely than not aided in the development of and permanently aggravated sleep apnea. Dr. S. cited to medical studies showing that psychiatric disorders were commonly associated with obstructive sleep apnea. Specifically, it was noted that a recent study found that subjects with psychiatric disorder such as an adjustment disorder, depression or anxiety had a higher prevalence of sleep apnea diagnosis. This study found that with CPAP treatment, both sleep apnea and psychiatric symptoms decreased providing further evidence of the co-morbidity of these conditions. As service connection for an acquired psychiatric disability to include PTSD has been denied in this decision, there is no basis on which to grant service connection for sleep apnea as secondary to a psychiatric disorder. Therefore, the claim is denied on this basis. Next, in December 2019 a VA medical opinion the examiner essentially opined that the Veteran's sleep apnea was due to his weight gain/obesity. The Veteran argued that the examiner failed to consider whether the Veteran's weight gain/obesity, which caused sleep apnea, was caused by his inability to exercise as a result of his service-connected right knee disability. In this regard, obesity may act as an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38 C.F.R. § 3.310(a). VAOPGCPREC 1-2017. However, after review, the Board finds that the Veteran's service-connected right knee disability did not result in the Veteran's obesity. In this regard, service connection for right knee strain with arthritis was granted, effective May 3, 2011, and assigned a 10 percent rating and has been at that rating since. According to VA treatment records, the Veteran's weight has fluctuated over the years. In March 2005, he weighed 254 lbs., in February 2006 265 lbs., in March 2008 269 lbs., and in May 2009 288 lbs. In January 2013, he weighed 300 lbs., in September 2013 297 lbs., in June 2014 287 lbs., and in November 2014 300 lbs. In January 2015, the Veteran weighed 287 lbs., in June 2015 270 lbs., in October 2015 279, in March 2016 245 lbs., and in April 2016 a low of 204 lbs. In November 2016, weighed 212 lbs., in June 2017 254 lbs., in March 2019 311 lbs., in November 2019 323 lbs., and in May 2020 332 lbs. A review of the treatment records does not note significant disability due to the right knee and there is no medical evidence that the Veteran is precluded from exercising due to his right knee. His most significant source of pain, and physical disability is his nonservice-connected right ankle problems including osteomyelitis, as well as his back problems. Importantly, and as shown by weight loss in 2015-2016, he has not been precluded from losing weight due to his service-connected right knee disability as he contends. Moreover, an October 2012 VA examination report reflected that the Veteran received no treatment for his right knee, there was no functional limitation/impairment due to the right knee, the examiner opined that on examination there was overreaction, superficial nonanatomic tenderness and significant poor effort/purposeful resistance to range of motion testing. Subsequent VA treatment records repeatedly note he was encouraged to exercise. As such, there is no evidence that obesity resulted from his right knee disability, and the medical evidence does not support a claim for sleep apnea due to weight gain from a right knee disability. The Board has considered the Veteran's lay statements that his claims are due to service or to a service-connected disability. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. However, he is not competent to offer an opinion as to the diagnosis of TBI or etiology of his current disorders due to the medical complexity of the matters involved. Such competent evidence has been provided by the service records, clinical evidence, and examinations obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. In light of the above, the preponderance of the evidence is against the claims for service connection for TBI, an acquired psychiatric disorder, a disability manifested by loss of balance, and a respiratory disorder (sleep apnea), and there is no doubt to be otherwise resolved. As such, the appeals are denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). L. HOWELL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Redman, 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.