BRAIN DISEASE DUE TO TRAUMA

PAUL SORISIO · 2026 · Case ID: A26038689

GRANTED

Summary

The veteran, who served from June 1973 to July 1976, sought service connection for TBI, headaches as residuals of TBI, and acquired psychiatric disorders secondary to headaches. The Board granted service connection for TBI, finding it resulted from an in-service training injury, supported by credible lay testimony from a fellow service member and a private medical opinion. The Board also granted service connection for headaches as residuals of the TBI, noting in-service treatment for a forehead laceration and the veteran's credible testimony about the injury and subsequent symptoms. The Board applied the benefit of the doubt doctrine, finding the evidence in approximate balance for both TBI and headaches, leading to a favorable outcome. For the secondary psychiatric claim, the Board found the veteran had current diagnoses of MDD and PTSD, and with service connection for headaches now established, the second element was met. A private medical opinion concluded the veteran's persistent depressive disorder was at least as likely as not secondary to his chronic headaches, which the Board found competent and credible. Applying the benefit of the doubt doctrine again, the Board granted service connection for the acquired psychiatric condition. The Board acknowledged negative VA medical opinions but found them less probative due to their reliance on the lack of contemporaneous records and failure to consider credible lay evidence.

Rationale

Competent and probative evidence shows TBI resulted from in-service training injury.; Veteran's testimony regarding injury credible and consistent.; Buddy statement corroborates in-service event.; Private medical opinion found TBI at least as likely as not related to in-service injuries.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210713-171774

Full Decision Text

Citation Nr: A26038689
Decision Date: 04/24/26 Archive Date: 04/24/26

DOCKET NO. 210713-171774
DATE: April 24, 2026

ORDER

Service connection for traumatic brain injury (TBI) is granted.

Service connection for headaches, as a residual of TBI, is granted.

Service connection for an acquired psychiatric condition, to include major depressive disorder (MDD), persistent depressive disorder, and posttraumatic stress disorder (PTSD), as secondary to service-connected headache residuals is granted.

FINDINGS OF FACT

1. The competent and probative evidence shows that the Veteran's TBI was the result of his in-service training injury.

2. The competent and probative evidence shows that the Veteran's headaches are residuals of his in-service training injury and TBI.

3. The competent and probative evidence shows that the Veteran's acquired psychiatric disorder is due to his now service-connected headache residuals.

CONCLUSIONS OF LAW

1. The criteria for service connection for TBI are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for service connection for headaches, as a residual of TBI, are met. 38 U.S.C. §§ 1110, 5103, 5107; 38 C.F.R. § 3.303.

3. The criteria for service connection for an acquired psychiatric condition, to include MDD, persistent depressive disorder and PTSD, as secondary to service-connected headache residuals are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310(a).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from June 1973 to July 1976.

This matter is before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in June 2021 by a Department of Veterans Affairs (VA) Regional Office (RO).

In the July 13, 2021 VA Form 10182 Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing before the undersigned Veterans Law Judge was held on December 2, 2024. See 12/2/2024 Hearing Transcript. Based upon the selection of the Hearing docket, the Board may consider the evidence of record as of June 16, 2021-the date of the rating decision on appeal, and evidence submitted at or within 90 days of the December 2, 2024 Board hearing. See 38 C.F.R. § 20.302. If the Veteran submitted evidence that was added to the record after June 16, 2021 and before the December 2, 2024 Board hearing, or more than 90 days following the Board hearing, the Board did not consider it. If the Veteran wishes to have VA consider any evidence that was not considered, a supplemental claim should be submitted identifying such evidence. See 38 C.F.R. § 3.2501.

The Veteran seeks service connection for several acquired psychiatric disorders. See 2/15/2021 VA Form 20-0995. The Board has recharacterized the claim to encompass all possible psychiatric diagnoses of record, including MDD, persistent depressive disorder, and PTSD. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009); Murphy v. Wilkie, 983 F.3d 1313, 1320 (Fed. Cir. 2020).

New and Relevant Evidence

As an initial matter, the Board notes that the RO found that new and relevant evidence had not been received regarding the Veteran's claim for service connection for TBI. See 6/16/2021 Rating Decision, p. 2. However, the RO did find that new and relevant evidence had been received in relation to the Veteran's claim for headaches as residuals of his TBI, as well as for an acquired psychiatric disorder. Id. at 3-4.

VA will readjudicate a claim if new and relevant evidence is presented or secured. 38 C.F.R. § 3.156(d). "New evidence" is evidence not previously part of the actual record before agency adjudicators. "Relevant evidence" is evidence that tends to prove or disprove a matter in issue. 38 C.F.R. § 3.2501(a)(1).

The Board finds that, since the denial of the Veteran's claim for service connection for TBI and headache residuals, medical opinions from private clinicians discussing the et
had been received in relation to the Veteran's claim for headaches as residuals of his TBI, as well as for an acquired psychiatric disorder. Id. at 3-4.

The Board finds that, since the denial of the Veteran's claim for service connection for TBI and headache residuals, medical opinions from private clinicians discussing the etiology of the Veteran's conditions, including whether they are proximately due to service, were submitted by the Veteran within an open evidentiary window. See 2/19/2025 Uploaded Documents. Accordingly, the Board finds such evidence to be both new and relevant and that readjudication of the claim is warranted.

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; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). To substantiate a claim of secondary service connection, there must be evidence of (1) a current disability for which service connection is sought; (2) an already service-connected disability; and (3) that the already service-connected disability caused or aggravated the disability for which service connection is sought. See Allen v. Brown, 7 Vet. App. 439 (1995).

In addition, "for a veteran to receive secondary service connection on a causation basis under § 3.310(a), the primary disability need not be service connected, or even diagnosed, at the time the secondary condition is incurred." Frost v. Shulkin, 29 Vet. App. 131, 138 (2017).

The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed Cir. 2009).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). The benefit of the doubt rule is a unique standard of proof, and "the nation, 'in recognition of our debt to our veterans,' has 'taken upon itself the risk of error' in awarding such benefits." Wise v. Shinseki, 26 Vet. App. 517, 531 (2014).

1. Service connection for TBI.

2. Service connection for headaches, as a residual of TBI.

The Veteran contends that he suffered an in-service TBI during a grenade simulation while training that resulted in ongoing headaches residuals that were onset at the time of injury and have persisted to the present time. 12/2/2024 Hearing Transcript, pp. 5-6.

The RO's June 2021 rating decision made favorable findings that the Veteran has current diagnoses of TBI and migraine headaches. 6/16/2021 Rating Decision, pp. 2, 3. The Board sees no clear and unmistakable error in these findings and now finds that the first element of service connection is established by the record. 38 C.F.R. § 3.104(c).

As to the second element of service connection, the RO made separate favorable findings that the Veteran's service treatment records (STRs) indicated a forehead laceration in approximately 1973 and that the Veteran complained of headaches due to wearing glasses during service. 6/16/2021 Rating Decision, pp. 2, 4.
June 2021 rating decision made favorable findings that the Veteran has current diagnoses of TBI and migraine headaches. 6/16/2021 Rating Decision, pp. 2, 3. The Board sees no clear and unmistakable error in these findings and now finds that the first element of service connection is established by the record. 38 C.F.R. § 3.104(c).

As to the second element of service connection, the RO made separate favorable findings that the Veteran's service treatment records (STRs) indicated a forehead laceration in approximately 1973 and that the Veteran complained of headaches due to wearing glasses during service. 6/16/2021 Rating Decision, pp. 2, 4. The Board further notes the Veteran's indication of a head injury, eye trouble, and frequent or severe headaches on his March 1976 report of medical history. 3/3/2010 STR, p. 5.

Additionally, during the Veteran's December 2024 Board hearing, the Veteran testified regarding the events surrounding his in-service injury. See 12/2/2024 Hearing Transcript, pp. 4-7. Specifically, the Veteran described that during a simulated war exercise, he was subjected to multiple simulated grenade explosions near his head, the worst of which resulted in a laceration for which he was provided medical treatment. Id. at 7-8. The Board does recognize that the Veteran's STRs do not include an in-service diagnosis of TBI. However, the Board finds the Veteran's testimony regarding his injuries credible, as the statements are internally consistent, have been accurately repeated on numerous occasions over many years, and are plausible based on the corresponding STRs indicating a forehead laceration. See Jandreau, 492 F.3d at 1377. Moreover, the Board notes a 2013 signed affidavit from a fellow service member, B.T., corroborating that during permanent party training, both he and the Veteran were part of training exercise during which he personally and distinctly recalls the Veteran receiving burn marks on his forehead following a simulated grenade explosion. 10/18/2013 Affidavit, p. 1. Following the event, B.T. recalls the Veteran complaining of headaches and using prescription dark glasses to aid his symptoms. Id. The Board finds no reason to question the credibility or veracity of B.T. and assigns his statements substantial probative weight.

After review of the competent and probative evidence of record, including the RO's favorable findings, testimony at the Board hearing, and buddy statement, the Board finds that the second element of service connection is established by the record.

Turning to the final element of service connection, that of a medical nexus linking the Veteran's current disability to his in-service injury, the Board notes that there are probative opinions weighing both in favor and against the claim.

Following the December 2024 Board hearing, the Veteran submitted a private medical opinion regarding his TBI and headaches. See 2/19/2025 Uploaded Documents, pp. 10-15. The private physician acknowledged review of the Veteran's military personnel records (MPRs), STRs, and VA treatment records. After review, the physician concluded it was at least as likely as not that the Veteran's in-service injuries sustained during the simulated war exercise resulted in a TBI. Id. at 14. As rationale, the physician relied upon the Veteran's report of being minimally dazed and subsequent development of difficulties with memory loss, concentration, and executive functions, as well as his development of chronic migraines and light/noise sensitivity. Id. Furthermore, the physician also concluded that based upon the Veteran's reports regarding the in-service simulated grenade explosion, it was at least as likely as not that the Veteran's chronic headaches that have continued since that time are the result of his in-service head injury. Id.

The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for a medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez, 22 Vet. App. 295 (2008). Here, the private physician conducted a thorough review
Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for a medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez, 22 Vet. App. 295 (2008). Here, the private physician conducted a thorough review of the Veteran's STRs, post-service medical records, and statements regarding both the in-service event and his ongoing symptomatology thereafter. The Board finds that his medical conclusions are supported by reference to the Veteran's records and contain a detailed rationale. The Board finds the physician to be competent and credible and assigns the medical opinions substantial probative weight.

The Board acknowledges the negative VA medical opinions also of record but finds that, because they relied on the lack of contemporaneous STRs in the Veteran's record and did not consider the Veteran's credible lay reports, they are of minimal probative value. See 8/11/2017 C&P Exam, p. 6; see 6/1/2012 C&P Exam, p. 1.

After review of the competent and probative record, and after having resolved all doubt in the Veteran's favor, the Board finds the evidence to be at least in approximate balance as to whether the Veteran's current TBI and headache residuals are related to service. As the evidence is in approximate balance, the benefit-of-the-doubt rule is applicable, and the claims for service connection for TBI and headache residuals are granted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021); Wise, 26 Vet. App. at 531 (the benefit of the doubt rule is a unique standard of proof, and "the nation, 'in recognition of our debt to our veterans,' has 'taken upon itself the risk of error' in awarding such benefits").

3. Service connection for an acquired psychiatric condition, to include MDD, persistent depressive disorder and PTSD, as secondary to service-connected headaches.

The Veteran seeks service connection for an acquired psychiatric disability, to include both MDD and PTSD. 2/15/2021 VA Form 20-0995.

As to the first element of secondary service connection, that of a current disability, the Board acknowledges the RO's June 2021 favorable findings that the Veteran has a current diagnosis of MDD and a current diagnosis of PTSD. 6/16/2021 Rating Decision, pp. 3-4. The Board sees no clear and unmistakable error in these findings and no finds that the first element of secondary service connection has been satisfied by the record. 38 C.F.R. § 3.104(c).

As to the second element of secondary service connection, that of a primary disability for which service connection has already been established, the Board notes that as a result of the present decision, the Veteran is service connected for headaches. See Green v. McDonough, 37 Vet. App. 127, 136 (2024) (stating that an agency decision which post-dates the decision on appeal may result in an error requiring remand because a decision does not constitute "evidence" and as such, the decision need not have been of record at the time of the decision on appeal). Therefore, the Board finds that the second element of secondary service connection is established in the record.

Turning to the final element of secondary service connection, that of a medical nexus linking the Veteran's current acquired psychiatric condition with his service-connected headaches, the Board notes that although the Veteran has been afforded VA examinations addressing direct service connection for his acquired psychiatric condition, there is no VA medical opinion of record addressing secondary service connection.

However, following the December 2024 Board hearing in the open 90-day evidence window, the Veteran submitted a private medical opinion addressing acquired psychiatric condition as secondary to his headache condition. See 2/19/2025 Uploaded Documents, pp. 3-9. The private clinician conducted a thorough psychological interview with the Veteran and acknowledged review of his STRs and post-service medical records. Id. at 3. After a discussion of the Veteran's relevant treatment notes and history of symptomatology, the clinician rendered a diagnosis of persistent depressive disorder, but indicated that the Veteran does not have PTSD. Id. at 8-9. The clinician then went on to discuss how the Veteran's chronic headaches, which often result in isolating in a quiet room, affect his mood and increase worry that there is something wrong with his brain. Id. Furthermore, his headaches cause anxiety and lead him to feelings of hopelessness. Based on this rationale, the clinician concluded that the Veteran's persistent depressive disorder was at least as likely as not secondary to his migraine condition. Id. The Board finds the private clinician to be competent and credible and assigns the examination report moderate probative weight.

After review of the competent and probative record, the Board finds that the evidence is at least in approximate balance as to whether the Veteran's acquired psychiatric condition is the result of his now service-connected headaches. As the evidence is in approximate balance, the benefit-of-the-doubt rule is applicable, and the claim for service connection for an acquired psychiatric condition is granted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch, 21 F.4th at 776; Wise, 26 Vet. App. at 531 (the benefit of the doubt rule is a unique standard of proof, and "the nation, 'in recognition of our debt to our veterans,' has 'taken upon itself the risk of error' in awarding such benefits").

Paul Sorisio

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Donahue, Thomas P.

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.

Analyze in VA Law Explorer