Citation Nr: 1032166 Decision Date: 08/26/10 Archive Date: 09/01/10 DOCKET NO. 04-35 275 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for fibromyalgia with sleep disturbance and gastrointestinal disability, to include as due to an undiagnosed illness. 2. Entitlement to service connection for irritable bowel syndrome, to include as due to an undiagnosed illness. 3. Entitlement to service connection for a cardiovascular disability, to include as due to an undiagnosed illness. 4. Entitlement to service connection for Gulf War Syndrome. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD L. Barstow, Associate Counsel INTRODUCTION The Veteran had active military service from June 1965 to June 1972, and from September 1990 to December 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a March 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Augusta, Maine. The case was remanded by the Board in August 2007 to obtain additional treatment records and to afford the Veteran a VA examination. A review of the record indicates that the Board's directives have been substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board acknowledges that in its August 2007 remand, the issues of sleep apnea, claimed as sleep disturbance, and gastrointestinal disability were considered as two separate claims for service connection. As discussed in detail below, recent medical evidence shows that the Veteran's sleep disturbance and gastrointestinal disability are actually symptomatology of his fibromyalgia. Accordingly the Board has recharacterized the issue of service connection for fibromyalgia to include sleep disturbance and gastrointestinal disability. In July 2009, the Veteran submitted a statement regarding his fibromyalgia and irritable bowel syndrome being considered as chronic illnesses and not as undiagnosed illnesses. Normally, absent a waiver from the Veteran, a remand is necessary when evidence is received by the Board that has not been considered by the RO. Disabled Am. Veterans v. Sec'y of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). Here, however, since the Veteran's claims as to those two issues are being granted, the Veteran is not harmed by the Board's consideration of the statement. Consequently, a remand is not necessary. On October 13, 2009, in accordance with authority provided in 38 U.S.C. § 1116, the Secretary of Veterans Affairs announced his decision to establish presumptions of service connection, based upon exposure to herbicides within the Republic of Vietnam during the Vietnam era, for three new conditions: ischemic heart disease, Parkinson's disease, and B cell leukemias. As required by 38 U.S.C. 1116, the VA will issue regulations through notice and comment rule- making procedures to establish the new presumptions of service connection for those diseases. Those regulations will take effect on that date that a final rule is published in the Federal Register. Until that time, VA does not have authority to establish service connection and award benefits based upon the planned new presumptions. On November 20, 2009, the Secretary of Veterans Affairs directed the Board to stay action on all claims for service connection that cannot be granted under current law but that potentially may be granted based on the planned new presumptions of service connection for ischemic heart disease, Parkinson's disease, and B cell leukemias based upon exposure to herbicides used in the Republic of Vietnam during the Vietnam era. As the Veteran's claim seeking service connection for a cardiovascular disability may be affected by these new presumptions, the Board must stay action on this issue in accordance with the Secretary's stay. Once the planned final regulations are published, the adjudication of this issue will be resumed. As noted in the Board's August 2007 remand, in his notice of disagreement, the Veteran requested service connection for hearing loss, rashes, cysts, and an atrophied and painful testicle. A review of the record indicates that the Veteran was sent notification in accordance with the Veterans Claims Assistance Act of 2000 in November 2004 concerning these issues. However, the claims file does not indicate that a decision was ever made on these issues. Therefore, the Board again refers the issues of service connection for hearing loss, rashes, cysts, and an atrophied and painful testicle to the Agency of Original Jurisdiction for appropriate action. FINDINGS OF FACT 1. The Veteran served in the Southwest Asia theater of operations during the Persian Gulf War. 2. The Veteran has fibromyalgia with sleep disturbance and gastrointestinal disability that is as likely as not related to his military service. 3. The Veteran has irritable bowel syndrome that is as likely as not related to his military service. 4. Gulf War Syndrome is not a recognizable disease entity. CONCLUSIONS OF LAW 1. The Veteran has fibromyalgia with sleep disturbance and gastrointestinal disability that was incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1113, 1117, 1118, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2009). 2. The Veteran has irritable bowel syndrome that was incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1113, 1117, 1118, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2009). 3. Gulf War Syndrome is not a recognizable disease entity. Compensation for Certain Undiagnosed Illnesses, 60 Fed. Reg. 6660, 6661 (1995) 60 Fed. Reg. 6661 (February 3, 1995). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2009). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). But see Mayfield v. Nicholson, 19 Vet. App. 103, 128 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (when VCAA notice follows the initial unfavorable AOJ decision, subsequent RO actions may "essentially cure[] the error in the timing of notice"). The Board notes that the Veteran was apprised of VA's duties to both notify and assist in correspondence dated in December 2003, before the AOJ's initial adjudication of the claims, and again in October 2005, August 2006, and September 2007. Although the complete notice required by the VCAA was not provided until after the RO adjudicated the appellant's claims, any timing errors have been cured by the RO's subsequent actions. Id. Specifically regarding VA's duty to notify, the notifications to the Veteran apprised him of what the evidence must show to establish entitlement to the benefits sought, what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. Although the initial notification did not include the criteria for assigning disability ratings or for award of an effective date, see Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Veteran was apprised of those criteria in correspondence dated in March 2006. The RO also provided a statement of the case (SOC) and supplemental statements of the case (SSOC) reporting the results of its reviews of the issues on appeal and the text of the relevant portions of the VA regulations. Regarding VA's duty to assist, the RO obtained the Veteran's service treatment records (STRs), post-service medical records, and Social Security Administration (SSA) records. The RO also secured examinations in furtherance of the Veteran's claims. VA has no duty to inform or assist that was unmet. VA opinions with respect to the issues on appeal were obtained in July 2008, December 2008, and February 2009. 38 C.F.R. § 3.159(c)(4). To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted below, the Board finds that VA opinions obtained in this case were sufficient, as they were predicated on a full reading of the VA medical records in the Veteran's claims file. They consider all of the pertinent evidence of record, the statements of the appellant, and provide explanations for the opinions stated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). Finally, there is no sign in the record that additional evidence relevant to the issues being decided herein is available and not part of the record. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). The duty to assist has been fulfilled. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (finding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis herein focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (holding that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). II. The Merits of the Claims The Veteran contends that he has fibromyalgia, irritable bowel syndrome, a cardiovascular disability, sleep apnea, a gastrointestinal condition, and Gulf War Syndrome related to his military service. He contends that the disabilities are either directly related to service or are due to an undiagnosed illness. Law Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. In addition, service connection may be granted for any disease diagnosed after discharge, when all the evidence including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Pursuant to 38 C.F.R. § 3.303(b), VA may award service connection where a claimant can demonstrate "(1) that a condition was 'noted' during service; (2) evidence of post service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (emphasis added). A claimant may rely on lay evidence "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) (footnote omitted). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has also held that "the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence." Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Service connection may also be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air 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, 2011. 38 U.S.C.A. § 1117 (West 2002 & Supp. 2009); 38 C.F.R. § 3.317 (2009). Persian Gulf Veteran means a Veteran who, during the Persian Gulf War, served on active military, naval, or air service in the Southwest Asia theater of operations, which includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(d). For purposes of section 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. 38 C.F.R. § 3.317(a)(2). 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, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Further, lay persons are competent to report objective signs of illness. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). A medically unexplained chronic multi-symptom illness is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. 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 multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2). 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. 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. 38 C.F.R. § 3.317(b). For purposes of section 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. 38 C.F.R. § 3.317(a)(4). Lastly, compensation shall not be paid under section 3.317 if there is affirmative evidence that an undiagnosed illness was not incurred during active military service in the Southwest Asia theater of operations during the Persian Gulf War; if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). Analysis The Veteran's DD 214 from his second period of service confirms that he is a Gulf War Veteran with participation in the Southwest Asia theater of operations. His STRs show no treatment for, or diagnosis of, any of his claimed disabilities. Fibromyalgia with Sleep Disturbance and Gastrointestinal Condition A VA Persian Gulf examination dated in October 2003 reveals that the Veteran was diagnosed with gastroesophageal reflux disease (GERD). No etiology was provided. A private colonoscopy dated in October 2004 indicates that the Veteran was diagnosed with probable Barrett's esophagus; sliding hiatal hernia; thickened folds in the duodenal bulb; too numerous to count number of small ulcerations in the second and third portion of the duodenum; terminal ileum was similar, but less numerous small ulcerations; normal colonic mucosa; and grade-1 internal hemorrhoids. A private neurology record dated in December 2004 shows that the Veteran complained of numbness and tingling in his toes, hands, and left shoulder. He also had complaints of pain in the left shoulder, sharp pain in the left tibial shaft, and pain in the left hip. They were intermittent in nature. He reported that he had had those problems since 1996 and they were getting worse. Neurological examination failed to reveal any set pattern. The physician opined that the Veteran's symptoms could be explained with peripheral neuropathy. He was prescribed Neurontin. Follow-up records dated from February 2005 through October 2005 reveal that the Veteran's initial peripheral neuropathy work-up was normal. The use of Neurontin was discontinued due to the Veteran developing skin rashes and the Veteran was instead prescribed other medications. Private treatment records continue to show the prescription of medication for his symptoms. Post- service medical records also reveal the Veteran's complaints with fatigue and difficulty sleeping, in addition to gastrointestinal complaints. The Veteran was afforded a VA general medical examination in February 2005. His claims file was reviewed by the VA examiner. The Veteran's various symptoms and medications used to treat his symptoms were noted. Following an exhaustive examination, the Veteran's pertinent diagnoses included chronic malaise, fatigue and tiredness of unknown etiology since 1991 by history; no chronic fatigue syndrome or fibromyalgia as per that examination; chronic diffuse joint, muscle and body pain of unknown etiology since 1996 by history; sliding hiatal hernia; and sleep apnea by history since 1993. With regards to the diagnosis of sleep apnea, the examiner made a notation to please refer to the February 2005 psychiatric examination. The February 2005 VA psychiatric examination indicates that the Veteran reported difficulty falling and remaining asleep. He awoke frequently and was never successful in achieving more than three hours of sleep. No matter when he attempted to sleep, he never felt rested or refreshed upon waking. A private treatment record dated in April 2005 shows that the Veteran was diagnosed with fibromyalgia. No etiology was provided. The Veteran underwent a VA Gulf War examination in December 2006. He reported numbness and joint pain in the elbows, knees, shoulders, and other sites. He also reported stomach problems of a sour stomach, GERD, nausea, etc. Following an exhaustive examination that noted the Veteran's symptoms and pertinent medical history, the Veteran's joint pain was opined to be unlikely to be rheumatoid arthritis, but fit into fibromyalgia and possibly degenerative joint disease based on patterns, descriptions, x-ray reports, etc. The examiner also diagnosed the Veteran, in pertinent part, with fatigue and GERD/hiatal hernia/Barrett's esophagus. The Veteran was afforded a VA examination in July 2008 by the same physician who performed the December 2006 examination. His claims file was reviewed. The examiner noted that the Veteran had been diagnosed with fibromyalgia and that private work-ups were negative for rheumatoid arthritis. The Veteran reported taking medication for his GERD. He also reported that he was usually fatigued. The Veteran further reported sharp jabs or jolts; three to four seconds of pain in the legs at times and it felt as though his legs would not hold him up; then they went away. The Veteran reported variable muscle pains, aches in the fingers, cold feet, etc. The examiner indicated that the Veteran had the following symptoms: chronic joint pain; chronic muscle pain; malaise; numbness and tingling of the hands; forgetfulness; weight problems; and nausea. Following examination, the Veteran was diagnosed in pertinent part with fibromyalgia and gastrointestinal disability, including gastritis. The examiner also noted that the Veteran had Barrett's and GERD. With regards to the Veteran's sleep disturbance including sleep apnea, the examiner was unable to render a diagnosis without the results of the sleep study that was ordered. The examiner opined that the symptoms listed above went hand in hand with chronic fatigue syndrome, and in turn, chronic fatigue syndrome was associated with fibromyalgia, often occurring together. The examiner opined that the Veteran definitely had a medically unexplained chronic multisystem illness, which he believed included fibromyalgia. He further opined that he was unable to say whether the Veteran had an undiagnosed illness without resorting to mere speculation. The Veteran underwent a private sleep study in October 2008 as ordered in the July 2008 VA examination. The Veteran was afforded another examination in December 2008. The examination shows that the October 2008 sleep study ruled out sleep apnea. The Veteran reported that his fatigue was not long lasting. He also reported occasional sleep problems. The examiner opined that they were unable to state that the Veteran had chronic fatigue syndrome without resort to speculation. No diagnosis was evident for that examination. With regards to fibromyalgia, the Veteran reported joint pains that would lock up his joints, but one at a time. Private work- ups were negative for arthritis. He reported that he had sharp pain in the large muscle groups, not really in the joints. He reported that the pains were episodic. They occasionally were as bad as lasting for two to three days after a spike type of pain. Other times it would last only severely at about nine out of ten (9/10) for three to four seconds, then decrease to about 6/10 for about 60 seconds, and then it was about 1-2/10 and could last for the rest of the day. The Veteran reported that he could not move when the stabbing pains occurred. He stated that in that regard, he had stiffness but otherwise no significant stiffness, no heat, redness or swelling. The examiner noted that the claims file showed that the Veteran had had other evaluations and all examinations revealed no significant pathology or arthritic condition to account for the Veteran's complaints. The examiner opined that the lack of trigger points made it somewhat difficult to ascribe fibromyalgia; the Veteran's symptoms were not classic fibromyalgia. However, the Veteran's symptoms and history indicated a best nexus of fibromyalgia. The examiner concluded that the Veteran at least as likely as not had fibromyalgia. An additional opinion from the December 2008 examiner was obtained in February 2009. He continued the diagnosis of fibromyalgia and opined that he was not able to comment as to whether it was related to an undiagnosed illness without resort to mere speculation. With regards to the Veteran's claimed sleep apnea, the examiner opined that it was not at least as likely as not that the Veteran had sleep apnea or as due to an undiagnosed illness. The examiner noted that the issue of sleep disturbance was a symptomatology that was also found in people with fibromyalgia with frequent sleep interruptions and fatigue. The examiner concluded that it was at least as likely as not that the Veteran's sleep disturbance and fatigue was related to fibromyalgia. With regards to the Veteran's claimed gastrointestinal disability, the examiner noted that the issue of dysphagia, GERD, and irritable bowel syndrome were often found as symptomatology with fibromyalgia. Therefore, it was opined that the Veteran's gastrointestinal disability claimed as abdominal problems outlined as GERD and occasional nausea were at least as likely as not related to the diagnosis of fibromyalgia. The examiner was unable to comment without resort to mere speculation if it was related to an undiagnosed illness. Here, the evidence shows that the Veteran served in the Southwest Asia theater of operations during the Persian Gulf War. Post- service, the Veteran has been diagnosed with fibromyalgia with no etiology. The July 2008 examiner opined that it was definitely a medically unexplained chronic multi-system illness. As noted above, service connection can be granted for Persian Gulf War Veterans with medically unexplained chronic multi- symptom illness such as fibromyalgia if it is manifest to degree of 10 percent or more not later than December 31, 2011, and existed for six months or more. The evidence shows that the Veteran's fibromyalgia is a medically unexplained chronic multi-system illness. Additionally, the evidence shows that it has existed for six months or more. The Board will now turn to whether it is manifest to a degree of 10 percent or more. In this regard, fibromyalgia is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5025. Diagnostic Code 5025 provides that fibromyalgia (fibrositis, primary fibromyalgia syndrome) with widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud's-like symptoms, is to be rated 10 percent disabling if the symptoms require continuous medication for control; 20 percent disabling if the symptoms are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but symptoms that are present more than one-third of the time; and 40 percent disabling if the symptoms are constant or nearly constant, and are refractory to therapy. A Note to Diagnostic Code 5025 provides that widespread pain means pain in both the left and right sides of the body, that is both above and below the waist, and that affects both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or low back) and the extremities. 38 C.F.R. § 4.71a, Diagnostic Code 5025 (2009). Here, based on a thorough review of the evidence, the Board finds that the Veteran's fibromyalgia has been shown to be manifest to a degree of 10 percent or more. Additionally, the Board also finds that as per the February 2009 VA opinion, the Veteran has associated symptomatology of fatigue, sleep disturbance, and gastrointestinal disability outlined as GERD and occasional nausea. As noted above, the rating criteria for fibromyalgia includes fatigue. In light of the Veteran having service in the Southwest Asia theater of operations during the Persian Gulf War, his diagnosis of a chronic medically unexplained multi-system illness of fibromyalgia that has continued for over six months and is manifest to a degree of 10 percent or more, associated symptomatology of fatigue, sleep disturbance, and gastrointestinal disability outlined as GERD and occasional nausea, the Board finds that it is at least as likely as not that the Veteran has fibromyalgia with sleep disturbance and gastrointestinal disability that is related to his military service. Therefore, service connection for fibromyalgia with sleep disturbance and gastrointestinal disability is warranted. Irritable Bowel Syndrome A letter from W.S., M.D. dated in November 2004 indicates that it was entirely within the realm of possibility that the Veteran's diarrhea was caused by irritable bowel syndrome. The VA general medical examination in February 2005 shows that the Veteran was diagnosed, in pertinent part, with irritable bowel syndrome by history following an exhaustive examination. At the December 2006 VA Gulf War examination the Veteran was diagnosed with bowel pattern variability; motility problems were suspected. The examiner found that the Veteran had irritable bowel syndrome symptoms, but apparently it was not found on biopsies done. The examiner would have suspected Crohn's disease, but his gastroenterologist said no on that. The examiner noted that the Veteran had excellent gastrointestinal follow-up on all of his gastrointestinal issues. At the July 2008 VA examination, the examiner opined that the Veteran had a medically unexplained chronic multi-system illness that included irritable bowel syndrome. He was unable to state whether the Veteran had an undiagnosed illness without resorting to mere speculation. The February 2009 VA medical opinion shows that the Veteran's irritable bowel syndrome was at least as likely as not related to his fibromyalgia. The examiner opined that it was often found in fibromyalgia. The examiner noted that the complicating factor would be whether it was also related to an undiagnosed illness. The examiner opined that it was possible, but that they were unable to further comment without resort to mere speculation on the issue of irritable bowel syndrome and undiagnosed illness. Here, the evidence shows that the Veteran has been diagnosed with irritable bowel syndrome. The February 2009 VA medical opinion indicates that the Veteran's irritable bowel syndrome is secondary to his fibromyalgia. In this regard, the Board acknowledges that irritable bowel symptoms are symptoms associated with fibromyalgia under the diagnostic code used for rating fibromyalgia. However, the July 2008 examiner characterized the Veteran's irritable bowel syndrome as a separate medically unexplained chronic multi-system illness. Moreover, irritable bowel syndrome is specifically listed as a separate medically unexplained chronic multi-system illness. See 38 C.F.R. § 3.317(a)(2). Therefore, affording the Veteran the benefit-of-the-doubt, the Board finds that the Veteran's irritable bowel syndrome is a separate disability apart from his fibromyalgia. Since irritable bowel syndrome is a medically unexplained chronic multi-symptoms illness, the Board will now turn to whether it has existed for six months or more, and whether it is manifest to a degree of ten percent or more. The evidence shows that it has existed for six months or more. Irritable bowel syndrome is rated under 38 C.F.R. §4.114, Diagnostic Code 7319, irritable colon syndrome. A 10 percent rating requires that it be moderate with frequent episodes of bowel disturbance with abdominal distress. 38 C.F.R. §4.114, Diagnostic Code 7319 (2009). A review of the evidence shows that the Veteran's irritable bowel syndrome has been manifest to a degree of 10 percent or more. In light of the Veteran having service in the Southwest Asia theater of operations during the Persian Gulf War, his diagnosis of a chronic medically unexplained multi-system illness of irritable bowel syndrome that has continued for over six months and is manifest to a degree of 10 percent or more, the Board finds that it is at least as likely as not that the Veteran has irritable bowel syndrome that is related to his military service. Therefore, service connection for irritable bowel syndrome is warranted. In granting service connection separately for irritable bowel syndrome apart from the symptomatology associated with fibromyalgia, the Board is cognizant that VA regulations include an anti-pyramiding provision, which provides that the evaluation of the "same disability" or the "same manifestation" under various diagnoses is to be avoided. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261 (1994). The United States Court of Appeals for Veterans Claims (Court) has interpreted the anti-pyramiding provision as implicitly containing the concept that the rating schedule may not be employed as a vehicle for compensating a claimant twice, or more, for the same symptomatology; such a result would overcompensate the claimant for the actual impairment of his or her earning capacity and would constitute pyramiding. Brady v. Brown, 4 Vet. App. 203, 206 (1993). To avoid pyramiding, the critical question is whether the symptomatology of one condition is duplicative or overlapping with that of another condition. Esteban, 6 Vet. App. at 262. In this regard, the collective medical evidence indicates that the Veteran has diarrhea, constipation, abdominal cramps, loose stools, and other symptoms that have been separately attributed to a diagnosis of irritable bowel syndrome, and have not been included as symptomatology of the Veteran's fibromyalgia. Therefore, affording the Veteran the benefit-of-the-doubt, the Board finds that separate service connection for irritable bowel syndrome is warranted, especially as it is listed separately from fibromyalgia as a chronic medically unexplained multi-system illness. Gulf War Syndrome The Veteran has claimed service connection for Gulf War Syndrome. However, "Persian gulf syndrome" is not a disease entity currently recognized by VA or within the medical community. 60 Fed. Reg. 6661 (February 3, 1995). The same is true for what the Veteran and his representative have termed "Gulf War Syndrome." Accordingly, service connection for Gulf War Syndrome may not be granted. As discussed thoroughly above, some of the symptomatology that the Veteran has attributed to "Gulf War Syndrome" has been granted service connection. ORDER Entitlement to service connection for fibromyalgia with sleep disturbance and gastrointestinal disability, to include as due to an undiagnosed illness, is granted. Entitlement to service connection for irritable bowel syndrome, to include as due to an undiagnosed illness, is granted. Entitlement to service connection for Gulf War Syndrome is denied. ____________________________________________ WILLIAM YATES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs