Citation Nr: 0812530 Decision Date: 04/15/08 Archive Date: 05/01/08 DOCKET NO. 96-23 725 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for joint pain and weakness due to undiagnosed illness. 3. Entitlement to an initial rating in excess of 20 percent for duodenitis with duodenal ulcer and abdominal pain. ATTORNEY FOR THE BOARD C. Chaplin, Counsel INTRODUCTION The veteran served on active duty from April 1980 to March 1984 and from December 1990 to March 1991. He also had a period of active duty for training from May to July 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 1995 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, that denied service connection for joint pain and weakness, claimed as due to an undiagnosed illness; and service connection for PTSD. In an April 2000 decision, the Board denied as not well grounded the veteran's claim for service connection for joint pain and weakness due to undiagnosed illness. The issue of entitlement to service connection for PTSD was remanded to the RO for further development. The veteran appealed to the United States Court of Appeals for Veterans Claims (Court) the Board's April 2000 decision denying service connection for joint pain and weakness due to undiagnosed illness. In November 2000, the parties to the appeal filed a Joint Motion for Remand and to Stay Proceedings. In the joint motion it was agreed that the Board's April 2000 decision denying service connection for joint pain and weakness due to undiagnosed illness should be vacated and this issue be remanded due to the enactment of the Veterans Claims Assistance Act of 2000. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West Supp. 2002). By Order dated in December 2000, the Court granted the joint motion and remanded this matter to the Board. In March 2001, the Board remanded the issues of entitlement to service connection for joint pain and weakness, claimed as due to an undiagnosed illness, to the RO for further development and adjudication in order to ensure compliance with VA's duties to notify the veteran and develop the claim. After compliance with the Board's remand instructions, in September 2001 the RO again denied service connection for joint pain and weakness, claimed as due to an undiagnosed illness as well as entitlement to service connection for PTSD. The case was then returned to the Board where further development was undertaken by the Board's Evidence Development Unit pursuant to then authority granted by 38 C.F.R.§ 19.9(a)(2) (2002), a regulation that was later invalidated. The case was then remanded to the RO in December 2003 for further development to include consideration of all the evidence added to the record. This matter also arises from an April 2003 rating decision wherein the Montgomery, Alabama RO implemented a March 2003 decision of the Board that had granted entitlement to service connection for duodenal ulcer disease with duodenitis. The RO granted service connection for duodenitis with duodenal ulcer and assigned a 20 percent evaluation effective from March 6, 1994. The veteran disagreed with the evaluation assigned. In a January 2005 rating decision the RO granted entitlement to service connection for abdominal pain which was evaluated with his duodenal ulcer and duodenitis and the 20 percent evaluation was continued. The case was returned to the Board in March 2007 at which time the appeal was remanded because of further redefining of VA's duties to notify and assist. In a supplemental statement of the case issued in May 2007, the RO denied entitlement to service connection for PTSD and for joint pain and weakness, claimed as due to undiagnosed illness. The RO also denied an initial evaluation in excess of 20 percent for duodenitis with duodenal ulcer and abdominal pain. The case has been returned to the Board. FINDINGS OF FACT 1. The veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War. 2. The preponderance of competent and probative medical evidence establishes that the veteran does not meet the diagnostic criteria for PTSD related to his service during the Persian Gulf War. 3. Joint pain and weakness of the left knee and left elbow are not shown as manifestations of an undiagnosed illness 4. The clinical evidence of record does not reveal the existence of arthritis of the left elbow or left knee to a compensable degree within one year of the appellant's separation from service. 5. The veteran is not shown to have a currently diagnosed left elbow disorder or a left knee disorder related to his service or otherwise due to any event in service. 6. The veteran's duodenitis with duodenal ulcer is manifested by abdominal pain; objectively, there is no demonstration of moderately severe symptoms with impairment of health manifested by anemia or weight loss and there is no showing of recurrent incapacitating episodes averaging 10 days in duration at least four or more times a year. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD are not met. 38 U.S.C.A. §§ 1110, 5100, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.304 (2007). 2. The veteran is not shown to have a disability manifested by painful left elbow joint or a painful left knee due to disease or injury, to include as due to an undiagnosed illness, that was incurred in or aggravated by service, or is presumed due to service. 38 U.S.C.A. §§ 1110, 1117, 1131, 5100, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.317 (2007). 3. The criteria for a rating in excess of 20 percent for duodenitis with duodenal ulcer and abdominal pain have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A (West 2002); 38 C.F.R. §§ 3.159, 4.114, Diagnostic Codes (DC) 7305 (2000 and 2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a 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. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice errors are presumed prejudicial unless VA shows that the error did not affect the essential fairness of the adjudication. To overcome the burden of prejudicial error, VA must show (1) that any defect was cured by actual knowledge on the part of the claimant; (2) that a reasonable person could be expected to understand from the notice what was needed; or, (3) that a benefit could not have been awarded as a matter of law. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). In the present case, the unfavorable rating decision that is the basis of this appeal was already decided and appealed prior to the enactment of the current § 5103(a) requirements in 2000. The Court acknowledged in Pelegrini that where, as here, the § 5103(a) notice was not mandated at the time of the initial rating decision, the RO did not err in not providing such notice. Rather, the veteran has the right to a content complying notice and proper subsequent VA process. Pelegrini, 18 Vet. App. at 120. The veteran's increased rating claim arises from his disagreement with the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. With respect to the veteran's service connection claims, the RO sent correspondence in March 2001 that fully addressed all four notice elements. The letter informed him of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. He was also asked to submit evidence and/or information in his possession to the RO. Subsequent letters were also sent providing notice on these issues. Here, the duty to notify was not satisfied prior to the initial unfavorable decision on the claim by the RO. Under such circumstances, VA's duty to notify may not be "satisfied by various post-decisional communications from which a claimant might have been able to infer what evidence the VA found lacking in the claimant's presentation." Rather, such notice errors may instead be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the RO's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the RO); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). As previously discussed, appropriate VCAA notice was sent to the veteran in the present case. Following such notice, the claims were properly readjudicated, curing the timing defect. With respect to the Dingess requirements, in March 2006, the RO provided the veteran with notice of what type of information and evidence was needed to establish a disability rating, as well as notice of the type of evidence necessary to establish an effective date. With that letter, the RO effectively satisfied the remaining notice requirements with respect to the issues on appeal. Based on the foregoing, adequate notice was provided to the veteran prior to the transfer and certification of his case to the Board and complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist the veteran in the development of the claim. This duty includes assisting him in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the veteran's service medical records, as well as post-service reports of VA and private treatment and examination. Moreover, the veteran's statements in support of his claim are of record. The Board has carefully reviewed such statements and concludes that he has not identified further evidence not already of record. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the veteran's claim. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Pertinent legal criteria for service connection Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). With chronic disease shown as such in service, or within a pertinent presumption period under 38 C.F.R. § 3.307, so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Continuity of symptomatology after discharge is required only where the condition noted during service (or in the presumption period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Service connection may also be granted if the evidence shows that the condition was observed during service and continuity of symptomatology was demonstrated thereafter, and if the evidence includes competent evidence relating the current condition to that symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997); 38 C.F.R. § 3.303(b). Where a veteran served continuously for 90 days or more during a period of war or after December 31, 1946, and specified diseases, such as arthritis or a psychosis, become manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. § 1101, 1112, 1113 (West 2002); 38 C.F.R. § 3.307, 3.309 (2007). To prevail on the issue of service connection, there must be medical evidence of (1) a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). When a disability is not initially manifested during service or within an applicable presumption period, direct service connection may nevertheless be established by evidence demonstrating that the disability was in fact incurred or aggravated during the veteran's service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002). PTSD The veteran seeks entitlement to service connection for PTSD. He claims that he has PTSD related to events he experienced during his Persian Gulf service. It is noted that during the pendency of this appeal, on November 7, 1996, the criteria for establishing PTSD underwent revision. For service connection to be awarded for PTSD prior to November 7, 1996, the evidence must show: (1) a current medical diagnosis of PTSD; (2) medical evidence of a causal nexus between current symptomatology and the claimed in- service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. 3.304(f); Moreau v. Brown, 9 Vet. App. 389 (1996). Effective November 7, 1996, element (1) listed above has been revised to require a medical diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a). In turn, the provisions of 38 C.F.R. § 4.125(a) require that a diagnosis of a mental disorder conform to the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994). Further relating to claims of service connection for PTSD, in Zarycki v. Brown, 6 Vet. App. 91 (1993), the United States Court of Appeals for Veterans Claims (Court) set forth the analytical framework and line of reasoning for determining whether a veteran was exposed to a recognizable stressor during service, which, as discussed above, is an essential element in solidifying a claim for service connection for PTSD. In Zarycki, it was noted that, under 38 U.S.C.A. § 1154(b), 38 C.F.R. §§ 3.304(d) and (f), and the applicable provisions contained in VA Manual 21-1, the evidence necessary to establish the incurrence of a recognizable stressor during service to support a claim of service connection for PTSD will vary depending on whether the veteran "engaged in combat with the enemy." See Hayes v. Brown, 5 Vet. App. 60 (1993). The determination as to whether the veteran "engaged in combat with the enemy" is made, in part, by considering military citations that expressly denote as much. Doran v. Brown, 6 Vet. App. 283, 289 (1994). However, the Court has held that the Board may not rely strictly on combat citations or the veteran's military occupational specialty to determine if he engaged in combat; rather, other supportive evidence of combat experience may also be accepted. See Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996); West v. Brown, 7 Vet. App. 70, 76 (1994). If combat is affirmatively indicated, then the veteran's lay testimony regarding claimed combat-related stressors must be accepted as conclusive as to their actual occurrence and no further development or corroborative evidence will be required, provided that the veteran's testimony is found to be "satisfactory," i.e., credible, and "consistent with the circumstances, conditions, or hardships of such service." Zarycki, 6 Vet. App. at 98. If there is no combat experience, or if there is a determination that the veteran engaged in combat but the claimed stressor is not related to such combat, there must be independent evidence to corroborate the veteran's statement as to the occurrence of the claimed stressor. Doran, 6 Vet. App. at 288-89 (1994). The veteran's testimony, by itself, cannot, as a matter of law, establish the occurrence of a non-combat stressor. Dizoglio, 9 Vet. App. at 166 (1996). Further, an opinion by a mental health professional based on a post-service examination of the veteran cannot be used to establish the occurrence of a stressor. Moreau v. Brown, 9 Vet. App. at 395-96 (1996); Cohen v. Brown, 10 Vet. App. 128 (1997). Here, the veteran has described several stressful in-service events. For example, in June 1994 the veteran submitted a stressor statement wherein he described how he had reported some questionable drug test results concerning his unit and which resulted in judicial punishment for two servicemen involved. He also related that while in Saudi Arabia he had injured his shoulder which was then strapped in a sling. As a result, he had to rely on other people to help him put on his gas mask during SCUD missile attacks. He was always scared and thought he might die because of this. He was also told that someone was out to get him because of what he knew about the drug falsification and other things. He described that on one occasion, he was told to sit in the back of the bus which was crowded even though there were empty seats in the front. A SCUD missile went off but because it was so crowded no one was able to help him put on his gas mask. He felt that he had been deliberately placed in a position where he would be harmed. As reported in VA treatment notes associated with a hospitalization from September to October 1997 at the PTSD Day Treatment Program in Tuscaloosa, the veteran was the unit clerk during service and was involved in registration of graves and dealing with the wounded with the medical unit. Upon VA examination in September 1998 the veteran contended that he was jailed and harassed for reporting abuses by superior officers in the Persian Gulf. A lay statement from the veteran's brother received in December 2000 indicated they were both deployed to the Persian Gulf. During the time the veteran was unable to put on his Mission Oriented Protective Posture gear, known as "MOP gear"; he had to wait until someone helped him or his brother found him and helped him. The brother also felt that the first sergeant was out to get the veteran and at times seemed to endanger his life. The brother felt this was due to jealousy over a female soldier with whom the veteran was friends. At his April 2002 VA examination, the veteran again described the traumatic event of not being able to put on his mask when he was on a bus in Saudi Arabia. However, he also described a number of things that troubled him about his experience in Saudi Arabia including the alleged inappropriate actions by his supervisors, his reporting the supervisors, his fellow soldiers' anger towards him, and his treatment upon return to the United States. The Board again notes that, if combat is affirmatively indicated, then the veteran's lay testimony regarding claimed combat-related stressors must be accepted as conclusive as to their actual occurrence and no further development or corroborative evidence will be required, provided that the testimony is found to be "satisfactory," i.e., credible, and "consistent with the circumstances, conditions, or hardships of such service." Zarycki, 6 Vet. App. at 98. The evidence of record does not support the conclusion that the veteran engaged in combat with the enemy. Indeed, the DD-214 does not reveal any awards or decorations indicative of combat. Moreover, his military occupational specialty of Personnel Administration Specialist is not suggestive of combat. It is acknowledged that "conclusive evidence" of combat participation may also be established by "other supportive evidence" that the claimant was in a plane crash, ship sinking, explosion, rape or assault, or duty on a burn ward or in a graves registration unit. See Zarycki, supra. The Board finds the term "other supportive evidence" is unclear as to the limitations, if any, on what can constitute "other supportive evidence." At a minimum, however, the law precludes the use of the claimant's own assertions as "other supporting evidence," nor would post-service medical evidence suffice as "other supporting evidence." To the extent that the term "other supporting evidence" in this context could consist of service department records, the Board finds that there are no service department medical or administrative records to establish that the claimant was in a plane crash, ship sinking, explosion, rape or assault, or had duty on a burn ward or in a graves registration unit. Thus, the Board finds that the record does not contain "conclusive evidence" that the veteran "engaged in combat with the enemy." As noted previously, where the record, as here, fails to establish that the veteran engaged in combat with the enemy, his lay statements as to in-service stressors cannot be accepted without further corroboration through independent evidence. Doran, 6 Vet. App. at 288-89. In the present case, the veteran contends that the stressor he experienced during service was after injuring his arm that he was unable to put on his protective gear during missile attacks. Service medical records indicate that the veteran had suffered a shoulder injury and wore a sling. In addition, the veteran's brother has written that the veteran was unable to put on his protective gear as needed due to his arm being in a sling. The Board finds that this is evidence of a stressor that the veteran experienced during service. In any event, the Board finds that the first element required to establish service connection for PTSD has not been met, inasmuch as the preponderance of the competent and probative medical evidence of record establishes that the veteran does not meet the diagnostic criteria for PTSD. Indeed, hospitalization records dated in July and August 1994 show treatment for paranoid schizophrenia. The discharge summary noted that prior to that he had been in a VA Medical Center in Tuscaloosa, Alabama for 7 weeks in their PTSD program and that he had been hospitalized for one week in April to May 1992 because of anxiety. However, the August 1994 discharge summary noted that during the course of the veteran's hospitalization, it was decided that he did not have PTSD but did have probably paranoid schizophrenia which probably did start when he was in Saudi Arabia. Moreover, on psychometric testing in November 1994 the summary was that his profile did not support a diagnosis of PTSD when compared to normative data for Vietnam veterans. He reported symptoms more consistent with a diagnosis of depression, somatoform disorder, or generalized anxiety. Furthermore, an addendum to a late September 1997 examination noted that psychological testing in November 1994 was not supportive of a diagnosis of PTSD. The diagnosis was given as schizophrenia, paranoid. Furthermore, SSA records show that the veteran is in receipt of SS disability benefits. The initial determination in October 1994 was based on a primary diagnosis of paranoid schizophrenia and other psychotic disorders. In May 1998, a determination was entered that his disability continued. The preliminary diagnosis was traumatic stress disorder and a secondary diagnosis of paranoid. A review found that his disability continued as of January 2004. The primary diagnosis shown was major depression, recurrent, severe without psychotic features and a secondary diagnosis of paranoia. Thus, the SSA records essentially reflect current disability diagnosed as other than PTSD. Additionally, VA examiners in April 2002, May 2002, and September 2004 concluded that the veteran did not meet the criteria for PTSD. The examiner in April 2002 concluded that although on the surface the veteran endorsed many symptoms of PTSD, it was difficult to attribute all of them to the traumatic event involving the gas mask. The examiner noted that many of the symptoms were related to the other incidents and circumstances of his experience. His reported traumatic event involving the gas mask did not meet all of the criterion for a PTSD diagnosis in DSM-IV. The examiner in April 2002 acknowledged prior diagnoses of PTSD and thought it was quite possible that the veteran had met the criteria in the past. Although, the examiner was concerned with the previous diagnoses due to the veteran's documented history of alcohol abuse which clouded the clinical picture. Regarding a previous diagnosis of paranoid schizophrenia, the veteran did not appear to suffer from this or any other psychotic disorder at the time of examination. It was also noted that the veteran appeared to have some narcissistic and paranoid traits that contributed to his current presentation and symptoms. The examiner noted this had also been the opinion of the examiner in February 1997 for a SSA examination. The examiner noted that other evidence in the medical record that put the diagnosis of PTSD in question included the psychological testing from April 1994 and November 1994. The examiner also noted that the veteran had suffered two significant personal losses since returning from the Gulf War which had surely contributed to his psychological problems through the years. At a VA examination for mental disorders other than PTSD in May 2002, it was determined that the veteran did not meet Criterion B for PTSD because he described no clear signs or symptoms of persistently re-experiencing traumatic events. He also did not endorse symptoms of numbing and was able to experience loving feelings for others as he was engaged to be married soon. After providing examples, the examiner concluded that the veteran did not meet Criterion C for a diagnosis of PTSD. Although he might meet Criterion D for a diagnosis of PTSD, these symptoms were more closely linked to psychosocial stressors in his life at the present time in addition to some symptoms of depression, (e.g. insomnia and irritability). The examiner noted that the veteran had previously been diagnosed and treated for PTSD. He found that it was during those time periods that the veteran was drinking heavily. Although PTSD was previously diagnosed, the course of the disorder can remit spontaneously and not evolve into a chronic condition meeting full criteria. This possibly explained why he did not have PTSD at that time. The examiner observed that despite the diagnosis of PTSD given to explain his symptoms in the past, objective testing conducted to clarify the diagnosis had brought this into question on more than one occasion. This included testing mentioned in a June 1994 discharge summary, and psychometric testing in November 1994. In a 1996 progress note for a PTSD day treatment program, it was mentioned that depression, anxiety and hopeless subscales were scored lower than average for a typical PTSD patient. The examiner noted that anxiety, depression, and hopelessness were not specific to PTSD. The examiner noted that the veteran had previously been diagnosed and treated for PTSD. He found that it was during those time periods that the veteran was drinking heavily. Although PTSD was previously diagnosed, the course of the disorder can remit spontaneously and not evolve into a chronic condition meeting full criteria. This possibly explained why he did not have PTSD at that time. The examiner observed that despite the diagnosis of PTSD given to explain his symptoms in the past, objective testing conducted to clarify the diagnosis had brought this into question on more than one occasion. This included testing mentioned in a June 1994 discharge summary, and psychometric testing in November 1994. In a 1996 progress note for a PTSD day treatment program, it was mentioned that depression, anxiety and hopeless subscales were scored lower than average for a typical PTSD patient. The examiner noted that anxiety, depression, and hopelessness were not specific to PTSD. In conclusion, the examiner found that it was likely that the onset of problems was after the alleged events which took place while he was on active duty. His problems seemed to have been most likely related to an adjustment disorder initially and not acute stress disorder or PTSD. The above reported problems, which seem to have worsened upon his return from active duty, were best explained by a diagnosis of adjustment disorder, chronic, with mixed disturbance of emotions and conduct. This disorder was likely complicated and worsened by a co-morbid diagnosis of alcohol abuses. Many of the symptoms and problems experienced over the years were best explained by an additional diagnosis of major depressive disorder, recurrent. There was no evidence to support a diagnosis of a psychotic disorder, bipolar disorder, panic disorder, general anxiety disorder or any current substance related disorder. The diagnosis was major depressive disorder, recurrent, moderate, without psychotic features, in partial remission. A VA physician provided a record review for PTSD in September 2004. The claims folder was reviewed and it included the records from the veteran's private physician. The reviewer noted that the VA psychiatrist who conducted an examination in April 2002 did not find criteria for a diagnosis of PTSD. The veteran was also examined in May 2002 by a psychiatrist. Neither of the two psychiatrists found enough evidence provided by the veteran to meet the criteria for PTSD as listed in the DSM-IV psychiatric diagnostic manual. Both VA psychiatrists reached the conclusion that the veteran suffered major depressive disorder. The VA reviewer physician reiterated some of the information provided by the May 2002 psychiatrist. The VA reviewer noted that although PTSD had been previously diagnosed, the course of this disorder "can remit continuously not evolve" into a chronic condition meeting four criteria. This possibly explained why the veteran did not have PTSD. The VA reviewer also reviewed the records from the veteran's private physician in which a diagnosis of PTSD is listed in the problem list. She stated that there was no evidence in the progress note reviewed of specific symptoms related to PTSD. There was no documentation that one can assess and entertain this diagnosis only that it is listed in the problem list. After review of all the information that had been provided, the VA physician reviewer confirmed the diagnosis provided by two VA psychiatrists during two prior compensation and pension examinations of depressive disorder, recurrent, moderate. It is noted that some evidence of record reflects diagnoses of PTSD. For example, VA treatment notes associated with a hospitalization from September to October 1997 at the PTSD Day Treatment Program in Tuscaloosa reveal diagnoses of PTSD. Also, a VA examination in September 1998 diagnosed post- traumatic stress disorder and dysthymic disorder. A private medical doctor wrote in November 2001 that the veteran had been a patient since July 2000. He had been diagnosed with PTSD since serving in the Gulf War from 1990 to 1991. He had been having some medical problems which were symptoms of PTSD, namely, insomnia, nightmares, mood swings, palpitations and agoraphobia. He was presently under psychiatric care but still had many significant symptoms. The doctor's clinical records from July 2000 to April 2004 show that in June 2001 the veteran complained of needing medication for PTSD status post military service. The assessment was PTSD. In August 2001 the diagnosis was post traumatic stress syndrome and in October 2001 the diagnosis was PTSD. Additionally, treatment records dated in July 2006 show a diagnosis of PTSD, along with alcohol dependence, paranoid schizophrenia, and depression. Although some medical records show a diagnosis of PTSD, it is again noted that two VA psychiatric examinations in 2002 and a review of the medical record by a VA mental health physician in September 2004, fail to diagnose the appellant with PTSD. Neither of the two psychiatrists who examined the veteran in 2002 found enough evidence provided by the veteran to meet the criteria for PTSD as listed in the DSM-IV psychiatric diagnostic manual. One psychiatrist, mentioned by the reviewer, specifically noted that the veteran reported a traumatic event while on active duty service which met the criterion A for the DSM-IV diagnosis of PTSD; however, he did not meet criteria B or C under DSM-IV. As criteria B and C are essentially the same under the prior version in DSM-III- R, he did not meet the criteria for PTSD as listed in DSM- III-R. Thus, neither version is more favorable to the veteran. The Board accords great probative value to the VA psychiatric evaluation in September 2004, which was specifically obtained for the purpose of resolving the question of whether the veteran met the criteria for PTSD. The reviewer's conclusion was based on a review of the private and VA medical records, the veteran's history, and the examination reports of the veteran. As such, the Board finds that such evidence is persuasive on the question of diagnosis, and hence, dispositive of the issue on appeal. Based upon careful review of the evidence of record, the Board concludes that the preponderance of the evidence is against a finding that the veteran has PTSD related to his Persian Gulf War service. Initially the Board notes, that although during a hospitalization in July and August 1994, a diagnosis of paranoid schizophrenia was entered and an opinion was that it probably did start when the veteran was in Saudi Arabia, a current diagnosis of schizophrenia is not shown. In addition, the discharge summary noted that the veteran had been hospitalized for one week in April to May 1992 because of anxiety, this would be after the applicable presumptive period, but more importantly a current diagnosis of anxiety disorder is not shown. The April and May 2002 VA examiners found no evidence of schizophrenia or other psychotic disorder or general anxiety disorder. The Board has carefully considered the veteran's statements and the lay statements of his brother in adjudicating the issue on appeal. Each is certainly competent, as a lay person, to report that as to which he has personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Although there is some indication that the veteran has worked as a Medical Clerk, neither he nor his brother, are competent to offer a medical opinion as to cause or etiology of the claimed disability, as there is no evidence of record that either has specialized medical knowledge. See Routen v. Brown, 10 Vet. App. 183, 186 (1997) (a layperson is generally not capable of opinion on matter requiring medical knowledge), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The lay statements are not competent medical evidence as to a nexus between the veteran's claimed current disorder of PTSD and active service, or as to claimed continuity of symptomatology demonstrated after service. In this case, the Board finds the post-service medical record, as a whole, provides highly probative evidence against a finding that the veteran has PTSD. As a result, on this basis, further stressor development would be moot, and the claim must be denied. As the preponderance of the competent and probative medical evidence medical evidence establishes that the appellant does not meet the diagnostic criteria for PTSD, the Board finds that a critical element necessary to establish service connection for such disorder is lacking, and that further analysis into the remaining criteria of 38 C.F.R. § 3.304(f), such as stressor verification, simply is not necessary. The claim on appeal must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Joint Pain and weakness The veteran seeks entitlement to service connection for joint pain and weakness due to undiagnosed illness. As documented by his military records, the veteran is a Persian Gulf War veteran, having served in the Southwest Asia Theater of operations during the Persian Gulf War during the period from January 11, 1991 to January 31, 1991. 38 U.S.C.A. § 1117(e); 38 C.F.R. § 3.317(d). Accordingly, the VA provisions pertaining to Persian Gulf veterans are applicable to this case. Under the provisions of specific legislation enacted to assist veterans of the Persian Gulf War, service connection may be established for a chronic disability resulting from an undiagnosed illness which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2011. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. The term "Persian Gulf veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(d)(1). The Southwest Asia Theater of operations 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)(2). On December 27, 2001, the President signed HR 1291, the "Veterans Education and Benefits Expansion Act of 2001" (VEBEA), Pub. Law 107-103, 115 Stat. 976 (December 27, 2001). Section 202(a) of the Act amended 38 U.S.C.A. 1117 to expand the definition of "qualifying chronic disability" (for service connection) to include not only a disability resulting from an undiagnosed illness as stated in prior law, but also any diagnosed illness that the Secretary determines in regulations warrants a presumption of service-connection under 38 U.S.C.A. 1117(d). Section 202(a) also expanded compensation availability for Persian Gulf veterans to include "medically unexplained chronic multisymptom illness," such as fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome, which is defined by a cluster of signs or symptoms. The regulation was amended in 2003 to incorporate these changes, and that amendment was made retroactively effective March 1, 2002. See 68 Fed. Reg. 34539-543 (June 10, 2003). The new 38 C.F.R. § 3.317(a)(2)(ii) was added defining the term "medically unexplained chronic multisymptom illness" to mean "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." It was further stated that, "Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained." As yet, VA has not identified any illness other than the three identified in section 202(a) as a "medically unexplained chronic multisymptom illness;" therefore, the new 38 C.F.R. § 3.317(a)(2)(i)(B) only lists chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome as currently meeting this definition. See 68 Fed. Reg. 34539-543 (June 10, 2003). It was provided, however, in the new 38 C.F.R. § 3.317(a)(2)(i)(B)(4) that the list may be expanded in the future when the Secretary determines that other illnesses meet the criteria for a "medically unexplained chronic multisymptom illness." A "qualifying chronic disability" means a chronic disability resulting from any of the following (or any combination of any of the following): an undiagnosed illness; a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms; and any diagnosed illness that the Secretary determines. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1)(i). Objective indications of a 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. 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. A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from the VA's Schedule for Rating Disabilities for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. A disability referred to in this section shall be considered service- connected for the purposes of all laws in the United States. 38 C.F.R. § 3.317(a). Signs or symptoms which may be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, fatigue, unexplained rashes or other dermatological signs or symptoms, headaches, muscle pain, joint pain, neurological signs and symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317(b). Here, the Board notes that VA does not generally grant service connection for symptoms alone, without an identified basis for those symptoms. For example, "pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted." Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), dismissed in part, vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001); Evans v. West, 12 Vet. App. 22, 31-32 (1998). The notable exception to this rule is 38 C.F.R. § 3.317, which permits, in some circumstances, service connection of signs or symptoms that are objective indications of chronic disability, as though such disability is due to an undiagnosed illness. The United States Court of Appeals for the Federal Circuit has held that when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. Combee v. Brown, 34 F.3d 1039 (Fed. Cir.1994). The Board has therefore also given consideration to whether service connection may be granted for the appellant's claimed disorder regardless of his Persian Gulf service. Service medical records do not show complaints, signs or symptoms of generalized joint pain or weakness. The veteran was in an automobile accident in October 1983 and bruised his knees, elbow and back. At the time of his separation examination in December 1983, it was noted that he had a bruised right knee and the others had had resolved. At the time of his enlistment examination in June 1989, his spine and upper and lower extremities were clinically evaluated as normal. In June 1990 he complained of left leg pain from the ankle to the knee. The assessment was shin splints and "LLC" ligament sprain. In July 1990 he suffered a fall and was treated for left elbow and shoulder complaints. He recovered from these injuries; however, in January 1991 he reinjured his left shoulder while in Saudi Arabia. He was medically evacuated to the United States for an evaluation. Post service, at a VA orthopedic examination in November 1994 the veteran complained of generalized joint aches and cramps. All tests including for rheumatoid factor were negative. The examination showed left shoulder sprain and arthroscopic surgery with sequelae and left elbow medial epicondylitis. Service connection for a left shoulder disability is in effect. A November 1996 statement from a private chiropractor indicates that the veteran sought treatment in September 1996 for symptoms related to the service-connected left shoulder. At a VA examination for joints in July 1997, the veteran stated that he had been involved in a car wreck in 1983 at which time he had neck pain and back pain and was told he had broken vertebrae. The examiner noted that the claims file did not indicate any of those. The veteran also gave a history of knee pain, and left hip pain and multiple other complaints. The veteran stated that his left hip had been painful intermittently over the last two years, but in recent months it had been constant. His left knee started bothering him approximately one year earlier. On examination he denied any lower back problems, right lower extremity or right upper extremity problems. He did mention that his neck hurt but it did not bother him at that time. The diagnosis was degenerative joint disease of the left knee. Otherwise, the remainder of the examination was within normal limits. At a VA examination in September 1997, review of his musculoskeletal system was negative except for problems with chronic left shoulder pain related to an old injury and some chronic low back pain problems and chronic pain in his feet, believed related to ingrown toenails. On examination, he had full range of motion of his extremities with all pulses 3+ and equal with no pedal edema. The assessment was history of traumatic injury to the left shoulder lifting sand bags in Gulf War with continued chronic pain. An outpatient discharge summary in November 1997 for a period of treatment from September to October 1997 for an unrelated disorder noted that during the treatment period the veteran had complained of knee and ankle pain. X-rays showed a slight effusion of the left knee but no fracture or other acute change was noted. On Axis III, included was traumatic arthritis, particularly of knees. In January 1998 when evaluated for a psychiatric condition, his complaints of chronic weakness and fatigue were noted as may be related to depression. Private medical records show that the veteran sought treatment in October 2001 for complaints of knee pain and hand pain. On examination his knees showed laxity with the left lateral collateral ligament greater than the right collateral ligament. He was assessed with joint pain. He was assessed with left knee pain in August 2002. At an April 2004 VA general medical examination, the examiner noted that the veteran had been involved in a motor vehicle accident in 1983 while off duty. He had injuries to his head, face and knees. He also injured his left shoulder. He was told that he had a torn cartilage in his left knee. The diagnoses were arthralgias of the left shoulder, with no significant loss of function. History of trauma to his left knee in the motor vehicle accident, with residual mild loss of function due to pain, apparently due to a torn meniscus. At a VA medical examination in July 2006 for joints, a review of the musculoskeletal system noted that the veteran had occasional arthralgias and myalgias and joint pain of the left shoulder, knee and elbow. The veteran related that he had fallen off a cliff in the field in 1989 while stationed at Fort Ben Harrison, Indiana. He injured his left elbow and left thigh. He was seen at a post hospital and kept four days. He also had a head injury. He was given a left elbow sling. He was given a profile due to left elbow injury. He complained of continued pain. He developed left knee pain after he stepped the wrong way. He had left knee pain once every few months. The history noted injury to the left elbow, left knee and left shoulder. The joints involved were the left elbow, shoulder and knee and no other. X-rays revealed no abnormalities of the left elbow or bilateral knee. The diagnosis was residuals of left shoulder arthroscopic surgery. He had left knee pain with insufficient evidence to warrant an acute diagnosis. There was a normal examination and normal x-ray. He had left elbow pain with insufficient evidence to warrant an acute diagnosis with normal examination and normal x-ray. The veteran is seeking entitlement to service connection for chronic multiple joint pain and weakness as a result of unknown environmental conditions to which he was exposed during his service in the Southwest Asia theater of operations. As shown at the July 2006 VA examination for joints, the joints involved are the left elbow, shoulder and knee and no other. The veteran gave a history of injury to the left elbow, left knee and left shoulder. As previously stated, the veteran is service-connected for a left shoulder disorder. As the veteran has claimed that he suffered an injury to the left elbow and left knee, the claimed condition of joint pain cannot be the product of an unidentified etiology. Although arthritis of the left knee was not diagnosed at the July 2006 VA examination, at an earlier VA examination in July 1997, there was a diagnosis of arthritis of the left knee and traumatic arthritis was shown in an outpatient discharge summary in November 1997. Therefore, his complaints of left knee pain (or joint pain) would be attributed to a known diagnosis of arthritis. There is no evidence of joint pain as manifestation of an undiagnosed illness. Thus, service connection is not warranted pursuant to the provisions of 38 C.F.R. § 3.317. The Board thus turns to the merits of the veteran's claim on a direct basis. Service medical records show that he bruised his elbow and knees in an automobile accident in October 1983 which had resolved by his December 1983 separation examination. At a June 1989 re-enlistment examination, no defects of his upper or lower extremities were noted. The records show that in July 1990 he was treated for left elbow complaints after a fall but recovered from this injury. Thus, a chronic acquired left knee or left elbow disorder is not shown in service. The evidence of record does not show findings or a diagnosis of arthritis of the left knee or left elbow to a compensable degree within the first year post service. Accordingly, service connection cannot be granted on a presumptive basis. At a VA examination in July 1997, the veteran stated that his left knee had started to bother him approximately in summer of 1996. The diagnosis was degenerative joint disease of the left knee. This medical evidence, however, shows onset of left knee disability many years after service and does not provide a link to service or an incident in service. Although traumatic arthritis, particularly of the knees, was shown on a November 1997 discharge summary for an unrelated disorder, this is not competent medical evidence of a nexus between the veteran's claimed joint pain and active service. A VA examiner in April 2004 diagnosed history of trauma to the left knee in a motor vehicle accident, with residual mild loss of function due to pain, apparently due to a torn meniscus. However, the diagnosis relating a left knee condition to a motor vehicle accident in service is based on the history as provided by the veteran. Although he is competent to relate that he was in an automobile accident, the history he provided in April 2004 as to the injury suffered in that accident is not substantiated by the medical evidence of record at the time of the accident. The contemporaneous medical records in October 1983 show that the veteran bruised his knees in the automobile accident and that condition had resolved by the time of an examination in December 1983. Accordingly the April 2004 medical report is of no probative value. Swann v. Brown, 5 Vet. App. 229, 233 (1993) (generally observing that a medical opinion premised upon an unsubstantiated account is of no probative value, and does not serve to verify the occurrences described); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (the Board is not bound to accept a physician's opinion when it is based exclusively on the recitations of a claimant). At a July 2006 VA joints examination, a history of injury to the left elbow and left knee was provided. However, the examination of his left knee and left elbow was normal as were the x-rays. The examiner diagnosed left knee pain and left elbow pain with insufficient evidence to warrant an acute diagnosis. In the absence of proof of a current disease or injury, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. §§ 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328 (1997). That said, the evidence simply does not demonstrate the appellant carries a diagnosis of any clinical joint disorder of the left knee or left elbow. Pain alone, without a diagnosed or identifiable underlying malady or condition, does not, in and of itself, constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), aff'd in part, vacated and remanded in part on other grounds by Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). As such, there is no basis on the current record to grant service connection for the claimed disability of joint pain. The veteran is competent, as a layman, to report that as to which he has personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, lay individuals are not considered competent to offer medical opinions or diagnoses, and statements to that effect do not provide a basis upon which to establish service connection. See Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opinion on matters requiring medical knowledge"), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Therefore, the veteran's assertions are not competent medical evidence of a nexus (that is, a causal link) between current joint pain and his active service, or claimed continuity of symptomatology demonstrated since he left service. Based upon careful review of the evidence of record, the Board concludes that the preponderance of the evidence is against a finding that the veteran has a left knee or left elbow disorder that began during service. The documentary record is of high probative value. There is no competent medical evidence of record that shows arthritis of the left knee or left elbow was manifested within one year after service. There is no competent medical evidence that the veteran currently has a chronic acquired left knee disorder or left elbow disorder which has been linked to service. No probative, competent medical evidence exists of a relationship between any claimed current left knee disorder or left elbow disorder and any continuity of symptomatology asserted by the veteran. See McManaway v. West, 13 Vet. App. 60, 66 (1999) (holding that, where there is assertion of continuity of symptomatology since service, medical evidence is required to establish "a nexus between the continuous symptomatology and the current claimed condition"), vacated on other grounds sub nom. McManaway v. Principi, 14 Vet. App. 275 (2001); Voerth v. West, 13 Vet. App. 117 (1999); Savage v. Gober, 10 Vet. App. 488 (1997). In summary, the Board concludes that the preponderance of the competent and probative evidence is against finding that the veteran's claimed joint pain and weakness is related to any incident during service or to a service-connected disability. Thus, the preponderance of the evidence is against granting service connection, either on a direct basis, a presumptive basis, or as a manifestation of undiagnosed illness. Since the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, the claim for service connection for joint pain and weakness must be denied. Duodenitis with duodenal ulcer and abdominal pain The veteran seeks an initial rating in excess of 20 percent for his duodenitis with duodenal ulcer and abdominal pain. Disability ratings are based upon schedular requirements that reflect the average impairment of earning capacity occasioned by the state of a disorder. 38 U.S.C.A. § 1155. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4 (2007). In determining the level of impairment, the disability must be considered in the context of the entire recorded history, including service medical records. 38 C.F.R. § 4.2 (2007). An evaluation of the level of disability present must also include consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (2007). Also, where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2007). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 199 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). There are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding. 38 C.F.R. §§ 4.14, 4.113 (2007). Ratings under DCs 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Effective July 2, 2001, the rating criteria used to determine the severity of disabilities affecting the digestive system were revised. However, there were no substantive changes to DC 7305. Diagnostic Code 7305, under both the previous and revised versions, provides that a 20 percent rating is warranted for a moderate ulcer disorder with recurring episodes of severe symptoms two or three times per year averaging ten days in duration, or with continuous moderate manifestations. A 40 percent rating is warranted for a moderately severe ulcer condition with less than severe symptoms, but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging ten days or more in duration at least four or more times per year. A maximum 60 percent rating is warranted for a severe ulcer condition with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. 38 C.F.R. § 4.114 DC 7305 (2000 and 2007). After review of the claims file, the Board finds that entitlement to an initial rating in excess of 20 percent for duodenitis with duodenal ulcer with abdominal pain is not shown. Service medical records show that the veteran was seen during his first period of service two times in 1981 for complaints of stomach pain, vomiting and diarrhea assessed as gastroenteritis. When privately hospitalized in October 1983 for injuries sustained in an automobile accident, a history of a diagnosed peptic ulcer with bleeding in 1981 was reported. At his December 1983 examination prior to separation from his first period of service, a clinical evaluation revealed no pertinent abnormalitities. In the Medical History accompanying this examination the veteran answered yes in regard to stomach trouble. The physician's comment was that the veteran had had a peptic ulcer in 1982 that had resolved. During a VA medical examination conducted in November 1994 the veteran complained of continuous abdominal pain. The diagnoses of the examination included either erosion of the stomach or ulcer of the stomach and probable duodenal ulcer with duodenitis. Based on the above, the Board in a March 2003 decision concluded that the veteran probably experienced the initial symptoms of duodenal ulcer disease and chronic duodenitis during service and granted entitlement to service connection for these disorders on a direct incurrence basis. In an April 2003 rating decision, the RO granted service connection for duodenitis with a duodenal ulcer and assigned a 20 percent evaluation effective March 6, 1994 under DC 7305 for moderate manifestations of pain. For a rating in excess of 20 percent to be assigned, the evidence must demonstrate a moderately severe ulcer condition with less than severe symptoms, but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging ten days or more in duration at least four or more times per year. 38 C.F.R. § 4.114, DC 7305. VA medical records show that on examination during a period of hospitalization for another disorder from April to June 1994 the veteran's weight was 152 and his abdomen was tender in the right lower quadrant. Anemia was not shown. In July 1994 his weight was 162 and his abdomen was soft and moderately obese. He had active bowel sounds and no tenderness. In November 1994, the veteran weighed 164 pounds and his maximum weight in the prior year was 145. He was well developed and well nourished. Testing revealed his complete blood count was normal. He complained of continuous pain described as a spasm or sharp pain. At a VA examination in August 1997 the veteran weighed 155 pounds and his maximum weight the prior year was 160. He was well developed and well nourished. He complained of cramping pain and had been placed on medication for an infection. He was improved but still had cramping pain and constipation. On examination, he had mild pain to the right of the umbilicus with no rebound tenderness. His bowel sounds were normoactive. Anemia was not shown in blood work in September and October 1997. In January 1998 his weight was 152. On examination in September 1997, a history of diverticulitis with chronic right lower quadrant pain and excessive gas at times was noted. The examiner noted that his history was negative for any history of blood disorder. Clinical findings were that he weighed 150 pounds and was well developed and well nourished. His abdomen was nontender. There was no rebound tenderness and bowel sounds were normal. The impression was history of diverticular disease, chronic right lower quadrant pain and excessive flatulence. On routine examination in October 1997, he was well developed and well nourished. His weight was 150 pounds. Anemia was not shown. Private medical records show that from July 2000 to October 2003 his weight ranged from 164 1/2 to 179 pounds. At a VA examination in April 2004, the veteran had complaints of abdominal pain with constipation. He weighed 168 pounds. Examination of his abdomen was negative. The diagnosis was recurrent abdominal pain of unknown cause. There was no evidence for peptic ulcer disease or diverticulosis. He did have one cecal diverticulum which had been removed. Private medical records from February to May 2004 show the veteran was seen on referral for evaluation of pain in his right upper quadrant of about three months duration. The pain seemed to increase after eating and he had some nausea and vomiting. He also had problems with alternating diarrhea and constipation. There was no definite history of peptic ulcer disease. He had lost about 10 pounds in the prior month. His abdomen was soft with present bowel sounds and no mass or tenderness. The impression was abdominal pain, nausea, vomiting, alternating constipation, diarrhea and weight loss. His private medical doctor noted after testing in April 2004 that an endoscopy found the veteran had a hiatal hernia and gastritis but was otherwise negative. The exam was otherwise negative. In May 2004 his weight was 170. His doctor noted that a CAT scan did not see evidence of a hernia. A colonoscopy was negative except for a couple of polyps which were removed and were hyperplastic. The impression was abdominal pain, etiology not clear. At a VA general medical examination in July 2006 the veteran noted continued abdominal pain occurring once in three months and lasting one to two days. He took Maalox on an as needed basis. The course has been stable since onset. The review of the abdomen/gastrointestinal system noted that the veteran had abdominal discomfort when he ate spicy foods and took Maalox which helped. He also had a duodenal ulcer and duodenitis. He reported no problems and was asymptomatic at the time of the examination. On examination in July 2006, he appeared well developed and well nourished. His weight was 174 pounds. A weight loss was noted which was less than 10 percent when compared to his baseline. Anemia was not shown. His bowel sounds were normal. There was no tenderness and no abdominal guarding. He had no period(s) of incapacitation. The examiner concluded that the veteran had duodenitis with duodenal ulcer causing abdominal pain. At that time, he got abdominal pain rarely. He took Maalox. The examiner opined that the veteran had mild symptoms at times which did not interfere with daily activities or with work. The evidence in this case reflects that the veteran has continued complaints of abdominal pain that is relieved by over the counter medication. There is no evidence, however, demonstrating moderately severe symptoms averaging 10 days in duration at least four or more times a year. Most recently, at his examination in July 2006 he reported having abdominal pain once every three months that lasted only for a day or two. The evidence throughout the period does not show that anemia has been diagnosed. The veteran's weight has fluctuated during the time period on appeal with a weight loss of 10 pounds reported in early 2004 and the July 2006 examiner noted the veteran had a weight loss which was less than 10 percent when compared to his baseline. But fluctuation of his weight and a weight loss of less than 10 percent are not manifestations of impairment of health due to moderately severe symptoms as he was consistently described as well nourished. The July 2006 examiner also described the veteran's symptoms as mild. Accordingly, the duodenal ulcer disease may not reasonably be characterized as moderately severe. The Board has also considered whether the record raises the matter of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2005). In this case, the Schedule is not inadequate. The Schedule does provide for higher ratings for the veteran's gastrointestinal disability, but, as discussed above, findings supporting a higher rating have not been documented. In addition, it has not been shown that the service-connected disability has required frequent periods of hospitalization or has produced marked interference with the veteran's employment. For these reasons, the Board finds that referral for assignment of an extraschedular rating for this disability is not warranted. In sum, the weight of the credible evidence demonstrates that the veteran's gastrointestinal disability warrants no more than a 20 percent rating for the entire period under consideration. The veteran's symptoms remained constant throughout the course of the period on appeal and as such a staged rating is not warranted. Fenderson v. West, 12 Vet. App. 199 (1999). As the preponderance of the evidence is against the claim for an initial increased rating for the veteran's service-connected duodenitis with duodenal ulcer with abdominal pain, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for PTSD is denied. Entitlement to service connection for joint pain and weakness is denied. Entitlement to a disability rating in excess of 20 percent for duodenitis with duodenal ulcer with abdominal pain is denied. ____________________________________________ ERIC S. LEBOFF Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs