Citation Nr: 1303465 Decision Date: 02/01/13 Archive Date: 02/08/13 DOCKET NO. 09-07 591 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD), an adjustment disorder, bipolar disorder, and a depressive disorder. 2. Entitlement to service connection for nightmares, fatigue, memory loss, quick temper, depression, and difficulty sleeping, to include as due to an undiagnosed illness. 3. Entitlement to service connection for headaches, to include as due to an undiagnosed illness. 4. Entitlement to service connection for joint pain, muscle pain, and spasms, to include as due to an undiagnosed illness. 5. Entitlement to service connection for loss of tooth number eight due to trauma. 6. Entitlement to service connection for a right ankle disorder, to include as secondary to service-connected left ankle disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Whitehead, Counsel INTRODUCTION The Veteran served on active duty from September 1986 to March 1994, to include service in the Southwest Asia theater of operations. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in March 2008 and September 2010 issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho. The Board notes that although the Veteran currently lives in Oregon, his claims were adjudicated by the Boise RO because the Veteran is a VA employee at the RO in Portland, Oregon. The medical evidence of record includes multiple psychiatric diagnoses, to include PTSD, an adjustment disorder, bipolar disorder, and a depressive disorder. Case law provides that a claim for a mental health disability includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Brokowski v. Shinseki, 23 Vet. App. 79 (2009); see also Clemons v. Shinseki, 23 Vet. App. 1 (2009). Thus, pursuant to the holding in Clemons, the Board has more broadly characterized the psychiatric claim on appeal. A video conference hearing was held in November 2012 before Kathleen K. Gallagher, a Veterans Law Judge who was designated by the Chairman to conduct hearings pursuant to 38 U.S.C.A. § 7107(c) (West 2002) and who is rendering the determination in this case. A transcript of the hearing is in the claims file. In his September 2008 notice of disagreement, the Veteran claimed that he currently has a left shoulder disorder due to injuries he sustained in service. He appears to be seeking service connection for a left shoulder disorder. Thus, the issue of service connection for a left shoulder disability has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issues of service connection for headaches, joint and muscle pain, a right ankle disorder, and loss of tooth number eight are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. All known and available service medical records have been obtained; the Veteran has been advised under the facts and circumstances of this case as to the evidence which would substantiate his claim for service connection for a psychiatric disability, to include PTSD and service connection due to an undiagnosed illness; and he has otherwise been assisted in the development of his claims. 2. The Veteran had active duty service in the Southwest Asia theater of operation during operation Desert Storm. 3. There is a diagnosis of PTSD due to service stressors made by a VA psychologist. 4. The Veteran has PTSD that is due to an event or incident of his active service. 5. The evidence of record shows that the Veteran's reports of depression, fatigue, memory loss, nightmares, quick temper, and sleep difficulty are attributable to his PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD are met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). 2. As to the claim for service connection for depression, nightmares, fatigue, memory loss, quick temper, and difficulty sleeping, these are symptoms of, and cannot be separated from, the Veteran's now service-connected PTSD; his claim for service connection for these symptoms is moot, and the appeal is therefore dismissed. 38 U.S.C.A. § 7105(d) (West 2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Board is granting in full the benefits sought with respect to the claim for service connection for PTSD. Accordingly, assuming, without deciding, that any error was committed with respect to the duty to notify or the duty to assist for this issue, such error was harmless and will not be discussed. With regard to the issue of service connection for a disorder manifested by depression, fatigue, quick temper, memory loss, nightmares, and difficulty sleeping, to include as due to an undiagnosed illness, the facts in this appeal are not in dispute and the issue will be decided as a matter of law (see discussion below). The legal outcome is clearly dictated by the existing law regardless of any further notice the Veteran might receive. See Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (VCAA notice not required where there is no reasonable possibility that additional development will aid the veteran); see also Mason v. Principi, 16 Vet. App. 129, 132 (2002) (VCAA not applicable "because the law as mandated by statute and not the evidence is dispositive of the claim"). Thus VA's duties to notify and assist with regards to this claim will not be discussed further. Legal Criteria for Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996)(table). The second and third elements may be established by showing continuity of symptomatology. Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (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); see also Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). Service connection for certain "chronic" diseases, such as psychoses, may also be established based on a legal "presumption" by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.307, 3.309. 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). Pertaining to veterans who served in the Southwest Asia theater of operations during the Persian Gulf War, service connection may also be established under 38 C.F.R. § 3.317. Under that section, service connection may be warranted for (1) a Persian Gulf Veteran who (2) exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; which (3) became manifest either 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; and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. See 71 Fed. Reg. 75669,75672 (Dec. 18, 2006); 38 C.F.R. § 3.317(a)(1). Section 3.317 explicitly acknowledges that a claimant's "signs or symptoms" need not be shown by medical evidence; however, the regulation does specifically require some "objective indications" of disability. See 38 C.F.R. § 3.317(a). "'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)(2). Thus, although medical evidence of signs or symptoms is clearly not required to grant a claim, the regulation does require that there be some objective, independently verifiable evidence of the symptoms. Id. For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multisymptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A. § 1117(d) warrants a presumption of service-connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470, 472 (2006). A medically unexplained chronic multi-symptom illnesses is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multi-symptom illness. 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)(ii). "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 multisymptom 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). 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). In cases where a Veteran applies for service connection under 38 C.F.R. § 3.317 but is found to have a disability attributable to a known diagnosis, further consideration under the direct service connection provisions of 38 U.S.C.A. §§ 1110 and 1131 is warranted. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). In relevant part, 38 U.S.C.A. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Finally, in a claim for service connection, the ultimate credibility or weight to be accorded evidence must be determined as a question of fact. The Board determines whether (1) the weight of the evidence supports the claim, or (2) the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim- the appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. Ap. 49 (1990). PTSD The Veteran claims that he is entitled to service connection for PTSD, which he attributes to his service in the Persian Gulf. In addition to the criteria for service connection explained above, service connection for PTSD requires medical evidence establishing a diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressors. 389 C.F.R. § 3.304(f). Under a recently amended regulation, if a stressor claimed by a veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304(f)(3) (effective July 13, 2010). The Veteran served in Desert Storm, specifically from September 1990 to April 1991. His military decorations and badges include the Southwest Asia Service Medal with two Stars, the Kuwait Liberation Medal, the Army Achievement Medal, M16 Sharp-shooter Badge, and the National Defense Service Medal. Campaigns included the Defense of Saudi Arabia and the Liberation and Defense of Kuwait. His service personnel records reflect that he served as a mobile subscriber equipment transmission system operator. Thus, his service in the Southwest Asia theater of operations has been confirmed. The Veteran's service treatment records do not contain complaints or findings of a psychiatric disorder. PTSD was diagnosed during a VA Persian Gulf Registry examination in July 2006, at which time the Veteran reported frequently seeing dead bodies during his service in the Persian Gulf. He also recalled being awakened numerous times by the sound of rocket launchers, experiencing some mortar fire, and being involved in some small arms fire. The Veteran was also assessed as having depression. A July 2006 VA psychiatry note shows an Axis-I diagnosis of adjustment disorder, rule out PTSD from childhood. During a January 2007 VA psychiatric evaluation, the Veteran reported symptoms of poor concentration, combat related nightmares and sleep impairments, irritability, and mood swings. Additional symptoms included flashbacks, intrusive memories, and hypervigilance. The examiner noted that PTSD was initially diagnosed in early 2006 by either a clinical social worker and/or psychiatrist and that the Veteran wished to receive follow up treatment to control his psychological distress. Following a mental status examination, the assessment was PTSD with combat symptoms, rule out adjustment disorder with mixed depression and anxious mood. The Veteran underwent an additional psychiatric evaluation in February 2007. The examiner noted that he was deployed to the Persian Gulf area and that although his military occupational specialty was in communications, the Veteran functioned as a M60 gunner on a M-88 recovery vehicle. His description of this service included a report of his involvement in recovery missions in areas of heavy combat, seeing many dead bodies and body parts, experiencing rocket attacks and incoming fire, his unit being misdirected and having to navigate through a mine field, and being present on several occasions when the chemical detectors in his camp went off. The Veteran described feeling scared and terrified during these events. Axis-I diagnoses of PTSD and bipolar disorder were provided following the clinical evaluation. Subsequent VA treatment records dated in May 2007 reflect a diagnosis of PTSD with a history of combat related trauma included as a psychosocial and environmental stressor. The Veteran was provided a VA PTSD examination in July 2011. After a review of the claims files and evaluation of the Veteran, the VA clinical psychologist concluded that the Veteran met the criteria for a PTSD diagnosis. The stressors that contributed to this diagnosis included the Veteran events during the Veteran's service in Saudi Arabia and Iraq, specifically reported as: (1) witnessing burned out wreckage, skulls, and other body parts; (2) hearing chemical detectors go off while on vehicle patrol and witnessing dead animals with no obvious source of death; and (3) seeing and hearing gunshots, explosions, military aircrafts, and scud missiles. The examiner determined that all of the identified stressors related to the Veteran's fear of hostile military or terrorist activity. The symptoms associated with the PTSD diagnosis included depressed mood, panic attacks, chronic sleep impairment, mild memory loss, impaired abstract thinking, disturbances of motivation and mood, and suicidal ideations. The examiner also rendered a diagnosis of a depressive disorder; the examiner determined that it was not possible to differentiate the symptoms specifically attributable to each of the psychiatric diagnoses, as the depression appeared to be at least partially secondary to PTSD. Regarding the Veteran's reports of experiencing abuse as a child, the examiner stated that it likely served as a vulnerability leaving the Veteran more susceptible to the later development of PTSD. However, his childhood did not appear to directly account for his symptoms, as the re-experiencing content is of Iraq and his PTSD symptoms developed after his deployment. The above evidence reveals that there is a diagnosis of PTSD due to service stressors by a VA psychologist during a psychiatric evaluation in July 2011 that included review of the claims files; and that the examiner essentially concluded that the Veteran's claim of service stressors, such as hearing gunshots and missile fire, and seeing dead bodies, was credible evidence resulting in fear of hostile military action. There is evidence that the Veteran received medals showing service in Desert Storm, that he served as a mobile subscriber equipment transmission system operator, and that he was trained in the use of an M16 rifle. The Board does not find clear and convincing evidence to negate the finding that the Veteran's PTSD symptoms are due to service stressors. Moreover, the Board concludes that the claimed stressors are consistent with the places, types, and circumstances of the Veteran's service in Desert Storm. The requirements under the amended VA regulation 38 C.F.R. § 3.304(f)(3) as to stressors are met. Because there is a July 2011 diagnosis of PTSD due to service stressors; credible supporting evidence that the claimed in-service stressor actually occurred; and a link, established by the July 2011 report between the Veteran's psychiatric symptomatology and the claimed in-service stressors, service connection for PTSD is warranted. As a final matter, the Board observes that, in addition to PTSD, the Veteran has been diagnosed with an adjustment disorder, depressive disorder, and bipolar disorder during the pendency of the appeal. However, the Veteran's now service-connected psychiatric disorder essentially includes all of the symptoms of his PTSD and other diagnosed psychiatric conditions. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Even without considering the dictates of Clemons, the Board would be precluded from differentiating between the symptoms of the Veteran's PTSD and other psychiatric conditions in the absence of clinical evidence that clearly showed such a distinction. See Mittleider v. West, 11 Vet. Ap. 181, 182 (1998), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). Thus, the Board need not address whether service connection is warranted for the Veteran's other psychiatric diagnoses. Depression, Fatigue, Memory Loss, Nightmares, Quick Temper, and Difficulty Sleeping The Veteran claims that service connection is warranted for his symptoms of depression, fatigue, memory loss, nightmares, and difficulty sleeping as due to an undiagnosed illness. He claims that these symptoms began following his return from service in Desert Storm. The Veteran essentially states that he has experienced a continuity of symptomatology since service. VA psychiatric treatment records document the Veteran's reports of his claimed symptoms. Treatment records dated from January 2007 to July 2007 collectively show his psychiatric symptoms as including a depressed mood, irritability, low frustration tolerance, decreased energy, difficulty sleeping, and nightmares. A January 2007 treatment record includes his report of a poor quality of sleep, nightmares, and feeling fatigued upon wakening. As reflected in a May 2007 treatment record, the Veteran reported having decreased energy, as he slept, on average, three to four hours per night. He stated that he had difficulty falling asleep and going back to sleep after waking up in the middle of the night. As noted above, the Veteran underwent a VA examination in July 2011, which revealed diagnoses of PTSD and a depressive disorder The clinical examination revealed that the Veteran's psychiatric disability was manifested by symptoms which include the following: recurrent distressing dreams; chronic sleep impairments; irritability or outbursts of anger; mood swings; fatigue; difficulty concentrating; depressed mood; and mild memory loss. The examiner determined that the depressive disorder was at least partially secondary to PTSD. Given the foregoing, the Board finds that the grant of direct service connection or presumptive service connection under 38 C.F.R. § 3.317 is not possible for the Veteran's claimed depression, fatigue, memory loss, nightmares, quick temper, and difficulty sleep symptomatology. The Board concedes that the Veteran does experience this symptomatology, but notes that these symptoms have been ascribed to a psychiatric disorder, either to his PTSD or to a depressive disorder. Service connection for PTSD has been granted herein and the medical evidence does not distinguish the symptoms of his PTSD from his depressive disorder. See Mittleider, 11 Vet. Ap. 181. The evidence does not indicate that his claimed symptomatology is distinct from that of his psychiatric disorders. Indeed, the Veteran has consistently reported symptoms of depression, fatigue, memory loss, nightmares, quick temper and difficulty sleeping during numerous psychiatric consultations. Thus, the Veteran himself attributes these symptoms to his psychiatric condition. If the Veteran were granted service connection for the claimed symptomatology, the symptoms encompassed in this claim would overlap with his now service-connected psychiatric disability. Essentially, the Veteran claimed symptomatology will be considered by the RO in determining the appropriate disability rating for his newly service-connected PTSD disability. As there are no separate and distinct manifestations of a disability involving depression, fatigue, memory loss, nightmares, quick temper, and difficulty sleeping which will not be contemplated by the disability rating assigned for his service-connected PTSD, the Board cannot award a separate evaluation for these symptoms due to an undiagnosed illness- even if service connection was warranted- as rating such overlapping symptomatology would result in pyramiding. See 38 C.F.R. § 4.14; see also Estaban v. Brown, 6 Vet. App. 259 (1994) (in cases where separate and distinct manifestations have arisen from the same injury, separate disability ratings may be assigned where none of the symptomatology of the conditions overlaps). Rather, the RO shall take these symptoms into consideration when it assigns the Veteran's disability rating for PTSD. Thus, no issue of law or fact remains to be decided with this claim. Pursuant to 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105. Therefore, the Veteran's claim of entitlement to service connection for a disability manifested by depression, fatigue, memory loss, nightmares, quick temper, and difficulty sleeping, to include as due to an undiagnosed illness under 38 C.F.R. § 3.317, is dismissed. ORDER Service connection for posttraumatic stress disorder is granted, subject to the statues and regulations governing the payment monetary awards. The appeal concerning entitlement to service connection for depression, fatigue, memory loss, nightmares, quick temper, and difficulty sleep symptomatology, to include as due to an undiagnosed illness, is dismissed. REMAND Reasons for Remand: To provide notice, obtain service personnel records, and schedule VA examinations. Multiple Joints and Muscle Pain The Veteran seeks service connection under 38 C.F.R. § 3.317 due to an undiagnosed illness for joint and muscle pain and spasms. He claims to experience joint and/or muscle pain in his bilateral shoulders, hands, hips, thighs, knees, stomach, and feet. The Veteran has also reported experiencing tremors in his hands and numbness in his bilateral thighs and upper extremities. These symptoms reportedly began following the Veteran's return from service in Desert Storm. VA medical records document the Veteran's reported symptomatology affecting the joints and muscles in his upper and lower extremities. These records also include diagnoses of arthralgias (joint pains), left shoulder impingement, rotator cuff tendonitis/tear, and lateral femoral cutaneous neuropathy. To date, the Veteran has not been afforded a VA examination with respect to his claim for joint pain, muscle pain, and spasms due to an undiagnosed illness. Although the medical records include the diagnoses listed above, it is unclear whether these conditions account for some of the Veteran's claimed symptomatology. Additionally, the medical evidence does not clearly show whether the claimed symptoms are attributable to a diagnosed disorder or whether they may be manifestations of an undiagnosed illness attributable to his service in Desert Storm. Assistance by VA includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering a medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). Given the Veteran's confirmed service in the Southwest theater of operations, his competent lay statements as to his current joint and muscle symptomatology, and the unanswered medical questions in this case, VA's duty to assist has been triggered. Thus, the Veteran must be afforded a VA examination to determine whether the claimed symptomatology is attributable to his military service. Colvin, 1 Vet. App. 171. The Veteran also appears to assert that his claimed condition may be due, at least in part, to his exposure to oils fires during his service in Desert Storm. In support of this contention, he submitted a September 2007 letter from the Director of Health Risk Management for the U.S. Army Center for Health Promotion and Preventative Medicine. This letter indicates that the Veteran experienced 13 days of exposure to smoke from oil fires during his service in the Persian Gulf. It is unclear from a review of the claims folder whether the service personnel records that have been obtained and associated with the claims file reflect all of the particular areas in which the Veteran traveled during his service in Desert Storm. Such information is necessary to determine what specific environmental toxins the Veteran may have been exposed to, including, but not limited to, the oil fires. Thus, a remand is necessary to accord the RO an opportunity to procure any additional service personnel records that may be available and that may provide information as to the specific location of the Veteran's service during Desert Storm. In addition, the RO should contact the appropriate Department of Defense agency to obtain any such relevant information. Such data is necessary to determine the type of potential contaminants to which the Veteran may have been exposed during his service in Iraq. See VBA Training Letter 10-03. Headaches and Right Ankle Disorder The Veteran claims that service connection is warranted for headaches and a right ankle disorder. At the time that he initially filed his claims in July 2006, he attributed his headaches to his service in the Persian Gulf; thus, he essentially requested service connection for headaches due to an undiagnosed illness. As for the right ankle claim, the Veteran claimed that this disorder was due to injuries he sustained during his military service. In the March 2008 rating decision and January 2009 statement of the case, the RO denied the headaches claim under the provisions of 38 C.F.R. § 3.317 pertaining to undiagnosed illnesses. The RO adjudicated and denied the right ankle claim under a theory of direct service connection, i.e. whether his right ankle disorder was related to an in-service incident or occurrence. See 38 C.F.R. § 3.303, 3.304 (2011). Thereafter, in an August 2009 statement, the Veteran claimed that his headaches were secondary to his service-connected low back and cervical spine disabilities. During the November 2012 video conference hearing, the Veteran essentially testified that he currently has right ankle symptomatology due to his tendency to favor his service-connected left ankle disability. Separate theories in support of a claim for a particular disability are to be adjudicated under one claim. See Robinson v. Mansfield, 21 Vet. App. 545, 550-51 (2008), citing, Bingham v. Principi, 421 F.3d 1346, 1349 (Fed. Cir. 2005). The Veteran has not been apprised of the information and evidence necessary to substantiate his claims for service connection for headaches and a right ankle disorder on a secondary basis, to include by aggravation. The Board notes that service connection on a secondary basis may granted under the provisions of 38 C.F.R. § 3.310 for non-service connected disorders that are caused or aggravated by a service-connected condition. Allen v. Principi, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310. The Veteran has not been notified of the information and evidence not of record that is necessary to substantiate his claims for service-connection for headaches and a right ankle disability on a secondary basis, as required by the VCAA. Moreover, his claims for secondary service connection have not been addressed by the RO in the first instance. Thus, these claims must be remanded so that the Veteran may be provided with VCAA notice and his claims for secondary service connection may be first adjudicated by the RO/AMC. Additionally, a remand is warranted so that the Veteran may be afforded medical examinations with respect to these claims. The medical evidence currently of record reveals a diagnosis of tension headaches in July 2006. Additionally, these records include the Veteran's December 2010 report of experiencing headaches for approximately twenty years. Although the medical evidence does not reveal a current right ankle diagnosis, the Veteran described experiencing pain and a burning sensation in his right ankle during the November 2012 hearing. The Veteran is competent to report that he currently experiences right ankle symptomatology. The Board notes that lay statements, such as those by the Veteran, may be competent to support claims for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). In this regard, the medical evidence currently of record does not address whether the claimed headaches and right ankle disorders are related to the Veteran's military service or to a service-connected disability. Assistance by VA includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering a medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). Given the medical evidence showing a current headaches diagnosis and the Veteran's competent lay statement of headache and right ankle symptomatology, the Board finds it necessary to provide the Veteran with appropriate VA examinations so as to determine whether the claimed headaches and right ankle disorders are related to his active duty service or to a service-connected disability. Therefore, a remand is needed for VA examinations and medical opinions. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). Loss of Tooth Number Eight In conjunction with his dental claim, the RO sent a duty to assist type letter to the Veteran in April 2010. While this letter informed the Veteran of the various aspects of VCAA with respect to a nondental claim, it did not inform him of the requirements of the VCAA with respect to a dental claim. That is, the RO had a duty to inform the Veteran in the VCAA letter the difference between a grant of service connection for a dental injury or trauma versus a grant of service connection for dental outpatient treatment. See 38 U.S.C.A. § 1712; 38 C.F.R. §§ 3.381, 17.161. Although the RO notified the Veteran in the September 2010 rating decision that his claimed was referred to the Portland VA medical center to determine his eligibility for dental treatment, the RO did not provide notice of the distinction between the different types of dental claims (service connection for compensation versus dental outpatient treatment purposes). Accordingly, the Board finds that VA has not satisfied its duty under the VCAA to notify and assist the Veteran with regards to his claim, and as such, the claim must be returned to the RO so that proper notice may be provided to the Veteran. The Board notes that VA compensation is only available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150. The types of dental conditions covered are: loss of teeth due to bone loss of the body of the maxilla or the mandible due to trauma or disease such as osteomyelitis, but not periodontal disease. See 38 C.F.R. §§ 4.150, Diagnostic Code 9913; 17.161(a). Otherwise, a veteran may be entitled to service connection for dental conditions including treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal (i.e., gum) disease, for the sole purposes of receiving VA outpatient dental services and treatment, if certain criteria are met. See 38 U.S.C.A. § 1712; 38 C.F.R. §§ 3.381, 17.161. The rating activity should consider each defective or missing tooth and each disease of the teeth and periodontal tissues separately to determine whether the condition was incurred or aggravated in line of duty during active service and, when applicable, to determine whether the condition is due to combat or other in-service trauma, or whether the Veteran was interned as a prisoner of war. See 38 C.F.R. § 3.381(b). The Veteran essentially claims that he sustained dental trauma while on active duty. He asserts, and the service treatment records reflect, that he was involved in a physical altercation during service that resulted in a fracture to his front tooth number eight in February 1987. His service treatment records reflect treatment for his injuries, to include a root canal, treatment of caries and abscess, and the placement of a crown and bridge. He claims that tooth number eight was extracted following his separation and that several attempts have been made to replace the tooth. He submitted records of his post-military private dental treatment showing treatment for his tooth as recently as May 2010. Although it appears that the Veteran has received dental treatment for tooth number eight during the pendency of the appeal, it remains unclear whether a dental condition for which disability compensation may be provided has been diagnosed--specifically, loss of teeth due to bone loss of the body of the maxilla or the mandible due to trauma or disease such as osteomyelitis, but not periodontal disease. See 38 C.F.R. §§ 4.150, Diagnostic Code 9913; 17.161(a). He has not been afforded a VA examination in regards to his dental claim. Here, the Board notes that VA adjudicators may consider only independent medical evidence to support their findings; they may not rely on their own unsubstantiated medical conclusions. If the medical evidence of record is insufficient, VA is always free to supplement the record by seeking an advisory opinion, or ordering a medical examination to support its ultimate conclusions. See Colvin, 1 Vet. App. 171. Therefore, a clinical assessment and medical opinion is necessary to adequately address the Veteran's claim of entitlement to service connection for a dental disorder. Accordingly, the Board finds that the Veteran should be afforded a VA examination in order to determine nature and etiology of the Veteran's claimed dental disability. See McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). See also 38 C.F.R. § U.S.C.A. § 5103A(d)(1); 38 C.F.R. § 3.3159(c)(4) (VA has an affirmative duty to obtain an examination of the claimant at VA health-care facilities if the evidence of record does not contain adequate evidence to decide a claim). Accordingly, the case is REMANDED for the following action: 1. Request from the Veteran a statement containing as much detail as possible regarding his allegations of exposure to environmental toxins during his service in Desert Storm. He should be asked to provide specific details including dates, places, his service units, duty assignments and the names and other identifying information concerning any individuals involved in the events. He should be told that the information is necessary to obtain supportive evidence related to his allegations of exposure to environmental toxins and that failure to respond may result in adverse action. 2. Contact the appropriate agencies, including, but not limited to, the National Personnel Records Center (NPRC) and the appropriate Department of Defense agency and request verification of any herbicide and/or environmental toxins to which the Veteran may have been exposed during his service in Desert Storm. See VBA Training Letter 10-03. 3. Provide the Veteran with notice as required under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) with regards to dental claim. The letter should specifically cover dental claims (treatment versus service connection) and how the Veteran can prevail on his claim for benefits. A copy of the letter sent should be included in the claims folder for review, and any information obtained as a result of this action should also be included in the claims folder. 4. Obtain and associate with the claims file any VA medical records that are relevant to the issues being remanded, and any private medical records that the Veteran identifies and requests that VA obtain on his behalf. 5. After all outstanding records have been associated with the claims file, schedule the Veteran for an appropriate VA examinations to determine the nature and etiology of the claimed joint pain, muscle pain, and spasms disorder, headaches disorder, and right ankle disorder. The claims file and all records on Virtual VA must be made available to the examiner, and the examiner must specify in the report that the claims file and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records that were reviewed. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. Thereafter, the VA examiner should address the following: (a) Is any of the Veteran's reported joint/muscle pain and spasms symptomatology (affecting the bilateral upper and lower extremities and stomach) or the Veteran's headaches due to a diagnosed disease or disability? (b) If the answer to (a) is in the affirmative, the examiner should opine whether it is at least as likely as not (50 percent probability or greater) that any of the underlying disease or disability began during service or is casually linked to any incident in service. (c) If any condition cannot be attributed to a known diagnosis, the examiner should so note and provide an opinion as to whether the condition is attributed to an undiagnosed illness. The examiner should also determine whether the Veteran has a medically unexplained chronic multi-symptoms illness (a cluster of signs or symptoms, and specifically to include chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome). (d) If the Veteran's headaches are attributable to a diagnosed disease or disability, the examiner should opine whether it is at least as likely as not (50 percent probability or greater) that the headaches were caused or aggravated by the Veteran's service-connected cervical spine and/or lumbar spine disabilities. By aggravation, the Board means a permanent increase in the severity of the underlying disability beyond its natural progression. (e) Regarding the right ankle disorder, the examiner should opine whether it is at least as likely as not (50 percent probability or greater) that any diagnosed right ankle disorder began during service or is casually linked to any incident in service. The examiner should also opine as to whether it is at least as likely as not (50 percent probability or greater) that the diagnosed right ankle disorder was caused or aggravated by the Veteran's service-connected left ankle disability. By aggravation, the Board means a permanent increase in the severity of the underlying disability beyond its natural progression. In providing the requested opinions, the examiner is advised to discuss and consider the Veteran's report of exposure to smoke/fumes from oil fires during his service in Desert Storm and his reports of a continuity of symptomatology since service. The examiner is advised that an undiagnosed illness is defined as a condition that by history, physical examination, and laboratory test cannot be attributed to a known clinical diagnosis. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Since it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 6. After all outstanding medical records have been associated with the claims file, schedule the Veteran for an appropriate VA examination to determine the current nature and etiology of his alleged dental disorder affecting tooth number eight. The claims file and all records on Virtual VA must be made available to the examiner, and the examiner must specify in the report that the claims file and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records that were reviewed. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner should identify all current diagnoses of dental disorders, specifically those affecting tooth number eight. Thereafter, the examiner should state an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any diagnosed dental disorder is related to the Veteran's military service, to include any dental treatment/trauma. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Since it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 7. After conducting any additional development deemed necessary, the RO should readjudicate the claims considering all the evidence of record and all relevant theories of entitlement. If the benefits requested on appeal are not granted to the Veteran's satisfaction, the Veteran and his representative should be furnished a supplemental statement of the case and be provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs