Citation Nr: 1320834 Decision Date: 06/27/13 Archive Date: 07/05/13 DOCKET NO. 08-03 537 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder. 2. Entitlement to service connection for fibromyalgia. 3. Entitlement to service connection for a temporomandibular joint (TMJ) disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Hannan, Counsel INTRODUCTION Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The appellant was a member of the United States Air Force Reserve from August 1982 to December 2005, when she retired. The appellant had an initial period of active duty for training (ACDUTRA) from October 22, 1982 to February 3, 1983. She was called to active duty for a period of 21 days from February 25, 1991 to March 15, 1991. The appellant also had numerous additional periods of ACDUTRA, as well as numerous periods of inactive duty for training (INACDUTRA). This case originally came before the Board of Veterans' Appeals (Board) on appeal from an October 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Board most recently remanded the case for additional development in January 2013; the case has now been returned to the Board for appellate review. A claim of service connection for one psychiatric disorder includes claims for all such disorders, as veterans, as laypersons, are not competent to render a diagnosis and distinguish amongst conditions in formulating their claim. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The appellant's claim has therefore been characterized to reflect a single issue of service connection for an acquired psychiatric disorder. In addition to the paper claims files, there is an electronic file (Virtual VA) associated with the claims. Virtual VA does not currently contain evidence pertinent to the claims that is not already included in the paper claims files. FINDINGS OF FACT 1. No psychiatric disorder, fibromyalgia or temporomandibular (TMJ) disorder was manifested at the time of the appellant's June 1982 enlistment examination. 2. There is no clear and unmistakable evidence that the appellant had any psychiatric disorder, fibromyalgia or TMJ disorder prior to her entry into active service on February 25, 1991; there is no evidence that any such disorder(s) had manifested by March 15, 1991, the date of her separation from active service. 3. The appellant underwent a Class III Flying medical examination in July 1991; her clinical evaluation was normal. 4. The appellant has reported that she had been in counseling since age 28, and that she was at least 28 years old before she started having problems with her head, neck and jaw. 5. An August 1992 private medical report states that the appellant had no medical problems, that she had a history of TMJ syndrome and that her review of systems and physical examination were negative. 5. The appellant was treated for right TMJ pain in December 1993, and she reported at that time that she had just started taking Xanax. 6. The appellant underwent TMJ surgery in November 1996, and her medical records reflect that she reported that her fibromyalgia had started a couple of years prior to her jaw surgery. 7. The appellant's private pharmacy prescription records reflect that she was prescribed Zoloft in August 1999, Xanax in October 1999, and Ambien in August 2003. 8. On March 19, 2004, the appellant sought treatment for feelings of depression, anxiety and panic. 9. The appellant was diagnosed with a psychiatric disorder (bipolar disorder) in December 2004. 10. The competent and probative medical evidence of record preponderates against a finding that the appellant's current psychiatric disorder is due to any aspect of her military service whether active duty or ACDUTRA. 11. The competent and probative medical evidence of record preponderates against a finding that the appellant's current fibromyalgia is due to any aspect of her military service whether active duty or ACDUTRA. 12. The competent and probative medical evidence of record preponderates against a finding that the appellant's current TMJ disorder is due to any aspect of her military service whether active duty or ACDUTRA. CONCLUSIONS OF LAW 1. The criteria for the establishment of service connection for any psychiatric disorder, including depression, anxiety and bipolar disorder, are not met. 38 U.S.C.A. §§ 101, 1101, 1110, 1111, 1112, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 2. The criteria for the establishment of service connection for fibromyalgia are not met. 38 U.S.C.A. §§ 101, 1101, 1110, 1111, 1112, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 3. The criteria for the establishment of service connection for a TMJ disorder are not met. 38 U.S.C.A. §§ 101, 1101, 1110, 1111, 1112, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant contends that she has a psychiatric disorder, fibromyalgia and a TMJ disorder that are all related to her service in the Air Force Reserve. In her December 2005 VA Form 21-526, the appellant stated that her psychiatric disability (consisting of posttraumatic stress disorder (PTSD), depression and bipolar disorder) began on December 7, 2004. She also stated that her fibromyalgia disorder started on December 7, 2004. In a January 2006 written statement, the appellant withdrew her claim for service connection for PTSD and amended her remaining claims to include anxiety and a bilateral TMJ disorder; she stated that these conditions had been aggravated by her military service. In an April 2006 written statement, the appellant declared that her bipolar disorder had started up when she was activated from March 29, 2004 to June 11, 2004, and then peaked in December 2004. She furthered contended that her depression, anxiety, fibromyalgia and TMJ disorder were all aggravated by her service. The appellant stated, in her November 2006 Notice of Disagreement (NOD), that she believed that she was originally diagnosed with fibromyalgia in "maybe 1993". She argued that there was a pattern of her fibromyalgia being "exacerbated" when she was working as a flight nurse and an evacuation controller in the Air Force Reserve because she would experience additional pain due to her required sitting position. The appellant stated that she received treatment for her fibromyalgia when she was on duty in the Air Force Reserve. The appellant further stated that she was diagnosed with bipolar disorder, depression and anxiety during her December 2004 psychiatric hospitalization and that she believed that her bipolar disorder had started earlier that year when she was stationed at Nellis Air Force Base for three months. She said that this was the first time in her life that she could not sleep. The appellant also stated that she now realized that she may have had bipolar symptoms before and after September 11, 2001. She also said that her TMJ disorder had been "exacerbated" by the same things that had affected her fibromyalgia. The appellant further stated that her TMJ would flare up under stress but "nowhere like the continued pain before the jaw surgery for TMJ." She said that her Air Force activities always flared her TMJ. In written statements submitted in March 2007, the appellant stated that she had been placed on Zoloft for gynecological problems and that she had been at least 28 years old before her head/neck/jaw problems arose. Also of record are lay statements from Air Force Reserve colleagues of the appellant along with written statements from her parents and her sister. One statement, dated in March 2006, indicated that the writer (a retired lieutenant colonel) had worked as a flight nurse with the appellant at Scott Air Force Base in the early to mid-1990s and that the appellant had had TMJ symptoms, pain in her back, neck, shoulders and hips and sensitive trigger points. The writer further stated that the appellant was often tired and exhibited personality fluctuations where mood swings were commonplace and the appellant's thought processes were not based in reality. Another statement, also dated in March 2006, indicated that the second writer had met the appellant in 1989, and worked with her until 1996, at Scott Air Force Base. The writer stated that the appellant often complained of TMJ pain and that she had frequently spoken to the appellant following her surgery. The writer further stated that the appellant had been treated for fibromyalgia since she had known her and that she had often complained of joint pain. The writer further stated that the appellant's depression did not interfere with her flight nurse duties between 1989 and 1996, although she often had significant mood swings off duty. A third written statement, dated in January 2007, was from a retired colonel who had been the commandant of the appellant's squadron from November 1989 to August 1994. The writer noted that the appellant had fulfilled her flying duties as a flight nurse, including the requirement to pass a Class III flying physical each year. As reflected in a November 2007 report of contact (VA Form 119), this retired officer was contacted and she stated that, except for a brief period of active duty in 1991, the appellant's reserve duty consisted of reporting for drill, namely ACDUTRA and INACDUTRA. The appellant's sister wrote in an April 2007 letter that the appellant did not have any problems growing up. The sister also said that the appellant often complained of pain each time she was scheduled to fly. The sister believed that flying increased the appellant's pain and stress level. In a January 2008 letter, the appellant's parents indicated that the appellant had developed TMJ problems when she was in her mid- to late-twenties which later resulted in surgery. The parents stated that the appellant developed fibromyalgia in-between the onset of the TMJ problems and the TMJ surgery and that her symptoms were worsened by flight duty and also when sitting while working as a mission controller. The parents said that the appellant had no problems sleeping prior to March 2004, and that the appellant had had a relationship that ended abruptly in November 2004. A. Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In addition, the decision of the United States Court of Appeals for Veterans Claims (Court) in Dingess v. Nicholson, 19 Vet. App. 473 (2006), requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date. The appellant submitted her claims in December 2005, and January 2006. In a letter sent to the appellant in February 2006, the RO provided notice to the appellant regarding what information and evidence is needed to substantiate a claim for service connection, and what information and evidence must be submitted by the claimant, and what evidence VA would obtain. The letters informed her that VA would assist her in obtaining evidence necessary to support her claims, such as medical records, records from other Federal agencies, etc. She was advised, under 38 C.F.R. § 3.159(b)(1), that it is her responsibility to provide or identify, and furnish authorization where necessary for the RO to obtain, any supportive evidence pertinent to her claims. As to the duty to notify, the Veteran received compliant notification prior to the initial unfavorable agency decision through the February 2006 notice letter. 38 U.S.C.A. § 5103. The appellant has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). With respect to the Dingess requirements, the appellant was not provided with notice of the type of evidence necessary to establish a disability rating or effective date for the claims on appeal. However, there is no prejudice in issuing a final decision because the preponderance of the evidence is against each claim for service connection. Any questions as to the appropriate disability rating or effective date to be assigned are moot. VA must also make reasonable efforts to assist the appellant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The appellant's service medical treatment records, including dental treatment reports, have been associated with the claims file. Private and VA medical records have been obtained and associated with the claims file. VA has also assisted the appellant in obtaining evidence and afforded her the opportunity to present written statements and evidence. The appellant did not provide any information to VA concerning available relevant treatment records that she wanted the RO to obtain for her that were not obtained. She had previously been given more than one year in which to submit evidence after the RO gave her notification of her rights under the pertinent statute and regulations. A Court or Board remand confers upon a veteran the right to substantial, but not strict, compliance with that order. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The RO obtained etiologic opinions as directed by the January 2013 Board remand. Therefore, substantial compliance has been achieved. The appellant was afforded VA examinations in February 2013. Those examinations were adequate for the purposes of determining service connection, as they involved reviews of the appellant's pertinent medical history and were based on supporting clinical data. See generally Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board concludes that the appellant was afforded adequate examinations for her claimed disorders. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board finds that the information provided to the appellant complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify and assist. In addition, the October 2006 rating decision, along with the December 2007 Statement of the Case (SOC) and the November 2008, December 2008, November 2012, and April 2013 Supplemental Statements of the Case (SSOCs), explained the bases for the RO actions and provided the appellant with opportunities to submit more evidence. It appears that all obtainable evidence identified by the appellant relative to her claims has been obtained and associated with the claims file, and that she has not identified any other available pertinent evidence, not already of record, which would need to be obtained for a fair disposition of this appeal. No further assistance to the appellant in developing the facts pertinent to the issues on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103 and 5103A; 38 C.F.R. § 3.159. Under the circumstances of this case, a remand would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). B. The Merits of the Claims In adjudicating a claim, the Board determines whether (1) the weight of the evidence supports the claim or, (2) whether 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. App. 49 (1990). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993). To establish service connection for a disability, symptoms during service, or within a reasonable time thereafter, must be identifiable as manifestations of a chronic disease or permanent effects of an injury. Further, a present disability must exist at some point during the claim process, and it must be shown that the present disability is the same disease or injury, or the result of disease or injury incurred in or made worse by the appellant's military service. Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); 38 C.F.R. § 3.303(a); McClain v. Nicholson, 21 Vet. App. 319 (2007). A veteran is presumed in sound condition except for defects noted when examined and accepted for service. 38 U.S.C.A. § 1132. Clear and unmistakable evidence that the disability existed prior to service and was not aggravated by service will rebut the presumption of soundness. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.304(b); VAOPGCPREC 3-2003. A pre-existing disease will be considered to have been aggravated by active service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. Temporary or intermittent flare-ups during service of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993), citing Hunt v. Derwinski, 1 Vet. App. 292 (1991). When a veteran is found not to be entitled to a legal presumption of service connection for a given disability, the claim must nevertheless be reviewed to determine whether service connection can be established on a another basis. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). In addition, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). There is a clear distinction between individuals who serve on active duty and those who only serve on ACDUTRA. An individual seeking VA disability compensation based only on ACDUTRA must establish a service-connected disability in order to achieve veteran status and be entitled to disability compensation benefits. Further, the burden to establish "veteran" status for a claim based on a period of ACDUTRA is on the appellant. Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Smith v. Shinseki, 24 Vet. App. 40, 44 (2010); Donnellan v. Shinseki, 24 Vet. App. 167, 171-75 (2010). The Court in Donnellan noted that the placement of the burden of proof on the Veteran was consistent with the distinction made in § 101(24) between an ACDUTRA claimant and an active duty claimant. Active military, naval, or air service includes any period of ACDUTRA during which the individual concerned was disabled from disease or injury incurred in the line of duty. 38 U.S.C.A. § 101(22), (24); 38 C.F.R. § 3.6(a), (c). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated while performing active duty or ACDUTRA, or from injury (but not disease) incurred or aggravated while performing INACDUTRA. Id. See also 38 U.S.C.A. §§ 106, 1110, 1131; 38 C.F.R. § 3.303(a). ACDUTRA includes full time duty performed by members of the Armed Forces Reserves or the National Guard of any state. 38 C.F.R. § 3.6(c). To establish status as a "veteran" based upon a period of ACDUTRA, a claimant must establish that she was disabled from disease or injury incurred or aggravated in the line of duty during that period of ACDUTRA. 38 C.F.R. § 3.1(a), (d); Harris v. West, 13 Vet. App. 509, 511 (2000); Paulson v. Brown, 7 Vet. App. 466, 470 (1995). The fact that a claimant has established status as a veteran for other periods of service does not obviate the need to establish that she is also a veteran for purposes of the period of ACDUTRA where the claim for benefits is based on that period of ACDUTRA. Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998). Certain evidentiary presumptions - such as the presumption of sound condition at entrance to service, the presumption of aggravation during service of pre-existing diseases or injuries which undergo an increase in severity during service, and the presumption of service incurrence for certain diseases, such as a psychosis, which manifest themselves to a degree of disability of 10 percent or more within a specified time after separation from service - are provided by law to assist veterans in establishing service connection for a disability or disabilities. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.304(b), 3.306, 3.307, 3.309. The advantages of these evidentiary presumptions do not extend to those who claim service connection based on a period of ACDUTRA or INACDUTRA. Paulson v. Brown, 7 Vet. App. 466, 470-71 (1995) (noting that the Board did not err in not applying presumptions of sound condition and aggravation to appellant's claim where he served only on ACDUTRA and had not established any service-connected disabilities from that period); McManaway v. West, 13 Vet. App. 60, 67 (citing Paulson, 7 Vet. App. at 469-70, for the proposition that, 'if a claim relates to period of [ACDUTRA], a disability must have manifested itself during that period ; otherwise, the period does not qualify as active military service and claimant does not achieve Veteran status for purposes of that claim."). See also Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). A veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). See also Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that a layperson may comment on lay-observable symptoms). The Board notes that the appellant is a nurse, and thus, her opinions regarding medical matters carry weight beyond that of a mere lay person, and will be considered as such by the Board. Review of the appellant's service medical treatment records reveals that she underwent an enlistment examination in June 1982. Her clinical evaluation at that time was listed as normal. Her report of medical history was also negative for the claimed conditions. The appellant underwent a Class III flying examination in May 1986; her clinical evaluation was normal at that time. The appellant underwent another physical examination in February 1988; again her medical history was negative and her physical examination was normal. The appellant underwent an annual flight physical in October 1989. Her clinical evaluation was normal and her report of medical history was negative for the claimed conditions. A May 1993 dental medical history form includes no mention of any health issues and the dentist made a notation that the appellant's health history was negative. The appellant underwent Class III flying examinations in July 1991, May 1993, and July 1996. The clinical evaluations were all normal. After her November 1996 jaw surgery, the appellant was put on a no-fly status; she was cleared for flying in April 1997, when it was noted that she had recovered completely from her facial surgery. The appellant underwent another Class III flying examination in October 1999; her clinical evaluation was normal. The appellant noted at that time that her neck/jaw was not perfect, but she was doing well albeit with pain at times. A June 2003 Reserve Component Health Risk Assessment form includes the appellant's notation of possible fibromyalgia and mild fibromyalgia that had been treated with vitamins but no treatment presently. The appellant's service medical records also include a December 22, 2004 Line of Duty (LOD) determination that the appellant had arrived for duty on December 6, 2004, and promptly presented for depression. She had manic symptoms and was hospitalized and diagnosed with bipolar disorder. The appellant was noted to have reported a prior history of depression and PTSD, but no history of bipolar disorder. The LOD determination was that the bipolar disorder was not related to the appellant's reserve duty as it was a pre-existing disorder. It was stated that the appellant apparently had personal issues that precipitated her manic episode prior to her scheduled "active duty drill time". Turning to the private medical evidence of record, private primary care physician records dated between 1992 and 1999 have been included in the claims file. An August 1992 report states that the appellant was in excellent health and that she had no medical problems. She was noted to have a history of TMJ syndrome. The review of systems (ROS) was noted to be entirely negative. An undated record that apparently was written sometime between 1995 and 1997, indicates that the appellant complained of being very depressed; she had recently broken off her engagement. She wanted to get a prescription for an antidepressant. A June 1997 note indicates that the appellant had all kinds of problems with TMJ syndrome and various aches and pains in her face and neck. The doctor stated that the appellant had no other joint complaints. In September 1999, the physician noted that the appellant had been plagued for some time with symptoms of fibromyalgia and a TMJ syndrome. She was noted to be on Zoloft. Her examination was entirely negative other than for some obvious muscle atrophy in the right mandibular area. In December 1999, the appellant presented with her usual constellation of complaints referable to her fibromyalgia. In January 2000, the doctor referred the appellant to the Washington University School of Medicine Sleep Disorder Center for evaluation of possible obstructive sleep apnea. The appellant was noted to have a chief complaint of fibromyalgia. The appellant's private pharmacy prescription records indicate that this doctor and/or his colleague prescribed Vioxx for the appellant in September 1999, and Xanax in October 1999, February 2000, May 2000, and January 2001. The appellant's private gynecologist prescribed Zoloft in August 1999, and July 2000, as well as Xanax in April 2001. A December 1993 report from the Missouri Baptist Medical Center indicates that the appellant was diagnosed with right TMJ pain in December 1993. She stated that the right TMJ pain had started three years before and that she had just started taking Xanax. A January 1994 Doctor of Medical Dentistry (DMD) treatment note indicates that the appellant ground her teeth at night and that she had been having problems for about three years. She had tightness in her neck and jaws and reported bad pain since September/October. In November 1996, the appellant underwent TMJ surgery at Saint Luke's Hospital. In March 1999, the appellant was seen at the clinic at Northland MidAmerica Orthopedics. She reported knee pain with an onset date of December 1997, and November 1998. A motor vehicle accident was noted. The appellant's medical history included chronic pain syndrome of the jaw, neck and back. In February 2000, the appellant sought treatment from another private physician. She gave a history of generalized muscle aches and pains, fatigue, jaw discomfort and feeling stress and anxiety; the duration of these was given as ten years. The appellant's major diagnoses included fibromyalgia, but no psychiatric diagnoses were listed. Her current medications included Zoloft and Xanax; the Xanax having been started a couple of months before and the Zoloft six months prior. The appellant was noted to have been fine from ages 0 to 20. Around age 28, the appellant developed a lot of muscle aches and joint pains that started in the jaw area. She also had symptoms of fatigue, dizziness and confusion. She was diagnosed with fibromyalgia between ages 30 and 40. Her fibromyalgia was noted to have started a couple of years prior to her jaw surgery. An April 2000 note indicates that the appellant wanted treatment for her symptoms of pain, fogginess and anxiety. She said that she was working 70 hours a week. In January 2001, the doctor noted that the appellant's symptoms of depression, irritability, nervousness, reduction in concentration, inability to think clearly and mood swings continued to be a problem. This physician prescribed Ambien for the appellant in August 2003; Ambien (zolpidem) is a sedative used for treatment of insomnia. On March 19, 2004, the appellant was noted to be having massive problems with her relationship with her boyfriend which put her into a panic attack. She was described as feeling depressed, anxious and panicky. She was referred to a psychologist whom she had already seen. The appellant was wondering if she could be hospitalized. A note dated November 29, 2004, states that the appellant had had massive stress over the Thanksgiving break; the physician again referred her to the psychologist she had seen previously on his referral. The doctor indicated that the psychologist had diagnosed the appellant with PTSD, depression and anxiety. A March 2007 letter from this physician states that the appellant developed manic depression in 2004. On December 6, 2004, the appellant was admitted to Saint Elizabeth Hospital from Scott Air Force Base for depression; she was noted to have been depressed and anxious since November 20, 2004. The discharge assessment was bipolar disorder. In January 2005, the appellant started seeing a private psychiatrist. Her listed current psychosocial stressors included an abruptly separated relationship on November 20, 2004. The appellant gave a previous psychiatric history that included counseling since the age of 28. Her family history included two nieces with bipolar affective disorder (BAD), an aunt with BAD and a brother with depression. In February 2005, the appellant presented at a VA facility as a new patient. She was noted to have been recently diagnosed with bipolar disorder after having broken up with a boyfriend of eight months in November 2004. The appellant indicated that her chief complaint had been insomnia. The notation concerning the appellant's previous medical history included a diagnosis of fibromyalgia in 1994. The appellant was subsequently hospitalized for psychiatric treatment in private facilities on two occasions in 2007. She also continued to receive treatment at VA and from her private providers. The appellant was afforded an examination by a VA psychologist in February 2013; the examiner reviewed the appellant's claims file. The psychologist stated that the appellant did not meet the criteria for a diagnosis of PTSD. The examiner rendered an Axis I diagnosis of bipolar disorder. The examiner noted that the appellant had been diagnosed with sleep apnea and that the appellant reported that she felt tired all the time due to the fibromyalgia. The examiner stated that there was no evidence that the appellant had any psychiatric disorder prior to her military service in 1991. The appellant was noted to report being given an antidepressant for the first time between 1998 and 2000 by a gynecologist for premenstrual syndrome (PMS). The examiner further stated that the appellant's current condition was diagnosed in December 2004. The examiner noted that the appellant was able to relocate and find work after her December 2004 hospitalization and stated that there was no evidence to suggest that the current psychiatric condition was aggravated beyond its natural progression during the months she was on reserve duty from December 2004 to October 2005 (just prior to her retirement from the Air Force Reserve). The appellant was afforded a VA medical examination for fibromyalgia in February 2013; the examining physician reviewed the appellant's claims file. The examiner noted that the appellant's diagnosis was fibromyalgia and the onset date was in the 1990s. The examiner stated that there was no clear and unmistakable evidence that the fibromyalgia pre-existed the appellant's 1991 active duty service. The examiner stated that it was less likely than not that the appellant's fibromyalgia was incurred in or resulted from that 1991 active duty service or from any specific period of ACDUTRA or INACDUTRA. The examiner pointed out that the appellant had had negative physical examinations in May 1991 and in July 1991. In addition, the examiner concluded that it was less likely than not that the appellant's fibromyalgia was aggravated during a specific period of ACDUTRA or INACDUTRA. The doctor noted that fibromyalgia is a condition that develops gradually over time and that symptoms do not usually begin abruptly. The examiner further stated that the appellant's medical reports did not describe any such abrupt onset of fibromyalgia and that reports dated in June 2003 and June 2004 included notations that the appellant's fibromyalgia was stable with no mention of any aggravation. The appellant was also afforded a VA examination by a dentist in February 2013; the examiner reviewed the claims file. The examiner stated that the appellant's current diagnoses were myofascial pain syndrome with onset in 1993; bruxism with onset in 1994; and bilateral osteotomies performed in 1996, with additional surgeries in 2009, and 2010. The examiner concluded that the appellant's limited active duty in 1991 did not cause her TMJ disorder. The dentist opined that the appellant's symptoms thereafter were a normal progression of her disease. The dentist further stated that the appellant's records did not indicate that the appellant's TMJ pathology was aggravated during any period of ACDUTRA or INACDUTRA. The dentist also opined that the appellant would have her same TMJ problems regardless of her military obligations. As noted above, in order for service connection to be warranted for a claimed condition, there must be evidence of a present disability that is attributable to a disease or injury incurred during service. Rabideau v. Derwinski, supra. "[I]n order to establish service connection or service-connected aggravation for a present disability the veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Thus, service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. The evidence of record is not clear as to the exact onset date of the claimed conditions. However, the majority of the evidence of record does not demonstrate that the appellant was diagnosed with a psychiatric disorder (including depression, anxiety and bipolar disorder), with fibromyalgia or with a TMJ disorder prior to her entry on active duty on February 25, 1991. While there are one or two indications that the conditions may have existed prior to February 25, 1991, most of the evidence of record, including private medical treatment records and the appellant's own statements that she did not have least problems until she was at least 28 years old, place the onset of the claimed conditions as occurring after February 25, 1991. Therefore, there is no clear and convincing evidence that the claimed conditions pre-existed the appellant's entry into active service in February 1991. See 38 U.S.C.A. § 1131; 38 C.F.R. § 3.304(b); VAOPGCPREC 3-2003. The evidence of record also does not demonstrate that the onset of her currently diagnosed psychiatric disorder (including depression, anxiety and bipolar disorder), fibromyalgia or TMJ disorder arose during those 21 days of active duty in early 1991. As previously noted, the appellant herself has stated that the onset of her conditions of fibromyalgia and TMJ problems occurred after she turned 28 years old in October of that year. In addition, there is medical record evidence that the appellant went into counseling at age 28, that she was diagnosed with right TMJ pain in December 1993, and that her fibromyalgia started between December 1993 and November 1996. Furthermore, there is no formal psychiatric diagnosis of record until November 2004, when a private psychologist rendered diagnoses of PTSD, anxiety and depression; complaints of depression were first noted in approximately 1995. Therefore, the preponderance of the evidence is against a finding of direct service incurrence between February 25, 1991 and March 15, 1991. Accordingly, service connection is not warranted on a direct basis for any one of the claimed conditions. Where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and certain chronic disabilities, such as a psychosis or arthritis, 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. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Here, the appellant only served for 21 days of active duty; thus, these provisions are not applicable in the instant case. Accordingly, service connection for a psychiatric disorder (including depression, anxiety and bipolar disorder), for fibromyalgia and for a TMJ disorder is not warranted on a presumptive basis for the appellant's 21 days of active duty. Turning to the appellant's periods of ACDUTRA and INACDUTRA following her separation from active service on March 15, 1991, the term "active military, naval, or air service" includes: (1) active duty; (2) any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; and (3) any period of inactive duty for training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a); see also Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). Because psychiatric disorders, fibromyalgia and TMJ syndrome are considered diseases and not an "injury," service connection may only be awarded by establishing that the appellant's claimed conditions had their onset during, or were aggravated by, a period of ACDUTRA in relation to the appellant's service in the Air Force Reserve. Service connection would not be warranted for any one of the claimed conditions during a period of INACDUTRA. Exceptions to the requirement of an injury during INACDUTRA are for an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident. See 38 C.F.R. § 3.6(a).The record does not indicate, and the appellant does not contend, that any of these three "injuries" occurred. Therefore, as the claimed conditions are not injuries, service connection for them is not available based on any period that the appellant served on INACDUTRA. In this case, the evidence of record indicates that the appellant's current psychiatric pathology was diagnosed in November 2004, and that events that took place on November 20, 2004 had led to the development of her condition. While the appellant had had ACDUTRA from November 13 to 18 of that year, she was not on ACDUTRA on November 20, 2004. Furthermore, the evidence of record indicates that the appellant had experienced psychiatric problems earlier that same year. A private treatment note dated March 19, 2004, states that the appellant was noted to be having massive problems with her relationship with her boyfriend which put her into a panic attack. She was described as feeling depressed, anxious and panicky and wondering if she could be hospitalized. Her treating private physician referred her to a psychologist whom she had already seen. The appellant subsequently reported for a period of ACDUTRA that ran from March 28, 2004 to June 11, 2004. Thus, the evidence of record does not place the onset of the appellant's psychiatric pathology within any period of ACDUTRA in 2004. In addition, the Board notes that, while the appellant has reported that she was in counseling from the age of 28, and there are notations in her private treatment records that reflect that she was prescribed antidepressants and complained of psychiatric symptoms such as depression and mood swings between 1999 and 2001, there is no psychiatric diagnosis of record until November 2004. The evidence of record also indicates that the appellant was initially diagnosed with fibromyalgia before November 1996, when she had her jaw surgery; the evidence of record suggests that the earliest onset date for the fibromyalgia would be approximately 1993. For example, an August 1992 private physician report states that the appellant was in excellent health and her physical examination was entirely negative; that same physician subsequently recorded the appellant's complaints of joint pains and aches, as well as her diagnosis of fibromyalgia in 1999. There is nothing in any of the appellant's private medical records to indicate that the appellant's fibromyalgia was linked to any period of ACDUTRA that took place between March 1991 and November 2004. In addition, there is a February 2013 medical opinion of record that indicates that fibromyalgia is a condition that develops gradually over time and would not be expected to develop during a discrete period of reserve duty. The Board notes that the appellant's various periods of ACDUTRA between 1991 and 1994 lasted nine days at most, and generally just one to three days. Thus, the evidence of record does not place the onset of the appellant's fibromyalgia within any period of ACDUTRA. The evidence of record also indicates that the appellant was initially diagnosed with her current TMJ disorder before November 1996, when she had her jaw surgery; the evidence of record suggests that the earliest onset date for the fibromyalgia would be approximately December 1993, when she was diagnosed with right TMJ pain. The Board notes that 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). In any case, there is nothing in any of the appellant's private medical records to indicate that the appellant's current TMJ disorder is linked to any period of ACDUTRA that took place between March 1991 and December 1993, or later. In addition, there is a February 2013 medical opinion of record that indicates that the appellant's ACDUTRA service did not cause her TMJ disorder. The Board notes that the appellant's various periods of ACDUTRA between 1991 and 1993 lasted nine days at most, and generally just one to three days. Thus, the evidence of record does not place the onset of the appellant's current TMJ disorder within any period of ACDUTRA. The remaining theory upon which the appellant's claimed conditions could be found to be service-connection is the theory of aggravation wherein an increase in severity is demonstrated during a period of ACDUTRA. The appellant has the responsibility to establish an increase in severity. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). Such increase must be shown through independent medical evidence. See Paulson v. Brown, 7 Vet. App. 466, 470-471 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1994). Any increase in severity must also be permanent. Recurrence or temporary flare-ups of symptoms do not constitute an increase in severity. Davis v. Principi, 273 F.3d 1341, 1345 (Fed. Cir. 2002); see Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993); Hunt v. Derwinski, 1 Vet. App. 292 (1991). Thus, in order to establish aggravation of a preexisting condition during a period of ACDUTRA, a claimant has the burden of showing both that she experienced a permanent increase in disability during her period of ACDUTRA, and that such permanent increase was beyond the natural progress of that disability. See Donnellan v. Shinseki, 24 Vet. App. 167, 173-75 (2010). Review of the evidence of record does that establish that the appellant experienced a permanent increase in psychiatric-related disability during any pertinent period of ACDUTRA. As noted in the February 2013 VA psychologist opinion, the appellant's current psychiatric condition was diagnosed in 2004, and she was able to relocate and find work after her December 2004 psychiatric hospitalization. The psychologist concluded that there was no evidence to suggest that the appellant's current psychiatric condition was aggravated beyond its natural progression during any period of ACDUTRA that took place after the 2004 hospitalization. The Board notes that the appellant's next psychiatric hospitalization did not occur until 2007 - after she was retired from the Air Force Reserve. Likewise, the February 2013 VA medical opinion indicates that the appellant's fibromyalgia was less likely than not aggravated by any period of ACDUTRA. The appellant herself, in a June 2008 written statement, said that she suffered from a mild case of fibromyalgia with moderate to severe symptoms occurring only every few months and severe pain only twice a year. In addition, there is no evidence of record to indicate that the appellant's TMJ disorder was aggravated by any period of ACDUTRA. The February 2013 VA dental opinion indicates that the appellant would have had the same TMJ problems regardless of her military service. The preponderance of the record indicates the appellant did not experience any permanent increase in her TMJ disorder during any period of ACDUTRA prior to her retirement from the Air Force Reserve. The Board has scrutinized the record with a view towards ascertaining whether there is any basis (e.g., direct, presumptive, by way of aggravation or secondary) to indicate that any claimed condition was incurred by any incident of military service, but it has gleaned no such supporting evidence or suggestion thereof. Schroeder v. West, 212 F.3d 1265 (Fed. Cir 2000); Combee, 34 F.3d at 1043 (Both for the general proposition that in claims involving presumptive service connection, the Board must also examine the evidence of record to ascertain if there is any other basis upon which to develop or grant the claim, including direct service connection). See Bingham v. Principi, 421 F.3d 1346 (Fed. Cir. 2005); Roebuck v. Nicholson, 20 Vet. App. 307, 312-313 (2006). Based on the totality of the evidence of record, including lay statements, the service treatment records, the private and VA treatment records and the reports of VA examinations, the Board finds that the preponderance of the evidence is against each one of the appellant's three claims for service connection. The Board concludes that the weight of the "negative" evidence, principally in the form of the service medical treatment records (which do not document any in-service chronic condition); the lack of a diagnosis of any chronic pathology until at least 1993 (when there may have been a diagnosis of TMJ syndrome and fibromyalgia); and the negative medical opinions finding no etiologic nexus between the claimed conditions and service, including by way of aggravation, substantially outweighs that of the "positive" evidence of record which basically amounts to the appellant's contentions and other lay statements. Acknowledgement has been given to the statements of the appellant and her former Air Force reserve colleagues because, as nurses, they have medical training, knowledge, and experience. Indeed, the Board has specifically taken the appellant's accounts of her medical history into consideration. However, in relation to the questions of etiology and aggravation, more probative value is assigned to the VA examiners' opinions rather than the statements of the nurses, in part because nurses have less medical expertise than the examiners who are physicians. See Black v. Brown, 10 Vet. App. 297, 284 (1997) (an individual's knowledge and skill in analyzing the medical data is a factor in evaluating the probative value of medical statements). See also Cathell v. Brown, 8 Vet. App. 539, 543(1996) (the adjudication of the Board includes the responsibility of determining the weight to be given to the evidence of record, and this responsibility includes the authority to favor one medical opinion over another). In addition, the written statements of the appellant's fellow nurses either did not address the questions of etiology and aggravation or did not provide any specific onset date but rather just gave a list of symptoms that occurred over many years without mention of changes in severity levels. See Guerrieri v. Brown, 4 Vet. App. 467(1993); Sklar v. Brown, 5 Vet. App. 140(1993) (the probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion). After consideration of all of the evidence of record, the Board finds that the appellant has failed to carry her burden to show aggravation of her pre-existing psychiatric disorder, her fibromyalgia and her TMJ disorder during any period of ACDUTRA. Indeed, the appellant has presented no evidence to rebut the February 2013 VA medical opinions that her claimed conditions had not been aggravated by her ACDUTRA service. In sum, the evidence fails to show that the any one of the appellant's claimed conditions, including bipolar disorder, depression, anxiety, fibromyalgia and a TMJ disorder, was first manifest during a period of active duty or ACDUTRA and the evidence does not otherwise establish a nexus between her currently diagnosed conditions and her service, including by way of aggravation. See 38 C.F.R. §§ 3.303, 3.304; see also Smith Shinseki, 24 Vet. App. 40 (2010). Therefore, the Board finds that the preponderance of the evidence is against the appellant's claims for service connection and that service connection for a psychiatric disorder, for fibromyalgia and for a TMJ disorder is not warranted. Because the preponderance of the evidence is against each one of these three service connection claims, the benefit of the doubt doctrine does not apply. Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). ORDER Service connection for a psychiatric disorder is denied. Service connection for fibromyalgia is denied. Service connection for a TMJ disorder is denied. ____________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs