Citation Nr: 1321324	
Decision Date: 07/02/13    Archive Date: 07/12/13

DOCKET NO.  09-04 812	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in St. Petersburg, Florida


THE ISSUES

1. Entitlement to service connection for hypothyroidism, to include as secondary to service-connected generalized anxiety disorder with depressive disorder, or for purportedly associated signs and symptoms as an undiagnosed illness or medically unexplained chronic multi-symptom illness related to Persian Gulf War service.

2. Entitlement to service connection for gastroesophageal reflux syndrome (GERD), claimed as gastrointestinal symptoms, to include as secondary to service-connected generalized anxiety disorder with depressive disorder.


WITNESS AT HEARING ON APPEAL

The Veteran


ATTORNEY FOR THE BOARD

Rutkin, Joshua M.


INTRODUCTION

The Veteran served on active duty from July 1982 to May 1986 and from August 1990 to March 1991.  She served in the Southwest Asia Theater of operations, in Saudi Arabia, from September 15, 1990 to March 10, 1991.

This matter comes to the Board of Veteran's Appeals (Board) on appeal from a May 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied the claims.  In August 2009, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge.  A copy of the transcript is of record.  The Board remanded these claims in November 2009 and September 2012 for further development and to ensure that all due process requirements had been satisfied.  

In March 2012, the Board referred these claims for expert medical opinions.  See VHA Directive 2010-044 (September 29, 2010); 38 U.S.C.A. §§ 5103A, 7109 (West 2002); 38 C.F.R. § 20.901 (2012).  The opinions were provided in January 2012 and May 2012 by an endocrinologist and a gastroenterologist, respectively.  In May 2012, copies of the opinions were sent to the Veteran for her review, and she was offered the opportunity to present additional evidence or argument in response, in accordance with 38 C.F.R. § 20.903 (2012).  See Thurber v. Brown, 5 Vet. App. 119 (1993).  She submitted a written statement responding to these opinions in May 2012.  The Board may proceed with appellate review. 



FINDINGS OF FACT

1. The Veteran's hypothyroidism is not related to a disease, injury, or event during active service, to include reported fatigue and weight gain, and has not been caused or aggravated by her service-connected psychiatric disorders. 

2. The Veteran's hypothyroidism is not an undiagnosed illness or medically unexplained chronic multisymptom illness related to her Persian Gulf service, and symptoms purportedly related to hypothyroidism, including weight gain, fatigue, cold sensitivity, and joint pain likewise do not qualify as such as they have been attributed to known diagnoses or other factors. 

3. The Veteran's GERD did not manifest during active service, is not related to a disease, injury, or event during service, and was not caused or aggravated by her service-connected psychiatric disorders. 


CONCLUSIONS OF LAW

1. The criteria for service connection for hypothyroidism on a direct, presumptive, or secondary basis have not been satisfied.  38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310, 3.317 (2012).

2. The criteria for service connection for fatigue, weight gain, joint pain, and cold sensitivity as signs or symptoms of an undiagnosed illness or medically unexplained chronic multisymptom illness related to service in the Persian Gulf have not been satisfied.  38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317 (2012).

3. The criteria for service connection for GERD on a direct or secondary basis have not been satisfied.  38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Board has thoroughly reviewed all the evidence in the claims file, and has an obligation to provide an adequate statement of reasons or bases supporting its decision.  See 38 U.S.C.A. § 7104(d)(1) (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000).  While the Board must review the entire record, it need not discuss each piece of evidence.  See id.  The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim.  See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant).  

The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant.  Caluza v. Brown, 7 Vet. App. 498, 506 (1995).  A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence.  See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102.  When the evidence is in relative equipoise, the claimant prevails.  See Gilbert v. Derwinski, 1 Vet. App. 49 (1990).  The preponderance of the evidence must weigh against a claim for benefits to be denied.  See Alemany v. Brown, 9 Vet. App. 518 (1996). 




I. VA's Duties to Notify and Assist

The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified as amended at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002), sets forth VA's duty to notify and assist claimants in substantiating a claim for VA benefits.  See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012).  

Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim.  38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b).  In order to satisfy its duty to notify the claimant under the VCAA, the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide.  Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002).  

All notice under the VCAA should generally be provided prior to an initial decision on a claim by the agency of original jurisdiction (AOJ).  Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004).  However, a delay in timing of the notice is "cured," and therefore harmless, when a fully compliant VCAA notification letter is followed by readjudication of the claim (such as through issuing a statement of the case or supplemental statement of the case) after the claimant has had an opportunity to submit additional evidence.  See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370 (2006).  

A claim of entitlement to service connection consists of five elements: (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.  Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006).  The Court has held that notification of what evidence is necessary to substantiate the claim under 38 U.S.C.A. § 5103(a) requires notice of these five elements.  See id. at 486; Quartuccio, 16 Vet. App. at 187. 

Here, prior to the initial rating decision in this matter, a December 2007 letter informed the Veteran of all five elements of service connection, gave examples of the types of evidence she could submit in support of her claims, and provided notice of the Veteran's and VA's respective responsibilities for obtaining relevant records and other evidence on her behalf.  Further, similar notice was provided in a March 2010 letter which also informed the Veteran of the elements of secondary service connection.  Although this letter was not sent prior to initial adjudication of the Veteran's claims, the delay was harmless as the Veteran had an opportunity to respond with additional information and evidence before her claims were readjudicated in several supplemental SOC's.  See Mayfield, 499 F.3d at 1323.  Therefore, the duty to notify has been satisfied.  See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Dingess/Hartman, 19 Vet. App. at 484; Quartuccio, 16 Vet. App. at 187. 

VA's duty to assist under the VCAA includes helping the claimant to obtain service treatment records and other pertinent records, as well as providing an examination or obtaining a medical opinion when such is necessary to make a decision on the claim.  See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c).  

Here, the Veteran's service treatment records and VA medical records are in the file.  She has not identified any private treatment records.  A number of scientific articles, an opinion by a private physician, N. Rasgon, M.D., Ph.D., and witness statements are also of record.  The Veteran has not identified any other records or other evidence that remains outstanding.  Thus, the duty to obtain relevant records on the Veteran's behalf is satisfied.  See 38 C.F.R. § 3.159(c).  

The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law.  See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006).  When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate.  Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).  However, unless the claimant challenges the adequacy of the examination or opinion, the Board may assume that the examination report and opinion are adequate, and need not affirmatively establish the adequacy of the examination report or the competence of the examiner.  Sickels v. Shinseki, 643 F.3d, 1362, 1365-66 (Fed. Cir. 2011) (holding that although the Board is required to consider issues independently raised by the evidence of record, the Board is still "entitled to assume" the competency of a VA examiner and the adequacy of a VA opinion without "demonstrating why the medical examiners' reports were competent and sufficiently informed"); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-1291 (Fed. Cir. 2009) (holding that the Board is entitled to assume the competency of a VA examiner unless the competence is challenged).  Id.

Here, a VA thyroid and parathyroid examination and a VA mental health examination were performed in April 2012.  A VA esophagus and hiatal hernia examination, Gulf War examination, thyroid and parathyroid examination, and a joints examination were also performed in April 2008.  Finally, as noted above, expert medical opinions from a VA endocrinologist and gastroenterologist were obtained in January 2012 and May 2012, respectively.  The VA examination reports and medical expert opinions are adequate for the purpose of deciding these claims, as they included a review of the claims file and medical history, an examination of the Veteran in the case of the VA examinations, and the opinions stated are supported by thorough explanations which are consistent with the medical professionals' findings and the credible evidence of record.  See Monzingo v Shinseki, 26 Vet. App. 97, 107 (2012) (holding that "examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion" even when the rationale does not explicitly "lay out the examiner's journey from the facts to a conclusion") (citing Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners)); see also D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination is adequate when it is based on consideration of the claimant's medical history and describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one).  There are no apparent inconsistencies or ambiguities in the examination reports.  See Sickels, 643 F.3d at 1365-66; Rizzo, 580 F.3d at 1290-1291.  Moreover, the expert opinions provided by the endocrinologist and gastroenterologist are based on a thorough review of the Veteran's pertinent medical history and supported by thorough explanations, and correct for any deficiencies present in the VA examination reports.  As noted above, the Veteran was given an opportunity to respond to these opinions, and provided such a response in May 2012.  Accordingly, VA's duty to obtain a VA examination and opinion has been met.  See 38 C.F.R. §§ 3.159(c)(4); 3.326(a); McLendon, 20 Vet. App. at 83; Barr, 21 Vet. App. at 312. 

In her May 2012 response to the expert medical opinions, the Veteran stated that there was "little identifying" information with regard to the endocrinologist, and that without having further information as to the endocrinologist's credentials, the Veteran was "denied the opportunity to argue" that the endocrinologist may not have been "up to date" on the "latest research."  However, it is sufficient that the endocrinologist provided his or her first initial and full last name in the report, as well as some information about his or her educational and vocational background, stating that he or she is a board-certified endocrinologist with an active practice that includes treating many patients with thyroid disease.  This information is enough to establish the competency of the physician.  See Rizzo, 580 F.3d at 1290-1291.  

Moreover, the endocrinologist provided a detailed explanation in support of the opinion, and the Veteran thus had an adequate opportunity to respond to the specific reasons provided by the endocrinologist, including with articles or studies putting these opinions into question, or with a countervailing opinion by another expert.  The Veteran has in fact submitted several studies addressing how stress and psychiatric disorders may affect thyroid hormones, and also provided detailed arguments in the May 2012 statement specifically engaging with the endocrinologist's opinion.  As will be discussed below, the articles submitted by the Veteran, most of which are dated in the last ten years, simply reflect tentative findings in an emerging field of study that there is a potential correlation between the endocrine system and mental health.  These findings on their face, both as a matter of probability and as a matter of the tentative, uncertain nature of the conclusions reached, cannot translate into a likelihood that the Veteran's hypothyroidism is related to in-service stress or to her service-connected anxiety disorder with depressive disorder, especially given the small pool of subjects involved in the study.  Thus, these articles do not put into question the more definitive opinion provided by the endocrinologist, who reviewed the articles and stated that they did not show that stress or psychiatric disorders cause long-term changes in thyroid hormone levels in humans.  The endocrinologist noted based on his or her own experience and expertise that the vast majority of patients with stress or psychiatric disorders never develop hypothyroidism, and that patients with hypothyroidism commonly do not have psychiatric disorders or stress linked to hypothyroidism.  Accordingly, the Veteran has had an adequate opportunity to respond to the May 2012 opinion. 

The Veteran also noted in her May 2012 response that the gastroenterologist was a VA physician, which seemed to be in contravention of the purpose of an "outside medical opinion."  However, the Board did not request an outside medical opinion, but rather an opinion by a medical expert, and such an opinion may be provided by a physician employed by VA.  Thus, the fact that this opinion was rendered by a VA physician was not improper. 

In sum, VA's duty to notify and assist under the VCAA has been satisfied.  The Veteran has had ample opportunity to participate in the development of his claim.  See Arneson v. Shinseki, 24 Vet. App. 379, 389 (2011) (citing Overton v. Nicholson, 20 Vet. App. 427, 435 (2006) (finding that any error depriving a claimant of "a meaningful opportunity to participate effectively in the processing of his or her claim . . . . must be considered prejudicial")).  As shown above, any defect in the notice or assistance provided did not affect the outcome of this claim or compromise the "essential fairness of the adjudication."  See Mayfield v. Nicholson, 19 Vet. App. 103, 116 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006).  Thus, any error in the notice or assistance provided was harmless, and no prejudice exists.  See Shinseki v. Sanders 556 U.S. 396, 407, 410 (2009) (holding that the "rule of prejudicial error" requires a case-by-case determination as to whether the error in question was harmless, and that it is the burden of the claimant to show that the error was harmful by at least providing an explanation as to how the error caused harm); see also 38 U.S.C.A. § 7261(b)(2) (West 2002).  Accordingly, the Board may proceed with appellate review.  

II. Procedural Due Process

A. Compliance with Board's Remand Directives

The Board remanded these claims in November 2009 and September 2012.  In Stegall v. West, 11 Vet. App. 268, 271 (1998), the Court held that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to insure compliance with the terms of the remand.  See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall).

Here, the Board's remand directives to send the Veteran VCAA-compliant notice with regard to establishing her claims on a secondary basis; to obtain any outstanding VA treatment records from the Nashville VA Medical Center (VAMC) dating between 1996 and 1999, the Murfreesboro (Alvin C. York) VAMC, and the Tampa VAMC dating from 2002 to December 2007 and from February 2008; to provide appropriate VA examinations and opinions; and then to readjudicate the claims on the merits and issue a supplemental SOC, to include reviewing an After Action Report by the California Army National Guard dated February 1991, have been satisfied.  Thus, there has been substantial compliance with the Board's remand directives.  See id.


B. Compliance with Hearing Officer's Duties Under Bryant

As noted above, the Veteran testified at a Board hearing before the undersigned in August 2009.  Under 38 C.F.R. § 3.103(c)(2) (2012), it is the responsibility of the hearing officer to explain fully the issues and suggest the submission of evidence which the claimant may have overlooked and which would be of advantage to the claimant's position.  In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that the hearing officer has two distinct duties under section 3.103(c)(2).  First, the hearing officer must explain fully the issues still outstanding that are relevant and material to substantiating the claim by explicitly identifying them for the claimant.  Id. at 496 (finding that a hearing officer's inquiries regarding the existence of a current disability and a nexus to service did not equate to explaining to the claimant that these issues were material to substantiating the claim).  Second, the hearing officer must suggest that a claimant submit evidence on an issue material to substantiating the claim when such evidence is missing from the record or when the testimony at the hearing raises an issue for which there is no evidence in the record.  Id., at 496-97.  

Importantly, the Court observed that the rule of prejudicial error applies in assessing any deficiency with respect to the hearing officer's duties under section 3.103(c).  See id. at 498.  Citing Sanders, 556 U.S. at 407, 410, the Court noted in this regard that the rule of prejudicial error requires a case-by-case determination as to whether the error in question was harmless.  Id.  Thus, in Bryant, 23 Vet. App. at 498-99, the Court held that although the hearing officer did not explicitly lay out the material issues of medical nexus and current disability, the "clarity and completeness of the hearing record was intact" and the purpose of section 3.103(c)(2) fulfilled because the record reflected that these issues were developed by VA, including the provision of a VA examination, and there was no indication that the appellant had any additional information to submit.  

Here, the outstanding issues are whether the Veteran's hypothyroidism and GERD were incurred in or aggravated by active service, or caused or aggravated by a service-connected psychiatric disorder.  In addition, there is an issue as to whether symptoms purportedly associated with the Veteran's hypothyroidism may instead be due to an undiagnosed illness or a medically unexplained chronic multisymptom illness related to her Gulf War service.  Although the undersigned did not explicitly identify these issues for the Veteran, the Veteran had an opportunity to present testimony in support of her contentions with respect to these issues facilitated by questioning from the undersigned.  

Moreover, any deficiencies in the Board hearing under section 3.103(c)(2) were not prejudicial.  Specifically, VA has otherwise developed this claim, including obtaining records on the Veteran's behalf and providing several VA examinations and obtaining two expert medical opinions which directly address the outstanding issues, as discussed above with regard to VA's duty to assist under the VCAA.  The Veteran has also submitted a number of articles and studies in support of her claims, as well as an opinion by a private physician and witness statements.  Thus, in light of the information and evidence already of record, including that submitted by the Veteran, there is no indication of any outstanding evidence that may have been overlooked.  See id. at 499.  Finally, the Veteran did not raise any new issues in her hearing testimony.  See id.  Accordingly, given the development undertaken by VA with respect to this claim, the evidence and argument submitted by the Veteran, and her testimony at the hearing, the "clarity and completeness of the hearing record [is] intact" and the purpose of section 3.103(c)(2) to develop the record has been fulfilled.  Id. at 498-99.  Therefore, the Veteran's right to a Board hearing has been satisfied and no prejudicial error exists with regard to the hearing officer's duties under section 3.103(c)(2).  See id.; see also Sanders, 556 U.S. at 407, 410.


III. Analysis

Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a).  Service connection may be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).

In interpreting sections 1110 and 1131 of the statute and section 3.303(a) of the regulations, the Federal Circuit held that a three-element test must be satisfied in order to establish entitlement to service connection.  Walker v. Shinseki, 708 F.3d 1331, 1333 (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))).  Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement).  Id.

However, claims for certain chronic diseases-namely those listed in 38 C.F.R. § 3.309(a)-benefit from a somewhat more relaxed evidentiary standard under 38 C.F.R. § 3.303(b).  See Walker, 708 F.3d at 1339 (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases").  Specifically, when a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to causes unrelated to service ("intercurrent causes").  38 C.F.R. § 3.303(b).  In order to establish the existence of a chronic disease in service, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic."  Id.  Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain in a claim for arthritis or abnormal heart action in a claim for heart disease) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned.  Id.  If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim.  Id.  

The Federal Circuit noted that the requirement of showing a continuity of symptomatology after service under subsection 3.303(b) is a distinct and lesser evidentiary burden than the nexus element of the three-part test discussed above: "The primary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the 'nexus' requirement of the three-element test, whereas the former benefits from presumptive service connection . . . or service connection via continuity of symptomatology" (emphasis added).  Walker, 708 F.3d at 1338-1339.  Thus, showing a continuity of symptomatology after service is an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation" for chronic diseases.  Id. at 1338; see also id. at 1336 (observing that section 3.303(b) provides a "second route by which a veteran can establish service connection for a chronic disease").  The Federal Circuit explained that a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period."  Id. at 1338.

Not all diseases that may be considered "chronic" from a medical standpoint qualify for the more relaxed evidentiary standard under section 3.303(b).  Rather, the Federal Circuit held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a).  Id.  Thus, if the claimed disability is not one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and "the 'nexus' requirement of the three-element test" must be satisfied in order to establish entitlement to service connection benefits.  Id.  

Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service connected disease or injury.  38 C.F.R. § 3.310(a).  The Court has construed this provision as entailing "any additional impairment of earning capacity resulting from an already service connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service connected condition."  Allen v. Brown, 7 Vet. App. 439, 448 (1995).  In order to establish entitlement to service connection on a secondary basis, the evidence must show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability.  Id.  

For claims for service connection on a secondary basis submitted on or after October 10, 2006, as is the case here, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury.  The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities (38 C.F.R. part 4) and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level.  38 C.F.R. § 3.310(b). 

A. Hypothyroidism

The Veteran has articulated three arguments in support of her service connection claim for hypothyroidism and related symptoms.  First, she argues that her hyperthyroidism initially manifested during her deployment to Saudi Arabia from September 15, 1990 to March 10, 1991 in the form of fatigue, weight gain, sensitivity to the cold, and menstrual abnormalities.  Second, she argues that her hypothyroidism was caused or aggravated by her service-connected anxiety disorder with depressive disorder.  Finally, she argues that to the extent her symptoms of weight gain, fatigue, sensitivity to the cold, and other such symptoms are not accounted for by the hypothyroid diagnosis (as has been suggested by the April 2011 VA examiner and the January 2012 opinion by the endocrinologist, as discussed below), then they are symptoms of an undiagnosed illness or medically unexplained chronic multisymptom illness related to her Persian Gulf service.  The Board will address each argument in turn, with a separate section below devoted to the issue of service connection for Gulf War syndrome.

The Veteran argues that although she was not diagnosed with hypothyroidism until November 1998 (as shown in an April 1999 VA treatment record, which also reflects the date she established care with VA) it nevertheless first manifested during active service in the form of certain symptoms.  Specifically, in her May 2008 notice of disagreement (NOD), the Veteran stated that none of her hypothyroid symptoms existed prior to her deployment to Saudi Arabia, but most such symptoms were apparent by the time of her return to the United States.  She stated that she did not receive or seek treatment at the time because she "did not realize [that] being overweight, tired, and cold were symptoms of a treatable illness until later, and considered the muscle and joint pains to be effects of exercise."  She had "never experienced problems with weight, fatigue, heartburn, joint and muscle pains, or any associated symptoms prior to deployment, but [had] experienced them to a progressive degree since with only temporary and/or partial relief . . . even after treatment."  She indicated that she did not seek treatment in the first few years after service because she did not have insurance, and stated that she tends not to seek medical attention "until an issue seriously interferes with [her] activities of daily living" or if it appears that the issue will not resolve on its own or with self-treatment. 

With regard to in-service signs and symptoms of hypothyroidism, the Veteran stated in the May 2008 NOD that at the time of her deployment her Army battle fatigues were a size extra small and that she had never experienced any weight gain.  By the time of her return to the U.S., she could barely fit into her pants and had to buy much larger clothing on her return.  She then began a strict diet and exercise regimen and "over a period of time" was "able to lose a portion of the weight."  However, "struggling through the fatigue [and] weight control" became an "'up and down' issue for [her]."  By November 1992 the Veteran's clothing sizes ranged from size 10 to 14, as opposed to the size 3 she wore prior to her deployment in September 1990.  She also experienced puffiness around her eyes.  By the time of her pregnancy, which occurred from 1993 to 1994, her clothing size range had increased so that the "high" was now a 16.  She also continued to experience fatigue and sensitivity to cold and heat.  She stated that during the pregnancy "weight gain and fatigue were factors," but a possible thyroid problem was never mentioned by her doctor.  After her pregnancy, she was able to lose some weight so that she could fit into "a low of size 10" clothing, but was not really able to fit into clothing smaller than that. 

Thereafter, according to the Veteran's May 2008 NOD, she continued to experience symptoms of fatigue, cold intolerance, and weight gain until they became overbearing and interfered with her ability to function in daily life.  The Veteran learned of hypothyroidism from a co-worker who had the condition and mentioned it to her "after [the Veteran] had again gained a significant amount of weight while dieting and exercising, [and also because she was] constantly complaining of being cold and running a space heater in [her] cubicle in the middle of summer."  After doing more research on hypothyroidism, the Veteran went to a doctor and specifically asked that her thyroid be evaluated.  The test yielded a diagnosis of hypothyroidism, and the doctor prescribed thyroid replacement medication.  The Veteran stated that the thyroid replacement therapy "noticeably relieved [her] fatigue and stopped the weight gain."  She began care with VA soon thereafter, and was told by the treating nurse practitioner that her "presentation was classic for longstanding hypothyroidism."  

Based on the history provided above, the Veteran argued in her May 2008 NOD that while her hypothyroidism may have been "exacerbated by [her] pregnancy," it was "more likely than not" that the illness had first manifested during her deployment to the Persian Gulf, although it initially may have been "subclinical" or "sporadic" at the time.  

Thus, to summarize, the Veteran contends that she did not seek treatment for or even suspect that she had hypothyroidism or an illness during her deployment to Saudi Arabia because the symptoms came on gradually and progressed slowly and intermittently over the ensuing years, so that she did not recognize them as indicative of a disorder until they became severe enough to pursue medical attention. 

In support of her contention, the Veteran submitted two photographs of herself.  The first shows her in a military uniform.  According to a statement next to the photograph, it was taken in September 1990 while she was preparing for her deployment.  The photograph clearly shows her to be slender at the time.  The second photograph is purportedly dated in November 1992, according to the Veteran, and shows that she had a fuller figure at this time.  

The Veteran also submitted statements by her mother and her husband, J.A.  According to her mother's statement, the Veteran was "little" and skinny" and had a lot of energy at the time she deployed to Saudi Arabia.  When she returned she had gained weight to the point where she had trouble fitting in her pants, and also tired easily and experienced aches and pains that had never been present before, as well as difficulty sleeping.  The Veteran's mother further stated that although the Veteran would diet and exercise, she could never get back down to her initial size, and eventually gained increasing weight.  According to this statement, although the Veteran's doctors kept increasing her thyroid medication, it did not seem to alleviate her fatigue or weight gain.  

The statement by the Veteran's husband reflects that he knew her at the time she deployed to Saudi Arabia, and that she had been thin and full of energy when she went overseas, but when she returned had gained enough weight that she could no longer fit into her clothing and could never get back down to the size she had been prior to her deployment.  He also noted that the Veteran complained of minor muscle and joint pains and tiring more easily, and that she had not experienced these symptoms before her Persian Gulf service. 

The Veteran also submitted a July 2009 statement by N. Rasgon, M.D., PhD, who is a professor of psychiatry and behavioral sciences, obstetrics, and gynecology at the Stanford University School of Medicine, as well as director of the behavioral neuroendocrinology program at Stanford.  Doctor Rasgon stated that she had reviewed the Veteran's available medical records and conducted interviews with her twice by telephone.  According to Dr. Rasgon, the Veteran's main symptoms associated with hypothyroidism were fatigue, difficulty concentrating, and weight gain.  Doctor Rasgon noted that the Veteran had been sexually assaulted during her first period of active service following which she experienced flashbacks and nightmares occurring almost nightly, which had continued to the present time.  Doctor Rasgon further noted that during the Veteran's deployment to Saudi Arabia she witnessed "numerous events of death and devastation."  During that time, the Veteran started gaining weight, developed chronic fatigue, cold intolerance, and menstrual abnormalities.  Doctor Rasgon stated that these were symptoms of hypothyroidism that went undiagnosed and thus untreated.  Doctor Rasgon also noted that the Veteran's problems with attention and concentration started shortly after the sexual assault, and "became exacerbated" thus leading her to "finally seek help" in 1998.  Doctor Rasgon concluded that the Veteran's PTSD had its onset during her first period of active service, was aggravated by her second period of active service, and that "more likely than not" her hypothyroidism was "a subsequence of an untreated PTSD."  Doctor Rasgon also stated that depression and anxiety often accompany PTSD, and that these disorders "could further compound her endocrinological dysfunction, as hypothyroidism is frequently co-morbid with depression."  Finally, Doctor Rasgon stated that the Veteran's giving birth did not cause her hypothyroidism, as hypothyroidism in the postpartum period is usually a mild and transient condition, which was inconsistent with her chronic illness.  Doctor Rasgon noted that the Veteran's PTSD, anxiety, and depression had been present long before she gave birth.  

Also submitted by the Veteran are several articles on scientific studies showing findings that repeated stress and psychological disorders can affect the thyroid.  

One article, which was published in 2000, is titled "Chronic Stress Influences the Immune System through the Thyroid Axis."  In the article, the authors concluded based on studies with stressed animals that the "findings suggest that chronic stress induces an alteration of the function of thyroid axis that alters the immune response."  The authors also observed that "the present work would be the first experimental evidences that point to the stress-thyroid axis-immune response interaction."

Another article, published in 2005, is titled "Relation Between the Hypothalamic-Pituitary-Thyroid (HPT) Axis and the Hypothalamic-Pituitary-Adrenal (HPA) Axis During Repeated Stress."  The article states that "[p]revious work has indicated that acute and repeated stress can alter thyroid hormone secretion," and that "[c]orticosterone, the end product of [HPA] axis activation and strongly regulated by stress, has been suggested to play a role in [HPT] axis regulation."  The article concludes that a study consisting of administering repeated electrical shocks to rats "lead to a decrease in peripheral thyroid hormone levels," and that "[s]tress-induced changes in potential regulators of the HPT axis . . . were also observed."  The authors noted that a "decrease in thyroid hormone levels after inescapable stress may reflect a conservation and protection of available resources in an unpredictable environment."  

Another article, published in 2006, is titled "Thyroid Hormone Levels and Psychological Symptoms in Sexually Abused Adolescent Girls."  The article concludes that the interpretation of the data with regard to the relationship between thyroid hormones and psychological symptoms was "plausible, but speculative," and the authors further stated that "we do not know . . . whether thyroid hormones, in fact, shifted at all" in response to stress.

Another article of record, published in 2007, was authored by Dr. Rasgon, among other authors, and is titled "Hypothalamic-Pituitary-End Organ Function in Women with Bipolar Depression."  The article states, in pertinent part, that "[d]isturbance of each of the three hypothalamic-pituitary-end organ systems [including the HPT axis] has been reported in depressive disorders."  However, the authors noted that "[l]ittle is known about potential reciprocal interaction among the three HP-end organ systems in patients with depressive disorders," and that the data gathered from a "pilot study" conducted by the authors "suggest lower levels of cortisol in women with bipolar depression," although "previously published studies reported higher cortisol in patients with depression."  The authors stated that after treatment with synthetic thyroid hormone (levothyroxine), the depression scores had significantly decreased in women subjects with normal thyroids and bipolar depression, while their thyroid hormones increased significantly.  The authors also cautioned that the results of the study were "preliminary" and "require[d] replication in larger samples."  The article states that "[s]ome caution is necessary in interpreting [the] data" as the study was "limited by the small number of subjects and the lack of a placebo control group," as well as the fact that the bipolar patients were also taking antidepressants and mood stabilizing medications other than thyroid hormones.  

Another article, published in 2005, is title "Thyroid Hormone Alterations Among Women with Posttraumatic Stress Disorder Due to Childhood Sexual Abuse."  The article states that altered thyroid activity was found in measuring thyroid function in women with PTSD due to childhood sexual abuse.  This article appears to focus on the relationship between hyperthyroidism and PTSD rather than hypothyroidism.  The authors conclude that the findings derived from the study "add to the growing literature suggesting that pathophysiological alterations associated with PTSD constitute a risk factor for medical illness," and that notably thyroid function "appears to be increased among both men and women with PTSD." 

The Veteran's March 1990 enlistment examination does not reflect any pertinent abnormalities, and shows that her weight at the time was recorded as 114 pounds.  Her physical build was noted as "slender."  A September 1990 treatment record dated about two weeks prior to her deployment reflects that the Veteran was seen for heat exhaustion after she "passed out" during a work assignment.  She reported feeling a little tired but otherwise "okay" and was returned to full duty.  As noted above, she served in Saudi Arabia from September 15, 1990 to March 10, 1991.  A November 1990 treatment record, dated during her deployment, reflects that the Veteran had insomnia.  A March 1991 separation examination, conducted upon her return to the United States, report shows normal clinical findings.  Her weight was again entered as 114.  However, her physical build was now noted as "medium" rather than slender.  Moreover, in the report of medical history, the Veteran indicated that she had experienced recent weight gain.  With regard to the weight gain, it was noted by a medical professional on the back of the form that the Veteran attributed it to "care packages."  She also reported a change in menstrual pattern.  She denied a history of painful joints in this report. 

The Veteran has provided credible evidence that her separation examination was perfunctory and incomplete.  In particular, she states that she was not actually weighed at separation, but merely entered the weight recorded on her identification card.  In support of this contention, she submitted a February 1992 After Action Report issued by the California Army National Guard which states that separation examinations for redeploying soldiers were inadequate, and improperly performed at the Demobilization Station, as the Veteran contends was the case with her.  The After Action Report, the fact that the Veteran's build was noted as slender at entrance and as medium at separation, the fact that her weight at entrance was recorded as exactly the same as her weight at separation (supporting her argument that the weight was simply copied from an identification card), and her report of weight gain in the March 1991 medical history form, all reinforce the credibility of her assertion that she gained weight during this period of active service, and was not actually weighed at separation.  Thus, the Board finds that the Veteran gained weight during her deployment to Saudi Arabia.

The VA treatment records show that the Veteran established care with VA in April 1999.  There are no treatment records in the file prior to this date.  The April 1999 VA treatment record documenting her initial visit to VA states that the Veteran had been diagnosed with a hypothyroid in November 1998 and started on Synthroid (levothyroxine)-a thyroid hormone replacement-at a dosage of 0.05mg qd.  Her weight was recorded at this time as 164 pounds.  

An April 2003 VA treatment record reflects that the Veteran's TSH (thyroid-stimulating hormone) level was 4.13 uIU/mL, with a normal reference range of .35 to 5.5.  It was noted that she was "doing well" with the Synthroid dosage of .05mg, and had no active complaints of fatigue, headaches, cold intolerance, constipation, or weight gain.  

An April 2004 VA treatment record reflects laboratory results showing a TSH level of 5.69 uIU/mL.  It was noted by the treating physician that her TSH level was mildly elevated.  The Veteran was diagnosed with a hypothyroid associated with a report of increased fatigue.  

In a November 2004 VA treatment record, the physician indicated that the Veteran's most recent TSH level of 5.69 should be slightly lower, and thus increased the Synthroid medication to .075 mg qd. 

An October 2005 VA treatment record shows that the Veteran was found to have subclinical hypothyroidism, and the Synthroid was increased to .088 mg qd. 

A June 2006 VA treatment record shows that the Synthroid dosage was increased to 0.125 mg qd.  A reason was not provided for this increase.

A December 2006 VA treatment record shows a TSH level of 3.78.

A July 2007 VA treatment record reflects that the Veteran had gained more weight, and it was noted that her "hypothyroidism vs diet/exercise [were] contributors."   This record also reflects that her weight was 225 pounds at the time. 

A December 2007 VA treatment record shows that the Veteran reported insomnia. 

At the April 2008 VA examination, the Veteran stated that after her pregnancy she experienced a 25-pound weight gain in one week.  She felt that her fatigue was secondary to her weight, sleeplessness, and hypothyroidism.  After reviewing the claims file and examining the Veteran, the examiner opined that the Veteran's hypothyroidism was less likely as not caused by or the result of active service.  In support of this opinion, the examiner stated that the Veteran's hypothyroidism was diagnosed after the birth of her child, and her deployment was not likely a contributing factor to this condition. 

At a separate VA examination for respiratory disorders, the Veteran reported having sleep difficulties that she believed were present prior to the 1990's.

At the August 2009 Board hearing, the Veteran stated that she first experienced fatigue and weight gain during her deployment to the Persian Gulf after nearby barracks were hit by a missile.  She further testified that she had missed a menstrual cycle during active service, and stated that this was also a symptom of hypothyroidism at the time. 

More recent laboratory results, as summarized by the April 2011 VA examination report, show that the Veteran's TSH levels were 8.072 in July 2009, 1.878 in October 2009, 1.897 in December 2009, 0.437 in July 2010, and 0.074 in March 2005, with a normal reference range of 0.46 to 4.7.

In the April 2011 VA examination report, the examiner opined after reviewing the claims file and examining the Veteran that her hypothyroidism was less likely as not related to active service.  The examiner explained that the Veteran's weight gain and fatigue could be attributed to a number of factors unrelated to hypothyroidism, and that the time frame did not otherwise support a relationship to service.  Specifically, the examiner noted that the Veteran attributed her weight gain during service to "care packages," suggesting that she had been sent "a lot food" during her deployment.  Moreover, the examiner noted that a February 2002 VA PTSD examination report reflects that the Veteran reported both an increase in weight gain and an increase in the consumption of "junk food."  The examiner also pointed out that notwithstanding the fact that the Veteran's hypothyroidism had been stabilized with medication (as shown by the laboratory results documented in the VA treatment records), she continued to gain a significant amount of weight, which suggested that her weight gain was independent of her hypothyroidism.  Although the Veteran reported that she "exercised a lot," the examiner stated that the type of exercises the Veteran performed-according to what the Veteran related at the interview-would generally not result in meaningful weight loss, assuming that the Veteran consumed no more than the average of 1800 calories a day for women.  With regard to the Veteran's fatigue, the examiner noted that the Veteran had reported having sleep problems, and that over a period of time lack of sleep can lead to chronic fatigue.  The examiner also noted that one of the symptoms of depression (with which the Veteran has been diagnosed) is fatigue, as well as body aches and myalgias.  Thus, the examiner concluded that with vague symptoms that can be attributed to a variety of factors, including depression, stress, anxiety, and medication side effects, and without any objective evidence of an elevated TSH during active service or shortly thereafter, it was less likely as not that the Veteran's hypothyroidism was related to service, as it was diagnosed over three years after separation from service.  The examiner also observed that the majority of cases of hypothyroidism are autoimmune in nature, and thus it was "very possible" that the Veteran's hypothyroidism was triggered by her pregnancy.

With regard to the issue of secondary service connection, a separate VA examination was conducted in April 2011 by a VA psychologist.  The VA psychologist opined in the examination report that it was less likely as not that the Veteran's service-connected anxiety and depression caused or aggravated her hypothyroidism.  The examiner explained that although research submitted by the Veteran addressed a possible correlation between exposure to stressors and changes in thyroid hormone levels, there was no research supporting a causal relationship between the two.  The examiner noted Dr. Rasgon's opinion suggesting that a causal relationship was present because the Veteran's reported symptoms of weight gain, fatigue, cold sensitivity, and menstrual abnormalities occurred after her in-service exposure to stressors.  However, the examiner stated that a temporal relationship was an insufficient basis upon which to support this conclusion.  Finally, the examiner stated that while it was widely acknowledged that hypothyroidism and depression share symptoms, including weight gain, fatigue, irritability, and sleep problems, it was not widely acknowledged that depression or anxiety actually cause hypothyroidism. 

The January 2012 opinion by the endocrinologist states that it was not at least as likely as not that the Veteran's hypothyroidism had its onset during active service, meaning "not 50 percent or greater."  In the context of the opinion, it is clear that the endocrinologist found that it was unlikely that the Veteran's hypothyroidism had its onset in active service.  The endocrinologist explained that although the Veteran had weight gain, fatigue, menstrual irregularities, and cold intolerance during active service, such symptoms were non-specific and occurred more often in those without hypothyroidism, especially when the symptoms were of modest severity.  The endocrinologist noted in this regard that cold intolerance and fatigue were subjective symptoms and difficult to quantify, and that if such symptoms were severe the record would reflect treatment for them at the time.  The endocrinologist also noted that the Veteran's reported cold intolerance and fatigue had continued despite normal thyroid hormone levels for years, which made it unlikely that these symptoms were related to her hypothyroidism.  The endocrinologist stated that these symptoms could be attributed to a wide range of conditions, including psychiatric conditions, and were not sufficient to establish a diagnosis of hypothyroidism absent laboratory confirmation.  Likewise, the endocrinologist noted that she had substantial weight gain of 167 pounds to 247 pounds from 2000 to 2010, despite years of full thyroid replacement treatment documented by many normal TSH values.  The endocrinologist stated that this data was consistent with weight gain due to diet rather than long term problems with thyroid alteration in metabolism. 

Significantly, the endocrinologist stated that when the Veteran was initially treated for hypothyroidism, it was subclinical and she was prescribed half the replace dose of thyroid hormones.  The endocrinologist stated that most patients with subclinical hypothyroidism would not have developed symptoms from thyroid disease years before the eventual diagnosis.  

With regard to the Veteran's abnormal menstrual patterns, the endocrinologist noted that the Veteran reported only "missing a period or two."  The endocrinologist stated that missing a period is very common in women under stress and also with weight gain, and thus did not find it indicative of hypothyroidism in service.  

With regard to the Veteran's report of having sensitivity to cold and being fatigued ever since her deployment to the Persian Gulf, the endocrinologist stated that the record showed appropriate and consistent use of increasing doses of levothyroxine, which is a thyroid replacement hormone, with many normal levels of thyroid hormone and normal or near normal TSH blood levels for over a decade.  The endocrinologist stated that most patients with "this typical, appropriate and complete treatment" would not have continuation of thyroid symptoms, including cold sensitivity and fatigue.  Thus, symptoms of being cold and fatigued ever since active service were not indicative of hypothyroidism when such symptoms continued to be present after many years of full treatment for this disorder.  The endocrinologist acknowledged that the Veteran did have a TSH level of 8.072 in June 2009, which was noted to be twice the normal level.  However, the endocrinologist stated that this change was actually a small one as TSH is inversely and exponentially related to thyroid hormone levels, and that many endocrinologists would not treat hypothyroidism unless the TSH level was persistently above 10.  

With regard to whether the Veteran's hypothyroidism could be attributed to giving birth in 1994, the endocrinologist agreed with Dr. Rasgon's statement that postpartum hypothyroidism is mild and transient.  The endocrinologist stated that only a few patients develop severe and persistent hypothyroidism following a pregnancy.  The endocrinologist observed that without TSH levels from this period it could not be determined whether the hypothyroidism was related to her pregnancy.  However, the endocrinologist noted that the progression of the Veteran's hypothyroidism from the date of initial diagnosis, with a gradual increase of hormone replacement therapy to 0.125 mg by 2006, was not unusual.  

With regard to whether an in-service disease, injury, or event during active service, such as stress or trauma, may have caused or aggravated the Veteran's hypothyroidism, the endocrinologist stated that it is possible that stress or psychiatric conditions "may very well have some influence on the immune or thyroid hormone systems."  However, the endocrinologist observed that "it has not been established that these influences are a clear cause of permanent hypothyroidism and certainly not a common cause."  The endocrinologist stated that the vast majority of patients with stress or psychiatric conditions never develop significant hypothyroidism and that patients with this disorder commonly do not have psychiatric or linked stress conditions.  The endocrinologist noted that the scientific papers submitted by the Veteran correctly state that stressful events and psychiatric conditions may have short term influences on some measurements of thyroid function.  However, the data did not show that these influences resulted in clinically significant and persistent thyroid dysfunction in humans.  Thus, the endocrinologist stated that although it was plausible and possible that the Veteran's active service had some effect on her thyroid, it was not likely to have caused significant and persistent clinical hypothyroidism.   

With regard to whether the Veteran's service-connected generalized anxiety disorder with depressive disorder caused her hypothyroidism, the endocrinologist stated that psychiatric conditions are generally not accepted to cause thyroid dysfunction.  Rather, it was generally accepted that the vast majority of hypothyroidism cases were associated with immune system mediated destruction of the thyroid, although it was not known what triggered the immune system to attack the thyroid.  The endocrinologist stated that it is possible that stress or psychiatric conditions may have some influence on the immune or thyroid hormone systems, but that it has not been established that these are a clear cause of permanent hypothyroidism, and were certainly not a common cause of it.  The endocrinologist reiterated that the vast majority of patients with stress and/or psychiatric conditions never develop significant hypothyroidism, and that patients with hypothyroidism commonly do not have psychiatric or linked stress conditions.  The endocrinologist noted that the studies submitted by the Veteran show that stress and psychiatric conditions may have a short term influence on some measurements of thyroid function, but that the data discussed in these studies did not show that these influences resulted in clinically significant and persistent thyroid dysfunction in humans.  

Finally, with regard to whether the Veteran's hypothyroidism was permanently aggravated by her service-connected generalized anxiety disorder with depression, the endocrinologist stated that psychiatric conditions are not known to alter the long term pathophysiology or course of hypothyroidism.  The endocrinologist observed that only if a psychiatric condition interfered with complying with thyroid hormone replacement could it affect the progression of hypothyroidism.  The endocrinologist noted that in the Veteran's case she appeared to have complied for years with the daily use of thyroid replacement therapy because the majority of her TSH levels had been acceptable.  Thus, the endocrinologist concluded that it was unlikely that her psychiatric disorders aggravated her hypothyroidism. 

The Board recognizes that it is possible that the Veteran's hypothyroidism may have first manifested during her six-month deployment to Saudi Arabia, as she stated in her March 1998 NOD, with a cluster of symptoms including weight gain, fatigue, sensitivity to the cold, and an abnormal menstrual pattern.  However, such a possibility is not sufficient by itself to establish service connection, and is outweighed by more probative evidence against a relationship between the Veteran's hypothyroidism and her in-service symptoms, as explained below. 

The standard for applying the benefit-of-the-doubt rule is found in 38 C.F.R. § 3.102, which provides that in order for the benefit-of-the-doubt rule to apply, there must be some "positive" evidence supporting the claim such that the doubt is "within the range of probability as distinguished from pure speculation or remote possibility."  See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (holding that medical evidence that is speculative, general or inconclusive is not sufficient by itself to support a claim); see also Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992) (holding that evidence that does little more than suggest a possibility that the Veteran's illnesses might have been caused by in-service radiation exposure is insufficient to establish service connection).  

The evidence submitted by the Veteran does not place a relationship between her hypothyroidism and her service in Saudi Arabia "within the range of probability."  See 38 C.F.R. § 3.102.  In this regard, the Veteran is competent to report that she experienced fatigue, weight gain, sensitivity to cold, and an abnormal menstrual pattern during active service, as these are symptoms that can be observed and described by a layperson.  See Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that lay testimony is competent as to matters capable of lay observation); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (holding that appellant was competent to testify as to factual matters of which he had first-hand knowledge, such as experiencing pain in his right hip and thigh in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy). 

However, as stated in the April 2011 VA opinion and the January 2012 endocrinologist's opinion, the Veteran's symptoms were not unusual and could be accounted for by a variety of factors unrelated to the onset of hypothyroidism.  Her weight gain was specifically attributed to increased food intake ("care packages") during her service in Saudi Arabia, and her fatigue was noted to be a symptom of depression (for which service-connection is already established) as well as poor sleep.  Indeed, the record shows that the Veteran reported insomnia during her deployment to Saudi Arabia, as well as after separating from active service, as in the December 2007 VA treatment record discussed above.  Moreover, at the VA examination for respiratory disorders, she reported having sleep difficulties prior to the 1990's, and thus prior to her second period of active service and deployment to Saudi Arabia.  The evidence also shows that her poor sleep has been associated with GERD, which in the past made it difficult to lie down, as reflected in VA treatment records dated in April and June 1999.  The September 1990 service treatment record, dated prior to her deployment, shows that she passed out one day due to heat exhaustion, which provides a clear explanation for this episode unrelated to hypothyroidism.  Thus, the record shows that the Veteran's fatigue and her weight gain during service have been specifically attributed to other factors, such as poor sleep and increased food intake, as found in the April 2011 VA opinion and the January 2012 opinion by the endocrinologist.  

Further, the endocrinologist noted that the Veteran reported only "missing a period or two," which is also confirmed by her testimony at the Board hearing and written statements submitted by her.  The endocrinologist explained that missing a period is very common in women under stress and also with weight gain, and thus was not indicative of hypothyroidism in service.  

In sum, the probative evidence of record shows that the Veteran's in-service symptoms were not manifestations of hypothyroidism but rather due to other factors. 

The Board has also considered whether the Veteran's reported in-service symptoms, when taken together, were as a cluster indicative of hypothyroidism at the time notwithstanding the fact that each one may also be attributed to a different cause.  However, as noted in the April 2011 VA examination report and the January 2012 endocrinologist's opinion, these symptoms are very common and readily explained by factors unrelated to hypothyroidism.  There is no reason, then, why they would be unusual or indicative of hypothyroidism even when manifesting together.  Indeed the evidence of record explicitly shows that the Veteran had increased her food intake while serving in Saudi Arabia (with the notation of "care packages" in the March 1991 report of medical history), and that her fatigue was likely a symptom of her service-connected psychiatric disorders and could also be attributed to her poor sleep patterns.  

Moreover, as explained in the January 2012 endocrinologist's opinion, the fact that the Veteran's reported in-service symptoms and her weight gain have continued to exist notwithstanding regular treatment with thyroid hormone replacement therapy and the stabilization of her TSH levels, indicates that they are not related to her hypothyroidism.  The July 2007 VA treatment record, for example, reflects that the Veteran's diet may have been a contributing factor to her weight gain.  Although the Veteran has argued that there have been fluctuations in her TSH levels coinciding with weight gain, the endocrinologist did not find these fluctuations to be clinically significant, and the record shows that her TSH levels have mostly been within the normal range, as reflected in the VA laboratory reports and the findings by the endocrinologist.  The endocrinologist did note the one-time TSH level of 8.072 in July 2009, but did not find this outlier in the laboratory results to be significant.  It follows, then, as found by the endocrinologist, that the Veteran's symptoms during service, which are common and explained by other factors, were not a manifestation of hypothyroidism at the time.  

Significantly, the January 2012 endocrinologist also found that the time period that elapsed between the Veteran's active service and the initial diagnosis of hypothyroidism did not support a relationship to her reported in-service symptoms.  Specifically, he stated that because the Veteran's hypothyroidism was subclinical at the time it was first diagnosed, it would not have been manifested by the symptoms reported by the Veteran several years earlier during active service. 

Thus, the April 2011 VA opinion and the January 2012 opinion by the endocrinologist, both of which are supported by the evidence of record, constitute probative evidence that it is unlikely that Veteran's reported symptoms and weight gain during service, even when considered as a cluster, were initial manifestations of hypothyroidism. 

The Veteran's report of cold intolerance and joint pains during service, symptoms which are not documented in the service treatment records, also deserve separate consideration.  As already discussed, even if the Veteran did experience unusual or clinically significant cold sensitivity and joint pains while serving in Saudi Arabia, it is still unlikely that such symptoms were indicative of hypothyroidism given the amount of time that elapsed between her period of service and the initial diagnosis of subclinical hypothyroidism, as well as the fact that the Veteran's reported symptoms and weight gain have persisted despite the regulation of her TSH levels with thyroid hormone replacement, as explained in the January 2012 endocrinologist's opinion.  

Further, with regard to the Veteran's in-service joint pain, a March 2008 VA joints examination report reflects that the Veteran's joint pain during service was present in the wrists and attributed to "extensive typing."  She was diagnosed with bilateral carpal tunnel syndrome, for which service connection has been granted.  There is no mention of any other joint pain in service.  Thus, her only joint pain during service, as reported by the Veteran, was bilateral wrist pain attributed to carpal tunnel syndrome from intensive use of her writs in typing, which indicates that she did not have other, unexplained or generalized joint pain related to hypothyroidism. 

Moreover, although the Veteran is competent to state that she experienced cold intolerance and joint pain (other than in her wrists) during service, the credibility of this allegation is in serious question.  In this regard, the competency of evidence differs from the weight assigned to the evidence, which varies according to its credibility, probative value, and relationship to other items of evidence.  See Layno, 6 Vet. App. at 469 (holding that the weight and credibility of testimony, as distinguished from its competency, is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted); accord Rucker v. Brown, 10 Vet. App. 67, 74 1997); see also Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the "authority to discount the weight and probity of evidence in the light of its own inherent characteristics in its relationship to other items of evidence"); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (stating that "although interest may affect the credibility of testimony, it does not affect competency to testify."); Washington, 19 Vet. App. at 368 (noting that the witness's credibility affects the weight to be given to his testimony). 

In determining whether a claimant's statements are credible, the Board may consider their internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant.  Caluza v. Brown, 7 Vet. App. at 711, aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table).  Further, the Federal Circuit has held that while the absence of contemporaneous medical records does not, in and of itself, render lay testimony not credible, the Board may weigh the absence of contemporaneous records when assessing the credibility of lay evidence.  See Buchanan, 451 F.3d at 1336 ("Nor do we hold that the Board cannot weigh the absence of contemporaneous medical evidence against the lay evidence of record.").  Moreover, although the Board cannot reject a claimant's statements merely because he or she is an interested party, the claimant's interest may affect the credibility of her testimony when considered in light of the other factors.  See Cartright, 2 Vet. App. at 25; accord Buchanan, 451 F.3d at 1337 (holding that "the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias . . . .").  

As will be explained below with regard to the Veteran's claim for GERD, the Board does not find it credible that she experienced symptoms of GERD during service as this allegation is patently inconsistent with the evidence of record, including with other statements made by the Veteran.  See Caluza, 7 Vet. App. at 511 (holding that when determining whether lay evidence is satisfactory, the Board may properly consider, among other things, its consistency with other evidence submitted on behalf of the Veteran); Madden, 125 F.3d at 1480 (observing that "lay evidence which is in fundamental conflict with other lay evidence and is, for that reason, found not credible in a given case, is surely suspect.").  The Board's finding that this allegation is not credible also casts significant doubt on the credibility of her assertion that she first experienced cold sensitivity and generalized or unusual joint pain (other than in her wrists) during her deployment to Saudi Arabia, which are symptoms not otherwise shown in the service treatment records.  Indeed, in the March 1991 report of medical history, the Veteran specifically denied a history of painful joints, although she indicated having a history of a number of other symptoms and conditions in this report, which shows that she did fill out the report with some care. 

Thus, the Board must discount the weight of the Veteran's allegation that she began experiencing a pattern of symptoms indicative of hypothyroidism during her six-month deployment to Saudi Arabia, including cold intolerance and joint pain, as the credibility of her statements in this regard is in serious doubt.  Washington, 19 Vet. App. at 368.  

The statements by the Veteran's mother and husband do not support the credibility of her assertions with regard to joint pain and cold sensitivity during service.  In this regard, as the Federal Circuit held, the Board "is obligated" to assess "whether lay evidence is credible in and of itself" due to factors such as "possible bias."  Buchanan, 451 F.3d at 1337.  The apparent, and certainly understandable, bias of the Veteran's mother and husband in helping her support a claim for benefits, in conjunction with the evidence otherwise casting doubt on the credibility of these allegations, as explained above, renders their statements not credible with regard to the onset of cold sensitivity and unusual or generalized joint pain during service.  Thus, for the reasons discussed above, the Board does not find it credible that the Veteran had clinically significant cold sensitivity, joint pains (other than carpal tunnel syndrome), or an unusual cluster of symptoms indicative of hypothyroidism during active service, including during her deployment to Saudi Arabia. 

In any event, even assuming for the sake of argument that the Veteran did experience symptoms of cold sensitivity and joint pain during service, the January 2012 endocrinologist's opinion, which assumed that the Veteran did experience such symptoms, in addition to weight gain, fatigue, and menstrual abnormalities, weighs against a finding that they evidenced hypothyroidism at the time, for the reasons discussed above. 

The weight of Dr. Rasgon's July 2009 opinion also must be discounted.  In Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008), the Court held that the probative value of a medical opinion comes from its reasoning, and therefore is not entitled to any weight if it contains only data and conclusions.  The Court further held that critical pieces of information from a claimant's medical history can lend credence to the opinion of a medical expert who considers them, and detract from the medical opinions of experts who do not.  Id.  Thus, the weight of a medical opinion is diminished to the extent its reasoning is deficient or limited.  

Doctor Rasgon did not explain why the Veteran's symptoms of fatigue, difficulty concentrating, and weight gain were due to hypothyroidism as opposed to other causes.  As explained in the April 2011 VA examination report and January 2012 endocrinologist's opinion, these are common symptoms that may be accounted for by a variety of factors unrelated to hypothyroidism, including diet, lack of sleep, and mental health disorders, all of which are present in the Veteran's case.  Doctor Rasgon also did not account for the fact that these symptoms have persisted notwithstanding stabilization of the Veteran's TSH levels and treatment with thyroid hormone replacement, as discussed in the April 2011 VA examination report and January 2012 endocrinologist's opinion.  Finally, the January 2012 endocrinologist explained that symptoms of hypothyroidism could not have been present during active service when it was only subclinical by the time it was diagnosed several years later.  Doctor Rasgon's opinion does not account for this time frame.  

Thus, Dr. Rasgon's explanation in support of her opinion with regard to the issue of whether the Veteran's hypothyroidism manifested during active service is deficient insofar as it does not account for the factors noted in the April 2011 VA examination report and January 2012 endocrinologist's opinion.  Consequently, its weight must be discounted.  See Nieves-Rodriguez, 22 Vet. App. at 304.  It is outweighed by the latter opinions, and especially the January 2012 opinion by the endocrinologist.  See id; see also Madden, 125 F.3d at 1481 (holding that the Board has the "authority to discount the weight and probity of evidence in the light of its own inherent characteristics in its relationship to other items of evidence").  The latter opinions are supported by much more thorough explanations than the one provided by Dr. Rasgon.  These explanations account for, are consistent with, and are fully grounded in the evidence of record, complete with specific citations to pertinent information in the Veteran's medical history, and clearly articulate the medical principles underlying them, specifically linking such principles to the facts in the Veteran's case.  By contrast, Dr. Rasgon's opinion operates at a much higher level of generality, draws little support from the facts specific to the Veteran's case, and does not account for pertinent factors indicating that the Veteran's hypothyroidism is not related to service, as explained in the April 2011 VA opinion and January 2012 endocrinologist's opinion.  Thus, these latter opinions have much more probative value than Dr. Rasgon's opinion and therefore carry more evidentiary weight in the Board's determination.  See id.
 
The issue of whether stress during active service caused or aggravated the Veteran's hypothyroidism overlaps with the issue of whether the Veteran's hypothyroidism is secondary to a service-connected psychiatric disorder.  Thus, both issues will be addressed together.  Preliminarily, the Board notes that although service connection has not been established for PTSD, service connection has been established for an anxiety disorder with depression.  The June 2002 rating decision granting service connection for these disorders, as well as a February 2002 VA examination report on which it was based, shows that service connection for PTSD was not granted as the Veteran's symptoms did not meet the criteria for PTSD at this time.  However, it appears that traumatic experiences during both the Veteran's first period of active service and her second period of active service, including her deployment to Saudi Arabia, may have informed the diagnoses rendered and the rating decision based on those diagnoses.  Thus, for the purposes of this decision, the Board's analysis will not turn on whether service connection has been established for PTSD or whether the Veteran experienced a clinically sufficient stressor during her second period of active service. 

In her July 2009 opinion, Dr. Rasgon stated that the Veteran had an untreated PTSD resulting from both periods of active service, and that her PTSD caused or aggravated her hypothyroidism.  She also stated that depression and anxiety often accompany PTSD, and that these disorders "could further compound [the Veteran's] endocrinological dysfunction, as hypothyroidism is frequently co-morbid with depression."  However, the weight of this opinion must also be discounted.  Again, for the reasons discussed above, it does not account for the significant factors weighing against a relationship between the Veteran's hypothyroidism and her period of active service, as explained in the April 2011 VA examination report and January 2012 endocrinologist's opinion.  

Moreover, Dr. Rasgon did not provide any explanation to support her opinion that the Veteran's PTSD directly caused or aggravated her hypothyroidism, and thus this aspect of the opinion is not entitled to any weight.  See Nieves-Rodriguez, 22 Vet. App. at 304.  To the extent this opinion was informed by the findings in the articles submitted by the Veteran, these findings, as shown above, were either based on short-term studies with rats, were characterized as "speculative," or indicated that hyper- rather than hypothyroidism was correlated with PTSD.  As explained by the January 2012 endocrinologist, there was no current medical knowledge that PTSD causes chronic hypothyroidism as opposed to acute shifts in thyroid hormones. 

Finally, although Dr. Rasgon stated that the Veteran's anxiety and depression "could" have caused or aggravated her hypothyroidism as hypothyroidism is often co-morbid with depression, she did not provide any further explanation as to the likelihood that the Veteran's depression or anxiety factored into her hypothyroidism.  To the extent this opinion was informed by the articles submitted by the Veteran, including the ones co-authored by Dr. Rasgon, she did not actually explain how the findings in the studies discussed in these articles applied to the facts in the Veteran's case.  Significantly, the language used in these articles-as selected out in the Board's discussion of them above-highlights the tentative nature of the findings in them, including words such as "suggest," and "preliminary," and phrases or characterizations such as "plausible, but speculative," "pilot study," or the observation in Dr. Rasgon's article that "[s]ome caution is necessary in interpreting [the] data."  In short, these articles underscore the fact that the correlation between thyroid hormone levels and stress and mental health is an emerging area of study and that the findings by researchers in this field, while generally supporting such correlations, remain tentative and uncertain.  The fact that Dr. Rasgon's opinion and these articles do not necessarily show a relationship between the Veteran's hypothyroidism and in-service stress, anxiety, or depression, is well explained in the April 2011 VA examiner's opinion discussed above.  As already discussed, in order for the benefit-of-the-doubt rule to apply, Dr. Rasgon's opinion must place the potential relationship between the Veteran's hypothyroidism and the stress she experienced in service, or between her hypothyroidism and her psychiatric disorders, within a range of probability rather than possibility or speculation.  See 38 C.F.R. § 3.102.  Thus, because Dr. Rasgon did not provide an adequate medical explanation placing such a relationship within the range of probability-irrespective of whatever language she used to express the opinion-the opinion lacks probative value and its weight must be discounted. 

The January 2012 opinion by the endocrinologist and the April 2011 VA examiner's opinion carry more weight than Dr. Rasgon's opinion.  The endocrinologist explained that the vast majority of patients with stress and/or psychiatric conditions never develop significant hypothyroidism, and conversely that patients with hypothyroidism commonly do not have psychiatric or linked stress conditions.  The endocrinologist noted that the studies submitted by the Veteran show that stress and psychiatric conditions may have a short term influence on some measurements of thyroid function, but that the data discussed in these studies did not show that these influences resulted in clinically significant and persistent thyroid dysfunction in humans.  The April 2011 VA examiner, a clinical psychologist with a PhD, also noted that it was not generally acknowledged that depression or anxiety cause hypothyroidism, even if depression and hypothyroidism share similar symptoms.  She also explained why the articles and Dr. Rasgon's opinion did not necessarily support a relationship between in-service stress or the Veteran's service-connected anxiety and depression, and her hypothyroidism, either by way of causation or aggravation.  The Board accords more weight to these more definitive and well-reasoned opinions than to Dr. Rasgon's opinion.  See Madden, 125 F.3d at 1481; Nieves-Rodriguez, 22 Vet. App. at 304. 

With regard to the articles submitted by the Veteran as they pertain to the issue of secondary service connection, the Board has already explained in the context of discussing Dr. Rasgon's opinion why such articles do not support the Veteran's contentions or place the evidence in equipoise, especially in light of the April 2011 VA examiner's opinion and the January 2012 endocrinologist's opinion.  As noted by the Court, a medical article or treatise can provide important support for a claim if it is combined with an opinion of a medical professional.  Sacks v. West, 11 Vet. App. 314, 317 (1998).  Alternatively, medical article or treatise evidence, standing alone, can provide support if it discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least a plausible argument for causality based upon objective facts rather than an unsubstantiated lay medical opinion.  Id.  As discussed above, these articles, either standing alone or in conjunction with Dr. Rasgon's opinion, are too general and speculative to provide more than minimal support for the Veteran's claim, and are outweighed by the more definitive and probative opinions by the April 2011 VA examiner and January 2012 endocrinologist, which are much more specific to the facts of the Veteran's case.  See id. (citing Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996)); see also Libertine v. Brown, 9 Vet. App. 521, 523 (1996).  These opinions considered the articles in question, as well as Dr. Rasgon's opinion, and provided cogent reasons for finding that the articles provided little support for a relationship between the Veteran's hypothyroidism and her psychiatric disorders, and further explained why such a relationship was unlikely in the Veteran's case based on the evidence of record.  Moreover, as already noted, apart from Dr. Rasgon's general observation that hypothyroidism is frequently co-morbid with depression, she did not specifically apply the findings in the articles to the facts of the Veteran's case.  

Finally, the Board has considered the Veteran's own statements in support of a relationship between her hypothyroidism and service or to her service-connected anxiety and depression.  The Veteran has presented admirably well-researched and well-expressed arguments in support of her claim.  To the extent these statements rely on the evidence discussed above, including the articles submitted by the Veteran and Dr. Rasgon's opinion, the Board has already explained why such evidence does not counterbalance the evidence weighing against a relationship to service or to her service-connected psychiatric disorders, either by way of causation or aggravation.  Moreover, the Veteran herself, as a layperson, does not have the medical training or expertise to provide a competent opinion as to whether her hypothyroidism is related to service or to her service-connected psychiatric disorders.  See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007)( observing that a layperson can be competent to identify conditions that are simple, such as a broken leg, but is not competent to identify more complex conditions such as a form of cancer); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that lay testimony is competent as to matters capable of lay observation, but not with respect to determinations that are "medical in nature"); Layno v. Brown, 6 Vet. App. 465, 469- 71 (1994) (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration, and that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise); see also Kahana v. Shinseki, 24 Vet. App. 428, 434 (2011) (holding that the Board erred in categorically rejecting lay evidence without analyzing and weighing it).  Such a relationship is too complex to be made based on lay observation alone, as indicated, for example, by the articles submitted by the Veteran showing ongoing research in this area, as well as the length of time that elapsed between service and the initial diagnosis of hypothyroidism.  Indeed, as shown above, the presence of hypothyroidism can only be definitely established by laboratory findings.  

Accordingly, the weight of the Veteran's opinions on the medical questions presented in this case is discounted.  See id.  Her opinions are outweighed by the April 2011 VA examiners' opinions and the January 2012 endocrinologist's opinion, which were authored by medical professionals with the appropriate expertise to render competent and informed opinions on the medical issues presented.  See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the medical issue in question); see also Layno, 6 Vet. App. at 469. 

The Veteran has not argued and there is no evidence otherwise suggesting that her hypothyroidism manifested in or is otherwise related to her first period of active service from July 1982 to May 1986.  To the extent Dr. Rasgon's opinion or other evidence of record addressed in the above discussion is applicable to this period, the same findings weighing against a relationship to service set forth in the preceding discussion apply, including with respect to exposure to a traumatic event.  Thus, further discussion of this issue is not warranted.

In sum, the preponderance of the evidence weighs against a chronicity in service, a continuity of symptomatology after service, or a medical nexus to service.  See Shedden, 381 F.3d at 1166-67; Walker, 708 F.3d at 1338-1339; 38 C.F.R. § 3.303.  Thus, the criteria for service connection on a direct basis have not been satisfied.  The preponderance of the evidence also weighs against a relationship between the Veteran's hypothyroidism and her service-connected psychiatric disorders, either by way of causation or aggravation.  Thus, service connection on a secondary basis is also not warranted.  See 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 448.

Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim.  Consequently, the benefit-of-the-doubt rule does not apply, and service connection for hypothyroidism is denied.  See 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. 

B. Gulf War Syndrome

The Veteran argues that to the extent her symptoms of fatigue, weight gain, sensitivity to the cold, and joint pain are not related to hypothyroidism, they must be considered symptoms of an undiagnosed illness or medically unexplained chronic multisymptom illness related to her Persian Gulf service in Saudi Arabia. 

The Veteran served in Saudi Arabia from September 1990 to March 1991, as reflected in her service personnel records.  Thus, because she had qualifying service in the Southwest Asia Theater of Operations during the Persian Gulf War, she is considered a Persian Gulf Veteran under 38 C.F.R. § 3.317(e).  See 38 C.F.R. § 3.2 (i) (2012) (providing that the Persian Gulf War began on August 2, 1990 and will continue until the date prescribed by Presidential proclamation or law).  VA regulations provide that compensation will be paid for disability due to undiagnosed illness and medically unexplained chronic multisymptom illnesses to a Persian Gulf War veteran who exhibits objective indications of a qualifying chronic disability if that disability (i) became manifest either during active service in the Southwest Asia theater of operations, or (ii) to a degree of 10 percent or more not later than December 31, 2016, and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis.  38 C.F.R. § 3.317(a)(1) (effective before and after Dec. 29, 2011).

For VA purposes, a qualifying chronic disability presently means a chronic disability resulting from any of the following (or any combination of the following): (A) An undiagnosed illness; or (B) A medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms such as chronic fatigue syndrome, fibromyalgia, or functional gastrointestinal disorders.  

The term medically unexplained chronic multisymptom 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 multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained.  "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.  Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic.  The 6-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 CFR § 3.317(a)(2)-(4).

Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: (1) Fatigue, (2) Unexplained rashes or other dermatological signs or symptoms, (3) Headache, (4) Muscle pain, (5) Joint pain, (6) Neurological signs and symptoms, (7) Neuropsychological signs or symptoms, (8) Signs or symptoms involving the upper or lower respiratory system, (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).

Presumptive service connection may be established for certain infectious diseases and long-term health effects associated with infectious disease.  38 C.F.R. § 3.317(c), (d).  Presumptive service connection may not be established if there is affirmative evidence the disease was not incurred during a qualifying period of service, 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 a qualifying period of service and the onset of the illness, or if there is affirmative evidence that the disease is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs.  38 C.F.R. § 3.317(c)(4).

If signs or symptoms have been attributed to a known clinical diagnosis, service connection may not be established under the specific provisions applicable to Persian Gulf veterans.  See VAOPGCPREC 8-98 at paragraphs 4-5 (Aug. 3, 1998).  However, service connection may still be established if otherwise warranted under VA law.

The evidence shows that the Veteran's symptoms have either been attributed to hypothyroidism, or to another known disorder, such as depression or insomnia.  At the April 2008 VA Gulf War examination, the Veteran reported weight changes, trouble sleeping, gastrointestinal symptoms, and fatigue.  After reviewing the claims file and examining the Veteran, the examiner concluded that the Veteran did not have any disorders related to Gulf War syndrome or an unknown diagnosis.  He stated that the Veteran's sleep problems were diagnosed as insomnia, her gastrointestinal symptoms were diagnosed as GERD, and referred to the April 2008 VA joints examination with regard to her joint pain, which shows that she only had symptoms in her wrists diagnosed as carpal tunnel syndrome.  The examiner's findings are supported by the record, which reflects these diagnoses and also shows that the Veteran's reports of fatigue and sleeplessness may be related to her anxiety and depression.  The Veteran's cold sensitivity is a symptom of hypothyroidism.  Moreover, her cold sensitivity is not by itself indicative of an undiagnosed or medically unexplained chronic multisymptom illness when all other symptoms are accounted for by other diagnoses and factors.  The Veteran's hypothyroidism itself, of course, is not a medically unexplained or undiagnosed illness, and thus does not qualify for presumptive service connection as a Gulf War illness.  See 38 C.F.R. § 3.317.  Finally, the Veteran has not been diagnosed with chronic fatigue syndrome or fibromyalgia.  

In sum, the competent and probative evidence shows that all of the Veteran's symptoms are attributed to known diagnoses.  With regard to weight gain, this is not itself a symptom associated with Gulf War syndrome (as opposed to weight loss), and has been attributed to diet and lack of exercise.  Thus, whether considered separately or in combination, the Veteran does not have a cluster of overlapping signs and symptoms that are unusual or medically unexplained; rather they have all been accounted for by specific diagnoses or other factors.  The Board accords more weight to the findings of the VA examiners than to the Veteran's lay statements on this issue.  See King, 700 F.3d at 1345; see also Madden, 125 F.3d at 1481; Layno, 6 Vet. App. at 469.  Thus, the preponderance of the evidence shows that the Veteran does not have an undiagnosed illness or medically unexplained chronic multisymptom illness.  Therefore, service connection for Gulf War syndrome based on the symptoms discussed above is not warranted.   See VAOPGCPREC 8-98; 38 C.F.R. § 3.317. 

Accordingly, the preponderance of the evidence is against the Veteran's claim.  Consequently, the benefit-of-the-doubt rule does not apply, and service connection for Gulf War syndrome is denied.  See 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. 

C. GERD

The Veteran argues that her GERD first manifested while deployed to Saudi Arabia during her second period of active service.  In the alternative, she argues that it was caused or aggravated by her service-connected anxiety and depression.  For the following reasons, the Board finds that the competent and credible evidence does not support a relationship to service or a relationship to her service-connected psychiatric disorders, either by way of causation or aggravation. 

At the Veteran's March 1982 enlistment examination, the Veteran indicated in the report of medical history that she had been hospitalized for acute gastritis in 1979.  However, she did not report having indigestion or stomach trouble at the time of the examination, and no gastrointestinal abnormalities were noted in the examination report.  The service treatment records associated with this period of active service make no mention of GERD or gastrointestinal problems, and the Veteran does not claim that her GERD manifested during this period. 

The service treatment records and examination reports associated with the Veteran's second period of active service, which occurred from August 1990 to March 1991, are also negative for diagnoses, treatment, or complaints of gastrointestinal problems or GERD.  No gastrointestinal abnormalities were noted in the March 1991 separation examination report.  Moreover, in the March 1991 report of medical history, the Veteran denied a history of frequent indigestion or stomach or intestinal trouble. 

The post-service evidence also shows that the Veteran's GERD is not related to service.  When she established care with VA in April 1999, she reported having GERD symptoms "all [her] life" which had worsened recently.  Further, a June 1999 VA treatment record reflects that the Veteran reported symptoms of reflux with heartburn and pain in her chest for approximately five years, which began toward the end of her pregnancy.  She stated that after she delivered her child, her symptoms improved but then progressively became worse.  This record also reflects that testing in May 1999 had shown a sliding hiatal hernia and mucosal folds in the esophagus consistent with reflux esophagitis. 

Because the Veteran's statements made in support of the present claim for benefits are contradicted by more probative evidence in the form of contemporaneous VA treatments and service treatment records, the Board does not find it credible that the Veteran's GERD manifested during her deployment to the Saudi Arabia or otherwise during her periods of active service.  See Caluza, 7 Vet. App. at 511 (holding that when determining whether lay evidence is satisfactory, the Board may properly consider, among other things, its consistency with other evidence submitted on behalf of the Veteran); Madden, 125 F.3d at 1480 (observing that "lay evidence which is in fundamental conflict with other lay evidence and is, for that reason, found not credible in a given case, is surely suspect."); Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than history as reported by the claimant); White v. Illinois, 502 U.S. 346, 356 (1992) (holding that statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (holding that although the Board cannot reject a claimant's statements merely because he is an interested party, the claimant's interest may affect the credibility of his testimony).  Thus, this allegation is not accorded any weight.  Washington, 19 Vet. App. at 368 (noting that the witness's credibility affects the weight to be given to his testimony). 

Accordingly, the credible and therefore most probative evidence of record shows that the Veteran's GERD did not manifest until around 1994, which was toward the end of her pregnancy, as reported by the Veteran.  The period of several years that elapsed between the Veteran's separation from active service in March 1991 and the initial onset of GERD symptoms, as well as the absence of any credible evidence of an in-service disease, injury, or event to which her GERD might be related, weighs against a direct relationship to service.  

Finally, there is no other evidence of record suggesting that the Veteran's GERD may have been caused or aggravated by a disease, injury, or event during her deployment to Saudi Arabia.  In the May 2012 opinion by the gastroenterologist, he stated that it was not at least as likely as not, meaning that it was unlikely, that the Veteran's GERD had its onset during active service or was related to any in-service disease, injury, or event, including any in-service trauma or service in the Persian Gulf.  He explained that "the only factor prompting her to possibly have heartburn/indigestion during her tour in [Saudi Arabia] relates to her weight gain and [diet] (including junk food)," presumably in reference to care packages.  However, he found it significant there was no evidence of her being evaluated for or admitting to GERD or indigestion in the service treatment records, and also stated that her emotional and other physical conditions existing at the time did not relate to her GERD.  In other words, the gastroenterologist indicated that if the Veteran's GERD was related to her diet during active service, it would have manifested at the time.  

The Board has also considered the fact that the Veteran was hospitalized for acute gastritis in 1979, according to the March 1982 enlistment examination.  Under 38 C.F.R. §  U.S.C.A. § 1111 (West 2002), "a veteran is considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed before acceptance and enrollment and was not aggravated by such service."  See 38 C.F.R. § 3.304(b); see also Wagner v. Principi, 370 F 3d 1089, 1096 (Fed. Cir. 2004) (holding that the "clear and unmistakable evidence" standard applies both to the issue of whether the disability pre-existed active service, and whether it was aggravated by active service); VAOPGCPREC 3-03 (July 16, 2003).  

Under 38 U.S.C.A. § 1153, "A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease."  In other words, there is a presumption of aggravation when disability from a pre-existing injury or disease increases during service, which can only be rebutted by clear and unmistakable (obvious or manifest) evidence.  See id.; see also 38 C.F.R. § 3.306(b).  However, aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service.  38 C.F.R. § 3.306(b).

The fact that the March 1982 enlistment examination states that the Veteran was hospitalized for acute gastritis in 1979 does not constitute a notation of this condition for purposes of rebutting the presumption of sound condition.  See 38 C.F.R. § 3.304(b)(1) (providing that a history of conditions existing prior to service recorded at the time of the entrance examination does not constitute a notation of such conditions for the purpose of establishing whether the Veteran was of sound condition at enlistment).  Thus, the Veteran is presumed to have been sound at entry. 

However, as there is no credible evidence showing that GERD or related gastrointestinal symptoms manifested during either period of active service, service connection is not warranted for a pre-existing condition that was aggravated by active service.  See 38 U.S.C.A. §§ 1111, 1153.  In this regard, the Veteran did state in the April 1999 VA treatment record that she had experienced GERD symptoms all her life, but did not state that they manifested during active service or became worse during that time.  Moreover, the fact that the Veteran's episode of gastritis in 1979 was characterized as "acute" in the March 1982 enlistment examination indicates that it was not a chronic or ongoing disorder that may have been aggravated during active service, but rather that it had completely resolved prior to enlistment.  Further, even if the Veteran's current GERD and hiatal hernia diagnoses were related to the 1979 episode of gastritis or to lifelong symptoms of gastritis, there is still no evidence showing that GERD manifested in or is otherwise related to service, or that it was aggravated thereby. 

Accordingly, because the Veteran's GERD did not manifest during active service or until several years later, the preponderance of the evidence weighs against a chronicity in service, a continuity of symptoms after service, or a medical nexus to service.  Therefore, service connection is not warranted on a direct basis.  See Walker, 708 F.3d at 1338-1339; Shedden, 381 F.3d at 1166-67; 38 C.F.R. § 3.303.

As discussed above, the Veteran's gastrointestinal symptoms have been diagnosed as GERD and thus are not considered an undiagnosed illness or component of a medically unexplained chronic multisymptom illness related to her Persian Gulf service.  See 38 C.F.R. § 3.317. 

In support of her claim for secondary service connection, the Veteran submitted an article, which was published in 2008, titled "The Influence of Co-Morbid IBS [irritable bowel syndrome] and Psychological Distress on Outcomes and Quality of Life Following PPI [proton pump inhibitor] Therapy in Patients with GERD."  The article states, in pertinent part, that the results of a study showed that "co-morbid psychological distress was independently associated with more severe GERD symptoms at baseline, and more residual symptoms after PPI therapy."  Thus, the article suggests that there may be a correlation between psychological distress and GERD symptoms. 

In the April 2011 VA examination report, the examiner opined after reviewing the claims file, including the articles submitted by the Veteran, and examining her that it was less likely as not that the Veteran's anxiety disorder with depressive disorder caused or aggravated any diagnosed gastrointestinal disorder.  The examiner explained that there was no research to support a causal relationship between anxiety and depression and gastrointestinal disorders, and referenced her discussion with regard to the Veteran's hypothyroidism, in which the examiner had stated that articles on "correlational studies" were not sufficient to show causation. 

In the May 2012 opinion by the gastroenterologist, he stated that the Veteran's GERD was neither caused nor aggravated by her service-connected generalized anxiety disorder with depressive disorder.  He explained that GERD is one of the most common conditions treated by gastroenterologists, and that it generally becomes worse over time unless treated.  He stated that a hiatal hernia may predispose one to GERD, but that ultimately it was "promoted by" differentials in esophageal sphincter pressure vis-à-vis gastric pressure, causing stomach content to regurgitate into the esophagus at a lower pressure than gastric pressure, which over time can cause damage to the esophagus with erosion.  He noted that this etiology applied in the Veteran's case.  In other words, he attributed GERD to physiological causes rather than psychological causes.  He noted that factors aggravating GERD include weight gain, smoking, alcohol, heavy or fatty meals, chocolate, peppermint, and coffee, lying down within three hours following a meal, exercising on a full stomach, and certain medications, including anti-depression medications.  He stated that there was no evidence of emotional conditions aggravating or causing GERD. 

The preponderance of the evidence weighs against a relationship between the Veteran's GERD and her service-connected anxiety disorder with depressive disorder.  The article submitted by the Veteran is not specific to the facts of this case and too general by itself to support the claim other than by suggesting that there is a possibility that GERD symptoms may be aggravated by psychological distress.  See Sacks, 11 Vet. App. at 317; Beausoleil, 8 Vet. App. at 463; 38 C.F.R. § 3.102.  Indeed, the article seems to focus more on how psychological distress may affect treatment for GERD with a certain form of therapy rather than how it affects GERD directly, although it does allude to the possibility that psychological distress may aggravate GERD symptoms.  In any event, the Board accords more weight to the more definitive opinion provided in the May 2012 report by the gastroenterologist.   This opinion is supported by a thorough explanation that applies clearly articulated medical principles to the facts of the Veteran's case and is otherwise consistent with the evidence of record.  The gastroenterologist explained that the etiology of GERD is physiological in nature, and that there are a variety of factors unrelated to psychiatric disorders that are known to aggravate GERD.  Indeed, the gastroenterologist indicated that psychiatric disorders are not known to aggravate GERD.  

Even if the article submitted by the Veteran provides some support for a finding that the Veteran's psychiatric disorders may have aggravated her GERD, the gastroenterologist's opinion clearly shows that there are many other factors that are more likely to aggravate GERD.  Thus, merely as a matter of probability, it is less likely that the Veteran's GERD was aggravated by her anxiety or depression, and more likely that it may have been aggravated by other factors, if in fact it were aggravated at all.  As indicated by the gastroenterologist, GERD can become progressively worse over time.  

The Board has considered the gastroenterologist's statement that certain anti-depressant medications can aggravate GERD.  However, there is no indication that any antidepressants that the Veteran might take are among such medications.  Moreover, according to the gastroenterologist's opinion, the odds are that if the Veteran's GERD has been aggravated by factors external to the progression of GERD itself, it is unlikely that such factors are related to antidepressant medications as this is only one among many known aggravating factors. 

Finally, because the Veteran does not have a medical background, her lay opinion that her GERD or any other gastrointestinal disorder was caused or aggravated by her service-connected psychiatric disorders is not competent, as this is a complex medication determination not amenable to lay observation.  See Jandreau, 492 F. 3d at 1376-77; Barr, 21 Vet. App. at 309.  The Board accords more weight to the May 2012 opinion by the gastroenterologist than to the Veteran's lay statements, as the former was authored by a medical professional with expertise in this area.  See King, 700 F.3d at 1345; Layno, 6 Vet. App. at 469. 

In sum, the preponderance of the evidence weighs against a relationship between the Veteran's GERD and her service-connected anxiety disorder with depressive disorder, either by way of causation or aggravation.  Thus, the criteria for service connection on a secondary basis have not been satisfied. See 38 C.F.R. § 3.310; Allen, 7 Vet. App. at 448. 

Accordingly, the preponderance of the evidence is against the Veteran's claim.  Consequently, the benefit-of-the-doubt rule does not apply, and service connection for GERD must be denied.  See 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. 


ORDER

Entitlement to service connection for hypothyroidism, to include as secondary to service-connected generalized anxiety disorder with depressive disorder, or as an undiagnosed illness or medically unexplained chronic multi-symptom illness related to Persian Gulf War service is denied. 

Entitlement to service connection for an undiagnosed illness or medically unexplained chronic multisymptom illness based on fatigue, weight gain, joint pain, and cold sensitivity is denied. 

Entitlement to service connection for gastroesophageal reflux syndrome (GERD), claimed as gastrointestinal symptoms, to include as secondary to service-connected generalized anxiety disorder with depressive disorder is denied. 



____________________________________________
P.M. DILORENZO 
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs