Citation Nr: 1328931 Decision Date: 09/10/13 Archive Date: 09/17/13 DOCKET NO. 04-03 285 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for chronic fatigue, to include as a chronic disability resulting from an undiagnosed illness. 2. Entitlement to service connection for sleep disturbances, to include as a chronic disability resulting from an undiagnosed illness. 3. Entitlement to service connection for headaches, to include as a chronic disability resulting from an undiagnosed illness. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD J. Murray, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1984 to January 1994, including in the Southwest Asia Theater of Operations from September 1990 to April 1991. These matters come to the Board of Veterans' Appeals (Board) on appeal from an April 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied the claims. The claims have been remanded by the Board in June 2007, September 2010 and March 2012 to the RO (via the Appeals Management Center (AMC)) for additional development and to address due process concerns. In June 2007, the Board instructed the AMC to verify the Veteran's dates of service in Southwest Asia Theater of Operations, obtain outstanding records of pertinent treatment, obtain records and documents associated with the Veteran's Social Security Administration (SSA) disability benefits award, and provide the Veteran with VA examination to determine the nature and etiology of his claimed conditions. In September 2010, the Board found that the February 2010 and April 2010 VA examination report failed to provide sufficient information for adjudicating the Veteran's claims, and the matters were remanded to obtain new VA examinations. The Board again remanded the matters in March 2012 to obtain another VA examination and a supplemental VA medical opinion on the etiology of the Veteran's claimed conditions as well as obtain any outstanding records of pertinent treatment. The Board finds that there has been substantial compliance with its June 2007, September 2010, and March 2012 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (noting that Stegall requires substantial compliance with remand orders, rather than absolute compliance.) A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. The Veteran served in Southwest Asia from September 1990 to April 1991. 2. The file contains no competent medical evidence that shows that the Veteran has a current diagnosed chronic fatigue syndrome that had its onset in or is otherwise related to his military service, to include as attributable to a medically "unexplained" chronic multi-symptom illness. 3. The medical evidence of record reflects that the Veteran's sleep disturbances is likely a symptom of his service-connected post traumatic stress disorder (PTSD) and schizophrenia, and thus, has been attributed to a known clinical diagnosis for which he is already receiving disability benefits. 4. The Veteran's current headache disorder did not have its onset during service, and the preponderance of the competent evidence is against a finding that it is otherwise related to his period of service, to include as attributable to a medically "unexplained" chronic multi-symptom illness. CONCLUSIONS OF LAW 1. Chronic fatigue was not incurred in or aggravated by service, and is not due to an undiagnosed illness. 38 U.S.C.A. §§ 1110, 1111, 1117, 1131, 5107 (West 2002); 38 C.F.R. § 3.303, 3.317, 4.14, 4.130 (2012). 2. Sleep disturbances were not incurred in or aggravated by service, and are not due to an undiagnosed illness. 38 U.S.C.A. §§ 1110, 1111, 1117, 1131, 5107 (West 2002); 38 C.F.R. § 3.303, 3.317, 4.14, 4.130 (2012). 3. Headaches were not incurred in or aggravated by service, may not be presumed to have been incurred therein, and are not due to an undiagnosed illness. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1117, 1131, 1137, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. VA's Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations requires VA to provide claimants with notice and assistance in substantiating a claim. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not in the 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, 186 (2002). These notice requirements apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Proper VCAA notice must be provided to a claimant prior to the initial unfavorable decision on the claim. Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004). In this case, the Veteran was advised in June 2001, February 2004 and June 2007 letters of the notice elements. The Veteran was informed of what evidence and information was necessary to substantiate his claims, and the responsibilities of the Veteran and VA in obtaining such evidence. He was further advised of the evidence and information necessary to establish a disability rating and an effective date, in accordance with Dingess/Hartman. With regard to the duty to assist, the Veteran's service treatment and personnel records, VA treatment records, records from Social Security Administration (SSA) and his lay statements of argument have been obtained. The Veteran was afforded a VA examination in February 2002, February 2010, and June 2010, September 2011, and December 2012. Any deficiencies found in the previous VA examinations were resolved by the December 2012 VA examination and supplement VA medical opinion. The VA examiners reviewed the claims folders and recorded the Veteran's reported history and the clinical findings in the examination report, and the examiners provided comprehensive statements in support of the conclusions. The Board finds that the medical opinions are adequate for adjudication purposes and the adequacy of these medical opinions are discussed in further details below. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The RO/AMC has substantially complied with the Board's March 2012 remand instructions with regard to obtaining a medical examination. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. See Bernard v. Brown, 4 Vet. App. 384 (1993). For the foregoing reasons, the Board therefore finds that VA has satisfied its duty to notify and its duty to assist pursuant to the VCAA. See 38 U.S.C.A. §§ 5102, 5103 (West 2002); 38 C.F.R. §§ 3.159(b), 20.1102 (2012); Pelegrini, supra; Quartuccio v. Principi, 16 Vet. App. 183 (2002). 2. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.303(a). Where a veteran served continuously for 90 days or more during a period of war or during peacetime service after December 31, 1946, service connection may also be allowed on a presumptive basis for arthritis and organic neurological disorders, and if the disability becomes manifest to a compensable degree within one year after the veteran's separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of certain chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. See 38 C.F.R. § 3.303(b). The chronicity provision of 38 U.S.C.A. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has such condition. A recent decision of the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court), however, clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which as mentioned is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To prevail on the issue of service connection, generally, there must be competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102. On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. In this case, the Veteran seeks entitlement to service connection for headaches, fatigue, and sleep disturbances. He reports that he first experienced these symptoms during his period of service. The Veteran reports that his fatigue is manifested by feeling constantly tired, unmotivated, and lack of energy. He reports that he only sleeps three hours a night and he frequently has nightmares. He contends that his claimed disorders are attributed to an undiagnosed illness due to his period of service in Southwest Asia Theater of Operations. In the alternative, he contends that his claimed conditions are related to his service-connected mental health disorders, to include medications used to treat his conditions. The Veteran's service treatment records do not show any complaints or treatment for any chronic disorder manifested by headaches and sleep impairment. The service treatment records do show a single complaint of fatigue. In October 1988, the Veteran had a positive PPD skin test for tuberculosis and he was prescribed Isoniazid (INH) Therapy. The Veteran was advised to seek follow-up treatment if he experienced symptoms of fatigue, loss of appetite, or weakness. The Veteran returned to the medical clinic with complaints of fatigue, which he felt resolved upon stopping INH treatment. He was placed on an alternative medication. There was no subsequent complaint of fatigue. The Veteran's November 1993 examination prior to separation shows that he received a normal head and neurologic evaluation. His blood pressure reading (BPR) was 150/80. A subsequent electrocardiogram (EKG) revealed findings of sinus bradycardia, but otherwise normal results. On the associated report of medical history, the Veteran reported having experienced high or elevated blood pressure, and it was noted that he had elevated blood pressure on clinical evaluation. However, the Veteran specifically denied having had experienced frequent or severe headache or any trouble sleeping during his period of active service. Post-service mental health treatment records starting in June 2000 show that the Veteran complained of headaches, fatigue, and sleep impairment. The Veteran filed his informal claims for service connection in September 2000. VA treatment records dated starting in December 2000 show that the Veteran received mental health treatment for his service-connected posttraumatic stress disorder (PTSD) and schizophrenia. These records show that the Veteran complained of sleep impairment with night sweats, shaking, and nightmares. He also complained of headaches, loss of interest, lack of motivation, and loss of energy. The Veteran was afforded VA general medical and psychiatric examinations in June 2002. The general medical examination report shows that the Veteran complained of daily headaches, nightly sleep disturbances, and fatigue. The Veteran stated that he believed that his fatigue was secondary to his psychiatric medications that he takes to control his schizophrenia. Clinical evaluation revealed BPR of 150/90 and he received a normal neurological evaluation. He was assessed with (1) Tension-like headaches; (2) sleep disturbances, which the examiner indicated that these were better assessed in the psychiatric examination report; and (3) fatigue, medication induced. In the June 2002 VA psychiatric examination report, the examiner noted that the Veteran complained of insomnia and nightmares, and it was noted that he took medication to treat his PTSD and schizo-affective disorder. In a June 2002 medical statement, the Veteran's treating VA physician noted that the Veteran was being treated for PTSD and schizoaffective disorder. The Veteran was on multiple medications that resulted in side-effects which compound his inability to work. The treating VA physician, however, did not indicate what kind of side-effects resulted from the Veteran's psychotherapeutic medications. Private treatment records dated in September 2005 show that the Veteran was admitted into the hospital for recurrent episodes of erratic shaking, limb movement, and state of confusion upon waking at night. Clinical evaluation ruled out diagnoses of seizures and rapid eye movement sleep disorder. He was assessed with episodes of erratic shaking at night with unknown etiology. The Veteran underwent VA Gulf War Illness examinations in February 2010. The examination report shows that the Veteran primarily complained of pain and stiffness in multiple joints. He also complained of snoring and chronic fatigue, and it was noted that he reported a history of sleep apnea with treatment in service. The examiner stated that after clinical evaluation of the Veteran and a review of the claims folder, the Veteran did not have an unexplained illness. The Veteran underwent a subsequent VA Gulf War Illness examination in June 2010. Again, the Veteran primarily complained of aches and pain in multiple joints. He did not complain of headaches, fatigue, or sleeping problems. The Veteran was assessed with a normal clinical evaluation and there was no evidence of any pathological condition on examination that could be attributed to the Veteran's complaints of body aches. Instead, his complaints were attributed to his post-service occupational history in construction and physical labor. The Veteran underwent VA psychiatric examinations in June 2010 and June 2011. The June 2010 VA examination report shows that the Veteran continued to complain of sleep impairment, manifested by interrupted sleep, difficulty falling back to sleep, and nightmares. However, the June 2011 VA examination report shows that the Veteran reported that he has "good sleep quality and quantity with his present medications." He continued to experience some drowsiness due to his medications and he took naps during the day. The June 2011 VA examiner opined that the Veteran's "past sleeping disturbances are more [than] likely as not related to or secondary to his mental conditions (e.g. hallucinations, paranoid ideations, intrusive thoughts, and anxiety)." The VA examiner concluded that the Veteran does not require a separate diagnosis for a sleep condition or that it would be resorting to speculation as to an etiology related to military service. In September 2011, the Veteran underwent a VA neurologic examination. The Veteran's claims folder was available and reviewed by the examiner. Following physical examination, the Veteran was diagnosed with headaches and the examiner opined that the Veteran's headaches were at least as likely as not related to his diagnosis of hypertension. In support of this medical conclusion, the examiner noted that the Veteran had been treated for hypertension in the past, but he had not been consistent with treatment and was not currently taking any medications for hypertension. However, the Board found that the opinion was problematic insofar as the examiner, in rendering an "at least as likely as not" opinion, as opposed to a "more likely than not" opinion, left open a fifty percent possibility of a different etiology. The report of a December 2011 VA medical opinion shows that after a review of the record, the examiner opined that there was no evidence of chronic fatigue condition or syndrome. The examiner noted that during the two VA Gulf War Illness examinations, the Veteran failed to complaint of chronic fatigue and the Veteran's complaints of joint pain were associated with his history as a construction worker. The examiner stated that since there was no mention of diagnosed chronic fatigue syndrome in the medical evidence, the examiner could only speculate if the claimed fatigue was due to some unknown condition. The examiner further concluded that the Veteran's complaints of chronic fatigue were not associated with his PTSD disability. The examiner noted that chronic fatigue was not likely a symptom of PTSD and the Veteran failed to complain of depression symptomatology during his June 2011 VA psychiatric examination. Rather, the examiner noted that the Veteran reported that his antipsychotic medication only made him drowsy during the day. Additional VA medical opinions regarding the etiology of the Veteran's claimed chronic fatigue and chronic headaches were obtained in December 2012. With respect to the Veteran's claimed chronic fatigue, the VA examiner stated that after a review of the claims folder and clinical evaluation, the Veteran did not now have or ever have a diagnosis of chronic fatigue syndrome. There was no evidence of findings, signs, or symptoms attributable to chronic fatigue syndrome. The examiner supported this medical conclusion by noting that the Veteran failed to complain of chronic fatigue at the time of the February 2010 and June 2010 VA Gulf War examinations, or the June 2011 VA psychiatric examination. The examiner further concluded that the Veteran's complaints of fatigue were not an attributable symptom of his PTSD or other mental health condition present. With regard to the Veteran's chronic headache claim, the VA examiner diagnosed the Veteran with headache syndrome. The examiner noted that the Veteran reported his headaches had an onset of five or six years before, and he experienced headaches daily for which he treated with over-the-counter medication. The examiner opined that the Veteran's current headache disorder was less likely than not related to his hypertension. The examiner noted that the Veteran's blood pressure readings over the past three years were only borderline elevated and the readings were not elevated enough to cause headaches in most individuals. The examiner further opined that the Veteran's current headache disorder was less likely than not related to his period of service since his headaches had an onset about 10 years after his separation from service. Undiagnosed Illness Claim The Veteran contends that his complaints of headache, chronic fatigue, and sleep disturbances are attributed to an undiagnosed illness due to his period of service in Southwest Asia Theater of Operations. Inasmuch as the record indicates that the Veteran served in served in Southwest Asia from September 1990 to April 1991, he is a Persian Gulf War Veteran within the meaning of the applicable statute and regulation. 38 C.F.R. § 3.317(b). Service connection may be established for a chronic disability resulting from an undiagnosed illness which became manifest during active service in the Southwest Asia Theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2016. 38 C.F.R. § 3.317(a)(1)(i). For purposes of this section, a qualifying chronic disability means a chronic disability resulting from an undiagnosed illness. This further includes such chronic medically unexplained multi-symptom illnesses defined by a cluster of signs or symptoms as chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, or any diagnosed illness that the Secretary determines under 38 U.S.C.A. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2)(i). Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from the VA's Schedule for Rating Disabilities for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. 38 C.F.R. § 3.317(a)(5). A disability referred to in this section shall be considered service-connected for the purposes of all laws in the United States. 38 C.F.R. § 3.317(a)(6). Signs or symptoms which may be manifestations of an undiagnosed illness include, but are not limited to, fatigue, signs or symptoms involving the skin, headaches, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317(b). Here, the competent evidence of record does not demonstrate that presumptive service connection is warranted for a qualifying chronic disability under 38 C.F.R. § 3.317. None of the Veteran's claimed symptomatology has been attributed to a medically unexplained multi-symptom illness, or as residuals of one of the infectious diseases listed in 38 C.F.R. § 3.317. In this regard, both the February 2010 and June 2010 VA examiners concluded that based on clinical examination and review of the medical evidence, the Veteran did not have an unexplained illness. The Veteran's complaints of chronic headaches have been associated with a diagnosis of a headache disorder by the September 2011 and December 2012 VA examiners. The June 2011 VA examiner attributed the Veteran complaints of sleep disturbances to his service-connected PTSD and schizophrenia. The Veteran's complaints of headaches and sleep disturbances are ineligible to be considered as a qualifying chronic disability under 38 C.F.R. § 3.317, because his symptomatology has been attributed to known conditions. Although the Veteran's complaints of fatigue have not been clearly associated with a known condition, it has also not been characterized as signs or symptoms of an undiagnosed illness or a medically unexplained chronic multi-symptom illness. None of the competent medical evidence of record has associated the Veteran's complaints of fatigue with an undiagnosed illness. Rather, both the December 2011 and December 2012 VA examiners noted that after a review of the record there was no evidence of a disorder manifested by chronic fatigue. The December 2012 VA examiner concluded that the Veteran's complaints of fatigue was a symptom and not associated with a chronic disorder of any kind. Some of the medical evidence suggests that the Veteran's complaints of fatigue are the result of side-effects of his medication to treat other conditions. For instance, the service treatment records show that the Veteran's in-service complaint of fatigue was associated with his INH treatment, and his symptoms resolved upon his termination of that treatment. Also, the VA mental health treatment records indicate that the Veteran's complaints of fatigue were associated with his antipsychotic medication. None of the competent medical evidence has attributed the Veteran's complaints of chronic fatigue to an undiagnosed illness or medically unexplained multi-symptom illness. Instead, the evidence of record suggests that the Veteran's complaints of fatigue are a side-effect symptom of his medication to treat another disorder. The Board finds that the preponderance of the evidence is against a finding that the Veteran's complaints of fatigue warrants presumptive service connection for an undiagnosed illness or as part of a chronic medically unexplained multi-symptom illnesses under 38 C.F.R. § 3.317. The availability of presumptive service connection for a disability based on a qualifying chronic disability under 38 C.F.R. § 3.317, however, does not preclude an appellant from establishing service connection with proof of direct causation. Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Chronic Fatigue and Sleep Disturbances As noted above, the medical evidence of record has not attributed the Veteran's complaints of fatigue and sleep disturbances to separately diagnosed disorders. Rather, his complaints have been assessed as symptoms and have been associated with his service-connected PTSD and schizophrenia, to include his antipsychotic medications. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). The June 2011 VA examiner concluded that the Veteran's complaints of sleep disturbances were symptoms of his PTSD disability. The June 2011 VA examiner expressly stated that the Veteran's complaints of sleep disturbances did not meet the criteria for a separately diagnosed disorder. Also, the September 2005 private clinical evaluations ruled out a diagnosis of seizure and sleep movement disorders. In addition, the December 2012 VA examiner stated that the medical evidence of record failed to demonstrate that the Veteran had a diagnosis of chronic fatigue syndrome. The December 2011 VA examiner said that the Veteran's fatigue was possibly related to his prescribed medications. Furthermore, the Veteran has submitted no evidence to show that he currently has a diagnosis of chronic fatigue syndrome. In short, no medical opinion or other medical evidence demonstrate that the Veteran currently diagnosis of chronic fatigue syndrome or a separate diagnosis of sleep disturbances. Brammer v. Derwinski, 3 Vet. App. at 223; Rabideau v. Derwinski, 2 Vet. App. at 143; Degmetich v. Brown, 104 F. 3d at 1328. The Board has considered the Veteran's contention that he has sleep disturbances and chronic fatigue syndrome and those disabilities are due to military service. In adjudicating this claim, the Board must assess the Veteran's competence and credibility. See Buchanan v. Nicholson, 451 F.3d at 1331; Washington v. Nicholson, 19 Vet. App. at 368- 69. The Board acknowledges that lay testimony is competent evidence if it is limited to matters that the witness has actually observed and is within the realm of the witnesses' personal knowledge. See 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. at 30. In this capacity, the Board acknowledges the statements from the Veteran with regard to experienced marked fatigue since approximately 1993. Even if the Board were to concede that the Veteran experienced marked fatigue after service, the fact remains that he does not have a current disability for VA purposes. While the Veteran is competent to attest to his fatigue and sleeping problems, the Veteran is not competent to attest to a chronic fatigue disability; that requires proper evaluation conducted by an appropriate examiner. Thus, the Veteran's assertions as to chronic fatigue problems following service are outweighed by the medical evidence that reflects that he does not currently meet the criteria for a diagnosis of chronic fatigue syndrome. In fact, the December 2011 VA examiner thought that the Veteran's fatigue was most likely a side effect symptom of his prescribed medications. Fatigue represent symptoms and symptoms, alone, not attributable to a diagnosed disorder, may not be considered a disability as defined by VA. See e.g., Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (holding that, pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted); dismissed in part and vacated in part on other grounds, Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). Without the required proof that he has a current chronic fatigue disability, the Board need not determine whether there is a correlation between for all intents and purposes a nonexistent disability and his military service, because this, quite simply, is impossibility. See Watson v. Brown, 4 Vet. App. at 314. See, too, Maggitt v. West, 202 F.3d at 1375; D'Amico v. West, 209 F.3d at 1326; Hibbard v. West, 13 Vet. App. at 548; and Collaro v. West, 136 F.3d at 1308. The Board also accepts the lay statements and testimony from the Veteran as credible evidence that he has sleep disturbances and the VA medical records demonstrate the Veteran has sought treatment for complaints of sleep disturbances. However, the medical evidence of record discussed above also reflects that the Veteran's current sleep disturbances are a symptom of his service-connected PTSD. See Barr v. Nicholson, 21 Vet. App. 303 (Fed. Cir. 2007). Therefore, as the Veteran is currently receiving disability compensation for PTSD, with sleep disturbances being a symptom thereof, service connection cannot be established for sleep disturbances separately on a direct basis. Except as otherwise provided in the rating schedule, all disabilities, including those arising from a single disease entity, are to be rated separately, and then all ratings are to be combined pursuant to 38 C.F.R. § 4.25 (1993)." Esteban v. Brown, 6 Vet.App. 259, 261 (1994). However, "evaluation of the 'same disability' or the 'same manifestation' under various diagnoses is to be avoided." Id. (citing "anti-pyramiding provision" of 38 C.F.R. § 4.14 (1998)); see also Evans (Samuel) v. Brown, 9 Vet.App. 273, 288 (1996) (finding that a "veteran can receive separate disability ratings unless the conditions constitute the 'same disability' or the 'same manifestation' under 38 C.F.R. § 4.14 "). The Court has interpreted 38 U.S.C.A. § 1155 as implicitly containing the concept that the rating schedule may not be employed as a vehicle for compensating a claimant twice (or more) for the same symptomatology; such a result would overcompensate the claimant for the actual impairment of his earning capacity and would constitute pyramiding of disabilities, which is cautioned against in 38 C.F.R. § 4.14. See Id. In order to avoid granting multiple awards for the same condition, the Court has held that separate awards may be granted only when "none of the symptomatology for ... [each of the claimed] conditions is duplicative of or overlapping with the symptomatology of the other ... conditions." Id. (emphasis in original). In this case, as the medical evidence of record demonstrates that the Veteran's sleep disturbances is a symptom associated with his service-connected PTSD, in which the diagnostic criteria provide compensation for symptoms including sleep impairment, the Board finds that service connection for sleep disturbances on a direct basis cannot be established as this would constitute a pyramiding of disabilities. 38 C.F.R. §§ 4.14, 4.130. Therefore, as the evidence of record demonstrates that the Veteran's sleep disturbances is associated with his PTSD, and the Veteran is service-connected for this disability, service connection for sleep disturbances, other than as a symptom of PTSD, cannot be established. 38 C.F.R. §§ 3.303, 4.14, 4.130. In reaching the conclusion above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Chronic Headaches The Veteran seeks entitlement to service connection a headache disorder. The medical evidence of record shows that he has a current diagnosis of headache disorder. See the reports of VA examinations dated in September 2011 and December 2012. The Veteran contends that his current headache disorder is related to his period of service. The Veteran's service treatment records do not show any complaints or treatment for headaches. His November 1993 separation examination shows normal head and neurologic evaluations, and the Veteran did not report having experienced headaches during service on his associated report of medical history. The first post-service medical evidence of headache complaints comes in 2000, well beyond the first year after his separation from service. See supra 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The record does not show that the Veteran received any treatment for his headaches, during service or until many years after his discharge from service. A lengthy period without treatment for related conditions is evidence against a finding of continuity of headaches since service, and it weighs heavily against a claim for service connection on a direct basis. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (noting that service incurrence may be rebutted by the absence of medical treatment of the claimed condition for many years after service). The Veteran asserts that his headaches had an onset during his period of service and he has continued to experience headaches since then. The Veteran's statements regarding the onset of her headaches may be competent to support his claim where the presence of disability or symptoms of a disability are subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (2006). While the Veteran's reports of a continuity of symptoms since service are competent, it appears to the Board that he has made such reports only recently and in conjunction with his claim for benefits. The contemporaneous evidence of record does not show such continuity. Not until after the Veteran filed his claims for service connection, and he was afforded the VA neurologic examination in 2011 does the medical evidence show that he reported continuity of symptoms going back to service. Given the lack of contemporaneous record, the Veteran's recent reports of a continuity of symptomatology are not credible. The evidence as a whole shows no continuity of symptomatology of headaches since service. 38 C.F.R. § 3.303(b); Mense v. Derwinski, 1 Vet. App. 354 (1991). As such, in order for service connection to be awarded, the evidence of record must show a link between the Veteran's currently diagnosed disorders and his period of service. Here, the December 2012 VA examiner opined against a link between the Veteran's current diagnosed headaches and his period of service. There is no contrary medical opinion of record that links the Veteran's headaches to his period of service. The Board acknowledges the September 2011 VA examiner's medical opinion that the Veteran has tension-like headaches likely related to his history of hypertension. However, the Veteran has not been award service-connection for hypertension. Moreover, the December 2012 VA examiner concluded that the Veteran's headaches were not associated with his hypertension since his blood pressure readings were not elevated enough over the past three years to likely cause headaches. Again, there is no competent opinion that supports a medical nexus between the Veteran's headaches and his period of service. In sum, the weight of the competent and credible evidence is against a finding that the Veteran's headaches are related to his period of service. As the preponderance of the evidence is against the claim for service connection for headaches, the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for sleep disturbances is denied. Entitlement to service connection for chronic fatigue is denied. Entitlement to service connection for chronic headaches is denied. ______________________________________________ LANA K. JENG Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs