Citation Nr: 1333342 Decision Date: 10/23/13 Archive Date: 10/24/13 DOCKET NO. 06-06 863A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include depression and post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for post-operative residuals of fibroid tumors, claimed as due to undiagnosed illness. 3. Entitlement service connection for dysmennorrhea and menorrhagia, claimed as due to undiagnosed illness. 4. Entitlement to service connection for joint pain, claimed as due to undiagnosed illness. 5. Entitlement to service connection for gastroesophageal reflux disease (GERD), claimed as due to undiagnosed illness. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. Layton, Counsel INTRODUCTION The Veteran served on active duty from September 1990 to May 1991, including service in Southwest Asia from November 1990 to April 1991. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2005 decision rendered by the Montgomery, Alabama Regional Office (RO) of the Department of Veterans Affairs (VA). In March 2010, the Veteran advised the RO that she had moved to San Antonio, Texas. In May 2010, the Veteran testified before the undersigned during a hearing held at a VA facility in San Antonio, Texas. A transcript of the proceeding is of record. During the May 2010 hearing, the Veteran raised a claim for service connection for a headache disorder, to include as due to undiagnosed illness. This issue was referred to the AOJ for appropriate action in the October 2010 and October 2012 remands. As it is unclear whether action has been taken with respect to this issue, it is again referred for appropriate action by the AOJ. The issue of entitlement to service connection for joint pain is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The most probative evidence of record does not support a finding that the Veteran has an acquired psychiatric disorder, to include PTSD or depression, that is related to active military service or events therein. 2. The most probative evidence of record does not support a finding that the Veteran has fibroid tumors resulting from undiagnosed illness that was shown during active service or currently manifested to a compensable degree; and there is no evidence of currently diagnosed fibroid tumors that are related to active military service or events therein. 3. The most probative evidence of record does not support a finding that the Veteran has a dysmennorrhea and menorrhagia disorder resulting from undiagnosed illness that was shown during active service or currently manifested to a compensable degree; and there is no evidence of a currently diagnosed dysmennorrhea and menorrhagia disorder that is related to active military service or events therein. 4. The most probative evidence of record does not support a finding that the Veteran has GERD resulting from undiagnosed illness that was shown during active service or currently manifested to a compensable degree; and there is no evidence of currently diagnosed GERD that is related to active military service or events therein. CONCLUSIONS OF LAW 1. The Veteran's claimed acquired psychiatric disorder was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.309 (2013). 2. The Veteran's claimed fibroid tumors were not incurred in or aggravated by active service, nor may they be presumed to be related to her period of service in the Persian Gulf. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2013). 3. The Veteran's claimed dysmennorrhea and menorrhagia were not incurred in or aggravated by active service, nor may they be presumed to be related to her period of service in the Persian Gulf. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2013). 4. The Veteran's claimed GERD was not incurred in or aggravated by active service, nor may it be presumed to be related to her period of service in the Persian Gulf. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by or on behalf of the appellant. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. 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 appellant). I. Stegall Concerns In October 2010 and October 2012, the Board remanded the appeal to the RO, via the Appeals Management Center (AMC), for further development. The Board instructed the RO to obtain the Veteran's VA treatment records from 1991 to 1998, and from 2008 through the present. The records from 2008 through the present were obtained and associated with the Veteran's Virtual VA file. In October 2012, the AMC attempted to obtain the Veteran's VAMC records from the 1990s from the Central Alabama Veterans Health Care System (CAVHCS). The AMC was informed in December 2012 that they had no records. In January 2013, the AMC contacted the Veteran and discovered that for the time period in question; the Veteran had changed her name to her maiden name. Later in January 2013, the AMC contacted CAVHCS and requested the Veteran's records from 1991 to 1998, using her maiden name. CAVHCS forwarded records to the AMC which reflect that the Veteran established care at CAVHCS in April 1998. Consequently, in April 2013, the AMC informed the Veteran that there were no records for the Veteran from CAVHCS for the time period of January 1991 to April 1998. The Veteran was requested to provide the records, if they were in her possession. The Veteran did not respond to the letter, and in May 2013, the AMC made a formal finding of the unavailability of the records. The Board also requested that the Veteran be scheduled for a VA examination. The Veteran underwent the requested VA examinations in December 2011, April 2013, and May 2013. In particular, the December 2011 VA examination followed the Gulf War Examination protocol, and the examiner provided support for the given opinions. In light of the aforementioned actions, the Board finds that there has been substantial compliance with the requirements articulated in the Board's prior remands. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999). II. Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her 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) (West 2002); 38 C.F.R. § 3.159(b) (2013); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the 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. A letter dated in March 2004 discussed the evidence necessary to support a claim for service connection. The Veteran was invited to submit or identify pertinent evidence. The evidence of record was listed and the Veteran was told how VA would assist her in obtaining additional relevant evidence. The Veteran was advised of the status of her claim in February 2009. In April 2012 the Veteran was informed of the manner in which VA determines disability ratings and effective dates. The content of the notice provided to the Veteran fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Veteran has been provided with every opportunity to submit evidence and argument in support of her claim and to respond to VA notices. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of her claims. Therefore, the record reflects that she was provided with a meaningful opportunity during the pendency of his appeal such that any error in the timing of the notice did not affect the essential fairness of the adjudication now on appeal. With respect to VA's duty to assist, service treatment records, private treatment records, and VA treatment records have been obtained and associated with the record. VA examinations were conducted. The Board finds that the examinations were adequate in that they were performed by trained health care providers who reviewed the record, interviewed the Veteran, and performed appropriate physical examinations prior to providing their conclusions. The Veteran has not otherwise identified any additional evidence or information which could be obtained to substantiate the claim. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is also satisfied that VA has complied with the duty to assist requirements of the VCAA and the implementing regulations. As noted above, the Veteran also was afforded a hearing before the undersigned Veterans Law Judge (VLJ), during which she presented oral argument in support of her claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2013) requires that the Veterans Law Judge or Decision Review Officer who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ fully explained the issues on appeal during the hearing and asked questions specifically regarding the elements necessary to establish the benefits sought. Significantly, neither the Veteran nor her representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has she identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the evidence necessary to substantiate the claim, and the Veteran, through her testimony, demonstrated that she had actual knowledge of the evidence necessary to substantiate her claim. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). III. Service Connection Claims A. Law and Regulations Service connection may be established for a disability resulting from (1) a disease or injury incurred in or aggravated by active duty or ACDUTRA, or (2) an injury incurred in inactive duty training. See 38 U.S.C.A. §§ 101, 1110, 1131 (West 2002); 38 C.F.R. §§ 3.1, 3.6 (2012); see also Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). For certain chronic disorders, including psychoses, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). The presumption provision applies only to periods of active duty, not INACDUTRA. See Biggins, supra; see also Paulson v. Brown, 7 Vet. App. 466, 469-70 (1995) [if claim relates to period of ACDUTRA, a disease or injury resulting in disability must have manifested itself during that period]. Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of 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. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). However, "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b). Service connection may be established for a chronic disability manifested by certain signs or symptoms which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2016, and which, by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1); 71 FR No. 242, pp. 75669-75671 (December 18, 2006). Consideration of a Veteran's claim under this regulation does not preclude consideration of entitlement to service connection on a direct basis. A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): an undiagnosed illness; the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) Chronic fatigue syndrome; (2) Fibromyalgia; (3) Functional gastrointestinal disorders; or (4) Any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a). 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 will not be considered medically unexplained. 38 C.F.R. § 3.317(a). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a). 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 C.F.R. § 3.317(a). A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. 38 C.F.R. § 3.317(a). A disability referred to in this section shall be considered service connected for purposes of all laws of the United States. 38 C.F.R. § 3.317(a). 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) Signs or symptoms involving skin (3) Headache (4) Muscle pain (5) Joint pain (6) Neurologic signs and symptoms (7) Neuropsychological signs or symptoms (8) Signs or symptoms involving the respiratory system (upper or lower) (9) Sleep disturbances (10) Gastrointestinal signs or symptoms (11) Cardiovascular signs or symptoms (12) Abnormal weight loss (13) Menstrual disorders. 38 C.F.R. § 3.317(b). Compensation shall not be paid under this section if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). The term "Persian Gulf Veteran" means a Veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(d). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002). B. Acquired Psychiatric Disorder, to include PTSD and Depression At the outset, the Board notes the record does not establish the Veteran's participation in combat. Thus, the Board finds that the provisions of 38 U.S.C.A. § 1154(b) (West 2002) do not apply. Service connection for post-traumatic stress disorder requires medical evidence diagnosing the condition in accordance with VA regulations; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d), (f). The Board observes that effective July 12, 2010, the regulations governing adjudication of service connection for posttraumatic stress disorder (PTSD) were liberalized, in certain circumstances, with respect to the evidentiary standard for establishing the required in-service stressor. For cases pending before VA as of that date, the following regulation applies: If a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304 (f)(3); see 75 Fed. Reg. 39843 (July 13, 2010). As discussed below, the Veteran does not have a current diagnosis of PTSD nor has she had such diagnosis at anytime during the course of the appeal; therefore, this amendment does not apply. Service treatment records show that on demobilization examination in April 1991 the Veteran denied depression, frequent trouble sleeping, loss of memory, or nervous trouble of any sort. The examiner indicated that the Veteran was psychiatrically normal. VA treatment records from Dothan, Alabama, reflect that the Veteran first presented herself to become established as a patient in April 1998. A private treatment record from March 2003 reflects that the Veteran had depression that was treated with generic Prozac. In March 2004, the Veteran told a VA treatment provider that a clinician thought she might be depressed. She further reported that a VA doctor told her when she returned from the Gulf War that she had the flu because she experienced aches and pains. The treatment note contains the Veteran's report that she did not recall experiencing any problems until 1998 when she went to a VA clinic. The treatment provider gave a diagnosis of mood disorder related to health condition/possible gulf war syndrome. At the Veteran's May 2010 Board hearing, she remarked that she feared for her life when she was stationed in the Gulf while on active duty. She related that she had to wear MOPP gear and did not know if she would be attacked with nuclear weapons. She said that surrounding areas were hit by missiles, although her direct area was not hit. She said that she received a diagnosis of depression in 1991, and she said she was placed on medication for depression sometime in the 1990s. She related that the first VA health facility she went to for mental health was located at Dothan, Alabama. On VA compensation and pension examination in December 2011, the examiner recorded the Veteran's history of childhood sexual abuse. It was noted that while on active duty, the Veteran was an accounting specialist and deployed to the Persian Gulf. The examiner also noted that the Veteran received no mental health treatment while in the Army and first received psychiatric care from a private treatment provider in 2003. The examiner indicated that the Veteran had a diagnosis of only one mental disorder: depression. After examining and interviewing the Veteran, the examiner opined that the Veteran's depression was less likely as not caused by or a result of her military service. The examiner specified that the Veteran did not meet the criteria for a diagnosis of PTSD, and she did not receive psychiatric care while in the military. The examiner indicated that part of the Veteran's depression seemed to be related to unresolved childhood sexual abuse issues. On VA compensation and pension examination in April 2013, the examiner opined that the Veteran's symptoms did not meet the diagnostic criteria for PTSD under DSM-IV criteria. The examiner indicated that the only current mental diagnosis present was depressive disorder, not otherwise specified. The prior VA examination report was reviewed, and the Veteran reported that she did not receive mental health treatment in the Army. After reviewing the Veteran's report of wearing MOPP gear and being frightened of enemy fire and chemical weapon attack while in the Gulf, the examiner opined that with the exception of the Veteran's childhood sexual trauma, the Veteran's claimed stressors were not adequate to support a diagnosis of PTSD. After careful consideration of the evidence pertaining to this issue, the Board finds that service connection for PTSD is not warranted. In this regard, the Board notes that a key element to establishing service connection for PTSD is to show that Veteran has the claimed disability. This element may only be shown through evidence of a diagnosis. In this case, the Board notes that none of the VA or private outpatient records contain diagnostic impressions of PTSD. In fact, none of the treatment providers who have treated the Veteran on an outpatient basis provided a discussion of whether the Veteran's symptoms meet the full DMS-IV diagnostic criteria for an accurate diagnosis. On the other hand, the December 2011 and April 2013 VA examiners determined that the Veteran's symptomatology does not meet the full criteria for a diagnosis of PTSD. In assigning high probative value to the VA examiners' opinions, the Board notes that they had the claims file for review, specifically discussed evidence contained in the claims file, obtained a history from the Veteran, and conducted a complete examination. There is no indication that the VA examiners were not fully aware of the Veteran's past psychiatric history or that they misstated any relevant fact. The Board thus finds the VA examiners' opinions to be of greater probative value than the Veteran's unsupported statements. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (noting that factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.); Neives- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The medical evidence of record reflects that the Veteran has a diagnosis of two psychiatric disorders-mood disorder and depression. However, as reviewed above, the Veteran herself indicated on demobilization in April 1991 that she did not experience depression, frequent trouble sleeping, loss of memory, or nervous trouble of any sort. At the time of her demobilization, a service examiner indicated that the Veteran was psychiatrically normal. The Veteran's first recorded report of experiencing depression appeared in a private treatment record from March 2003-nearly 12 years after she left active duty. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) [contemporaneous evidence has greater probative value than history as reported by the veteran]; see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) [noting that it was proper to consider the veteran's entire medical history, including the lengthy period of absence of complaint with respect to the condition he now raised]. Moreover, although the Veteran claims to have received a diagnosis of depression in 1991 and says that she received treatment from the VA throughout the 1990s, the Veteran indicated in her May 2010 Board hearing that she first received psychiatric care from the VA at the VA clinic in Dothan, Alabama. As noted above, the VA treatment records from Dothan, Alabama, reflect that the Veteran first presented herself to become established as a patient in April 1998. Further, the records from Dothan, Alabama reflect that the Veteran sought treatment for fatigue and not for psychiatric symptoms in April 1998. Pertinently, although the Veteran sought treatment for other ailments, she did not mention any depression, nor was he diagnosed with any acquired psychiatric disorder until 2003. The Board finds that the Veteran's statements on demobilization in April 1991, taken in conjunction with the treatment records, are far more probative than the more recent assertions from the Veteran that she experienced psychiatric symptoms since her period of active duty. In giving more weight to the Veteran's April 1991 demobilization statements and post-service treatment records, the Board observes that lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person (e.g. any evidence not requiring that the proponent has specialized education, training, or experience). 38 C.F.R. § 3.159(a)(2). As such, the Veteran can competently testify about symptoms she experienced in service. However, competency must be distinguished from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Layno v. Brown, 6 Vet. App. 465, 469 (1994). In the present case, the Board finds that the Veteran's presently asserted history of psychiatric symptoms is not credible in light of both the lack of post service treatment or complaints of depression until 2003. Accordingly, the Veteran's recent unsupported and self-serving statements concerning any continuity of psychiatric symptoms is at odds with the remainder of the record, which is devoid any indication that any injury or disease occurred during service or for nearly twelve years thereafter. As such, the Veteran's statements are lacking credibility and probative value. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) [VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence]. The first documented complaint or diagnosis of an acquired psychiatric disorder is dated in March 2003 when a private examiner indicated that the Veteran was treated with generic Prozac for depression. However, neither this record nor any subsequent treatment records relate to a period of ACDUTRA or active duty. Additionally, periods of Reserve or National Guard service do not in any event constitute qualifying active duty such to trigger the presumption in 38 C.F.R. § 3.309. See Paulson and Biggins, both supra [if a claim relates to a period of active duty for training, the disability must have manifested itself during that period]. Finally, the Board notes that the December 2011 VA examiner opined that it was less likely than not that there was a relationship between the Veteran's depression and her service. As analyzed previously, the Board has found the VA examiner's opinion to be of greater probative value than the Veteran's statements. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Significantly, no other opinion contradicts the opinion of the December 2011 VA examiner. As such, the Board finds the December 2011 VA examiner's opinion persuasive regarding the lack of a nexus between the Veteran's diagnosed depression and her service. Under these circumstances, the Board must conclude that the Veteran has not met the regulatory requirements of entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depression, and that, on this basis, her claim must be denied. C. Fibroid Tumors, Dysmennorrhea, and Menorrhagia, Claimed as Due to Undiagnosed Illness A service treatment record from November 1988 reflects that the Veteran experienced a vaginal discharge. The treatment provider gave a diagnosis of trichomoniasis. On demobilization examination in April 1991 the Veteran denied having changes in her menstrual pattern or treatment for a female disorder. The examiner indicated that the Veteran's genito-urinary system was normal. A private treatment record from October 1998 reflects that the Veteran had no vaginal discharge or pain. A private emergency room treatment record from March 1999 reflects that the Veteran had not been seen by anybody up to that point for her symptoms of right lower quadrant pain. An ultrasound revealed an ectopic pregnancy. It was noted that her past medical history was negative. The next day the Veteran underwent surgery. The post-surgery diagnosis was right tubal pregnancy with severe pelvic adhesive disease, with cul-de-sac adhesions and clubbed left fallopian tube. A pelvic examination conducted at a private facility in January 2000 yielded normal results. The Veteran underwent an ultrasound in May 2003 which revealed a hypoechoic mass at the anterior aspect of the uterine fundus. There was also free fluid in the pelvic cul-de-sac. In July 2003, the Veteran underwent another surgery which resulted in diagnoses of pelvic pain, severe dysmenorrheal, menorrhagia, adhesion of omentum to right ovary, absent right tube, and hydrosalpinx left. A VA treatment record from April 2004 indicates that the Veteran had a fibroid tumor, heavy bleeding, and severe pain. Another record from April 2005 recounts the Veteran's menstrual cramps and heavy bleeding. The examiner indicated that the symptoms were probably due to the Veteran's fibroids. A gynecological follow-up from May 2005 revealed a fibroid. At her May 2010 Board hearing, the Veteran reported that she experienced no menstrual periods while she was stationed in the Persian Gulf. She said that she experienced gynecological pain while she was on active duty that continued through the present time. She related that she had been taking pain medication since the 1990s. On VA compensation and pension examination in December 2011, the examiner noted that the Veteran had painful menses since the 1990s. It was noted that the Veteran had miscarriages in 1998 and 2004 and an ectopic pregnancy in 1999. She also had undergone a D&C in 2003. Since that time, the Veteran had regular menstrual cycles but with heavy bleeding. After performing an examination, the examiner gave a diagnosis of fibroid uterus causing menorrhagia and dysmenorrhea. In a March 2012 addendum, the examiner opined that the Veterans fibroid tumors, dysmenorrheal, and menorrhagia were less likely than not incurred in or caused by the Veteran's active service. The examiner explained that although the Veteran claimed that she had heavy, painful menses since the 1990s, the treatment records did not support her assertions. The examiner remarked that the fibroids were noted in 1999, and fibroids were caused by multiple factors to include race, heredity, menstrual history/parity, hormonal contraception, and diet. Transvaginal echography performed in February 2012 revealed multiple uterine fibroids. On VA compensation and pension examination in May 2013, the examiner recorded the Veteran's self-reported history of not having her menses while she was deployed to the Persian Gulf. The examiner indicated that her menses could have stopped due to stress. It was noted that the Veteran's menses returned three months after returning from deployment, and they were heavy but without pain. The report reflects that the Veteran's pain started years later. Later in the report, the examiner remarked that the Veteran's menorrhagia started in 1991, but the documentation was not available to substantiate treatment. It was further noted that the dysmenorrhea and fibroids were not diagnosed until 1999-eight years after the Veteran left the military. The examiner opined that the Veteran's menorrhagia, dysmenorrhea, and fibroids were less likely than not incurred in or caused by her active duty. As an initial matter, competent medical evidence has attributed the Veteran's menorrhagia and dysmenorrhea to a medical diagnosis of uterine fibroids. As the Veteran has been given a medical diagnosis of uterine fibroids, service connection cannot be granted for the Veteran's complaints of menorrhagia, dysmenorrheal, and uterine fibroids as due to an undiagnosed illness. As such, service connection for menorrhagia, dysmenorrhea, and uterine fibroids cannot be granted on a presumptive basis under 38 C.F.R. § 3.317. With regard to granting service connection on a direct basis, regulations provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. 3.303(d) (2013). Currently, there is no medical evidence of record indicating that the Veteran's menorrhagia, dysmenorrhea, and uterine fibroids were caused or aggravated by her active duty service. The Board acknowledges that the May 2013 VA examiner indicated that the Veteran's menorrhagia started in 1991; however, the same examiner also specified earlier in the report that the Veteran's heavy menses began three months after she returned from deployment and left active duty. Significantly, the May 2013 examiner specifically opined that the Veteran's menorrhagia, dysmenorrhea, and uterine fibroids were less likely as not incurred in or caused by her active duty. Additionally, the report of the December 2011 VA examination, specifically reflects that the Veteran's menorrhagia, dysmenorrhea, and uterine fibroids were less likely than not related to her time in the military, and the December 2011 provided alternative etiologies. The claims file contains no medical opinions to the contrary. Therefore, as there is no medical evidence linking a currently diagnosed disability to service, these claims must be denied on a direct basis. The Board acknowledges the Veteran's contentions that she experiences uterine symptoms as a result of her active duty. The Veteran can attest to factual matters of which she had first-hand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, while the Veteran is competent to report what comes to her through her senses, she does not have medical expertise to render an opinion on their etiology in this case; there is no observable cause and effect relationship. See Layno v. Brown, 6 Vet. App. 465, 469- 470 (1994). While the Board has considered the Veteran's contentions regarding the presence of symptoms, the Board ultimately places more probative weight on the etiological opinions of the VA medical professionals, who reviewed the claims file, examined the Veteran, and considered her assertions. In summary, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claims for service connection, and the benefit-of-the-doubt rule is not for application. D. GERD, Claimed as Due to Undiagnosed Illness Service treatment records show that on demobilization examination in April 1991 the Veteran denied experiencing frequent indigestion, stomach trouble, liver trouble, or intestinal trouble. The examiner indicated that the Veteran's genitor-urinary system was normal. An April 2003 private treatment record contains the Veteran's complaints of nausea, vomiting, indigestion, and occasional reflux. The examiner indicated that the Veteran's symptoms were of uncertain etiology. An H-pylori infection was noted. In August 2003, the Veteran underwent an esophagogastroduodenoscopy. She had been experiencing dyspepsia. The examiner found no abnormalities on examination. VA treatment records from April 2005 and March 2008 reflect treatment for GERD. At her May 2010 Board hearing, the Veteran said that she had problems with eating from the time she returned from the Persian Gulf. She related that she had regurgitated her food since returning from the Gulf. On VA examination in December 2011, the Veteran complained of a burning in the back of her throat. The Veteran treated her symptoms with Nexium and Omeprazole. After reviewing the treatment records and performing an examination, a diagnosis of GERD was given. In a March 2012 addendum, the examiner opined that the Veteran's GERD was less likely than not incurred in or caused by her active duty. The examiner explained that the Veteran's symptoms of GERD started in 2003 around the time she was diagnosed with H-pylori. Another VA examiner concurred in May 2013 that the Veteran had GERD. Further, the VA examiner specified that GERD was a diagnosable condition. Having reviewed the evidence pertaining to this claim, the Board has determined that service connection on a presumptive basis for GERD is not warranted. In that regard, the Board observes that the Veteran's claimed symptoms have been medically ascribed to the diagnosis of GERD. As the Veteran has been given a medical diagnosis of GERD, service connection cannot be granted for the Veteran's complaints of GERD as due to an undiagnosed illness. As such, service connection for GERD cannot be granted on a presumptive basis under 38 C.F.R. § 3.317. In cases where a Veteran applies for service connection under 38 C.F.R. § 3.317 but is found to have a disability attributable to a known diagnosis, further consideration under the direct service connection provisions of 38 U.S.C.A. §§ 1110 and 1131 is warranted. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994) (specifically addressing claims based on ionizing radiation exposure). Thus, the presumption is not the sole method for showing causation. In this case, however, there is no medical evidence of record indicating that the Veteran's GERD was caused or aggravated by her active duty service. The May 2013 examiner specifically opined that the Veteran's GERD was less likely as not incurred in or caused by her active duty. Additionally, the report of the December 2011 VA examination, specifically reflects that the Veteran's GERD was less likely than not related to her time in the military, and the December 2011 provided an alternative etiology. The claims file contains no medical opinions to the contrary. Therefore, as there is no medical evidence linking a currently diagnosed disability to service, this claim must be denied on a direct basis. The Board acknowledges the Veteran's contentions that she experiences GERD symptoms as a result of her active duty. The Veteran can attest to factual matters of which she had first-hand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, while the Veteran is competent to report what comes to her through her senses, she does not have medical expertise to render an opinion on their etiology in this case; there is no observable cause and effect relationship. See Layno v. Brown, 6 Vet. App. 465, 469- 470 (1994). While the Board has considered the Veteran's contentions regarding the presence of symptoms, the Board ultimately places more probative weight on the etiological opinions of the VA medical professionals, who reviewed the claims file, examined the Veteran, and considered her assertions. In summary, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for service connection, and the benefit-of-the-doubt rule is not for application. ORDER Entitlement to service connection for an acquired psychiatric disorder, to include depression and PTSD, is denied. Entitlement to service connection for post-operative residuals of fibroid tumors, claimed as due to undiagnosed illness, is denied. Entitlement service connection for dysmennorrhea and menorrhagia, claimed as due to undiagnosed illness, is denied. Entitlement to service connection for GERD, claimed as due to undiagnosed illness, is denied. REMAND Concerning the claim for service connection for joint pains, service treatment records show that on demobilization examination in April 1991 the Veteran denied experiencing arthritis, rheumatism, or bursitis; bone, joint, or other deformity; lameness; and painful or "trick shoulder or elbow. She indicated that she had recurrent back pain and "trick" or locked knee. The examiner indicated that the Veteran's upper extremities, lower extremities, and spine were normal. A private treatment record from October 1998 contains the Veteran's complaints of lower back pain. Another record from January 2003 reflects multiple myalgias of uncertain etiology. A January 2003 letter from D.M.M., M.D., reflects the Veteran's history of intermittent arthralgias in both the upper and lower extremities dating back approximately 10 years. Dr. M. dated the beginning of the arthralgias to the Veteran's service in the Gulf. At her May 2010 Board hearing, the Veteran reported that she experienced joint pain in 1991. She said that she had pain in her knees, elbows, and all over her body. On VA Gulf War protocol examination in December 2011, the Veteran's history was reviewed. Among the diagnoses was chronic fatigue syndrome. The examiner noted the Veteran's history of chronic fatigue since 1991, with episodes of severe fatigue once per month including myalgias, arthralgias, night sweats, and problems getting out of bed. He indicated that the signs and symptoms attributable to chronic fatigue syndrome included generalized muscle aches or weakness. The Board recognizes that service connection for chronic fatigue syndrome was granted in April 2012. As such, the certain manifestations of pains, such as myalgias and arthralgias, are ascribed manifestations of a service-connected disability. In that regard the Board observes that the evaluation of the same manifestation under different diagnostic codes is to be avoided. 38 C.F.R. § 4.14 (2012). However, specifically concerning the present claim for service connection for joint pains, the Veteran was given a VA examination in May 2013. The examiner gave diagnoses of back strain, epicondylitis of the elbow, iliotibial band syndrome, and pes anserine bursitis. The examiner specified that these were all diagnosable conditions, but without documentation during the Veteran's time on active duty, there was no connection to her time in the service. Once the VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, the VA must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The May 2013 VA examiner based his negative nexus opinion for the Veteran's back, elbow, and knee disorders on an absence of documentation of symptoms during the Veteran's time on active duty. However, as reviewed above, the Veteran indicated at her April 1991 post-deployment examination that she had recurrent back pain and "trick" or locked knee. As there is in-service documentation of symptoms, it is not clear how thoroughly the May 2013 VA examiner reviewed the claims file. As such, remand is required for clarification of the May 2013 VA examiner's rationale for the given opinion. If the May 2008 VA examiner is unavailable, the Veteran should be afforded a new VA examination for an adequately supported etiology opinion concerning her presently diagnosed back strain, epicondylitis of the elbow, iliotibial band syndrome, and pes anserine bursitis. Accordingly, the case is REMANDED for the following action: 1. The AMC/RO should forward the claims file to the examiner who conducted the May 2013 VA compensation and pension examination. The examiner is requested to clarify the rationale supporting his given opinion that the Veteran's back strain, epicondylitis of the elbow, iliotibial band syndrome, and pes anserine bursitis are less likely as not caused by or a result service. The examiner is specifically requested to discuss the April 1991 post-deployment examination which contains the Veteran's complaints of recurrent back pain and "trick" or locked knee. If the May 2013 examiner is unavailable, the AMC/RO should arrange for the Veteran to undergo a VA examination. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that back strain, epicondylitis of the elbow, iliotibial band syndrome, and pes anserine bursitis are related to any incident of the Veteran's active duty service. The rationale for all opinions expressed should be provided in a legible report. If the examiner is unable to render an opinion without resort to mere speculation, it should be indicated and explained why an opinion cannot be reached. 2. After completing the requested actions, and any additional notification and development deemed warranted, readjudicate the Veteran's claims, including consideration of any additional information obtained as a result of this remand. If the decision with respect to any of the claims remains adverse to the Veteran, she and her representative should be furnished a supplemental statement of the case (SSOC) and afforded an appropriate period of time within which to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs