Citation Nr: 0001520 Decision Date: 01/19/00 Archive Date: 01/28/00 DOCKET NO. 95-18 430 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Determination of a proper initial rating for service- connected post-traumatic stress disorder (PTSD), currently assigned a 50 percent evaluation. 2. Entitlement to service connection for bilateral joint pain of the knees and elbows, to include as due to an undiagnosed illness 3. Entitlement to service connection for coronary artery disease. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The veteran and his wife ATTORNEY FOR THE BOARD Wm. Kenan Torrans, Associate Counsel INTRODUCTION The veteran served on active duty from January 1971 to November 1972, and from November 1990 to May 1991. This matter arises from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which granted service connection for PTSD, assigning an initial 50 percent evaluation, effective from January 31, 1994, but which denied the remaining benefits sought. The veteran filed a timely appeal, contending that the severity of his now service-connected PTSD warrants assignment of a higher evaluation, and that service connection should be granted for the remaining benefits. The case has been referred to the Board of Veterans' Appeals (Board) for resolution. The veteran requested a hearing before a member of the Board sitting at the RO. That hearing was conducted in July 1999 by the undersigned Board member. At that hearing, the veteran requested to withdraw his appeal for service connection for hair loss. The transcript of that hearing has been reduced to writing. Therefore, his withdrawal of appeal as to that issue is valid. 38 C.F.R. § 20.204 (1999). FINDINGS OF FACT 1. The veteran's initial claim for service connection for PTSD, upon which this appeal is, in part, based, was received on January 31, 1994. 2. The veteran is currently in receipt of nonservice- connected pension benefits based on unemployability secondary to nonservice-connected disabilities. 3. From the time of the inception of the veteran's claim, his PTSD is objectively shown to be characterized by severe depression, impaired memory, difficulty in concentration, and difficulty in establishing and maintaining effective or favorable social relationships with some industrial impairment. 4. The veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War. 5. There is no competent medical evidence that the veteran's currently diagnosed osteoarthritis or degenerative changes of the knees and elbows are related to his period of active period of military service, nor is there any objective evidence that the veteran currently suffers from disorders of the knees and elbows which cannot be attributed to known diagnoses. 6. There is no competent medical evidence of a nexus or link between any currently diagnosed coronary artery disease and any incident of the veteran's active service. CONCLUSIONS OF LAW 1. The initial rating assigned for the veteran's PTSD is appropriate, and the criteria for assignment of an initial rating in excess of 50 percent have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1-4.14, 4.130, Diagnostic Code 9411 (1999); 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996). 2. Bilateral knee and elbow disorders were not incurred in or aggravated by the veteran's active military service. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.317 (1999). 3. The veteran's claim for service connection for coronary artery disease is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Determination of a Proper Initial Rating As a preliminary matter, the Board finds that the veteran's claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). See Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). A claim that a service-connected disability has become more severe is well grounded in cases in which the claimant asserts that a higher rating is justified due to an increase in severity. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994); Proscelle v. Derwinski, 2 Vet. App. 629, 631-32 (1992). After a review of the record, the Board is satisfied that all relevant facts and evidence have been properly and sufficiently developed. Such evidence includes the veteran's service medical records, records of treatment following service, reports of VA rating examinations, signed affidavits received from the veteran's wife and in-laws, and a transcript of personal hearing testimony given at the RO before the undersigned Board Member. The Board is not aware of any additional relevant evidence that is available in connection with this issue. Therefore, no further action is necessary to meet the duty to assist the veteran with the development of evidence in conjunction with his claim. See 38 U.S.C.A. § 5107(a); McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997). Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 C.F.R. § 4.1 (1999). In addition, where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (1999). Moreover, an appeal from the initial assignment of a disability rating requires consideration of the entire time period involved, and contemplates staged ratings where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). In the present case, the veteran's original claim for service connection for PTSD was deemed to have been received on January 31, 1994. Service connection for PTSD was granted by a September 1997 rating decision, and an initial rating of 50 percent was assigned, effective from January 31, 1994. The decision to grant service connection for PTSD was based upon several VA treatment records and rating examination reports diagnosing that disorder, and upon a series of unverified stressors which were found to be credible as claimed by the veteran. The veteran's initial claim was based primarily on memory loss. Shortly after his claim was filed, it was determined that he suffered from a dysthymic disorder, subsequently diagnosed as chronic major depression, and later as PTSD. VA outpatient treatment records dating from June 1994 through September 1997 show that in June 1994, the veteran underwent a Persian Gulf War (PGW) psychiatric examination. At that time, he complained of waking up screaming, but that he could not recall what he had been dreaming about. He also reported being easily angered. On examination, his presentation was appropriate, but his range, affect, and mood were characterized as "somber." The examiner offered an initial impression of minimal stress from the PGW, but a general high level of stress and depression resulting from unstated causes. The examiner observed that the veteran went fishing with his son and served as a scoutmaster in order to relieve stress. The clinical treatment records show that general symptoms of depression and nightmares persisted, and the veteran indicated that he had a quick temper, was often depressed and that he experienced unpredictable mood swings. The records show that during this period, the veteran continued to receive regular outpatient treatment for what was eventually diagnosed as PTSD and severe depression in October 1994, although the specific level of functional impairment due to that disorder was not indicated. The veteran was medically discharged from the Army Reserve in July 1995, due to his cardiac and psychiatric disabilities. In addition, the veteran reported having to quit his job in 1995 due to an inability to remember how to perform the job he had held for sixteen years. (In a subsequent rating examination conducted in November 1997, the veteran reported having participated in a early retirement "buy-out" in August 1995.) In March 1995, the veteran underwent a VA rating examination in which he was diagnosed with Axis I Dysthymic disorder, secondary to his health problems, and was noted to have an Axis V global assessment of functioning (GAF) score of 60. Under the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV), a GAF score of 60 to 51 suggests moderate symptoms of a psychiatric disorder (e.g., flat affect and circumstantial speech, occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, or conflicts with friends, peers, or co-workers). The examiner stated that he was unable to document PTSD at that time, because the veteran did not report experiencing the requisite symptoms such as flashbacks, avoidance, or increased arousal. At that time, the veteran reported that he was employed with the civil service, and that he enjoyed hunting and fishing with his son. He also complained of yelling and shouting at his wife and children. On examination, he was noted to have driven himself to the clinic, and was neat and clean in appearance with what was characterized as excellent hygiene. The examiner found that the veteran was fully oriented, maintained a good sense of reality, and had coherent and well-modulated speech. His long- and short-term memory was described as "good," and he was found to have "normal" intelligence. At that time, the veteran was not preoccupied. His emotional affect was blunted, and he was noted to have a depressed mood. The examiner observed that the veteran had recently experienced a severe heart attack, and concluded that he had a dysthymic disorder, secondary to his multiple health problems. The veteran underwent an additional VA rating examination in December 1996 in which he reiterated his complaints of experiencing nightmares, flashbacks, and unpredictable mood swings. The veteran reported that he could not stand to be around crowds, and that due to his decreased memory, he had lost the ability to work. In addition, he indicated that he had been married to the same woman for 24 years, and that he had a 23 year-old daughter and a 15 year-old son. He stated that after being discharged from the Army during his initial period of active duty, he had worked in the civil service for approximately 15 or 16 years as a mechanic. On examination, the veteran exhibited symptoms of depression, guilt, and worthlessness. In addition, he demonstrated poor concentration, memory, and insight, and indicated that he experienced night terrors and dissociative episodes. The examiner noted what he characterized as "discrepancies" in the veteran's claimed PTSD stressors, and noted a certain lack of detail in the veteran's account of having witnessed the death of a child. The examiner concluded with an Axis I diagnosis of recurrent, moderate major depression, and concluded with an Axis V GAF score of 58. The veteran underwent an additional VA rating examination in September 1997, and complained of experiencing depression, irritability, fatigue, memory loss, violent nightmares, dissociative episodes, and an inability to get along with others. The examiner stated that the veteran's reported dissociative episodes were not really flashbacks, per se, but rather were episodes in which the veteran was unable to recall what he did for a given period of time. In addition, the veteran reported avoiding other people, and that he became distressed upon witnessing reminders of Desert Storm or related stimuli. He also indicated that he experienced hypervigilance, and felt a compelling need to "guard his perimeter." On examination, the veteran was found to be alert, oriented, and cooperative, although the examiner also found him to be "demoralized, depressed, and generally discouraged." The veteran's thought content was characterized as clear and goal oriented, and there was no evidence of delusions or hallucinations. The examiner found that the veteran did experience problems with his short-term memory, noting that he was unable to recall three objects after a short period of time. The veteran denied experiencing any suicidal ideation. The examiner concluded with a diagnosis of PTSD based upon the veteran's symptoms and a self-reported stressor history. However, he did not offer an Axis V GAF score. The veteran underwent a VA rating examination in November 1997 in which it appears that his wife was also an active participant. The examiner noted the differing accounts of stressors as reported over time by the veteran, and found him to be fully oriented, but with a flat affect and depressed mood. The veteran claimed that he experienced intermittent suicidal ideation, and his wife offered that he had one such episode fairly recently. There was no evidence of hallucinations or delusional thinking. The veteran's speech was logical and coherent without circumstantiality, tangentiality, flight of ideas, or loosening of associations. In addition, his grooming and hygiene were characterized as "adequate." The examiner noted the veteran's complaints of experiencing nightmares, night sweats, and intrusive daytime recollections. However, the veteran denied that depictions of war or other, related stimuli of the Gulf War triggered such intrusive thoughts. In addition, the veteran indicated that he was easily startled, and that he was unable to concentrate for any extended period. He reported experiencing dissociative episodes, but indicated that he did not become violent with his wife and son, because he would leave their presence before becoming so agitated. The veteran and his wife stated that he no longer attended church, and avoided others. With respect to employment, the veteran reported that he had participated in an early retirement "buy-out" program with the civil service in August 1995, and had not worked since that time. The examiner concluded with an Axis I diagnosis of PTSD, and offered an Axis V GAF score from 28 to 32. Per the criteria set forth under DSM-IV, a GAF score from 28 to 32 is suggestive of some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). Under DSM-IV, such a GAF score is also suggestive of behavior that is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupations), or an inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends). In any event, the examiner continued to offer his opinion that the veteran's depression and anxiety were his greatest symptoms, and that the veteran's memory problems were perhaps suggestive of an inability to obtain or retain gainful employment or to otherwise establish and maintain effective relationships with others. The Board notes that in the report of an October 1997 rating examination, conducted for purposes of evaluating the veteran's physical symptoms, he reported to the examiner that he was experiencing difficulty in returning to work due to his bilateral joint pain in the knees and elbows and his back problems. He did not indicate to that examiner that his inability to work was impaired due to psychiatric problems. The veteran's wife, in-laws, and associates submitted a series of signed affidavits dating from June 1995 through September 1997 attesting to the personality changes the veteran had undergone following his return home from Operation Desert Storm. The veteran's wife stated that upon his return from Southwest Asia, the veteran experienced unpredictable mood swings, nightmares, night sweats, poor memory, and that he was very easily distracted. She indicated that he was no longer interested in working, attending church, or in serving as a scout master, and that he had developed an uncharacteristically short temper. All affiants stated that the veteran became increasingly disinterested in being around other people, and that he was no longer able to perform tasks such as appliance repair or outdoor barbecuing as he once did. These individuals all stated that the veteran often became angry and irritable, and would often stare into space. His wife characterized such occurrences as "dissociative episodes." In July 1999, the veteran and his wife appeared at a personal hearing before the undersigned Board Member, and testified that he had last worked in 1994 or 1995 as a diesel mechanic for the government. They testified that he could no longer remember how to perform the work he had performed for the past 16 years, and subsequently had to quit his job. The veteran indicated that he experienced nightmares weekly, although his wife testified that the nightmares occurred with greater frequency. In any event, the veteran stated that he averaged between four and five hours' sleep per night and that he was always tired. He stated that he no longer ventured out into public, and that his children were grown and had left home. According to the veteran he had served as a scout master, but was unable to serve in that capacity any longer due to his temper. He further indicated that he had a bad memory, and generally occupied his time by reading and watching television. The veteran's wife stated that a social worker had recommended that the veteran be hospitalized, and indicated that the veteran only sat around the house without engaging in any activities. The veteran's representative offered as a contention that it was inconceivable that the veteran could be assigned a GAF score from 28 to 32 as reflected by the November 1997 rating examination report, and only be assigned a 50 percent evaluation. Under the regulations governing PTSD evaluations which were in effect when the veteran filed his claim, assignment of a 50 percent evaluation was warranted upon a showing of a considerably impaired ability to establish or maintain effective or favorable relationships with people. Further, by reason of psychoneurotic symptoms, the reliability, flexibility, and efficiency levels were considered to be so reduced as to result in considerable industrial impairment. Assignment of a 70 percent evaluation was contemplated in cases in which the ability to establish or maintain effective or favorable relationships with people was severely impaired. The psychoneurotic symptoms were of such severity and persistence that there was severe impairment in the ability to obtain or retain gainful employment. For assignment of a 100 percent evaluation, the attitudes of all contacts except for the most intimate were required to be so adversely affected as to result in virtual isolation in the community. Totally incapacitating psychoneurotic symptoms bordering on the gross repudiation of reality with disturbed thought or behavioral processes associated with almost daily activities such as fantasy, confusion, panic, and explosions of aggressive energy resulting in profound retreat from mature behavior were also required. Further, a 100 percent disability rating was warranted where the veteran was demonstrably unable to obtain or retain employment as a result of the PTSD disorder. See 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996). In addition, in Johnson v. Brown, 7 Vet. App. 95 (1994), the United States Court of Appeals for Veterans Claims (Court) also held that a showing of any one of the above evaluative criteria for a 100 percent evaluation was a sufficient basis upon which to award a 100 percent evaluation. By regulatory amendment, which became effective from November 7, 1996, substantive changes were made to the schedular criteria for evaluating psychiatric disorders, previously set forth in 38 C.F.R. §§ 4.125-4.132. See 61 Fed. Reg. 52695- 52702 (1996). The revised regulations pertaining to the evaluative criteria for PTSD are now codified at 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999). When the law or regulations change during the pendency of an appeal, the version most favorable to the claimant applies, absent congressional intent to the contrary. See Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). As the veteran filed the original claim upon which this appeal is based prior to November 7, 1996, his claim must be evaluated under both the former and the revised criteria. However, where the amended regulations expressly provide for an effective date, and do not allow for retroactive application, the veteran is not entitled to consideration of the amended regulations prior to the established effective date. See Rhodan v. West, 12 Vet. App. 55 (1998); see also 38 U.S.C.A. § 1115(g) (West 1991). Therefore, the Board must evaluate the veteran's claim for a proper initial rating from November 7, 1996, under both the former and the current regulations in the VA Rating Schedule in order to ascertain which version is most favorable to his claim. Under the revised criteria, a 50 percent evaluation is assigned upon a showing of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Assignment of a 70 percent evaluation is contemplated where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation, obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance or hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish or maintain effective relationships. A 100 percent evaluation is warranted for total occupational and social impairment; due to such symptoms as gross impairment in thought processes or communication; persistent danger of hurting oneself or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation or own name. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999). Applying the former and the revised regulations governing PTSD evaluations to the evidence of record, the Board concludes that the initially assigned 50 percent evaluation is appropriate, and that the preponderance of the evidence is against assignment of an initial evaluation in excess of 50 percent under the relevant rating criteria. The Board observes that while the report of the most recent VA rating examination of November 1997 purports to show that the veteran is effectively totally disabled as a result of his service-connected PTSD, the remainder of the medical evidence, including a rating examination conducted some two months previously in September 1997, fails to show an overall disability picture to the degree of severity as reported by the veteran, his wife, and the examiner who conducted the November 1997 examination. Through his service representative, the veteran appears to argue that as he was most recently assigned an Axis V GAF score of 28 to 32, he should be assigned a total disability rating, because a 100 percent evaluation is most consistent with such a GAF score. The Board agrees with the veteran's contention that a 100 percent evaluation is indeed consistent with the symptomatology contemplated by a 28 to 32 GAF score. However, the Board finds that the objective medical evidence presented, in addition to the numerous affidavits offered by the veteran's wife, in-laws, and colleagues, fails to demonstrate an overall disability picture that is, of itself, consistent with a 28 to 32 GAF score. In this regard, the Board notes that as this appeal concerns the determination of a proper initial rating all evidence presented since the inception of the claim must be considered. The evidence presented discloses that since the time the veteran initially sought treatment for a psychiatric disorder, he was shown to have problems with family conflict, unpredictable mood swings involving anger, memory problems, and alleged dissociative episodes. At the outset of his treatment, the veteran was employed as a diesel engine mechanic with the civil service, and opted for an early buy out in August 1995. Initially, the veteran was found to have a somber range and effect, although presentation was appropriate. The first VA examination conducted for rating purposes in March 1995 shows that the veteran complained of yelling at his wife and son, but that he was employed and drove himself to the clinic to be examined. At that time, his memory was intact, and his speech was coherent and well modulated. As indicated by other medical evidence his emotions were blunted, and he presented with a depressed mood. The rating examiner concluded with an Axis V GAF score of 60. The report of the December 1996 rating examination shows that the veteran experienced worsening symptomatology, including dissociative episodes, "night terrors," poor memory and insight. However, the veteran was assigned an Axis V GAF score of 58. The report of the September 1997 rating examination, while not including a GAF score, per se, noted that the veteran's complaints of depression, irritability, fatigue, memory loss, nightmares, and dissociative episodes. The Board observes that these complaints appear to be consistent with those the veteran has presented since filing his claim. Moreover, the examiner found the veteran to be alert, oriented, and cooperative, albeit demoralized, depressed, and discouraged. The veteran's thoughts were characterized as clear and goal oriented, and there was no evidence of delusions or hallucinations. The veteran was noted to have problems with his short-term memory, but he denied experiencing any suicidal ideation. The Board notes that even in the absence of an assigned GAF score here, the veteran's objectively demonstrated symptomatology in September 1997 is not inconsistent with that demonstrated in earlier rating examinations such as in December 1996 and March 1995. Those rating examinations concluded with GAF scores of 58 and 60 respectively. In contrast, the examiner who conducted the November 1997 fee-basis rating examination appears to have attempted to construe the veteran's psychiatric test results as showing that he was totally disabled and incapable of obtaining or retaining employment as a result of PTSD. At that time, the veteran was fully oriented, his speech was logical and coherent without what the examiner characterized as "circumstantiality, tangentiality, flight of ideas, or loosening of associations." The veteran's grooming and hygiene were described as adequate. Further, there was no evidence of hallucinations or delusional thinking, which would necessarily be implied in a GAF score ranging from 28 to 32. As with previous examinations, the examiner found the veteran to have a depressed mood, that he experienced nightmares, night sweats, intrusive recollections, and dissociative episodes. He also noted that the veteran exhibited a flat affect, and unlike previous examinations, the veteran claimed to have intermittent suicidal ideation, an assertion which was supported by his wife. The examiner further found the veteran to be obsessional and highly ruminative, and cited these symptoms as evidence purporting to show that the veteran was totally incapacitated by his PTSD. The Board, however, finds that this most recent evidence, when considered in conjunction with other medical evidence dated since the inception of the veteran's claim, does not persuasively show that the veteran's overall disability picture warrants an initial assignment in excess of 50 percent for his PTSD. With the most recent November 1997 examination report, the veteran added suicidal ideation to his list of symptoms associated with his PTSD. As late as two months previously, in September 1997, he denied experiencing any suicidal ideation. Further, while the examiner who conducted the November 1997 examination found that the veteran was unemployable due to PTSD, it does not appear that his objectively demonstrated symptomatology differed substantially from the symptomatology demonstrated in previous examinations and treatment records. Those examination reports and treatment records generally concluded that the veteran had a GAF score ranging from 58 to 60. The Board finds that such conclusions are adequately supported by the objective medical evidence. In any event, when considering the veteran's overall disability picture in light of evidence dating from June 1994 through November 1997, the Board finds that the veteran's symptomatology was most consistent with "considerably impaired ability to establish or maintain effective or favorable relationships with people," with considerable industrial impairment as a result of his psychoneurotic symptoms. Further, while criteria for assignment of a 50 percent evaluation under the revised criteria, is not fully met, the Board finds that the evidence shows his symptomatology to be more consistent with the criteria assignment of a 50 percent evaluation than any other criteria. Specifically, the veteran is objectively shown to experience occupational and social impairment due to symptomatology due to symptomatology including flattened affect, panic attacks more than once per week, difficulty in understanding complex commands, impairment of memory, impaired judgment and abstract thinking, disturbances in motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999); 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996). However, the Board also finds that the objectively demonstrated symptomatology, in view of the veteran's overall disability picture does not warrant assignment of a 70 percent evaluation under either the former or revised rating criteria. The veteran is shown to have demonstrated difficulty to establish or maintain effective or favorable relationships with people and an impaired ability to obtain or retain employment, but the extent that such is due to service-connected PTSD is not shown. The veteran has maintained that he had to quit his job in 1995 due to an inability to remember how to perform the duties required of a diesel engine mechanic which he had performed for over 16 years. He reported in November 1997 that he had participated in a "buy-out" program which enabled him to retire earlier than he would have otherwise been able to do. The Board notes that in November 1997 the veteran reported experiencing suicidal ideation, and that the examiner stated that the veteran was "obsessional." Further, the Board notes that the veteran demonstrates some of the symptoms listed in the rating criteria for assignment of a 70 percent evaluation. However, the Board finds that the veteran's overall disability picture fails to demonstrate a disability to the degree of severity claimed by the veteran, and that the degree of severity of his PTSD is not objectively shown to be sufficient to warrant assignment of a 70 percent evaluation. The potential application of Title 38 of the Code of Federal Regulations (1999) have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The Board has carefully considered the veteran's contentions that his PTSD warrants assignment of an initial evaluation in excess of 50 percent, and that he is incapable of obtaining or retaining employment as a result of that PTSD. In exceptional cases where schedular evaluations are found to be inadequate, consideration of an "extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities" is made. See 38 C.F.R. § 3.321(b)(1) (1999). The governing norm in these exceptional cases is a finding that the case presents such an unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. Id. In this regard, the Board first notes that the schedular evaluations in this case are not inadequate. There is a full range of ratings, under the Rating Schedule, that anticipate greater disability for the veteran's PTSD. The record, however, does not establish the presence of findings that would support a higher rating under the Rating Schedule. Further, the Board finds no evidence of an exceptional or unusual disability picture in this case. The Board recognizes that the veteran's physical disabilities have effectively rendered him unemployable. Such disabilities primarily consist of a nonservice-connected heart disorder and residuals of a myocardial infarction. The Board notes that the veteran has been found to be entitled to VA nonservice-connected pension benefits based on unemployability due to a combination of mental and physical disabilities. The Board further recognizes that the veteran undergoes monthly treatment for his PSTD, consisting of a monthly visit to the VA psychiatrist and visits to a PTSD support group. However, the evidence presented fails to show that he has ever been hospitalized for this disorder, and fails to show that while he was employed, that he missed time from work as a result of PTSD (although the Board acknowledges that the veteran did miss time from work as a result of his nonservice-connected myocardial infarction). As indicated previously, the veteran reported having quit his civil service job in August 1995, and had participated in an early buy-out program. In any event, on the basis of the entire record, the Board must conclude that in the absence of factors suggestive of an unusual disability picture, further, development in keeping with the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) is not warranted. See Bagwell v. Brown, 8 Vet. App. 337, 339 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Because there is not an approximate balance of positive and negative evidence regarding the merits of the veteran's claim that would give rise to reasonable doubt in is favor, the provisions of 38 U.S.C.A. § 5107 are not applicable. Should the veteran's disability picture change, he may apply at any time for an increase in his assigned disability rating. See 38 C.F.R. § 4.1. At present, however, the Board finds no basis upon which to grant an initial rating in excess of 50 percent for the veteran's PTSD. II. Service Connection for Joint Pain, Claimed as Due to an Undiagnosed Illness As a preliminary matter, the Board finds that the veteran's claim for service connection for bilateral joint pain of the knees and elbows, claimed as secondary to an undiagnosed illness, is well grounded. See 38 U.S.C.A. § 5107(a) (West 1991). In that regard, the record reflects that the veteran served on active military duty in the Southwest Asia Theater of Operations during the Persian Gulf War. Accordingly, the provisions of 38 U.S.C.A. § 1117 (West 1991) regarding chronic disability due to an undiagnosed illness apply. The veteran's qualifying military service, his reported complaints, and the unique nature and statutory and regulatory provisions regarding disability due to undiagnosed illnesses render the veteran's claims plausible. The Board finds that the evidence of record allows for equitable resolution of the claim with respect to these issues currently on appeal and that the duty to assist the veteran in establishing these claims has been satisfied. See 38 U.S.C.A. § 5107(a). In general, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303(a) (1999). In addition, service connection may be granted for a chronic disease, including arthritis, if manifested to a compensable degree with one year following service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). Further, if a condition noted during service is not shown to be chronic, then generally, a continuity of symptomatology after service is required for service connection. See 38 C.F.R. § 3.303(b). (1999). 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. See 38 C.F.R. § 3.303(d) (1999). Additionally, 38 U.S.C.A. § 1117 provides for service connection in cases in which a veteran suffers from chronic disability resulting from an undiagnosed illness, which became manifest during service on active duty in the Southwest Asia Theater of Operations during the Persian Gulf War, or that became manifest to a degree of 10 percent or more between the end of such service and December 31, 2001. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1)(i) (1999). Further, VA regulations provide that the VA shall pay compensation to a Persian Gulf War veteran who "exhibits objective indications of chronic disability" (manifested by certain signs or symptoms), which, by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. See 38 C.F.R. § 3.317(a); see also 38 U.S.C.A. § 1117. Signs or symptoms which may be manifestations of undiagnosed illnesses include, but are not limited to fatigue, joint pain, symptoms involving the skin, and neuropsychological signs. See 38 C.F.R. § 3.317(b) (1999). "Objective indications" include both objective evidence perceptible to an examining physician and other, non-medical indicators that are capable of independent verification. See 38 C.F.R. § 3.317(a)(2) (1999). Further, pursuant to an opinion by the VA General Counsel, VAOPGPREC 4-99 (May 3, 1999), in order to establish a well- grounded claim for service connection predicated upon Persian Gulf War etiology, there must be (1) proof of actual military service in SWATO during the Persian Gulf War (PGW or Gulf War); (2) proof of one or more signs of an undiagnosed illness; (3) proof of indications of chronic disability manifest during service or to a degree of disability of 10 percent or more during the specified presumptive period; and (4) proof that the chronic disability is the result of an undiagnosed illness. The veteran essentially contends that following his service in the SWATO during the Gulf War, he developed bilateral joint pain in his knees and elbows. He principally maintains that these problems are due to an undiagnosed illness incurred during the Gulf War. The earliest documented instance of complaints of painful joints is contained in the report of a June 1994 PGW medical examination. At that time, the veteran's painful joints were considered to be the result of degenerative joint disease. A July 1994 Army Reserve physical examination report shows that the veteran complained of experiencing painful and swollen joints of two years' duration. However, his joints were not observed to be swollen at that time, and no diagnoses with respect to these complaints were rendered. The veteran underwent a VA rating examination in March 1995, in which he complained, in pertinent part, of bilateral joint pain in his knees and elbows. X-ray results showed that he had mild articular irregularities in his knees bilaterally, and a diagnosis of minimal degenerative joint disease was rendered. In addition, the veteran was diagnosed with degenerative joint disease of the elbows, although X-ray results did not confirm such abnormalities in his elbows. The veteran was also diagnosed with arthralgias of the elbows, of an unknown etiology. At that time, the veteran was shown to have full ranges of motion in his knees and elbows. The veteran underwent a VA examination in September 1997. At that time, X-rays of the veteran's knees and elbows were taken, and did not reveal any abnormalities. In October 1997, the veteran underwent a fee-basis rating examination. He was found to have a mild limitation of motion in his elbows and coarse crepitation in his knees with loss of range of motion due to weakness and instability, bilaterally. The examiner did not indicate whether X-rays were conducted at that time, but concluded with an impression of post-traumatic osteoarthritic changes involving both knees and elbows which could be associated with the veteran's activities in the Gulf War. The veteran and his wife appeared before the undersigned Board member at the RO in July 1999, and testified that he was being treated for arthritis of his knees and elbows. The veteran testified that this particular problem developed after he had returned home from the Gulf War, and that he had not sustained injuries to either his knees or elbows while serving on active duty overseas. He indicated that his joint pain probably began at some point in 1992, and that the diagnoses of arthritis were merely speculative. The veteran stated that prior to the Gulf War, he had not experienced problems with respect to his joints, and had no problems performing physical training exercises. The veteran's wife testified that upon his return home from the Gulf War, the veteran experienced increasing difficulty with loss of motor strength and with diminishing ability to perform routine tasks due to joint pain. The Board recognizes that the veteran currently experiences bilateral pain in his elbow and knee joints. However, none of these disorders have been shown to have been manifested to a degree of 10 percent or more as a result of an undiagnosed illness. See generally 38 C.F.R. § 3.317. Moreover, the Board notes that these problems have almost consistently been ascribed to a known clinical disability, usually characterized as degenerative joint disease or osteoarthritis of the elbows and knees. In light of these diagnoses, there is no basis for establishing service connection for multiple joint pain due to an undiagnosed illness under 38 U.S.C.A. § 1117. The Board observes further, that to the extent that the veteran's complaints of joint pain of the knees and elbows as noted by the clinical evidence to be due to arthritis, there would also have to be of record persuasive evidence of a nexus to the veteran's service or competent medical evidence showing that arthritis became manifest to a degree of 10 percent or more within one year of the veteran's discharge from service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303, 3.307, 3.309. The Board further recognizes that the examiner who conducted the October 1997 rating examination offered his conclusion that the veteran had post-traumatic osteoarthritic changes of the knees and elbows which could be associated with the veteran's activities in SWATO. However, the Board finds that the examiner's comment that such symptoms could be associated with the veteran's active service in the Gulf War to be speculative, and generally insufficient to form an adequate basis for a grant of service connection. In this regard, the Board notes that the examiner appears to have based this assessment entirely upon the veteran's self-reported history, and not on any clinical evidence showing service incurrence, per se. Accordingly, the examiner's comment is accorded little probative value in this analysis. See generally LeShore v. Brown, 8 Vet. App. 406 (1995). In terms of lay evidence, the Board acknowledges the veteran's and his wife's statements and testimony regarding his joint pain. Even accepting as true the lay statements and testimony of record, this claim cannot be granted because the Board finds that there is affirmative evidence that such claimed disability is not due to an undiagnosed illness or any other incident of military service. In reviewing the foregoing issues, the Board has considered the provisions of 38 U.S.C.A. § 5107(b) (West 1991). However, there is not such a state of equipoise of the positive evidence with the negative evidence to otherwise allow for a favorable resolution of the veteran's claims. His claim for service connection for bilateral joint pain of the knees and elbows is therefore denied. III. Service Connection for Coronary Artery Disease As stated, service connection may be granted for a disability resulting from a disability that was incurred in or aggravated by service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303 (1999). However, the threshold question which must be answered in this case is whether the veteran has presented a well-grounded claim for service connection for coronary artery disease. A well-grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. In this regard, the veteran has "the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded." See 38 U.S.C.A. § 5107(a) (West 1991); Grivois v. Brown, 6 Vet. App. 136, 140 (1994); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). If the evidence presented by the veteran fails to meet this threshold of sufficiency, no further legal analysis need be made as to the merits of the claim. See Boek v. Brown, 6 Vet. App. 14, 17 (1993). To establish that a claim for service connection is well grounded, the claimant must satisfy three elements. First, there must be evidence of an incurrence or aggravation of an injury or disease in service. Second, there must be competent (i.e. medical) evidence of a current disability. Third, there must be evidence of a nexus or link between the in-service injury or disease and the current disability, as shown through the medical evidence. Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). Lay or medical evidence, as appropriate, may be used to substantiate service incurrence. See Caluza v. Brown, 6 Vet. App. 489, 507 (1995); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Alternatively, a claim may be well grounded based on the application of the rule for chronicity of symptomatology, set forth in 38 C.F.R. § 3.303(b) (1999). See Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). The veteran essentially contends that while deployed overseas during Operation Desert Storm, he experienced fluttering in his chest and heart palpitations. He indicated that he reported these symptoms to military medical personnel and was informed that they were the result of stress experienced due to his deployment or due to the stress associated with his impending return home from the Gulf War. The veteran has maintained that he reported similar symptoms to Army Reserve medical personnel in July and August 1994, and that he experienced a massive myocardial infarction two weeks later in mid-August 1994. The veteran's service medical records from his initial period of service and from his deployment to SWATO during the Gulf War are completely negative for complaints of, treatment for, or diagnoses of any disorders associated with his heart or blood vessels. The service medical records include multiple blood pressure readings, but no abnormalities in that respect were noted. An April 1991 separation examination report does not disclose any heart disorders, and the veteran failed to indicate that he experienced any such symptomatology relating to heart palpitations or heart disorders. The report of a Army Reserve retention examination also fails to indicate any complaints or diagnosed heart or cardiovascular problems. However, an echocardiogram (ECG) conducted in December 1991, some six months following the veteran's discharge from service, shows that he had what was characterized as a "right bundle branch block." Further, an Army Reserve Health Risk Appraisal form, and a Cardiovascular Risk Screening Form, also dated in December 1991, note that the veteran had a safe blood pressure level, but that he needed to lower his cholesterol and to stop smoking. It was also noted at that time that the veteran had an abnormal ECG reading without left ventricular hypertrophy. The veteran was placed on a temporary profile excusing him from participating in Army Reserve physical training exercises. In June 1994, the veteran claimed that within six months of returning home from the Gulf War, he began experiencing heart palpitations, and complained of having an irregular heart beat. A July 1994 Army Reserve medical examination report shows that the veteran complained of having experienced chest pains and heart palpitations. No diagnosis was rendered at that time. The record shows that the veteran experienced a myocardial infarction in mid-August 1994. Shortly afterwards, in late August 1994, he was diagnosed as being post-myocardial infarction with severe single vessel coronary artery disease. The Board notes that a VA clinical treatment record dated in July 1994, before the veteran experienced his myocardial infarction, shows that the veteran had complained of experiencing an irregular heart beat and palpitations. However, no irregularities were found at that time. An echocardiogram also conducted in July 1994 did not disclose any abnormalities. Further, in early August 1994, also prior to the onset of the veteran's myocardial infarction, the veteran was seen at a Persian Gulf Clinic for a phase II evaluation, in which he complained of heart palpitations, irregular heartbeat, and tightness in his chest. At that time, the veteran reported that the onset of these symptoms had occurred while he was serving overseas in SWATO. However, the record is negative for any clinical findings to that effect. The report of a VA rating examination conducted in March 1995 contained the examiner's diagnosis of arteriosclerotic heart disease and status-post acute anterior myocardial infarction with mitral valve prolapse. Subsequent VA clinical treatment records and examination reports note that the veteran had experienced a myocardial infarction in August 1994, and that he had arteriosclerotic heart disease. However, the records fail to contain any medical opinion indicating that the veteran's coronary artery disease had been incurred during his active service. In July 1999, the veteran appeared at a personal hearing before the undersigned Board Member at the RO, and testified that prior to returning home from Desert Storm, he reported to military medical personnel that he had been having problems with his heart. However, the veteran testified that he was advised that such complaints were the result of anxiety over the prospect of returning home. According to the veteran he underwent his annual physical examination with the Army Reserve in December 1991. He stated that he was diagnosed with a prolapse, but was told that many people had such an irregularity and that it was not a cause for concern. Nonetheless, the veteran indicated that he did not pass the December 1991 physical examination due to the heart irregularity noted. Following this, in August 1994, the veteran testified that he had experienced a massive heart attack. He testified that he continued to experience symptoms up to that point. Following his heart attack, the veteran indicated that he continued to receive treatment, and had also undergone an angioplasty. The Board has evaluated the objective medical evidence, and concludes that the veteran has not submitted evidence of a well-grounded claim for service connection for coronary artery disease. The Board recognizes that the evidence shows that the veteran has a present disability with respect to coronary artery disease and residuals of a myocardial infarction. However, there is no competent medical evidence of record to establish the required nexus or link between the veteran's currently diagnosed coronary artery disease and his active service. The veteran has testified and stated that he had complained of heart irregularities such as palpitations and irregular heart beat while deployed in SWATO. However, his service medical records from his period of active service relating to the Gulf War are negative for any such complaints or diagnoses of any heart-related disorders. In fact, the report of the service examination conducted in SWATO in April 1994 shortly before the veteran's discharge from service, shows that he denied experiencing any chest pain or related symptoms. The Board further acknowledges that the report of the December 1991 Army Reserve annual physical examination included an echocardiogram report which indicated that the veteran had an incomplete right bundle branch block. However, this evidence fails to establish the presence of any coronary artery disease at that time. The first recorded instance of any complaints of irregular heartbeats or palpitations was dated in June 1994, some three years after the veteran's discharge from service. The Board recognizes that he complained of heart palpitations, chest pain, and irregular heartbeats in July 1994, shortly before experiencing his myocardial infarction and subsequently being diagnosed with coronary artery disease. However, this evidence fails to show a continuity of symptomatology following his separation from service sufficient to render his claim well grounded. See Savage, supra. In addition, the Board observes that while contemporaneous clinical treatment records and VA rating examination reports show that the veteran has a present disability with respect to his heart problems and coronary artery disease, aside from noting a history as provided by the veteran, none of these records contain any medical opinion indicating that that disability was incurred during his five-month period of active duty in Desert Storm. In addition, lay statements and testimony by the veteran and his wife do not constitute medical evidence. As lay persons, these individuals are not competent to address an issue requiring an expert medical opinion, to include medical diagnoses or opinions as to medical etiology. See Moray v. Brown, 5 Vet. App. 211, 214 (1995); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). What is missing here is medical evidence, contained in the veteran's service medical records, that the veteran actually complained of experiencing problems with his heart during his active service, and a medical opinion indicating that the veteran had a disorder related to coronary artery disease that was either incurred in or aggravated by his active service. Absent such evidence, his claim is not well grounded, and must be denied on that basis. Accordingly, for the above reasons, it is the decision of the Board that the veteran has failed to meet his initial burden of submitting evidence of a well-grounded claim for service connection for coronary artery disease. The Board has not been made aware of any additional evidence which is available which could serve to well ground the veteran's claim for service connection. As the duty to assist is not triggered here by a well-grounded claim, the Board finds that the VA has no obligation to further develop the veteran's claim. See 38 U.S.C.A. § 5103 (West 1991); McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997). The Board also views its discussion as sufficient to inform the veteran of the evidence necessary to inform the veteran of the evidence necessary to complete a well-grounded claim for service connection for coronary artery disease. See Robinette, 8 Vet. App. 69, 77-78 (1995). The Board recognizes that this matter is being disposed of in a manner that differs from that employed by the RO. The RO denied the veteran's claim on the merits while the Board has found his claim to be not well grounded. However, when an RO does not specifically address the question whether a claim is well grounded, but rather, as here, proceeds to adjudication on the merits, there is no prejudice to the veteran solely from the omission of the well-grounded analysis. See Meyer v. Brown, 9 Vet. App. 425, 432 (1996). ORDER The initial rating for the veteran's PTSD is appropriate, and entitlement to an initial evaluation in excess of 50 percent is denied. Service connection for bilateral joint pain in the knees and elbows, claimed as secondary to an undiagnosed illness, is denied. Evidence of a well-grounded claim not having been submitted, service connection for coronary artery disease is denied. S. L. KENNEDY Member, Board of Veterans' Appeals