Decision Date: 09/08/95 Archive Date: 09/07/95 DOCKET NO. 93-15 640 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for hypertension, on a direct basis and as secondary to Agent Orange exposure. 2. Entitlement to a permanent and total disability evaluation for pension purposes. 3. Whether the evidence is new and material to reopen a claim of entitlement to service connection for post- traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Charles G. Sener INTRODUCTION The appellant had active service from August 1965 to July 1968. In March 1983, the Board of Veterans' Appeals (Board) denied the appellant's claim of entitlement to an acquired psychiatric disability, on appeal from a July 1981 rating decision of the Department of Veterans Affairs (VA) Lincoln, Nebraska, Regional Office (RO), which denied a claim of entitlement to service connection for PTSD as not shown by the evidence of record. This matter comes before the Board on appeal from rating decisions by the RO, dated in January 1992 and April 1992, which denied claims of entitlement to a permanent and total disability for pension purposes and entitlement to service connection for PTSD. The January 1992 rating decision also denied service connection for hypertension, on a direct basis, and deferred the appellant's claim of entitlement to service connection for hypertension, secondary to Agent Orange exposure, pending the promulgation of regulations pertaining to Agent Orange exposure, as required by Nehmer v. United States Veterans Administration, 712 F. Supp. 1404 (N.D. Cal., May 2, 1989). In Nehmer, a United States District Court voided all benefit denials under 38 C.F.R. § 3.311a, the "dioxin" (Agent Orange) regulation, which was promulgated under the "Dioxin and Radiation Exposure Compensation Standards Act," 38 U.S.C.A. § 1154(a) (West 1991), and remanded the case to the Department of Veterans Affairs for revision of the regulation in accordance with the ruling of the Court. Final regulations were promulgated by VA in February 1994, and the RO, in a November 1994 rating decision, denied the appellant's claim of entitlement to service connection for hypertension, secondary to Agent Orange exposure, after considering the new regulations. The issue of whether the evidence is new and material to reopen a claim of entitlement to service connection for PTSD will be discussed in the Remand portion of this decision. CONTENTIONS OF APPELLANT ON APPEAL The appellant asserts that he incurred hypertension as a result of service, including exposure to Agent Orange. He also believes that he is entitled to a permanent and total disability evaluation for pension purposes because he has not performed significant work since 1985, due to a left knee injury and psychiatric problems. Moreover, he states that he receives disability payments from the Social Security Administration (SSA) which is further evidence of his unemployability. Finally, the appellant alleges that his psychiatric problems include PTSD, which developed as a result of his Vietnam experiences. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the appellant's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the appellant has not met the initial burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim of entitlement to service connection for hypertension, on a direct basis and as secondary to Agent Orange exposure, is well-grounded. It is the decision of the Board that the evidence supports entitlement to a permanent and total disability evaluation for pension purposes. FINDINGS OF FACT 1. The appellant had active service in Vietnam during the Vietnam era. 2. Hypertension is not recognized by the VA as etiologically related to exposure to herbicide agents used in Vietnam. 3. Although there is medical evidence of record indicating the diagnosis of "[b]orderline hypertension, questionably secondary to exogenous obesity," almost 24 years after the appellant's separation from service, no evidence has been submitted indicating that this disorder is related to service, or is due to any in-service occurrence or event, including Agent Orange exposure. 4. The appellant was born in November 1946, has a high school equivalency diploma, and has a poor occupational history, as evidenced by his statements indicating that he has had many, many jobs, in the vicinity of 200, in the past. 5. The appellant was last employed in 1991 as a janitor, and he claimed that he was unable to perform his duties as a result of a left knee disorder and psychiatric disabilities. 6. The appellant is service-connected for the following disabilities: scars of the right index, ring, and middle fingers, status post traumatic injury, evaluated as noncompensable; and a mid epigastric scar, status post subdural lipoma removal, evaluated as noncompensable. 7. The appellant is nonservice-connected for the following disabilities: personality disorder and PTSD, evaluated as 30 percent disabling; diabetes mellitus, evaluated as 20 percent disabling; tinea involving the hands and feet, evaluated as 10 percent disabling; degenerative disc disease, evaluated as 10 percent disabling; degenerative joint disease, right knee, evaluated as 10 percent disabling; chondromalacia patella, left knee, status post arthroscopy, evaluated as 10 percent disabling; degenerative joint disease, right ankle, evaluated as noncompensable; right hand arthritis, evaluated as noncompensable; hypertension, evaluated as noncompensable; slight scar, left chest area, evaluated as noncompensable; scar, anterior aspect of left thigh, evaluated as noncompensable; and scar, posterior aspect of right thigh, evaluated as noncompensable. 8. The appellant's combined schedular evaluation is 60 percent. 9. The appellant's ratable disabilities are not sufficient to render the "average person" unable to follow a substantially gainful occupation. 10. An October 1988 SSA decision determined that the appellant was disabled as of June 1987, due to residuals of a left knee injury, a back injury, and an emotional component. 11. In January 1993, a VA physician declared that the appellant had "a lifelong history of poor functioning and adaptation," and it was opined that the appellant was "totally disabled . . . [with] his current and recent adjustment [] far less effective than it was at the time prior to his entry into [service]." 12. The appellant's ratable disabilities are of sufficient severity to preclude him from engaging in substantially gainful employment when considered in conjunction with his age, education and general occupational background, and unusual mental effects. CONCLUSIONS OF LAW 1. The appellant has not submitted evidence of a well- grounded claim for service connection for hypertension, on a direct basis and as secondary to Agent Orange exposure. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5107(a) (West 1991); 38 C.F.R. §§ 3.307(a), 3.309(e) (1994). 2. The appellant is permanently and totally disabled for pension purposes within the meaning of governing law and regulations. 38 U.S.C.A. §§ 1155, 1502, 1521, 1523(a), 5107 (West 1991); 38 C.F.R. § 3.321, 3.40, 3.342, 4.15, 4.16, 4.17, and Part 4 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by wartime service. 38 U.S.C.A. § 1110 (West 1991). Additionally, where a veteran served continuously for 90 days or more during a period of war, and hypertension or psychosis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 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 (1994). Service connection may 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. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d) (1994). The threshold question to be answered at the outset of the analysis of any issue is whether the appellant's claim is well-grounded; that is, whether it is plausible, meritorious on its own, or otherwise capable of substantiation. Murphy v. Derwinski, 1 Vet.App. 78 (1990). The United States Court of Veterans Appeals (Court) has said that the statutory "duty to assist" under 38 U.S.C.A. § 5107(a) (West 1991) does not arise until there is a well-grounded claim. Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990). The question of whether or not a claim is well-grounded is significant because if a claim is not well-grounded, the Board does not have jurisdiction to adjudicate that claim. Boeck v. Brown, 6 Vet.App. 14, 17 (1993). In this regard, the Court has observed that the statutory prerequisite of submitting a "well-grounded" claim "reflects a policy that implausible claims should not consume the limited resources of the VA and force into even greater backlog and delay claims which--as well-grounded--require adjudication. . . . Attentiveness to this threshold issue is, by law, not only for the Board but for the initial adjudicators, for it is their duty to avoid adjudicating implausible claims at the expense of delaying well-grounded ones." Grivois v. Brown, 6 Vet.App. 136, 139 (1994). A veteran has, by statute, the duty to submit evidence that a claim is well-grounded. The evidence must "justify a belief by a fair and impartial individual" that the claim is plausible. 38 U.S.C.A. § 5107(a) (West 1991). Where such evidence is not submitted, the claim is not well-grounded, and the initial burden placed on the veteran is not met. See Tirpak v. Derwinski, 2 Vet.App. 609 (1992). Evidentiary assertions by the veteran must be accepted as true for the purposes of determining whether a claim is well-grounded, except where the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet.App. 19, 21 (1993). I. Hypertension A chronic, tropical, or prisoner-of-war related disease, or a disease associated with exposure to certain herbicide agents listed in 38 C.F.R. § 3.309 (1994) will be considered to have been incurred in service under the circumstances outlined in this section even though there is no evidence of such disease during the period of service. No condition other than one listed in 38 C.F.R. § 3.309(a) (1994) will be considered chronic. 38 U.S.C.A. §§ 1101, 1112, 1113, 1116 (West 1991); 38 C.F.R. § 3.307(a) (1994). If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6)(iii) (1994) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) (1994) are also satisfied: chloracne or other acneform disease consistent with chloracne, Hodgkin's disease, multiple myeloma, Non-Hodgkin's lymphoma, porphyria cutanea tarda, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e) (1994). Notwithstanding the foregoing, the United States Court of Appeals for the Federal Circuit recently determined that the Veterans' Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984) does not preclude a veteran from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed.Cir. 1994). However, the Court has held that where the issue involves medical causation, competent medical evidence which indicates that the claim is plausible or possible is required to set forth a well-grounded claim. Grottveit v. Brown, 5 Vet.App. 91, 93 (1993). The diseases listed at 38 C.F.R. § 3.309(e) (1994) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne and porphyria cutanea tarda shall have become manifest to a degree of 10 percent or more within a year, and respiratory cancers within 30 years, after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii) (1994). In this case, the evidentiary assertions as to the appellant's claim of service connection for hypertension, on a direct basis and as secondary to Agent Orange exposure, as incurred in or aggravated by military service are inherently incredible when viewed in the context of the total record. Review of the appellant's service personnel records reveals that he had military service in Vietnam from July 1966 to July 1967 and from March 1968 to July 1968. Review of the appellant's service medical records discloses no complaint, symptomatology, or finding of hypertension. An August 1965 service report of medical examination indicated normal clinical evaluation of the appellant's heart and vascular system, with no abnormality, defect, or diagnosis listed. The appellant's blood pressure was recorded as 122/70, with a pulse of 72. A July 1968 service report of medical examination divulged normal clinical evaluation of the appellant's heart and vascular system, with no abnormality, defect, or diagnosis listed. The appellant's blood pressure was recorded as 130/78. An evaluation of the appellant's cardiovascular system, performed at a June 1972 VA medical examination, showed that the heart was not enlarged, with regular rhythm and without murmurs. A physician reported that blood pressure was "135/90-80," and additional blood pressure readings were recorded as follows: 140/74, with a pulse of 84, sitting; 128/76, with a pulse of 94, standing; 150/78, with a pulse of 100, sitting after exercise; and 144/76, with a pulse of 86, two minutes after exercise. A diagnosis of hypertension was not reported. At an April 1983 VA medical examination, the appellant's blood pressure readings were reported as follows: 134/88, with a pulse of 100, sitting; 140/88, with a pulse of 106, recumbent; 126/84, with a pulse of 100, standing; 130/84, with a pulse of 120, sitting after exercise; and 130/86, with a pulse of 100, two minutes after exercise. A diagnosis of hypertension was not noted. At an August 1989 VA medical examination, the appellant's blood pressure readings were reported as follows: 146/84, with a pulse of 92, sitting; 152/84, with a pulse of 88, recumbent; 140/90, with a pulse of 96, standing. Cardiovascular examination revealed that the appellant's heart had regular rhythm, without click or gallop. A diagnosis of hypertension was not listed. Cardiovascular evaluation, conducted at an October 1991 VA medical examination, showed regular heart rhythm and rate, without rub, murmur, or gallop. Blood pressure readings were reported as follows: 140/74, with a pulse of 80, sitting; 154/84, with a pulse of 84, recumbent; 138/80, with a pulse of 80, standing; 160/74, with a pulse of 96, sitting after exercise; and 144/70, with a pulse of 92, two minutes after exercise. A diagnosis of hypertension was not noted. At a December 1991 VA medical examination, it was observed that the appellant had no cardiopulmonary abnormalities, with normal peripheral pulses and heart sounds, and without bruits. It was reported, by history, that the appellant had fluctuating blood pressure that was first noticed at discharge, in 1968, and that he had not recently been on any medication. The following blood pressure readings were recorded: 130/68, with a pulse of 80, sitting; and 140/82, with a pulse of 94, standing. It was also noted that the appellant's height and weight were 66 1/2 inches and 245 lbs., respectively. Although the final impression listed "[b]orderline mild essential hypertension[,] probably much depending on the situation at the time of which it is measured," a physician declared that the appellant's blood pressure, measured both sitting and standing, by himself and a nurse, showed "normal BP[,] both systolic and diastolic." A March 1992 VA medical examination showed no evidence of active heart disease and noted that the appellant had never been treated for hypertension. Blood pressure readings were listed as 138/92, sitting, 160/90, recumbent, and 138/84, standing. A "[h]istory of intermittent blood pressure elevation" and "[n]o history of hypertension" were noted as final diagnoses. At a September 1992 VA medical examination, the appellant's height and weight were 67 inches and 252 lbs., respectively, and blood pressure readings were 158/92, sitting, 142/86, recumbent, and 142/90, standing. A physician stated that the appellant was not taking medication for hypertension. A chest x-ray showed a normal heart size, and the physician observed that the apex beat did not appear to be significantly deviated laterally. Final diagnosis was "[b]orderline hypertension, questionably secondary to exogenous obesity." As noted above, to establish service connection there needs to be a showing that the disability for which service connection is sought is, in some way, related to service. No such showing has been made as to the appellant's hypertension. There is nothing in the clinical evidence that shows the presence of this disorder either during service or for almost 24 years following separation from service, or that suggests it is etiologically related to any of his service-connected disabilities. He has failed to provide any clinical evidence of a relationship to service or to a service-connected disability. Where the determination issue involves medical causation or a medical diagnosis, competent medical evidence to the effect that the claim is "plausible" or "possible" is required. Grottveit v. Brown, 5 Vet.App. at 93. Therefore, even though the appellant now has "[b]orderline hypertension, questionably secondary to exogenous obesity," there is no objective evidence of medical causality, and as such, the claim is not well-grounded. See Grivois v. Brown, 6 Vet.App. 136 (1994). Furthermore, there is no competent medical evidence suggesting a connection between the appellant's presumed herbicide exposure while in Vietnam and the subsequent development of "[b]orderline hypertension, questionably secondary to exogenous obesity." His assertions of medical causation alone are not probative because lay persons (i.e., persons without medical expertise) are not competent to offer medical opinions. Moray v. Brown, 5 Vet.App. 211 (1993); Grottveit v. Brown, 5 Vet.App. 91 (1993); Espiritu v. Derwinski, 2 Vet.App. 492 (1992). Although the appellant argues that his exposure to Agent Orange while in Vietnam, which is presumed for a veteran who served in the Republic of Vietnam during the Vietnam era and who has a disease listed at 38 C.F.R. § 3.309(e) (1994) (38 C.F.R. § 3.307(a)(6)(iii) (1994)), resulted in the development of hypertension, that disease is not recognized as one of the diseases attributable to Agent Orange exposure. Consequently, in the absence of competent evidence of medical causation between Agent Orange exposure and the appellant's "[b]orderline hypertension, questionably secondary to exogenous obesity," the claim is not well- grounded, and must be dismissed. Where there is no medical evidence of the claimed disorder during service, where there is no medical evidence linking the claimed disorder to service or an in-service event or occurrence, or where the disorders are not currently demonstrated, the claim is not well-grounded. See Rabideau v. Derwinski, 2 Vet.App. 141 (1992). The Court has expressed its concern that, in a situation in which the claim is not well-grounded, a decision on the merits, if deemed final, could constitute an unwarranted impediment to the appellant should he seek to reopen the claim because such reopening would require the submission of new and material evidence. The Court has deemed it appropriate, where a decision was made on the merits with respect to a claim that was not well-grounded, to recognize the nullity of the prior decision and allow the appellant to begin, if he can, on a clean slate. Grottveit v. Brown, 5 Vet.App. at 93 (1993). In view of the clear direction given by the Court, it is imperative that finality in accordance with 38 C.F.R. § 3.104 (1994) not attach to the January 1992 rating decision with respect to the claim of entitlement to service connection for hypertension, on a direct basis, as well as the November 1994 rating decision with respect to the claim of entitlement to service connection for hypertension, secondary to Agent Orange exposure. II. Pension Review of the appellant's claims file reveals that the appellant served for 90 days or more during a period of war, and he alleges that he is permanently and totally disabled for pension purposes due to disabilities not the result of his willful misconduct. Further review of the claims file shows that the SSA, in October 1988, determined that the appellant was disabled. In accordance with 38 U.S.C.A. § 5107 (West 1991), and Murphy v. Derwinski, 1 Vet.App. 78 (1990), the appellant has presented a well-grounded claim for entitlement to a permanent and total disability for pension purposes. The facts relevant to this appeal have been properly developed, and the obligation of the VA to assist the appellant in the development of the claim has been satisfied. Id. Under 38 U.S.C.A. § 501 (West 1991), the Secretary of the VA has the authority to prescribe all rules and regulations which are necessary or appropriate to carry out the laws administered by the VA. With regard to claims for pension benefits, the Secretary's authority to prescribe regulations providing for determinations of permanent and total disability may be based in whole or in part upon subjective criteria. Talley v. Derwinski, 2 Vet.App. 282, 285 (1992). Both objective and subjective standards are often set forth within the same statutory provision or regulation. The basic law referable to pension benefits, for example, states that pension is payable to a veteran who served for 90 days or more during a period of war and who is permanently and totally disabled due to nonservice-connected disabilities not the result of his own willful misconduct. 38 U.S.C.A. § 1521 (West 1991). Moreover, for the purpose of determining whether or not a veteran is permanently and totally disabled, ratings for service-connected disabilities may be combined with ratings for nonservice-connected disabilities. 38 U.S.C.A. § 1523(a) (West 1991); 38 C.F.R. § 3.342(a) (1994). If his disability is less than 100 percent, he must be unemployable by reason of disability. 38 C.F.R. §§ 3.321, 3.340, 3.342 and Part 4 (1994). With reference to the permanence of a disability, the Board notes that the latter part of 38 U.S.C.A. § 1502(a) (West 1991) subjectively defines permanence, stating that permanent and total disability will be held to exist where the person is unemployable as a result of disability reasonably certain to last throughout the remainder of the person's life. Talley v. Derwinski, 2 Vet.App. at 285 (1992). This definition of permanence is also set forth in 38 C.F.R. §§ 3.340(b), 4.15 (1994). Objective criteria to establish permanence of a disability is also provided in 38 U.S.C.A. § 1502 (West 1991). A finding of permanent and total disability is warranted where the person experiences any disability that is sufficient to render it impossible for an average person to follow a substantially gainful occupation. The "average person" standard is implemented by VA regulations, including 38 C.F.R. § 3.340(a) (1994) and 38 C.F.R. § 4.15 (1994), which also adds that the total rating is based primarily upon the average impairment in earning capacity, i.e., the economic or industrial handicap which must be overcome. In addition, 38 U.S.C.A. § 1502(a)(2) (West 1991) essentially provides that permanent and total disability may exist in any disorder determined by the Secretary to be of such a nature and extent as to justify that persons suffering therefrom are permanently and totally disabled. The presence of certain disabilities also provides a basis for an objective determination of permanent and total disability. Permanent loss of the use of both hands, or of both feet or of one hand and one foot, or the sight of both eyes is considered permanent and total disability for pension purposes. 38 C.F.R. § 4.15 (1994). Further, permanent total disability pension ratings will also be authorized, provided other requirements of entitlement are met, for congenital, developmental, hereditary, or familial conditions, as well as for certain types of disabilities requiring hospitalization for indefinite periods or, as with active pulmonary tuberculosis after six months' hospitalization without improvement. 38 C.F.R. § 3.342(b) (1994). Initially, the Board notes that a total disability rating is based primarily upon the average impairment in earning capacity. 38 C.F.R. § 4.15 (1994). The VA's Schedule for Rating Disabilities (Rating Schedule) also provides a means for objective determination of total disability. 38 C.F.R. Part 4 (1994). When impairment is commensurate with a 100 percent rating in accordance with schedular criteria, a total rating on a schedular basis is warranted. 38 C.F.R. § 3.340(a)(2) (1994). 38 C.F.R. § 4.17 (1994) provides that all veterans basically eligible and unable to secure or follow a substantially gainful occupation by reason of disability likely to be permanent shall be rated permanently and totally disabled. For pension purposes, the permanence of the percentage requirements of 38 C.F.R. § 4.16 (1994) is a requisite. 38 C.F.R. § 4.17 (1994). Pertinent regulations also provide that totally incapacitating diseases and injuries of long-standing will be regarded as permanently and totally disabling when the probability of permanent improvement under treatment is remote. 38 C.F.R. § 3.340(b) (1994). For pension purposes, when the percentage requirements are met and the disabilities involved are of a permanent nature, a rating of permanent and total disability will be assigned if the veteran is found to be unable to secure and follow substantially gainful employment by reason of such disability. 38 C.F.R. § 4.17 (1994). In making such determinations, marginal employment may be consistent with unemployability if the restriction of securing or retaining better employment is due to disability. Id. Marginal employment consists of employment as, for example, a self- employed farmer or other person, while employed in his own business, or at odd jobs, or while employed at less than half the usual remuneration. Id. In determining eligibility for pension benefits, subjective factors are also for consideration with regard to both permanence of the disability and total disability. As noted above, pension is payable to a veteran with the requisite service who is unemployable as a result of disability "reasonably certain" to last throughout the lifetime of the disabled person. Talley v. Derwinski, 2 Vet.App. at 285 (1992); 38 U.S.C.A. § 1502(a) (West 1991). Subjective factors for consideration are also included in 38 C.F.R. § 4.15 (1994), which provides that in individual cases, full consideration will be given to such factors as unusual physical or mental effects in individual cases, peculiar effects of occupational activities, defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability, and the effect of combinations of disabilities. Furthermore, 38 C.F.R. § 4.17(b) (1994) states that where the veteran fails to meet the percentage requirements, but meets basic eligibility criteria and is unemployable, consideration of 38 C.F.R. § 3.321(b)(2) (1994) is appropriate. In turn, 38 C.F.R. § 3.321(b)(2) (1994) provides that where the veteran does not meet the percentage requirements of the Rating Schedule, but is unemployable by reason of his age, occupational background, or other related factors, a permanent and total disability rating on an extra-schedular basis is warranted. The Board notes that a November 1994 rating decision assigned disability percentages to the disabilities shown in the record. VA law and regulations provide that the Rating Schedule shall be used for evaluating the degree of disabilities in claims for veteran's benefits. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 3.321 (1994). Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1994). Separate rating codes identify the various disabilities. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history. 38 C.F.R. § 4.2 (1994). 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. 38 C.F.R. § 4.7 (1994). In every instance where the schedule for rating disabilities does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (1994). The appellant is service-connected for the following disabilities: scars of the right index, ring, and middle fingers, status post traumatic injury, evaluated as noncompensable; and a mid epigastric scar, status post subdural lipoma removal, evaluated as noncompensable. The appellant is nonservice-connected for the following disabilities: personality disorder and PTSD, evaluated as 30 percent disabling; diabetes mellitus, evaluated as 20 percent disabling; tinea involving the hands and feet, evaluated as 10 percent disabling; degenerative disc disease, evaluated as 10 percent disabling; degenerative joint disease, right knee, evaluated as 10 percent disabling; chondromalacia patella, left knee, status post arthroscopy, evaluated as 10 percent disabling; degenerative joint disease, right ankle, evaluated as noncompensable; right hand arthritis, evaluated as noncompensable; hypertension, evaluated as noncompensable; slight scar, left chest area, evaluated as noncompensable; scar, anterior aspect of left thigh, evaluated as noncompensable; and scar, posterior aspect of right thigh, evaluated as noncompensable. The appellant's combined schedular evaluation is 60 percent. After comparing the appellant's symptomatology to the rating criteria under the applicable Diagnostic Codes of the Rating Schedule, 38 C.F.R. Part 4 (1994), it is clear that the current ratings have been correctly assigned. Both personality disorder and PTSD are psychoneurotic disorders which for VA purposes are rated according to 38 C.F.R. § 4.132, Diagnostic Codes 9400 through 9411 (1994). The Board notes that we cannot clearly disassociate the appellant's symptomatology as it relates to personality disorder and PTSD; therefore we will discuss the appellant's symptomatology as it relates to all of his psychoneurotic disorders for purposes of assigning a disability evaluation. A 30 percent evaluation is warranted for a psychoneurotic disorder when there is definite impairment in the ability to establish or maintain effective and wholesome relationships with people and when psychoneurotic symptoms result in such reductions in initiative, flexibility, efficiency, and reliability levels as to produce definite industrial impairment. A 50 percent evaluation requires that the ability to establish or maintain effective or favorable relationships with people be considerably impaired and that reliability, flexibility, and efficiency levels be so reduced by reason of psychoneurotic symptoms as to result in considerable industrial impairment. A 70 percent evaluation requires that the ability to establish and maintain effective or favorable relationships with people be severely impaired and that the psychoneurotic symptoms be of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. A 100 percent evaluation requires that attitudes of all contacts except the most intimate be so adversely affected as to result in virtual isolation in the community and that there be totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes (such as fantasy, confusion, panic, and explosions of aggressive energy) associated with almost all daily activities resulting in a profound retreat from mature behavior. The individual must be demonstrably unable to obtain or retain employment. 38 C.F.R. § 4.132, Diagnostic Codes 9410, 9411 (1994). In Hood v. Brown, 4 Vet.App. 301 (1993), the Court stated that the term "definite" in 38 C.F.R. § 4.132 was "qualitative" in character, whereas the other terms were "quantitative" in character, and invited the Board to "construe" the term "definite" in a manner that would quantify the degree of impairment for purposes of meeting the statutory requirement that the Board articulate "reasons or bases" for its decision. 38 U.S.C.A. § 7104(d)(1) (West 1991). In a precedent opinion, dated November 9, 1993, the General Counsel of the VA concluded that "definite" is to be construed as "distinct, unambiguous, and moderately large in degree." It represents a degree of social and industrial inadaptability that is "more than moderate but less than rather large." O.G.C. Prec. 9-93 (Nov. 9, 1993). The Board is bound by this interpretation of the term "definite." 38 U.S.C.A. § 7104(c) (West 1991). With these considerations in mind, the Board will address the merits of the claim at issue. At a November 1991 VA medical examination, the appellant reported a variety of symptoms, including occasional bad dreams of war experiences. A physician noted that the appellant had been seen by a psychiatrist, in May 1975, with a diagnosis of schizoid personality, and the physician indicated that he had given the appellant a diagnosis of sociopathic personality disorder in 1989. The appellant stated that he had been unable to sleep since Vietnam and that every time he had heard a "chopper" he had been unable to sleep. Furthermore, he commented that he could not tolerate firecrackers and other such noises. It was reported that the appellant had impregnated a Vietnamese girl and that later he had killed both the Vietnamese girl and her baby. He recounted that while on a perimeter patrol he had encountered the Vietnamese girl and the baby, as intruders, and that he had shot and killed both of them because the Vietnamese girl had fired upon him. Mental status evaluation, performed at the November 1991 VA medical examination, revealed that the appellant's associations were intact and that his mood was "generally fairly bland." The physician opined that the appellant appeared to be of "probable low average intellectual level" and that his insight was "pretty limited." However, the physician stated that the appellant's mental content did not reveal evidence of psychotic disorder. The physician observed that it was not possible to verify the accuracy of the appellant's painful situations in Vietnam, and the physician noted that the appellant did not describe "a life course marked by recurring [PTSD] type problems which have interfered with his functioning." Rather, it was opined that the appellant described impaired functioning related to his pattern of response to pressures, criticisms, and demands. The physician emphasized that he did not find an adequate basis to believe that the appellant was suffering from PTSD and that the evidence overwhelmingly showed that the appellant's predominant difficulty over the years had been personality problems. A final diagnosis of "[p]ersonality disorder, not otherwise specified (features of inadequate, probable anti-social, dependent are noted)" was listed. At a March 1992 VA medical examination for mental disorders, the appellant stated that he had been fired as a vehicle driver from the Salvation Army, in Kearney, Nebraska, after having worked there for 3 1/2 years. It was reported that the appellant was just "staying in the house," eating, sleeping, and watching TV because he did not like people. A physician noted that the appellant was receiving SSA compensation and that the appellant had not looked for work because the "Nebraska Voc Rehab said [he] was unemployable." The appellant explained that he had been sent for job training in 1985 but that he could not get a job after that. The physician reported that the appellant was "dissembling, manipulative and showing no evidence whatever of mental illness," and the physician declared that the appellant had a sociopathic personality disorder. A physician at a January 1993 VA medical examination noted that the appellant had had a long history of psychiatric problems with mixed depression and anxiety with some inappropriate behavior and possibly delusional ideation. It was reported that the appellant had had recurrent dreams of war experiences and that he was hyper vigilant. The physician observed that the appellant exhibited many signs of an inadequate personality and that his psychic adjustment was very poor at best. Furthermore, it was noted that the appellant's diagnoses ranged from schizoid personality to schizoaffective illness to undifferentiated schizophrenia. The appellant stated that he had attempted suicide on approximately ten occasions, the most recent in 1985, and that he had had many, many jobs, in the vicinity of 200, in the past. The last reported work was as a janitor, in 1991, and the appellant claimed that he was no longer able to work because of an injury to his knee and because of psychiatric problems. The physician at the January 1993 VA medical examination observed that the appellant was firmly outgoing, with a hint of suspiciousness, and had a moderate thinking disorder, with some active idiosyncratic mechanisms. There were no flight of ideas or thoughts of suicide present, and the appellant's judgment was noted only to be fair, with insight lacking. The physician's diagnostic impression included the following: borderline personality organization, with prominent schizoid and affective trims, severe; mild mental retardation; and possible adjunctive PTSD. In applying the schedular criteria for psychoneurotic disorders under Diagnostic Codes 9410 and 9411, and after careful and longitudinal review of the aforementioned evidence, the Board finds that the appellant's psychoneurotic symptomatology resulting from personality disorder and PTSD more nearly approximates disability of distinct, unambiguous, and moderately large degree affecting his social and industrial adaptability. Accordingly, a 30 percent disability evaluation is warranted under Diagnostic Codes 9410 and 9411. A 10 percent evaluation is warranted for mild diabetes mellitus that is controlled by a restricted diet, without insulin, where there is no impairment of health or vigor or limitation of activity. A 20 percent evaluation requires moderate diabetes mellitus that is controlled by a moderate insulin or oral hypoglycemic agent dosage and a restricted (maintenance) diet, where there is no impairment of health or vigor or limitation of activity. A 40 percent evaluation is appropriate for moderately severe diabetes mellitus requiring a large insulin dosage, a restricted diet, and careful regulation of activities, i.e., avoidance of strenuous occupational and recreational activities. 38 C.F.R. § 4.119, Diagnostic Code 7913 (1994). At a September 1992 VA medical examination, the appellant's height and weight were 67 inches and 252 lbs., respectively. An evaluation for diabetes mellitus revealed that there was no history of ketoacidic or hypoglycemic reaction. A physician noted that the appellant did "not appear to adhere to too strict of a diabetic diet and his activities are in no way regulated." Although the appellant did not require insulin, it was reported that he did take an oral hypoglycemic agent, Glipizide, 30 mg, every day. Accordingly, a 20 percent disability evaluation is warranted under Diagnostic Code 7913. A noncompensable evaluation is warranted for eczema with slight, if any, exfoliation, exudation or itching that is on a nonexposed surface or small area. A 10 percent evaluation requires exfoliation, exudation or itching, involving an exposed surface or extensive area. A 30 percent evaluation is warranted for eczema with constant exudation or itching, extensive lesions, or marked disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7806 (1994). A VA dermatological examination, performed in September 1991, showed that the appellant had scaly, reddish patches on his hands and feet that were compatible with tinea manuum and tinea pedis. A March 1992 VA medical examination indicated that the aforementioned rash involving the appellant's hands and feet was essentially unchanged. VA medical examination, conducted in September 1992, disclosed that the appellant's skin was "considered normal," with no mention of a rash involving the appellant's hands and feet. In applying the schedular criteria under Diagnostic Code 7806 for eczema, we find that the appellant has exhibited clinical evidence of tinea manuum and tinea pedis that is appropriately rated as eczema and more nearly approximates the evidence required for a 10 percent disability evaluation. Scars may be evaluated on the basis of any related limitation of function of the body part that they affect. 38 C.F.R. § 4.118, Diagnostic Code 7805 (1994). A 10 percent evaluation is warranted for superficial, poorly nourished scars with repeated ulceration. 38 C.F.R. § 4.118, Diagnostic Code 7803 (1994). A 10 percent evaluation is warranted for superficial scars that are tender and painful on objective demonstration. 38 C.F.R. § 4.118, Diagnostic Code 7804 (1994). Degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joints involved is noncompensable under the appropriate diagnostic codes, an evaluation of 10 percent is applied for each major joint or group of minor joints affected by limitation of motion. These 10 percent evaluations are combined, not added, under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups warrants a 10 percent evaluation. A 20 percent evaluation requires x-ray evidence of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. (The 10 percent and 20 percent evaluations based on x-ray findings, above, will not be combined with ratings based on limitation of motion and will not be utilized in rating disorders listed under Diagnostic Code 5013 to 5024, inclusive.). 38 C.F.R. § 4.71a, Diagnostic Code 5003 (1994). At an October 1991 VA medical examination, physical examination of the appellant's right hand digits disclosed essentially normal range of motion, with some decreased sensory ability. A May 1992 radiology report of the appellant's right hand disclosed some mild degenerative changes in the interphalangeal joints, with normal carpal bones and normal metacarpal joints. A June 1992 VA medical examination of the appellant's right hand revealed that the appellant had sustained lacerations to the tips of the index, ring, and middle fingers of the right hand, in service, and that the lacerations were evaluated and repaired without complication. Physical examination showed scarring over the distal tips of the index, middle, and ring fingers, involving the nails. We observe that the scars were not listed as tender or painful. At a September 1992 VA medical examination, it was noted that the appellant had virtually full range of motion in his upper extremities. Accordingly, a noncompensable evaluation is warranted for the appellant's scars of the right index, ring, and middle fingers, status post traumatic injury, with no evidence of limitation of function, tenderness, or painfulness. Inasmuch as the x-ray evidence shows only arthritic involvement of a single minor joint group, we find that a noncompensable evaluation is also warranted for right hand arthritis. Review of the appellant's service medical records reveals that in January 1968 the appellant underwent removal of a fibrolipoma in the epigastrium. A June 1972 VA medical examination showed that the appellant had very slight scars of the left chest, left anterior thigh region, and right posterior aspect of the right thigh. At the October 1991 VA medical examination, a well healed surgical scar in the epigastric region was noted. The appellant's skin was considered normal at the September 1992 VA medical examination, with no complaint, symptomatology, or finding referable to the aforementioned scars. Accordingly, noncompensable disability evaluations are warranted for the appellant's mid epigastric scar, status post subdural lipoma removal, slight scar of the left chest area, left anterior thigh scar, and right posterior thigh scar, under Diagnostic Code 7805. Slight limitation of motion of the lumbar segment of the spine warrants a 10 percent evaluation. A 20 percent evaluation requires moderate limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5292 (1994). A March 1992 VA medical examination of the appellant's spine showed lumbar range of motion as follows: forward flexion, approximately 100 degrees; backward extension, 20 degrees; lateral flexion, 20 degrees; and rotation, 35 degrees. The musculature of the back was reported normal, with no postural abnormality, no fixed deformity, and no evidence of neurologic involvement. A radiology report showed that the appellant had degenerative disc changes at L5-S1, with narrowing of the disc interspace. At a September 1992 VA medical examination, lumbar range of notion was noted as follows: forward flexion, approximately 90 degrees; backward extension, approximately 30 degrees; lateral flexion, 40 degrees; and rotation, normal. A physician reported no postural abnormality, no fixed deformity, and normal musculature of the back. The physician stated that there was no objective evidence of pain on motion and that there was no evidence of any neurological involvement. A radiology report of the appellant's lumbar spine was normal, with no remarkable degenerative or inflammatory changes noted. The Board notes that the medical evidence pertaining to the appellant's lumbar spine disclosed some slight limitation of motion, while the radiology reports contradicted each other as to the presence of degenerative disc changes. When there is an approximate balance of the positive and negative evidence regarding the merits of an issue material to the determination of the matter, including degree of disability, the benefit of the doubt in resolving each such issue shall be given to the appellant. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. § 3.102 (1994). Accordingly, a 10 percent disability evaluation is warranted under Diagnostic Code 5292 for degenerative disc disease. A slight impairment of either knee, including recurrent subluxation or lateral instability, warrants a 10 percent evaluation. A 20 percent evaluation requires moderate impairment. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (1994). Review of the appellant's claims file reveals an August 1985 private medical record, from J. K. Styner, M.D., which showed that the appellant underwent a left knee arthroscopy, with debridement of chondromalacia patella and abrasion chondroplasty of the medial condyle. Diagnoses listed were Grade IV chondromalacia involving the medial femoral condyle and Grade III chondromalacia patella, medial, and lateral facets. Physical examination of the appellant's left knee, performed at an August 1989 VA medical examination, demonstrated full range of motion, with chondromalacia patella present. At a March 1992 VA medical examination, the appellant reported that he had undergone another left knee arthroscopy because of problems with pain and his left knee collapsing. A physician noted that the appellant ambulated with a slight limp affecting his left knee. Physical examination of the appellant's knees disclosed no swelling or deformity. Range of motion in the left lower extremity was recorded, as follows: extension, full; flexion, 110 degrees; plantar flexion, normal; dorsiflexion, normal. Range of motion in the right lower extremity was recorded, as follows: extension, full; flexion, 120 degrees; plantar flexion, normal; dorsiflexion, normal. A radiology report of the appellant's knees disclosed minimal degenerative changes in the right knee and moderate degenerative changes in the left knee. The physician stated that the appellant's left knee symptoms had improved minimally with arthroscopic surgery. The appellant's medical complaints, noted at a September 1992 VA medical examination, included bilateral knee and ankle pain. A physician observed that the appellant ambulated with somewhat of a pronounced gait, favoring the left side, but that examination of the knees did not appear to reveal lateral instability, nonunion, or malunion. It was also reported that the appellant had normal movement in the left knee upon ambulation. Range of motion in the right knee was considered normal, with extension to 0 degrees and flexion to 140 degrees. Range of motion in the left knee showed extension limited to approximately 40 degrees and flexion limited to somewhat less than 120 degrees. Bilateral range of motion in the ankles was reported normal. A radiology report of the appellant's ankles divulged a normal impression, with no bony abnormality, and a radiology report of the knees showed possible early degenerative changes in the left knee, with a normal right knee. Although the clinical evidence did not demonstrate recurrent subluxation or lateral instability, we note that the appellant has exhibited limitation of motion in both knees, on occasion, and that there is radiographic evidence showing degenerative changes bilaterally, in the appellant's knees. Accordingly, we find that the appellant's bilateral knee disability is most appropriately rated under Diagnostic Codes 5003 and 5257 and that a separate 10 percent disability evaluation is warranted for the appellant's chondromalacia patella, left knee, as well as degenerative joint disease, right knee. We also note that a bilateral factor of 1.9 percent is appropriate for the appellant's bilateral knee disability. 38 C.F.R. § 4.26 (1994). Moderate limitation of motion of either ankle warrants a 10 percent evaluation. A 20 percent evaluation requires marked limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5271 (1994). Inasmuch as the clinical evidence discussed above showed that the appellant demonstrated no loss of motion in his right ankle and radiographic evidence disclosed no abnormality or defect, we find that a noncompensable evaluation is warranted for degenerative joint disease, right ankle, under Diagnostic Code 5271. A 10 percent evaluation is warranted for hypertensive vascular disease (essential hypertension) where the diastolic pressure is predominately 100 or more. A minimum 10 percent evaluation is also assigned when continuous medication is shown necessary for the control of hypertension, with a history of diastolic blood pressure predominately 100 or more. A 20 percent evaluation requires diastolic pressure of predominately 110 or more with definite symptoms. 38 C.F.R. § 4.104, Diagnostic Code 7101 (1994). At a September 1992 VA medical examination, the appellant's height and weight were 67 inches and 252 lbs., respectively, and blood pressure readings were 158/92, sitting, 142/86, recumbent, and 142/90, standing. A physician stated that the appellant was not taking medication for hypertension. A chest x-ray showed a normal heart size, and the physician observed that the apex beat did not appear to be significantly deviated laterally. Final diagnosis was "[b]orderline hypertension, questionably secondary to exogenous obesity." Accordingly, a noncompensable evaluation is warranted for hypertension under Diagnostic Code 7101. The ratings in effect for each of the appellant's disabilities combine to a 60 percent disability evaluation in accordance with the provisions of 38 C.F.R. §§ 4.25, 4.26 (1994). The 60 percent rating represents the average wage- earning impairment caused by all of the appellant's disabilities. As noted above, entitlement to pension benefits may be objectively determined if the appellant is unemployable as a result of a permanent disability or experiences a disability that would preclude an average person from following a substantially gainful occupation, if it is reasonably certain that such disability is permanent. 38 U.S.C.A. § 1502(a) (West 1991); 38 C.F.R. § 4.15 (1994). The Board notes that none of the appellant's disabilities that cause him impairment is considered to be a permanent total disability under 38 C.F.R. § 4.15 (1994). We also note that a total disability rating for the appellant's disorders is not warranted under applicable schedular criteria contained in the Rating Schedule. As noted above, the combined effect of the appellant's disabilities is appropriately designated a 60 percent rating. The ratings assigned the appellant's disabilities are clearly not within the aforementioned schedular ratings of 38 C.F.R. § 4.16 (1994) required for a total schedular evaluation. Although the appellant's principal disabilities may be considered to be of a permanent nature, the disorders are clearly not representative of total disability in accordance with applicable schedular criteria or applicable regulations. 38 C.F.R. Part 4, including §§ 4.16 and 4.17 (1994). Upon a review of the clinical findings of record referable to the appellant's principal disabilities and in consideration of the Rating Schedule with regard to such disabilities, the Board concludes that the appellant's disabilities would not preclude an average person from securing and following substantially gainful employment. We emphasize that the appellant's combined rating represents average wage-earning impairment. None of the appellant's disabilities, either in combination or alone, is so severely disabling as to render him permanently unemployable. As outlined above, the Rating Schedule supports the assignment of ratings which reflect minimal to moderate impairment, if any, for the appellant's various disabilities. As such, the evidence of record does not support a conclusion that the appellant experiences disability which, although permanent, would render the average person unable to follow a substantially gainful occupation. 38 U.S.C.A. § 1502(a) (West 1991); 38 C.F.R. § 4.15 (1994). Accordingly, a permanent and total disability evaluation based upon the objective "average person" standard of review is not warranted. As the appellant's disabilities do not meet the percentage requirements of 38 C.F.R. § 4.17 (1994), applied to pension cases through 38 C.F.R. § 4.16 (1994), the Board must determine whether the appellant would be eligible for pension benefits based upon subjective criteria, including consideration of the veteran's age, education and occupational history, and unusual physical or mental effects. 38 C.F.R. §§ 3.321, 4.15 (1994). In this regard, we note that in the appellant's case, the record reflects that he was born in November 1946 and that he did not obtain a general equivalency high school diploma until November 1986, while in prison. On a July 1989 VA Form 21-527, income-net worth and employment statement, the appellant indicated that he had last worked, in October 1989, at the Salvation Army, in Kearney, Nebraska, with annual earnings reported at $6,750.00. Education and training for "Auto Mach School" was also listed. We note that the January 1993 VA medical examination disclosed that the appellant had last worked as a janitor, in 1991; however, the appellant claimed that he was unemployable as a result of a left knee injury and psychiatric problems. A December 1977 classification study, from the Nebraska Penal & Correctional Complex, indicated that the appellant's previous record included convictions for grand larceny, in March 1973, strong arm robbery, in November 1976, second degree, sexual assault, in May 1977, and receiving stolen property, in October 1977. It was reported that the appellant's employment history was unstable. He had worked mostly as a department store mechanic at a K-Mart, until his arrest for receiving stolen property. Other employments included plumber's helper, electrician's helper, and elevator maintenance man. It was the conclusion of the evaluation team that the appellant's antisocial behavior did not stem from either a dyssocial or antisocial orientation, but rather from a manifestation of some unresolved and severe psychiatric problem. A September 1987 record, from V. Schaepler, M.S., Vocational Rehabilitation Counselor, Nebraska Department of Education, disclosed that the appellant had sought vocational rehabilitation service until January 1985, when his case had been closed due to incarceration. It was reported that the appellant had "essentially not been employed since 1977, due to a combination of problems." V. Schaepler expressed her opinion, as follows: [The appellant] is not capable of competitive level employment, due to the number of emotional problems which he has experienced on a long-term basis. He has poor decision making skills and also states difficulties in regards to chest pains, diet controlled, diabetes, low back pain and problems with his knees. His primary barrier to employment is emotional and given his previous diagnosis of chronic undifferentiated schizophrenia, he would be a poor candidate for employment. Review of the appellant's claims file also reveals an October 1988 decision of the SSA which determined that the appellant was disabled as of June 1987, due to residuals of a left knee injury, a back injury, and an emotional component. "Th[e] Court has held that although the [SSA's] decisions with regard to unemployability are not controlling for purposes of VA adjudications, the SSA's decision is "pertinent" to a determination of appellant's ability to engage in substantially gainful employment." Martin v. Brown, 4 Vet.App. 136, 140 (1993). Therefore, further review of the October 1988 SSA decision is warranted. The Administrative Law Judge (ALJ), in the October 1988 SSA decision, also determined that the appellant could not return to work that he had performed in the past or to any other types of work of lesser exertion which exist within the national economy. The ALJ stated that the appellant was limited to sedentary exertion, due to a history of back injury and a left knee disorder, with chondromalacia and degenerative arthritis, and the ALJ opined that the appellant's primary impairment was a personality disorder, with numerous suicidal attempts in the past. Furthermore, the ALJ declared that the appellant would likely decompensate under the stress of either production or people oriented jobs. Thus, it was concluded that "no sedentary jobs exist which the [appellant] could perform." As was previously discussed, a January 1993 VA medical examination noted that the appellant stated that he had attempted suicide on approximately ten occasions, the most recent in 1985, and that he had had many, many jobs, in the vicinity of 200, in the past. The VA physician declared that the appellant had "a lifelong history of poor functioning and adaptation," and it was opined that the appellant was "totally disabled . . . [with] his current and recent adjustment [] far less effective than it was at the time prior to his entry into [service]." The Board notes that the appellant is almost 49 years old, with a high school equivalency diploma, a history of incarceration that has probably affected his ability to find employment, and apparently has not worked since 1991. Furthermore, the appellant has a poor employment history, as evidenced by his statements indicating that he had had many, many jobs, in the vicinity of 200, in the past. An October 1988 SSA decision determined that the appellant was disabled and unable to perform either sedentary employment, due to an emotional disorder, or non sedentary employment, due to residuals of a back injury and a left knee injury. A November 1994 rating decision concluded that the appellant's disabilities, as previously discussed, warranted a 60 percent disability evaluation. The Board has deemed that evaluation to be appropriate. After careful and longitudinal review of the evidence of record, we are of the opinion that the appellant has "a lifelong history of poor functioning and adaptation," and upon consideration of the combined effect of the appellant's disabilities, in addition to his age, education and occupational history, and unusual mental effects, the Board is persuaded that the appellant is permanently and totally disabled. An allowance of pension benefits, therefore, is warranted based on an extra-schedular basis. 38 C.F.R. §§ 3.321, 4.15 (1994). ORDER A well-grounded claim for entitlement to service connection for hypertension, on a direct basis and as secondary to Agent Orange exposure, not having been submitted, the claim is dismissed, and the rating actions in January 1992 and November 1994 are vacated insofar as they pertain to that issue. A permanent and total disability rating for pension purposes is granted, subject to the law and regulations governing the award of monetary benefits. REMAND The appellant alleges that he was a guard at a prisoner of war (POW) camp, south of Saigon, when the Vietcong overran the perimeter. He also claimed that he spent seven days in a bunker with a dead soldier, and he asserts that he was with a friend, [redacted], when the friend's legs were shot off. Additionally, in January 1993, a VA physician listed a diagnosis of possible adjunctive PTSD. A well-grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). Where the issue is factual in nature, e.g., whether an incident or injury occurred in service, competent lay testimony, including a veteran's solitary testimony, may constitute sufficient evidence to establish a well-grounded claim under [38 U.S.C.A. §] 5107(a). See Cartright v. Derwinski, 2 Vet.App. 24 (1991). In accordance with 38 U.S.C.A. § 5107 (West 1991), and Murphy v. Derwinski, 1 Vet.App. 78 (1990), the appellant has presented a well-grounded claim for entitlement to service connection for PTSD. Review of the appellant's service personnel records reveals that he served in Vietnam from July 29, 1966, to July 20, 1967, as a duty soldier, with Headquarters and Band Support Command, 1st Infantry Division, USARPAC, and from March 24, 1968, to April 5, 1968, as an ammunition receiving clerk, with the 148th Ordinance Company and 574th Shipping and Supply Company, USARPAC. Furthermore, service personnel records disclose that the appellant received the Vietnam Service Medal, Republic of Vietnam Campaign Medal, and the National Defense Service Medal. The Board notes that the appellant's August 1966 service enlistment report of medical examination and July 1968 service separation report of medical examination demonstrated normal psychiatric clinical evaluations. Moreover, review of the appellant's service medical records reveals no complaint, symptomatology, or finding of PTSD. At a May 1981 VA psychological evaluation, it was reported that the appellant was having occasional bad dreams, particularly about Vietnam. The appellant stated that he had thought about the way POW's (presumably Vietnamese POW's) had been treated. He declared that he had observed incidents in which people had been stabbed with bayonets in order to coerce others into providing information, and he also recalled that there were a lot of "dead bodies laying around." A diagnosis of personality disorder, inadequate personality, was noted. A physician stated that he specifically considered the possibility of PTSD; however, he was not impressed with the evidence available. The physician declared that the appellant had described a lifelong process of social, educational, and occupational impaired adaptability that had persisted. Although it was reported that the appellant had complained of a number of things that could be related to PTSD, particularly bad dreams and recurring thoughts of Vietnam experiences, the physician noted that he found "nothing to establish the idea that these are so pervasive or disruptive as to represent any significant hindrance to [the appellant's] social and occupational adjustment." A June 1982 record of hearing transcript showed that the appellant testified that he had shot and killed a Vietnamese girl, along with a baby on her back, because the girl had been shooting at him with a submachine gun. He stated that this event had occurred while he had been out on patrol, in or around April 1967. A mental status examination, performed at an April 1983 VA medical examination, disclosed that the appellant's affect and mood were appropriate and that his memory and judgment were unimpaired. The appellant denied suicidal ideation, hallucination, and delusional ideation. A physician stated that the appellant appeared to have below average intelligence, and a diagnosis of inadequate personality disorder, with borderline mental retardation, was given. At an August 1989 VA psychological evaluation, a physician noted that he was unable to get any useful details concerning the appellant's Vietnam service to support a diagnosis of PTSD. The physician believed that the appellant had a sociopathic personality disorder and "not a mental illness." It was reported, at a November 1991 VA psychological evaluation, that the appellant was emphasizing Vietnam related issues. The appellant stated that the sound of a "chopper" had caused him to run and hide and that he could not tolerate firecrackers and other loud noises. The appellant noted that ever since Vietnam he had had trouble sleeping. Additionally, he described an incident, while on perimeter patrol, where he had shot and killed a Vietnamese girl, along with her baby. He claimed that the Vietnamese girl was his girlfriend and that the baby was his daughter. The appellant also stated that a friend of his had had his legs blown off and that he had seen an enemy barber cut the throat of an American officer. Although the appellant described dreams of painful situations in Vietnam, a VA physician stated that it was not possible to verify those situations. Furthermore, the physician observed that the appellant did not describe a "life course marked by recurring [PTSD] type problems which have interfered with his functioning." Rather, the appellant's impaired functioning appeared to be related to his pattern of response to pressures, criticisms, and demands. The physician also stated that he did not give the appellant's account concerning the killing of his girlfriend and baby much credence. It was reported that the appellant did not describe outbursts of anger or hyper-vigilance. A final diagnosis of personality disorder, not otherwise specified, with features of inadequate, probable anti- social, dependent noted, was listed, and the physician concluded with the following statement. Clearly, there is a judgement call here. My over-all impression is that his account is inconsistent, that I am not finding adequate basis for believing he is suffering from [PTSD]. Also, evidence appears overwhelming that his predominant difficulty over the years, since childhood, has related more to personality problems. He has highly maladaptive responses to demands, stresses, criticism. At a January 1993 VA psychological evaluation, a physician stated that the appellant had endured "a number of experiences with direct warfare as [an] infantryman on patrol, and suffered a number of traumatic incidences." It was reported, by history, that a Vietcong woman had pushed the appellant's fingers into an ice cream machine, severing his fingertips which were later reattached, and, while on a patrol in 1966, the appellant had accidentally killed his Vietnamese girlfriend and daughter because they had been part of a Vietcong patrol that had fired upon the appellant. The appellant commented that he had had recurrent dreams of war experiences. The physician observed that the appellant was hypervigilant and had a great deal of difficulty paying attention, along with a restricted affective range. It was reported that the appellant did not exhibit flight of ideas or suicidal ideation. Diagnoses listed included severe borderline personality organization, with prominent schizoid and affective trims, mild mental retardation, and "[p]ossible adjunctive" PTSD. The physician stated that some of the characteristics that the appellant exhibited that were related to PTSD were also characteristics of a borderline personality organization embedded in a borderline mental retardation matrix. Finally, the physician expressed his opinion, as follows. I would be inclined to see this patient as having some aspects of a [PTSD] and that even if the [PTSD] was preexisting with respect to military service, it would be my speculation that it was most probably aggravated by these experiences . . . . The Board notes that the Court has held in West v. Brown, 7 Vet.App. 70, 78 (1994), in effect, that a psychiatric evaluation based upon an incomplete or questionable history is inadequate for rating purposes and frustrates an effective judicial review. While the appellant's claims file contains his personnel service records, we observe that the RO has made no attempt to verify his alleged stressors relating to his PTSD claim. Although the appellant's first diagnosis of "[p]ossible adjunctive" PTSD does not appear until January 1993, we note that all of the appellant's psychiatric evaluations have been based upon an incomplete or questionable history and are, as a matter of fact, inadequate for rating purposes. In the case of Zarycki v. Brown, 6 Vet.App. 91, 97 (1993), the Court set forth the framework for establishing the presence of a recognizable stressor, which is an essential prerequisite to support the diagnosis of PTSD. The Court analysis consists of two major components, as follows: The first component involves the evidence required to demonstrate the existence of an alleged stressful event; and The second component involves a determination as to whether the stressful event is of the quality required to support the diagnosis of PTSD. With regard to the first component, under 38 U.S.C.A. § 1154(b) (West 1991), 38 C.F.R. § 3.304 (1994), and VA Manual M21-1, Part VI, para. 7.46(e), (f) (Dec. 21, 1992), the evidence necessary to establish the occurrence of the recognizable stressor during service to support a claim of entitlement to service connection for PTSD will vary depending on whether or not the veteran was "engaged in combat with the enemy." Hayes v. Brown, 5 Vet.App. 60, 66 (1993). In Zarycki v. Brown, the Court observed that where it is determined, through recognized military citations or other supportive evidence, that the veteran was engaged in combat with the enemy and the claimed stressors are related to such combat, the veteran's lay testimony regarding claimed stressors must be accepted as conclusive as to their actual occurrence and no further development for corroborative evidence will be required, provided that the veteran's testimony is found to be "satisfactory," e.g., credible, and "consistent with the circumstances, conditions, or hardships of such service." 6 Vet.App. at 98. Where, however, the VA determines that the veteran did not engage in combat with the enemy, or that the veteran did engage in combat with the enemy but the claimed stressor is not related to such combat, the veteran's lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor. Id. Instead, the record must contain service records which corroborate the veteran's testimony as to the occurrence of the claimed stressor. Id. Once the occurrence of a stressful event is established, it then must be determined whether the claimed stressful event was of sufficient gravity to support a diagnosis of PTSD. Id. The Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III), American Psychiatric Association, has been adopted by the VA for rating psychiatric disorders such as PTSD. 38 C.F.R. § 4.125 (1994). The Zarycki Court did not address whether the Board may or may not, in all instances, render a determination regarding the sufficiency of a stressor absent independent medical evidence; nevertheless, a significant diagnostic feature of PTSD requires that the sufficiency of the stressor be clinically established. West v. Brown, 7 Vet.App. at 79. The Court also held that a psychiatric examination for PTSD that relied on a questionable history of events was inadequate for rating purposes and that the psychiatric examination should be "based on a complete and accurate description of events during the appellant's service." Id. at 78. Upon reviewing Zarycki, West, and VA Manual M21-1, Part VI, para. 7.46, it appears that in approaching a claim for service connection for PTSD, the question of the existence of an event claimed as a recognizable stressor must be resolved by adjudicatory personnel. If the adjudicators conclude that the record establishes the existence of such a stressor or stressors, then and only then, the case should be referred for a medical examination to determine the following: The sufficiency of the stressor; Whether the remaining elements required to support the diagnosis of PTSD have been met; and Whether there is a link between a currently diagnosed PTSD and a recognized stressor or stressors in service. 38 C.F.R. § 3.304(f) (1994). In such a referral, the adjudicators should specify to the examiner(s) precisely what stressor or stressors have been accepted as established by the record, and the medical examiner(s) must be instructed that only those events may be considered in determining whether the appellant was exposed to a stressor and what the nature of the stressor or stressors was to which the appellant was exposed. In other words, if the adjudicators determine that the existence of an alleged stressor or stressors in service is not established by the record, a medical examination to determine whether PTSD due to service is present would be pointless. Likewise, if the examiner(s) render(s) a diagnosis of PTSD that is not clearly based upon stressors in service whose existence the adjudicators have accepted, the examination would be inadequate for rating purposes. VA has a duty to assist the appellant in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1994). The Court has held that the VA's duty to assist the appellant in obtaining and developing available facts and evidence to support his claim includes obtaining adequate VA medical examinations if existing medical information is insufficient for evaluation purposes. Littke v. Derwinski, 1 Vet.App. 90 (1990). Because our review of the claims file indicates that the additional development described above is required before an appellate decision can be rendered, this case is REMANDED to the RO for the following actions, which should be performed in the most efficacious manner that is deemed feasible: 1. The RO should contact the appellant and request that he provide the names and addresses of any health care providers who have treated him for PTSD in the years following service, and, if possible, specify the appropriate dates of treatment. Then, after any necessary authorization is obtained from the veteran, the RO should obtain copies of all treatment records for the appellant from the health care providers identified and associate them with the claims file. In any event, copies of any VA outpatient treatment records pertaining to treatment for PTSD should be obtained and associated with the claims file. 2. The RO should request that the appellant provide another comprehensive statement containing as much detail as possible regarding the stressor(s) to which he alleges he was exposed to while in service. The appellant should be asked to provide specific details of the claimed stressful elements during service, such as unit, company, platoon, dates, places, detailed descriptions of events, and any other identifying information concerning any other individuals (in particular, [redacted], a friend who allegedly had his legs shot off in the presence of the appellant) involved in the events, including their names, ranks, units of assignment, or any other identifying detail. The appellant is advised that this information is vitally necessary to obtain supportive evidence on the stressful events and that he must be asked to be as specific as possible. He should be informed that, without such details, an adequate search for verifying information cannot be conducted. He should be further advised that a failure to respond may result in an adverse action against his claim. 3. Thereafter, the RO should contact the appellant's service department, the U.S. Army, and request copies of the historical records for Headquarters and Band Support Command, 1st Infantry Division, USARPAC, from July 29, 1966, to July 20, 1967, and the 148th Ordinance Company and 574th Shipping and Supply Company, USARPAC, from March 24, 1968, to April 5, 1968, pertinent to the events identified in the statement of the appellant. The RO should also attempt to obtain any other information regarding activities of the aforementioned units during the time frame cited that would shed light on the events related by the appellant. When this information has been obtained, it, together with the stressor information that has been provided/obtained from the appellant, should be forwarded to the United States Army and Joint Services Environmental Support Group (ESG), 7798 Cissna Road, Springfield, Virginia 22160, for verification of the incident or incidents which the appellant reports that he re-experiences. Any information obtained is to be associated with the claims folder. 4. Following the above, the RO must make a specific determination, based upon the complete record, with respect to whether the appellant was exposed to a stressor or stressors in service, and, if so, what was the nature of the specific stressor or stressors. In rendering this determination, the attention of the RO is directed to the cases of Zarycki and West, and the discussion above. In any event, the RO must specifically render a finding as to whether the appellant "engaged in combat with the enemy." If the RO determines that the record establishes the existence of a stressor or stressors, the RO must specify what stressor or stressors in service it has determined are established by the record. In reaching this determination, the RO should address any credibility questions raised by the record. 5. If, and only if, the RO determines that the record establishes the existence of a stressor or stressors, then the RO should arrange for the appellant to be examined, if possible, by a Board of two psychiatrists who have not previously examined him to determine the nature and severity of his psychiatric disorder. The RO must specify, for the examiners, the stressor or stressors that the RO has determined are established by the record. The examiners must be instructed that only those events may be considered for the purpose of determining whether the appellant was exposed to a stressor in service. Each psychiatrist should conduct a separate examination with consideration of the criteria for PTSD. The examination should be conducted in accordance with the VA's Physician's Guide for Disability Evaluation Examination. If the examiners determine that the appellant has a psychiatric disorder, in addition to PTSD, the examiners should determine the relationship of any such disorders among themselves (including etiological origin and secondary causation) and specify which symptoms are associated with each disorder. If certain symptomatology cannot be disassociated from one disorder or the other, it should be so specified. If a diagnosis of PTSD is appropriate, the examiners should specify the credible "stressors" that caused the disorder and the evidence upon which they relied to establish the existence of the stressors. The examiners should also describe which stressors the appellant re-experiences and how he re-experiences them. If there are different psychiatric disorder(s) present, other than PTSD, the examiners should reconcile the diagnoses and should specify which symptoms are associated with each of the disorder(s). If certain symptomatology cannot be disassociated from one disorder or another, it should so be specified. If the examiners conducting the examination determine that a diagnosis of PTSD is appropriate, then they should describe the relationship between PTSD and any substance abuse and any personality disorder that the appellant may have. The examiners must specifically express an opinion as to whether the appellant's PTSD caused substance abuse. The report of the examination should also include a complete rationale for all opinions expressed. All necessary studies or tests, including psychological testing and evaluation such as the Minnesota Multiphasic Personality Inventory, the PTSD Rating Scale, and the Mississippi Scale for Combat- Related PTSD, are to be accomplished. The diagnosis should be in accordance with DSM-III. The entire claims folder and a copy of this Remand must be made available to and reviewed by the examiners prior to the examination. 6. The RO should review the examination reports to determine if they are adequate for rating purposes and in compliance with this remand. Any examination report that is deemed inadequate for rating purposes and not in compliance with this remand should be returned to the examiner for supplemental action. After the above requested actions have been completed, the RO should review the appellant's claim with regard to the additional evidence obtained. The RO should then adjudicate whether the evidence received since the Board's decision in March 1983, including the evidence of record as a result of this Remand, is both new and material to reopen the appellant's claim. If the claim is not reopened, the RO should provide the appellant and his representative with a statement of the case with the law and regulations applicable to reopening a claim after a final denial, and give them an opportunity to respond. If both new and material evidence is found, the RO should then proceed to adjudicate the claim on the merits. If the benefit sought on appeal remains denied, a supplemental statement of the case should be furnished to the appellant and his representative. They should be afforded a reasonable period of time to respond. Thereafter, the case should be returned to the Board for further appellate consideration. The purpose of this REMAND is to obtain additional evidence and to ensure that the appellant receives his procedural due process rights. No opinion, either legal or factual, is intimated as to the merits of the appellant's claim by this REMAND. He is not required to undertake any additional action until he receives further notification from the VA. BETTINA S. CALLAWAY Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been so assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue that was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. Appellate rights do not attach to those issues addressed in the remand portion of the Board's decision, because a remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1994). - 2 -