Citation NR: 9600467 Decision Date: 01/18/96 Archive Date: 02/06/96 DOCKET NO. 93-22 764 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES Whether new and material evidence has been presented to reopen a claim of entitlement to service connection for hypertension. Entitlement to service connection for residuals of an ear infection. Entitlement to service connection for a disability manifested by black rings around the eyes. Entitlement to service connection for a disability manifested by blurred vision. Entitlement to service connection for a heart disorder manifested by cardiac enlargement and rapid heartbeat. Entitlement to service connection for a disability manifested by dizzy spells. Entitlement to service connection for warts in the groin area. Entitlement to service connection for a stomach disorder manifested by nausea. Entitlement to service connection for a hole in the nose with sores. Entitlement to service connection for a disability manifested by loss of libido. Entitlement to service connection for ringing in the ears. Entitlement to service connection for hearing loss. Entitlement to service connection for a disability manifested by a sensation of the hands and feet falling asleep. Entitlement to service connection for a disability manifested by sweating. Entitlement to service connection for a skin disorder. Entitlement to service connection for residuals of shell fragment wounds to the right leg, right upper arm and chest. Entitlement to service connection for post-traumatic stress disorder (PTSD). Entitlement to an increased (compensable) rating for residuals of malaria. Entitlement to a permanent and total disability rating for pension purposes. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARINGS ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD Robert A. Leaf, Counsel INTRODUCTION The veteran served on active duty from May 1968 to February 1970. This appeal to the Board of Veterans' Appeals (Board) arises from a September 1991 rating decision of the Houston, Texas, Regional Office (RO) of the Department of Veterans Affairs (VA) which determined that new and material evidence had not been presented to reopen a previously denied claim of entitlement to service connection for hypertension. That rating decision also denied service connection for residuals of an ear infection, a disability manifested by black rings around the eyes, a disability manifested by blurred vision, a heart disorder manifested by cardiac enlargement and rapid heartbeat, a disability manifested by dizzy spells, warts in the groin area, a stomach disorder manifested by nausea, a hole in the nose with sores, a disability manifested by loss of libido, ringing in the ears, hearing loss, post-traumatic stress disorder (PTSD), a disability manifested by a sensation of the hands and feet falling asleep, a disability manifested by sweating, a skin disorder, and residuals of shell fragment wounds to the right leg, right upper arm and chest. In addition, a noncompensable rating for residuals of malaria was confirmed and continued, and a permanent and total disability rating for pension purposes was denied. CONTENTIONS OF APPELLANT ON APPEAL The veteran and his representative contend, in essence, that the disabilities for which service connection is sought had their onset in service or are attributable to service. They further contend that a higher rating should be assigned for residuals of malaria, and that non-service-connected pension benefits should be granted. 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 veteran'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 new and material evidence has not been presented to reopen a claim of service connection for hypertension. Further, it is the decision of the Board that the veteran has not submitted well-grounded claims for service connection for residuals of an ear infection, a disability manifested by black rings around the eyes, a disability manifested by blurred vision, a heart disorder manifested by cardiac enlargement and rapid heartbeat, a disability manifested by dizzy spells, warts in the groin area, a stomach disorder manifested by nausea, a hole in the nose with sores, a disability manifested by loss of libido, ringing in the ears, hearing loss, a disability manifested by a sensation of the hands and feet falling asleep, a disability manifested by sweating, a skin disorder, and residuals of shell fragment wounds to the right leg, right upper arm and chest. Additionally, the Board finds that the preponderance of the evidence is against claims for service connection for post-traumatic stress disorder, an increased rating for residuals of malaria, and a permanent and total disability rating for pension purposes. FINDINGS OF FACT 1. An October 1973 rating decision denied service connection for hypertension, and the veteran did not appeal the determination. The evidence received since the October 1973 rating decision is either cumulative or redundant, or when viewed in the context of all the evidence, both new and old, does not raise a reasonable possibility of a change in that adverse decision. 2. A claim for service connection for residuals of an ear infection is not plausible. 3. A claim for service connection for a disability manifested by black rings around the eyes is not plausible. 4. A claim for service connection for a disability manifested by blurred vision is not plausible. 5. A claim for service connection for a heart disorder manifested by cardiac enlargement and rapid heartbeat is not plausible. 6. A claim for service connection for a disability manifested by dizzy spells is not plausible. 7. A claim for service connection for warts in the groin area is not plausible. 8. A claim for service connection for stomach disorder manifested by nausea is not plausible. 9. A claim for service connection for a hole in the nose with sores is not plausible. 10. A claim for service connection for a disability manifested by loss of libido is not plausible. 11. A claim for service connection for a disability manifested by ringing in the ears is not plausible. 12. A claim for service connection for hearing loss is not plausible. 13. A claim for service connection for a disability manifested by a sensation of the hands and feet falling asleep is not plausible. 14. A claim for service connection for a disability manifested by sweating is not plausible. 15. A claim for service connection for a skin disorder is not plausible. 16. A claim for service connection for residuals of shell fragment wounds of the right leg, right upper arm and chest is not plausible. 17. The veteran does not have PTSD attributable to his experiences in service. 18. Residuals of malaria are asymptomatic. 19. The veteran was born in 1950; his education includes the equivalency of high school plus one year of college; his combined rating for non-misconduct disabilities is 40 percent; and he is gainfully employed as a full-time utility operator in a chemical plant. CONCLUSIONS OF LAW 1. Evidence received since the October 1973 rating decision denying service connection for hypertension is not new and material, the claim is not reopened, and the 1973 decision is final. 38 U.S.C.A. §§ 5108, 7105 (West 1991); 38 C.F.R. § 3.156 (1994). 2. Evidence of a well-grounded claim for service connection for residuals of an ear infection has not been submitted. 38 U.S.C.A. § 5107(a) . 3. Evidence of a well-grounded claim for a disability manifested by black rings around the eyes has not been submitted. 38 U.S.C.A. § 5107(a). 4. Evidence of a well-grounded claim for a disability manifested by blurred vision has not been submitted. 38 U.S.C.A. § 5107(a). 5. Evidence of a well-grounded claim for a heart disorder manifested by cardiac enlargement and rapid heartbeat has not been submitted. 38 U.S.C.A. § 5107(a). 6. Evidence of a well-grounded claim for service connection for a disability manifested by dizzy spells has not been submitted. 38 U.S.C.A. § 5107(a). 7. Evidence of a well-grounded claim for service connection for warts in the groin area has not been submitted. 38 U.S.C.A. § 5107(a). 8. Evidence of a well-grounded claim for service connection for stomach disorder manifested by nausea has not been submitted. 38 U.S.C.A. § 5107(a). 9. Evidence of a well-grounded claim for service connection for a hole in the nose with sores has not been submitted. 38 U.S.C.A. § 5107(a). 10. Evidence of a well-grounded claim for service connection for a disability manifested by loss of libido has not been submitted. 38 U.S.C.A. § 5107(a). 11. Evidence of a well-grounded claim for service connection for ringing in the ears has not been submitted. 38 U.S.C.A. § 5107(a). 12. Evidence of a well-grounded claim for service connection for hearing loss has not been submitted. 38 U.S.C.A. § 5107(a). 13. Evidence of a well-grounded claim for service connection for a disability manifested by a sensation of the hands and feet falling asleep has not been submitted. 38 U.S.C.A. § 5107(a). 14. Evidence of a well-grounded claim for service connection for a disability manifested by sweating has not been submitted. 38 U.S.C.A. § 5107(a). 15. Evidence of a well-grounded claim for service connection for skin disorder has not been submitted. 38 U.S.C.A. § 5107(a). 16. Evidence of a well-grounded claim for service connection for residuals of shell fragment wounds to the right leg, right upper arm and chest has not been submitted. 38 U.S.C.A. § 5107(a). 17. PTSD was not incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. 18. A compensable rating for residuals of malaria is not warranted. 38 U.S.C.A. §§ 1155; 38 C.F.R. §§ 4.31, 4.88b, Code 6304. 19. The criteria for a permanent and total disability rating for pension purposes have not been met. 38 U.S.C.A. §§ 1502, 1521; 38 C.F.R. §§ 3.321, 3.340, 3.342, 4.15, 4.16, 4.17. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Whether New and Material Evidence Has Been Presented to Reopen a Claim of Entitlement to Service Connection for Hypertension Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. In addition, certain chronic diseases, including hypertension, may be presumed to have been incurred during service if they first became manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The unappealed October 1973 rating decision denying service connection for hypertension is final. 38 U.S.C.A. § 7105. However, a claim may be reopened if new and material evidence is submitted. 38 U.S.C.A. § 5108. When determining whether new and material evidence has been submitted to warrant reopening of the claim, consideration must be given to all of the evidence submitted since the last final denial on the merits, rather than only the evidence submitted since the most recent refusal to reopen the claim for lack of new and material evidence. Glynn v. Brown, 6 Vet.App. 523 (1994). The October 1973 rating decision was the last final denial of the veteran's claim on the merits. New evidence is that which is not cumulative or redundant of previously considered evidence; material evidence is that which is relevant and probative to the issue at hand, and which, when viewed in the context of all the evidence, raises a reasonable possibility of a change in the prior adverse outcome. 38 C.F.R. § 3.156(a); Colvin v. Derwinski, 1 Vet.App. 171 (1991). Evidence which was of record in October 1973 may be briefly summarized. When the veteran was examined in April 1968 for service entrance, blood pressure was 138/74. When he was examined in January 1970 for service separation, blood pressure was 138/78. The veteran was hospitalized at a VA medical facility in July 1973. It was found that blood pressure was 180/100; subsequent blood pressure readings were 160/80 and 150/90. The diagnosis was essential hypertension. Based on the evidence cited above, the RO in October 1973 denied service connection for hypertension. In October 1973, the RO notified the veteran of this action, and he did not appeal. Evidence added to the claims file since October 1973 includes reports of the veteran's evaluation or treatment by the VA or by his private physician. Medical records cover the period from 1958 to 1994, and only show hypertension in 1973 and later. A hearing was held at the RO in April 1992, and before a member of the Board in April 1994. The veteran testified that he had developed hypertension in service and had been on medication for high blood pressure intermittently during the years since service. The additional medical evidence received since the 1973 RO decision is cumulative, not new, evidence, as it only confirms that the vetean has had hypertension since 1973 (well beyond the 1-year period for presuming service incurrence). The additional medical evidence also is not material, since it does not connect the post-service hypertension with service. Cox v. Brown, 5 Vet.App. 95 (1993). The veteran’s additional hearing testimony, that he has had hypertension due to service, is essentially repetitious of his contentions made when his claim was denied in 1973; such is not new evidence. Reid v. Derwinski, 2 Vet.App. 312 (1992). To the extent that the testimony might be considered new, it is not material, since, when viewed in the context of all the evidence (including medical records showing no hypertension during service or for years later) it does not raise a reasonable possibility of a change in the prior adverse outcome. Colvin, supra. The Board finds that new and material evidence has not been submitted. Thus, the claim for service connection for hypertension is not reopened, and the adverse 1973 RO decision remains final. II. Service Connection for Disorders Other Than PTSD The threshold question to be answered in this case is whether the veteran has presented well-grounded claims for the multiple disorders (other than PTSD) for which service connection is sought, i.e., claims which are plausible. If he has not, the claims must fail and there is no further duty to assist in the development of the claims. 38 U.S.C.A. § 5107; Murphy v. Derwinski, 1 Vet.App. 78 (1990). A well- grounded claim requires more than an allegation; the claimant must submit supporting evidence. Furthermore, the evidence must justify a belief by a fair and impartial individual that the claim is plausible. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). As will be explained below, the Board finds that the claims are not well grounded. Service medical records contain no complaints or findings with respect to any of the disorders for which service connection is sought. When the veteran was examined in January 1970 for service separation, all body systems were evaluated as normal. No scars were seen on the veteran’s right leg, right upper arm or chest. There was no medical evidence of shell fragment wounds in service. Uncorrected distant vision was 20/20 bilaterally. Audiologic testing showed that pure tone thresholds, in the frequency range 500 to 6,000 hertz, varied from 0 to 5 decibels in the right ear and from 0 to 10 decibels in the left ear. The veteran was hospitalized at a VA medical facility in July 1973 primarily for treatment of anxiety neurosis and essential hypertension. On physical examination, his pulse was 120 beats per minute. Physical examination was unremarkable except for elevated blood pressure readings. No heart disorder was identified. The veteran was hospitalized at a VA medical facility from June to July 1990. On physical examination, there was a superficial scar and evidence of foreign body in subcutaneous tissue beneath the right nipple. There was evidence of a soft tissue injury over the right deltoid and right triceps, which was well healed. The diagnoses included hypertension. A VA medical examination was conducted in January 1991. The veteran related that he had experienced a chronic tremor for several years. It was found that pulse was 80 beats per minute. The heart had regular rhythm. Heart sounds were normal, without murmur, gallop or ectopy. The eyes, ears and nose were normal, as were the genitalia. There abdomen was soft and benign, without organomegaly or remarkable tendrness. Peripheral pulses were palpable; there was no peripheral edema. Several skin lesions were noted on the arms, as well as onychomycosis on the fingers. A chest X-ray examination was normal. Electrocardiographic testing was normal and showed normal sinus rhythm. The diagnoses included mild tremors; hypertension, poorly controlled; and multiple skin lesions on arms, with onychomycosis of fingernails. On VA dermatologic examination in January 1991, the veteran related that he had experienced lesions of the hands, primarily the palms and arms, since 1975 or 1976. The examiner remarked that a clear diagnosis could not be formulated currently. Differential diagnoses provided were onychomycosis, other tinea infection of the skin, and eczematous reaction, an idiopathic reaction, or some other unknown dermatosis. VA neurological examination in January 1991 showed normal tone, mass and power of all extremities. Stretch tendon reflexes were Grade II/IV at the biceps, triceps, brachioradialis, knee and ankle; reflexes were symmetrical bilaterally. Testing showed normal gait and coordination. Sensory status was intact to light touch, pinprick and temperature sensation. It was noted that the examination was unremarkable neurologically, with the exception of diminished range of motion of the cervical spine and lumbar spine. VA ambulatory and outpatient care records of 1990 and 1991 reflect that the veteran complained of multiple problems, including a right ear infection, high blood pressure, a rash of the hands and arms and fungus of the fingernails, epigastric distress, chronic neck and back pain and a hearing problem. In September 1990, examination disclosed a furuncle of the right ear. A March 1991 report from Southeast Texas Cardiology Associates indicates that the veteran reported having episodes of chest discomfort dating to December 1990. The impression was that the veteran had a longstanding history of hypertension and now presented with episodes of chest discomfort with some characteristics suggestive of myocardial ischemia, with other characteristics atypical of myocardial ischemia. A hearing was held before an RO hearing officer in April 1992. The veteran testified that he developed hearing loss and ringing in the ears from exposure to the noise of repeated firings of 105 Howitzers. He also testified that heart enlargement developed secondary to high blood pressure and attributed falling asleep of the hands and feet to immersion foot in Vietnam. He further testified that he was not awarded a Purple Heart because he did not report shrapnel wounds to the right leg, right upper arm and chest because they were relatively minor. Associated with the claims folder in June 1992 were reports from Dr. Paul Brewer reflecting the veteran's treatment from 1958 to 1986. A treatment entry of May 1973 reflects a complaint of dizzy spells; there were no physical findings and no diagnosis was rendered. In September 1974, the veteran complained of epigastric distress. The examiner made no reference to any stomach or abdominal pathology. In May 1975, the assessment was right otitis media; left external otitis was noted in July 1977. Subsequent treatment notations reflect complaints of ear pain. An electrocardiogram in July 1980 showed sinus arrhythmia. A hearing was held before a member of the Board in April 1994. In testimony, the veteran related that he had sustained shrapnel wounds to the shoulder and leg when a grenade thrown at enemy troops exploded near him. He stated that dizzy spells and blurred vision were associated with hypertension; that he had various skin lesions as a result of jungle rot sustained in Vietnam; and that he experienced ear infections in service, which led to hearing loss accompanied by ringing in the ears. He remarked that heart enlargement and rapid pulse were discovered in 1978 while he was hospitalized at a state mental institution. He commented that black rings around the eyes resulted from chronic sleep problems attributable to depression and nightmares. He reported that a problem with sweating and falling asleep of the hands and feet had been present for many years. In other testimony, he attributed warts of the groin area to residuals of jungle rot in Vietnam. He noted that a stomach disorder with nausea was related to post-traumatic stress disorder, while loss of libido stemmed from depression. In order for service connection to be established, there must not only be evidence of a disease or injury during service, there must also be evidence of a current disability which is attributable to such disease or injury. Without evidence of a current disability, a claim for service connection is not well-grounded. Rabideau v. Derwinski, 2 Vet.App. 141 (1992); Brammer v. Derwinski, 3 Vet.App. 223 (1992). Moreover, when a condition is not shown in service or for many years later, competent medical evidence is required to show that the current condition is related to service; without such medical evidence of causality, a claim for service connection is not well-grounded. Grivois v. Brown, 6 Vet.App. 136 (1994); Grottveit v. Brown, 5 Vet.App. 91 (1993). As indicated above, a claim is not well grounded where there is no medical evidence that the claimed condition is actually present, or there is no medical evidence linking the claimed condition with service. As to all disorders for which service connection is sought, there is no medical evidence of the current existence of the conditions or, if present, there is no medical evidence of cuasality to link the conditions to service. The testimony of the veteran and his wife, to the effect that the conditions currently exist and are related to service, does not constitute cognizable evidence as to matters of diagnosis or etiology of conditions since, as laymen, they have no competence to give medical opinions. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). As previously noted, a claimant must submit supporting evidence that justifies a belief by a fair and impartial individual that the claims are plausible. As such evidence has not been presented, claims for service connection, other than for PTSD, are not well-grounded. Thus, those claims must be dismissed. Grivois, supra; Grottveit, supra. III. Service Connection for PTSD Stress Disorder The veteran’s claim for service connection for PTSD is well- grounded, meaning plausible, and the VA has fulfilled its duty to assist him in developing the facts pertinent to the claim. 38 U.S.C.A. § 5107(a). 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. 38 C.F.R. § 3.303(d). Service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in- service stressor. If the claimed stressor is related to combat, service department evidence that the veteran engaged in combat or that the veteran was awarded the Purple Heart, Combat Infantryman Badge, or similar combat citation will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed in-service stressor. 38 C.F.R. §§ 3.304(f). Service department personnel records disclose that the veteran was a rifleman in the Marine Corps and had service in Vietnam. He was involved in various operations against the enemy. He was awarded a Combat Action Ribbon. He was not awarded a Purple Heart. No psychiatric abnormalities are noted in service medical records, and the veteran was evaluated as psychiatrically normal on an examination in January 1970 for service separation. Dr. Brewer’s 1958-1986 records show the veteran had behavioral problems even prior to his 1968-1970 active duty, as well as psychiatric symptoms subsequent to service. Associated with the claims folder is a statement, from Paul L. Brewer, M.D., dated June 1972. It was stated that the veteran had become very disappointed when his grades had fallen in school and he had been removed from his football team; there had also been a romantic disappointment. He and some other boys had broken up tombstones in a cemetery. The town and his friends had turned against him and he had quit school to join the Marines. He had been very happy at boot camp and been in good health. He was soon sent to Vietnam and wrote to his parents that he did not expect to return home. When he returned home, he started drinking excessively and became obsessed with what he had done and seen in Vietnam. It was stated that the veteran's reaction to his Vietnam experiences had caused him to become cruel to animals, cutting out their eyes and bashing in their brains, thinking that he was inflicting punishment on Vietcong. He also worried about going to hell because of his concern that he killed innocent women and children in Vietnam. He became violent and beat up family members. His antisocial behavior had become so severe that it no longer took alcohol to precipitate the episodes. The diagnosis was antisocial behavior with belligerent attitude, aggravated with drinking with definite psychotic pattern developing. The veteran was admitted to a VA medical facility, upon court order, in June 1972. There had been a series of episodic drinking during which, under the influence, he had threatened to kill all members of his family, including his wife. It was indicated that the veteran had experienced trouble with the law and had displayed a probable character disorder prior to his entry into military service. On initial interview, it was believed that the veteran had anxiety neurosis, but after some observation, it was determined that his anxiety was due to the effects of alcoholism. The diagnosis was alcohol addiction. The veteran was hospitalized at a VA medical facility in July 1973. He complained of insomnia, depression, worry and headaches. He indicated that he had begun having these problems when he was in service. While in Vietnam, he had seen some of his friends killed by an enemy mine. From that time on, he could not relax. He had bad dreams about the war. He felt nervous and shaky inside. He believed that he was going to have a nervous breakdown. He was afraid that he was going to be killed. He indicated that, upon his return from service, he could not adjust to civilian life. He had no friends any longer and felt that someone might kill him. Sometimes he developed headaches and dizzy spells and would shake and feel sick to his stomach. The diagnosis was anxiety neurosis. A statement was received from the veteran in October 1990 describing his experiences in service. He related that he was involved in firefights in Vietnam and recalled the screams of the wounded and the smell of urine and bloody stool which followed firefights. He related that he had witnessed the death and mutilation of fellow servicemen who activated mines and booby traps, and remarked that sometimes only body parts remained. He related that blood covered his clothes after a comrade nearby was hit in the neck during a firefight and stated that several comrades right in front of him were severely injured or killed by mortar fire. He identified several injured comrades by name. He commented that he could not stand to be around people when he returned from Vietnam and that he was unable to hold a job or trust anyone thereafter. Statements were received in November 1990 from the veteran's cousin, aunt, spouse and mother. Statements described a pattern of threats or acts of violence by the veteran against others, including his wife and family members. The veteran was described as depressed, restless, hostile and socially isolated. He was preoccupied with recollections of Vietnam and experienced nightmares, sleep problems and startle response. Subsequent statements from associates and from the veteran's former spouse were to essentially the same effect. The veteran was hospitalized at a VA medical facility from June to July 1990. He presented for treatment of nervousness. He complained of episodes of anxiety associated with tachycardia, diaphoresis and dry mouth. These episodes were usually precipitated by stress such as marital conflict and memories of combat experiences in Vietnam. He remarked that memories of Vietnam had been a significant source of distress for the past 20 years. He complained of nightmares associated with combat. He felt anxious in social situations. He indicated that he was a sociable person prior to Vietnam, but now interacted minimally with people, including family members. The diagnosis was PTSD. The veteran was afforded a VA psychiatric examination in January 1991. The examiner remarked that the veteran's combat history had been documented and did not conflict with written statements provided by the veteran. The veteran referred to difficulty sleeping. He related that he became aggravated by minor irritations and could not tolerate being around crowds of people. He stated that his heart began to beat quickly and that he sweated excessively in crowded circumstances. He had a recurrent nightmare in which he could smell incense and hear enemy soldiers all around him shouting to him. He commented about the violent and sudden quality of death in combat. He referred to recurrent memories of Vietnam, sometimes occurring for no reason, at other times triggered by the sound of a helicopter landing. He remarked that he tried not to think about Vietnam, but that images of Vietnam lingered in his mind. The veteran related that he was afraid to start his car in case it was wired by a booby trap; he had frequently encountered booby traps in Vietnam. He avoided watching TV programs about Vietnam. The diagnosis was PTSD, chronic, severe. Of record is a July 1991 report from a board of three VA psychiatrists who reviewed the veteran's records. The examiners stated that the correct diagnosis would be PTSD, if the history provided by the veteran was correct and factual. However, it was the board's determination that the available evidence was insufficient and too contradictory to support a diagnosis of PTSD. It was the assessment that alcoholism was still the likely Axis I diagnosis. The psychiatrists noted that the veteran had shown evidence of a personality disorder with antisocial traits, and it was stated that this condition would not mature into any Axis I diagnosis such as PTSD. A hearing was held before a VA hearing officer in April 1992. The veteran testified that he had nightmares of Vietnam experiences; that he slept with a loaded gun by his bed; and that he could not cope with people and feared that someone intended to break into his home and cut his throat. His spouse testified that, on two occasions, the veteran had attempted to run from imagined Vietnamese whom he believed were in his house. She also testified that, while asleep, the veteran had uttered what sounded like Vietnamese words. At a hearing held before a member of the Board in April 1994, the veteran testified that he had been hospitalized at VA and state hospitals since service because of PTSD and problems with outbursts of anger. He further testified that he had nightmares of people trying to break into his home and attack him with a knife while he slept or nightmares of killing his two brothers-in-law with a knife. His spouse testified that she lived as if she were in Vietnam with the veteran every day. She also testified that he subjected her to beatings and ridicule and, at times, had awakened from sleep and begun choking her. She also testified that the veteran's explosive behavior had prevented relationships with friends or family. The file contains VA outpatient records from recent years, dated to 1994. Some of these contain a diagnosis of PTSD, but without a complete psychiatric examination; in fact, many of the records pertain to clinic visits for injuries and other physical ailments, and simply list PTSD among the clinical impressions. In order to establish service connection for PTSD, the evidence must demonstrate that the veteran was subjected to stressors in service. A stressor is an experience, such as the life-threatening situations of combat, recognized as producing stress in almost any individual. The veteran was awarded a Combat Action Ribbon. The record substantiates claimed combat exposure and indicates that the veteran may indeed have been subjected to stressors related to combat. However, even if there was an in-service stressor, service connection for PTSD may not be granted unless there is a clear medical diagnosis of the condition and medical evidence linking the condition and the in-service stressor. The Board is aware that a diagnosis of PTSD was rendered following VA hospitalization and following examination by a VA psychiatrist, and that there are some diagnoses of PTSD in the outpatient records. However, it would appear that the diagnosis of PTSD was rendered by examiners who were not fully apprised of the veteran's psychiatric history. There is no indication that the examiners were aware of the veteran's preservice displays of antisocial behavior or of his postservice pattern of alcoholism and violent and explosive behavior. In contrast, following review of the veteran's entire medical history by a board of three psychiatrists, it was determined that he did not, in fact, satisfy the diagnostic criteria for a diagnosis of PTSD. The Board finds that the most probative medical evidence as to the presence or absence of PTSD, and any interrelationship with service, is the report by the board of three psychiatrists. These doctors thoroughly analyzed the veteran’s history in light of diagnostic criteria for PTSD, and the doctors found that such disorder was not present. This critical medical analysis is not evident in the medical records listing a diagnosis of PTSD, and thus the Board finds those other records less persuasive. The weight of the evidence establishes that the veteran does not have a clear diagnosis of PTSD, which is a mandatory requirement for service connection. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). IV. Increased Rating for Residuals of Malaria The claim for an increased (compensable) rating for malaria is well-grounded, and the file indicates there is no further duty to assist the veteran in developing the facts pertinent to this claim. 38 U.S.C.A. § 5107(a). A service department medical record indicates that the veteran had an episode of malaria in May 1969 and a second episode which had begun in late November 1969. Falciparum malaria was noted on a smear. The clinical course was uncomplicated, and treatment was completed in mid-December 1969. At the conclusion of treatment, the veteran's laboratory studies and physical examination were normal. He was discharged from hospitalization in mid-December 1969 as symptomless and afebrile. He was returned to full and active duty. There is no post-service medical evidence of any recurrence of malaria. The record includes a June 1992 statement from an individual who indicated that he had known the veteran since high school. It was related that the veteran had returned from Vietnam with an ailment which was assumed to be malaria. The sickness sometimes kept him in bed and away from work. After a period of 12 years, the veteran had again contacted him and complained of the same persistent ailment, described as a rash of red bumps. At his RO and Board hearings, the veteran testified that the residuals of malaria were manifested in post-service years by heightened symptoms of flu. Disability evaluations are determined by application of a schedule of ratings which is based on the average impairment of earning capacity resulting from specific disabilities. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities and the criteria that must be shown for specific ratings. A 10 percent rating is warranted for malaria, recently active with one relapse in the past year; or old cases with moderate disability. 38 C.F.R. § 4.88b, Code 6304. Where the minimum schedular evaluation requires residuals and the schedule does not provide a noncompensable evaluation, a noncompensable evaluation will be assigned when the required residuals are not shown. 38 C.F.R. § 4.31. A review of the record discloses that in-service episodes of malaria had resolved, without residual symptoms, prior to the veteran's release from active duty. There is no medical evidence indicating any post-service relapse of malaria whatsoever or indicating that malaria is productive of moderate disability. The veteran believes he has symptoms attributable to malaria, but as a layman he has no competence to make a medical diagnosis. Espiritu, supra. The recent medical evidence shows no active malaria or residual disability from remote activity of the disorder. The criteria for assignment of a compensable rating are not satisfied. There is not an approximate balance of positive and negative evidence so as to warrant application of the benefit-of-the-doubt doctrine. Rather, the preponderance of the evidence is against an increased (compensable) rating, and the claim must be denied. 38 U.S.C.A. § 5107(b). V. Non-Service-Connected Pension Among the requirements for non-service-connected pension is that a veteran be permanently and totally diabled from conditons not due to his own willful misconduct. 38 U.S.C.A. §§ 1502, 1521; 38 C.F.R. §§ 3.321, 3.340, 3.342, 4.15, 4.16, 4.17. The RO has rated the veteran’s non-service-connected disabilities as anxiety (10%), hypertension (10%), a skin disorder (10%), a cervical spine condition (10%), and a low back disorder (10%). The veteran has numerous other conditions rated noncompensable. The combined rating for all disabilities is 40%. 38 C.F.R. § 4.25. The veteran was born in 1950 and is now 45 years old. His education includes the equivalency of high school (GED) plus one year of college. Records show his employment history includes, in part, various jobs in the oil industry. In his 1990 pension claim, the veteran reported he last worked in 1988, at which time he was a wireline operator for an oil equipment company. Various records refer to the veteran leaving that job due to a neck/back injury. At the time of his 1992 RO hearing, the veteran reported he was working part-time. At his 1994 Board hearing, the veteran reported that he was working full-time as a utility operator in a chemical plant and had held this job for about a year. One way for a veteran to be considered to be permanently and totally disabled for pension purposes is to satisfy the “average person” test of 38 U.S.C.A. § 1502(a)(1) and 38 C.F.R. § 4.15. Brown v. Derwinski, 2 Vet.App. 444 (1992); Talley v. Derwinski, 2 Vet.App. 282 (1992). To meet this test the veteran must have the permanent loss of use of both hands or both feet, or one hand and one foot, or the sight of both eyes, or be permanently helpless or permanently bedridden; or the veteran’s permanent disabilities must be rated, singly or in combination, as 100 percent. The veteran has none of these conditions, and his combined disability rating is only 40 percent. He does not satisfy the average person test for a permanent and total disability rating for pension. Another way for a veteran to be considered permanently and totally disabled for pension, is to qualify under the “unemployability” test of 38 U.S.C.A. § 1502(a) and 38 C.F.R. §§ 4.16, 4.17. Brown, supra; Talley, supra. A veteran may satisfy this test if he is individually unemployable, and has one permanent diability ratable at 40 percent or more, plus sufficient additional disability to bring the combined rating to 70 percent or more. The veteran, with a combined rating of only 40 percent, clearly does not qualify. The unemployability test may also be satisfied, on an extraschedular basis under 38 C.F.R. § 3.321(b)(2), when a veteran who is basically eligible fails to meet the disability percentage requirements but is found to be unemployable by reason of disabilities, age, occupational background, education, and related factors. The veteran clearly does not qualify on this basis. He is in his mid- forties, has at least the equivalency of a high school education, and, most significantly, he is gainfully employed in a full-time job. Even assuming, for the sake of argument, that the veteran was totally disabled when he filed his pension claim, it is obvious that he was not then and is not now permanently and totally disabled as required for non-service-connected pension benefits. Permanence of total disability will be taken to exist when the impairment is reasonably certain to continue throughout the life of the disabled person. 38 C.F.R. § 3.340. The veteran, who has been gainfully employed since filing his pension claim, is not permanently and totally disabled. Inasmuch as the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert, supra. ORDER The application to reopen a claim of service connection for hypertension is denied. The claim for service connection for residuals of an ear infection is dismissed. The claim for service connection for a disability manifested by black rings around the eyes is dismissed. The claim for service connection for a disability manifested by blurred vision is dismissed. The claim for service connection for a heart disorder manifested by cardiac enlargement and rapid heartbeat is dismissed. The claim for service connection for a disability manifested by dizzy spells is dismissed. The claim for service connection for warts in the groin area is dismissed. The claim for service connection for a stomach disorder manifested by nausea is dismissed. The claim for service connection for a hole in the nose with sores is dismissed. The claim for a disability manifested by loss of libido is dismissed. The claim for service connection for ringing in the ears is dismissed. The claim for service connection for bilateral hearing loss is dismissed. The claim for service connection for a disability manifested by a sensation of the hands and feet falling asleep is dismissed. The claim for service connection for a disability manifested by sweating is dismissed. The claim for service connection for a skin disorder is dismissed. The claim for service connection for residuals of shell fragment wounds to the right leg, right upper arm and chest is dismissed. Service connection for PTSD is denied. An increased rating for residuals of malaria is denied. A permanent and total disability rating for pension purposes is denied. L.W. TOBIN 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 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 which 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 which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. - 2 -