BVA9502668 DOCKET NO. 91-37 189 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in San Juan, Puerto Rico THE ISSUE Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for the cause of the veteran's death; and, if so, whether service connection for the cause of the veteran's death is warranted. REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs ATTORNEY FOR THE BOARD Michael E. Kilcoyne, Counsel INTRODUCTION The veteran had active military service from April 1965 to January 1967 and from November 1967 to September 1968. His death occurred in December 1982. The death certificate shows that he was born in 1946. The appellant is the veteran's widow. The record shows that entitlement to service connection for the cause of the veteran's death was denied in a March 1988 decision by the Board of Veterans' Appeals (Board). The current appeal arises from an attempt to reopen that claim which was denied by the San Juan, Puerto Rico regional office (RO) in November 1990. This appeal was previously before the Board, and in decisions dated in November 1991 and July 1992, the Board Remanded the case for additional development. CONTENTIONS OF APPELLANT ON APPEAL The appellant essentially contends that the veteran's service connected psychiatric disorder caused him to become dependent upon alcohol which in turn caused those disabilities which led to his death. Therefore, she maintains that a basis exists to grant entitlement to service connection for the cause of the veteran's death. It has also been contended that the veteran should have been service connected for post traumatic stress disorder (PTSD), which the appellant apparently believes would warrant a presumption of entitlement to benefits. (It was stated at a hearing conducted at the RO in January 1990 that "I want the reopening of the claim today to be not for schizophrenia but to change the diagnosis to post-traumatic stress disorder and to award the DIC based on that.") 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 although new and material evidence has been submitted to reopen the appellant's claim, service connection for the cause of the veteran's death is not warranted. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of this appeal has been obtained by the RO. 2. At the time of his death, the veteran was service connected for undifferentiated type schizophrenic reaction, rated 100 percent disabling effective from March 1977. 3. The veteran died in December 1982, with the primary cause of death set forth on the death certificate as sepsis, due to bronchopneumonia and liver cirrhosis. 4. By a decision dated in March 1988, the Board denied a claim for service connection for the cause of the veteran's death. 5. Evidence submitted since the Board's March 1988 decision, includes a statement from the veteran's former treating physician which suggests a relationship between the veteran's service connected schizophrenia and alcoholism and the presence of post- traumatic stress disorder. 6. The veteran's terminal hospital summary lists chronic ethanolism as the cause of the veteran's liver disease. 7. Sepsis, bronchopneumonia and liver cirrhosis were not shown until many years after the veteran separated from service. 8. There is no causal connection between the development of the veteran's schizophrenia and the development of his alcoholism. 9. The veteran's service connected disorder played no significant role in his death. CONCLUSION OF LAW 1. The evidence received since the Board's 1988 denial of the claim for service connection for the cause of the veteran's death is new and material and the claim is reopened. 38 U.S.C.A. § § 1101, 1110, 1112, 1113, 1137, 1310, 5107, 5108 (West 1991); 38 C.F.R. § § 3.307, 3.309, 3.312 (1993). 2. Sepsis, bronchopneumonia and liver cirrhosis were not incurred in or aggravated by service, nor may liver cirrhosis be presumed to have been incurred in service. 38 U.S.C.A. § § 1101, 1110, 1112, 1113, 1137, 5107 West 1991); 38 C.F.R. § § 3.307, 3.309 (1993). 3. A service connected disorder did not cause or contribute substantially or materially to cause the veteran's death. 38 U.S.C.A. § § 1310, 5107 (West 1991); 38 C.F.R. § 3.312 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board is satisfied that all relevant facts have been properly developed in this case. The claim has been Remanded once to provide the appellant with a supplemental statement of the case which included citation to appropriate law and regulation regarding final Board decisions and once to obtain additional treatment records pertaining to the veteran. The Board has also obtained an opinion from an independent medical expert in psychiatry regarding the etiological relationship between the veteran's service connected psychotic disorder and his alcohol abuse. Accordingly, the duty to assist the appellant in developing her claim, pursuant to 38 U.S.C.A. § 5107 has been satisfied. Under applicable criteria, service connection may be granted for disability resulting from disease or injury which was incurred in or aggravated by service. 38 U.S.C.A. § 1110. Service connection for cirrhosis of the liver may be presumed if it became manifest to a degree of 10 percent disabling during the veteran's first year after separation from service. 38 U.S.C.A. § § 1101, 1112, 1113, 1137; 38 C.F.R. § § 3.307, 3.309. The death of a veteran will be considered as having been due to a service-connected disability when the evidence establishes that such disability was either the principal or a contributory cause of death. In determining whether the service-connected disability contributed to death, it must be shown that it contributed substantially and materially; that it combined to cause death, that it aided or lent assistance to the production of death. It is not sufficient to show that it casually shared in producing death, but rather, it must be shown that there was a causal connection. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312. Where at the time of death, the veteran has service connected disability rated 100 percent disabling, careful consideration is given as to whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. Where the service connected condition affects a vital organ as distinguished from muscular or skeletal functions and is evaluated as 100 percent disabling, debilitation may be assumed. 38 C.F.R. § 3.312(c)(3). As set forth above, the Board previously adjudicated a claim for service connection for the cause of the veteran's death. In its March 1988 denial of that claim, the Board considered the veteran's claims file which included the veteran's service medical records, the post service private and VA medical treatment records dated in the 1970's and 1980's, the terminal hospital summary, the report of the provisional anatomical diagnoses on the autopsy performed on the veteran and the veteran's death certificate. None of these records refer to the veteran reexperiencing any traumatic event he may have been exposed to in service. The death certificate showed that the veteran died in December 1982. It was indicated that the primary cause of death was sepsis, due to bronchopneumonia and liver cirrhosis. At the time of his death, the veteran was service connected for undifferentiated type schizophrenia reaction which was rated as 100 percent disabling. This rating had been in effect since March 1977. The veteran was also considered incompetent for VA purposes from June 1978. The veteran's service medical records did not reveal any findings or diagnoses of sepsis, bronchopneumonia or liver cirrhosis. The post service medical records did not show the presence of liver disease, bronchopneumonia or sepsis until the veteran's terminal hospitalization, many years after service and no record linked these conditions to service or to the veteran's service connected psychiatric disability. Finally, no record showed that the veteran's service connected psychiatric disorder interfered with appropriate treatment of him or rendered him materially less capable of resisting the effects of sepsis, bronchopneumonia or liver disease. Upon its review of this evidence, the Board denied service connection for the cause of the veteran's death. In order to reopen a claim which has been finally denied, the appellant must submit new and material evidence. 38 U.S.C.A. § 5108. The United States Court of Veterans Appeals has established a two-part analysis that must be used when an appellant seeks to reopen a claim based upon new and material evidence. First, the Board must determine whether the evidence is in fact new and material. Manio v. Derwinski, 1 Vet.App. 140, 145 (1991). "New evidence is not that which is merely cumulative of other evidence on the record." Colvin v. Derwinski, 1 Vet.App. 171, 174 (1991). Material evidence is that which is relevant and probative and there must be a reasonable possibility that when viewed in the context of all the evidence, both old and new, it would change the outcome. Id. If the Board determines that the appellant has produced new and material evidence, the case is reopened and the Board must evaluate the merits of the appellant's claim in light of all the evidence, both new and old. Manio 1 Vet.App. at 145. The evidence submitted in connection with the appellant's attempt to reopen the claim consists of testimony taken at a hearing conducted at the RO in January 1990, an April 1992 statement of M. A. Cubano, M.D. (the veteran's former treating physician), as well as Dr. Cubano's treatment records pertaining to the veteran dated between December 1977 and December 1982. These records also do not refer to the veteran reexperiencing any traumatic event he may have been exposed to in service. The April 1992 statement by Dr. Cubano includes the remark that at the time of the veteran's death, he "had a long history of alcohol abuse, which is very frequent in this kind of patients, which due to his mental conditions of suspiciousness and denial of reality, recur to alcohol refusing medication. They take alcohol instead of prescribed medicine." As the veteran's terminal hospital summary showed that his liver disease was secondary to his chronic ethanolism, Dr. Cubano's statement is construed as suggesting that the veteran's service connected psychiatric disorder caused his alcoholism which in turn caused the liver disease that contributed to the veteran's death. As this is the first instance where a medical professional relates the veteran's service connected schizophrenia to the cause of his death, it is reasonable that when viewed in the context of all the evidence, there could be a change in the outcome of the appellant's claim. Therefore, this evidence is new and material with respect to the appellant's claim and it is reopened. Consideration may now be given to the entire evidence of record without regard to any prior denial. However, the Board must first decide in this regard whether the appellant will be prejudiced in any way by its consideration of the reopened claim when the RO has not addressed that underlying issue. The factors to be considered include whether the claimant has been given adequate notice of the need to submit evidence or argument on the underlying claim, an opportunity to submit such evidence or argument, and an opportunity to address the issue at a hearing. Bernard v. Brown, 4 Vet.App. 384 (1993). In the case at hand, the Board concludes that the appellant will in no way be prejudiced by its consideration of the underlying claim. The appellant was provided the appropriate law with respect to the underlying claim in the original statement of the case dated in February 1991 and the appellant's testimony which initiated the current claim primarily concerned the underlying claim. Accordingly, it is clear that the appellant understands the nature of the evidence needed to substantiate the claim on the merits. As previously set forth, the veteran's service medical records do not show any findings or diagnoses of sepsis, bronchopneumonia or liver cirrhosis. They also show no findings of alcohol abuse. Similarly, there are no post service medical records dated within the first few years after service that demonstrates the presence of these disabilities. A March 1970 Social Services Report did not make any reference to alcohol abuse, sepsis, bronchopneumonia or liver cirrhosis, a VA hospital summary dated in January 1973 did not refer to alcoholism, sepsis, bronchopneumonia or liver cirrhosis and a VA hospital summary dated in May 1973 did not refer to alcoholism, sepsis, bronchopneumonia or liver cirrhosis. The report of a VA psychiatric examination completed in July 1973, also failed to reveal the presence of alcoholism, sepsis, bronchopneumonia or liver cirrhosis. Moreover, it was recorded at that time that the veteran denied alcohol use to any significance. The earliest medical record on which the presence of sepsis, bronchopneumonia or liver cirrhosis is noted is the terminal hospital records dated in December 1982. The earliest dated medical record on which alcohol abuse was noted is the report of a VA hospital summary for a period of hospitalization which occurred in August and September 1981. The only other medical treatment records on which the presence of alcohol abuse is noted are a November 1981 report of treatment prepared by Dr. Cubano and the December 1982 terminal hospitalization summary. Significantly, none of these records attributed alcohol dependence, sepsis, bronchopneumonia or liver cirrhosis to service or to the veteran's service connected schizophrenia. The veteran's terminal hospital summary shows that he was in his usual state of health until four days prior to admission on December 30, 1982, when he started to have fever, chills, nausea, vomiting, black stools, and a cough productive of a green sputum. This was followed by disorientation and tremors. The last time the veteran drank was four days prior to admission. Two days prior to admission, he received trauma to the head, due to his poor balance. A history of chronic ethanolism with secondary chronic liver disease was noted. On physical examination the veteran appeared acutely ill and tachypneic, with evidence of a large ecchymosis over the left frontal area. He was disoriented in place and time, and he spoke incoherently, with active auditory hallucinations. Examination of the skin showed multiple ecchymoses over the body. Examination of the thorax showed ecchymoses and spider angiomas. Examination of the lungs revealed fine basal rales on the left, but were otherwise clear. Examination of the heart showed tachycardia and examination of the abdomen showed adequate peristalsis, voluntary guarding, and hepatomegaly. There were fine tremors of the extremities, without cyanosis or edema. Neurological examination showed no focal deficit. After blood cultures were taken, the assessments were delirium tremens, sepsis, alcoholic hepatitis, pancytopenia, dehydration, rhabdomyolysis, left lower lobe pneumonia, and upper gastrointestinal bleeding. The veteran was treated with medications and he was transferred to the intensive care unit, where he had a cardiorespiratory arrest. Cardiopulmonary resuscitation attempts were made without adequate response and the veteran was declared dead at 2:15 A.M. on December 31, 1982. The final diagnoses were chronic ethanolism, with secondary chronic liver disease; delirium tremens; left lower lobe pneumonia; sepsis; pancytopenia; dehydration; alcoholic hepatitis; and upper gastrointestinal bleeding. The provisional anatomical diagnoses on the autopsy performed on December 31, 1982 were micronodular liver cirrhosis; sepsis, clinically, secondary to left lower lobe bronchopneumonia; right retroperitoneal hematoma involving the psoas muscle, pericolic and perirenal fat; multiple body trauma; acute gastritis with bleeding and neuropsychiatric problem, by history. None of these records attributed sepsis, bronchopneumonia or liver cirrhosis to the veteran's service or his service connected schizophrenia. At the hearing conducted in July 1985, the appellant testified that the veteran consumed alcoholic beverages from Thursday through Sunday for months at a time and that she was told by the veteran's treating physician, Dr. Cubano, that he drank this much to control his nerves. At a hearing conducted in January 1990, the appellant testified that the veteran daily consumed excessive amounts of alcohol ever since his return from Vietnam. She also stated that the veteran became more relaxed after he drank. She indicated that she told the veteran's treating physician, Dr. Cubano, about the veteran's behavior, but she could not remember what the doctor advised. It was argued that the veteran's psychiatric disorder caused him to use alcohol excessively. As set forth above, the medical evidence of record does not show the presence of sepsis, bronchopneumonia or liver cirrhosis until many years after service and there is no record on which these are either related to service or to the veteran's service connected schizophrenia. Similarly, the medical treatment records in evidence, which includes the treatment reports from Dr. Cubano for the entire period during which he treated the veteran (December 1977 to December 1983) do not show that the veteran's alcohol abuse was attributed to service or to his service connected schizophrenia. The only medical record tending to suggest that the veteran's alcohol abuse was due to his schizophrenia is the April 1992 statement by Dr. Cubano, made almost 10 years after the veteran's death. However, it is unclear from Dr. Cubano's statement whether he is referring to the veteran in particular or to psychiatric patients in general. Nevertheless, in view of the treating physician's suggestion that the veteran's alcohol abuse was secondary to his schizophrenia, the Board sought an opinion by an independent medical specialist in psychiatry to address the question of whether the veteran's schizophrenia caused his alcoholism. This specialist, a clinical professor of psychiatry at the Robert Wood Johnson Medical School and a visiting professor of psychiatry at the Hahnemann University Medical School responded in October 1994. His report is set out below: This opinion is in response to the request from Charles W. Symanski, Chief Member, Section 20, Board of Veterans' Appeals, with regard to the question of whether this veteran's service-connected schizophrenia caused his alcoholism. I have reviewed the voluminous records covering the period from 1966 until his death December 31, 1982. At the time when he was first treated for psychiatric disorder in 1968 his history showed that he had come from a broken home, had lived with his mother in his grandmother's home and was essentially raised by his grandmother. His social adjustment was always turbulent; he showed a "lifelong pattern of disturbed behavior" with "frequent loss of impulse control". He got into many fights at school and in the ninth grade attacked his high school principal which led to his being suspended. He is also said to have had dissociation episodes including a bizarre self mutilation in which he inflicted a severe knife wound on his left arm in the street and attacked passers-by who tried to help him. He did not work until he enlisted in the army where he served January 1965 to January 1967. He saw combat in Viet Nam including a traumatic occurrence where he was responsible for mine detection and saw all the men in his fire team killed by a mine he had failed to detect. After his army service he returned home to Puerto Rico where he first experienced hallucinations of voices calling his name. He would awake during the night in an agitated and confused state, screaming and thrashing about. He is said to have experienced homicidal impulses and he got into many fights. When his family was trying to persuade him to enter a VA Hospital he refused and impulsively enlisted in the US Navy November 1967. He married a few weeks later and apparently tried to strangle his wife shortly afterwards around Christmas. He continued to have auditory hallucinations and poor sleep and attacked another sailor who provoked him when intoxicated. He went AWOL, returned home and was eventually hospitalized in Puerto Rico at Rodrigues Army Hospital 4/25/68 and was transferred to Philadelphia Naval Hospital 5/7/68. He improved with treatment and was diagnosed as suffering from schizophrenia, undifferentiated type after a very careful examination by a Spanish- speaking psychiatrist who found thought disorder, perseveration, blunting and blocking. The impression was that he was "always borderline psychotic" and that his Army service had exaggerated his disorder, causing it to become overt rather than latent as previously. He was released from active duty 30 September 1968. There are few records during the following ten years but it is noted that he was admitted twice to the VA Hospital in 1973 with symptoms of extreme anxiety when he had not been taking his medication (chlorpromazine) as prescribed. He was evidently paranoid, saying, "I keep the lights on at night so the voices under my bed go away". There were several hospitalizations in 1975 and 1976 related to irritability or insomnia. His main symptoms were hallucinations, insomnia and bad dreams. Treatment included antipsychotic and antidepressant medication and hypnotics to help him sleep. A psychiatric report in April 1975 noted paranoid ideation, that people in the street called him names and mocked at him. None of these reports mention any excessive use of alcohol at that time or any symptoms or laboratory findings suggestive of alcoholism. Although his wife stated that he never used drugs he came to the hospital May 4, 1975 requesting admission because he had returned to the intravenous use of heroin and wanted to stop. He stayed only two days and then left without medical consent. There is no mention of any evidence that he was in fact using heroin at any time . The longest and most consistent psychiatric record is from Dr. Cubano, who saw him on fee basis from January 1978 until close to the end of his life. Brief notes of visits one or two times a month show that he was seen either by himself, with his wife or other members of his family, or with a friend; that he was generally cooperative, sometimes complained of insomnia for which he received Dalmane with our (sic) without Benadryl, and he was also given Trilafon and Cogentin for his schizophrenia and sometimes Valium for anxiety and Darvon for pain. He was also given Maalox to take with his medications and vitamins. In 1978 he was able to purchase a home and adopt a child. He had fights with his wife but these were not addressed further in the progress notes. His dosage of Trilafon was generally 32 mg daily although only 8 mg daily was prescribed February 1980 to about January 1981, 16 mg in February 1981 and 48 mg daily from March 1981 to December 1982. Only in November 1981 did his wife mention that he was drinking heavily every day, and at that time he had already been hospitalized because of alcohol dependence and increasing schizophrenic symptoms, specifically ideas of reference. He was apparently given minor tranquilizers for possible alcohol withdrawal syndrome and was tapered off these without any problem. In June 1982 his wife reported he was intolerable, aggressive and hostile and had tried to hang himself. He was apparently stable until four days prior to his last admission on December 30, 1982 when he started to have fever, chills, nausea, vomiting, black stools and a productive cough. He died the next day. Final diagnoses were chronic ethanolism, with secondary chronic liver disease; delirium tremens, left lower lobe pneumonia, sepsis, pancytopenia, dehydration, alcoholic hepatitis and upper gastrointestinal bleeding. It is notable that the record only mentions heavy drinking in the last two years of his life. When his wife was asked about his drinking in 1985 she stated that he did not drink every day; that he would not drink for two, three, or four months but when he drank he would drink Thursday through Sunday. He would only drink beer; one beer would last 1 to 2 hours, and he would drink five or six beers in a day. When she was questioned again in 1990 she stated he drank every day, and that he drank a lot of beer. It is likely that her memory was more accurate at the earlier hearing. OPINION Diagnostic Considerations It has been suggested that the diagnosis in this case should be Post-traumatic Stress Disorder rather than Schizophrenia. This suggestion cannot be accepted. There is little or no evidence of symptoms favoring this diagnosis; even the disturbing dreams were not of any traumatic situation dating from Viet Nam but rather had to do with thoughts of fears of killing his wife. There is ample evidence to support a diagnosis of schizophrenia; not only were there persistent delusions of persecution and auditory hallucinations but characteristic schizophrenic thought disorder was found by the Spanish speaking psychiatrist in the Philadelphia Nowal (sic) Hospital. None of this would be found in post-traumatic stress disorder. The question may be raised as to how long his schizophrenia was present. The personality features which were taken as evidence of latent schizophrenia before his Army service would today be recognized as antisocial and borderline personality traits. These may predispose to a later psychotic breakdown in the form of schizophrenia but may also predispose to later alcoholism. If schizophrenia was not present before his military service it certainly developed during his service. On the other hand, although beer drinking may have been present to some extent early in life, although there is no mention of this, and binge drinking probably developed later, although there is no mention of this in any records while he was still alive, it is likely that alcoholism severe enough to be recognized did not develop until the last few years of his life. To satisfy the criteria for a diagnosis of Alcohol Dependence (DSM III R), which falls under the heading of Psychoactive substance dependence, he would have had to exhibit at least three of the following: (1) substance often taken in larger amounts or over a longer period than the person intended (2) persistent desire or one or more unsuccessful efforts to cut down or control substance use (3) a great deal of time spent in activities necessary to get the substance (e.g., theft), taking the substance (e.g., chain smoking), or recovering from its effects (4) frequent intoxication or withdrawal symptoms when expected to fulfill major role obligations at work, school, or home (e.g., does not go to work because hung over, goes to school or work "high," intoxicated while taking care of his or her children), or when substance use is physically hazardous (e.g., drives when intoxicated) (5) important social, occupational, or recreational activities given up or reduced because of substance use (6) continued substance use despite knowledge of having a persistent or recurrent social, psychological, or physical problem that is caused or exacerbated by the use of the substance (e.g., keeps using heroin despite family arguments about it, cocaine-induced depression, or having an ulcer made worse by drinking) (7) marked tolerance: need for markedly increased amounts of the substance (i.e., at least a 50 % increase) in order to achieve intoxication or desired effect, or markedly diminished effect with continued use of the same amount (8) some symptoms of the disturbance have persisted for at least one month, or have occurred repeatedly over a longer period of time. It is likely that the criteria were satisfied in 1981 when he was hospitalized for alcoholism, but there is insufficient evidence to support the diagnosis at an earlier time. The Question of Causation When schizophrenia and alcoholism occur in the same individual, the question is whether they are separate and independent illness or whether one caused the other, in particular, was alcohol used as a medication to relieve the symptoms of schizophrenia, and did this eventually lead to chronic dependence on alcohol? There are many theories of the causation of alcoholism. The disease model of alcoholism, favored by Alcoholics Anonymous states that alcoholism (the loss of control over use of alcohol and preoccupation with using it in spite of the adverse consequences of its use) is a disease with biological and genetic roots and is not the consequence of any other condition. According to this model schizophrenia does not cause alcoholism; they are independent diseases. The self-medication hypothesis associated with Dr. Khantzian proposes that specific pharmacologic effects of drugs of abuse are utilized by susceptible individuals to self-medicate for psychological disturbances and painful affects. This theory does not consider genetic or socio-cultural factors, but looks only at what drug the individual finds he needs to treat his symptoms. However in the particular case at issue the individual was allegedly drinking heavily in a period when not only was he receiving appropriate antipsychotic medication for his schizophrenia in large dose but also he was receiving sedative medication at night and large amounts of Valium (from December 1981) for anxiety; it is very unusual and probably unhelpful to prescribe large amounts of Valium to an alcoholic except during the process of detoxification, so we must assume that at this time his psychiatrist did not see signs of heavy use of alcohol. The most popular theory of alcoholism today is the biopsychosocial one, that genetic, psychological and socio-cultural variables contribute to alcoholism. I find this theory most acceptable and in the present case I believe that multiple factors contributed to the development of his alcoholism. Genetic factors may have played a part; however, we know nothing of alcoholism in his parents or other relatives. Early upbringing may be relevant; he quarreled often with his mother, was raised by his grandmother, adjusted poorly at school, was suspended and did not hold a steady job afterwards apart from his military service. After his service his persistent disability presumably led to poor self-esteem and this, rather than self medication for schizophrenia, may have led to his looking for relief in alcohol. His personality difficulties with persistent inability to relate to others, even his wife, without violence, could also have predisposed him to seek some distance from reality through drinking. Conclusion His schizophrenia developed while he was in the Service, but his alcoholism developed much later. Although his schizophrenia was one of many factors which could have played a part in the development of alcoholism, there is no evidence to show that it was the cause of his alcoholism or even that it played a major part. The drinking could well have developed and it might or might not have led to chronic alcoholism and death even if he had not suffered from schizophrenia. In my opinion there is no direct causal connection between his early development of schizophrenia and his much later development of alcoholism. As set forth in his opinion, this expert believes that the most acceptable theory relating to the cause of alcoholism is that genetic, psychological and socio-cultural variables contribute to it. However, after reviewing the veteran's entire history, he concludes that "there is no evidence to show that (schizophrenia) was the cause of (the veteran's) alcoholism or even that it played a major part." In the expert's opinion, "there is no direct causal connection between (the veteran's) early development of schizophrenia and his much later development of alcoholism." In considering the entire evidence of record, there is no contemporary record of treatment of the veteran indicating that alcoholism was etiologically related to his psychosis, and an independent specialist in psychiatry concluded after his review of the veteran's history since 1966 that no such relationship existed. Although the veteran's treating physician indicated in a statement made some 10 years after the veteran's death that the veteran may have resorted to alcohol use as a result of his schizophrenia, the tentative nature of his remarks in this regard as well as the silence of his actual treatment records on this question casts considerable doubt on the validity of such a conclusion. On the other hand, the independent specialist had the benefit of the veteran's medical history since service, he set forth the causes of alcoholism and pointed to an absence of evidence in the record demonstrating a link between schizophrenia and alcoholism. Moreover, it was persuasively pointed out that the veteran was allegedly drinking heavily during a period when he was receiving appropriate anti-psychotic medication. Thus, the need for some sort of alternate, self-medication satisfied through alcohol consumption was not present. The specialist's conclusion is also consistent with all of the other medical records associated with the claims file which fail to attribute the veteran's alcoholism to his schizophrenia. The only other evidence supporting the contention that the veteran's schizophrenia caused his alcoholism is the testimony taken at the hearing conducted at the RO. However, the appellant is not a physician and therefore is not competent to give a credible opinion on a medical question such as this. The United States Court of Veterans Appeals has held that lay persons cannot provide testimony where an expert opinion is required. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). Moreover, her testimony has not been consistent with respect to what the veteran's physician told her regarding this question. In view of this, the Board finds that the greater weight of the evidence supports the conclusion that the veteran's alcoholism was not caused by his schizophrenia. Because the evidence fails to show that sepsis, bronchopneumonia or liver cirrhosis was present in service or for many years after service and because the greater weight of the evidence fails to show that alcoholism was related to the veteran's service connected schizophrenia, a basis upon which to grant service connection for the cause of the veteran's death has not been presented. Moreover, the record does not show that the veteran's schizophrenia prevented any appropriate treatment for those disorders which resulted in his death. It also does not show that it caused a general impairment of health to an extent that it rendered the veteran materially less capable of resisting the effects of those disabilities primarily causing death. The terminal hospital summary did not even list schizophrenia as a diagnosis responsible for the veteran's hospitalization and the provisional anatomical diagnoses on the autopsy only listed a neuropsychiatric problem by history. Under these circumstances, there is no reasonable basis to conclude a service connected disorder substantially or materially contributed to the veteran's death. Finally, it is noted that the appellant contends that the veteran had PTSD during his lifetime. The appellant is not competent to diagnosis such a disability. See Espiritu. An opinion from an independent medical expert was to the effect that there was little or no evidence of symptoms favoring this diagnosis yet ample evidence to support a diagnosis of schizophrenia. He noted that even the veteran's disturbing dreams were not of traumatic situations dating from Vietnam, but rather of fears of injuring his wife. Dr. Cubano, on the other hand, opined that there was a possibility that the veteran would have been diagnosed as having PTSD with a paranoid personality. In the Quick Reference to the Diagnostic Criteria from DSM-IV, American Psychiatric Association, the criteria necessary to diagnosis PTSD is set forth. These include that the traumatic event is persistently reexperienced in one (or more) of the following ways: (l) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions... (2) recurrent distressing dreams of the event... (3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated.)... (4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event (5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Id. at 207-208. There is simply no confirmation in the treatment records compiled during the veteran's lifetime that he persistently reexperienced any traumatic event referable to service. The physician's and widow's statements, which have been considered, appear to be based on recollection of events many years previously. The treatment records of Dr. Cubano do not support his statement. Moreover, the wife's testimony, given many years after the veteran's death, are likewise not confirmed in contemporaneous treatment records. In summary, the opinion by the Independent Medical Expert to the effect that the veteran did not have PTSD during his lifetime will be given more weight as it is based on evidence contained in clinical records prepared contemporaneous with the veteran's treatment for his psychiatric disability. As a substantiated diagnosis of PTSD after service is not of record, there is no need to discuss whether alcoholism is a manifestation of this disability. ORDER Entitlement to service connection for the cause of the veteran's death is denied. I. S. SHERMAN 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. (Continued Next Page) 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.