Citation Nr: 19168929 Decision Date: 09/05/19 Archive Date: 09/05/19 DOCKET NO. 17-06 245 DATE: September 5, 2019 ORDER Entitlement to service connection for the cause of the Veteran’s death is granted. FINDING OF FACT The evidence is at least in equipoise that the Veteran’s service connected posttraumatic stress disorder (PTSD) contributed substantially and materially to his cause of death from acute and chronic alcoholism. CONCLUSION OF LAW The criteria for service connection for cause of death are met. 38 U.S.C. §§ 1310, 5107; 38 C.F.R. §§ 3.102, 3.312. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1987 to June 1990 and from January 1991 to June 1991. He died in July 2013 and the appellant is his surviving spouse. This matter comes before the Board of Veterans’ Appeals (Board) from an August 2014 rating decision of a Department of Veterans Affairs (VA) Pension Center in Milwaukee, Wisconsin. The Board notes that the appellant has also asserted entitlement to dependents and indemnity compensation (DIC) benefits pursuant to 38 U.S.C. § 1151 and 38 U.S.C. § 1318. However, in light of the fully favorable decision herein with respect to entitlement to DIC benefits pursuant to 38 U.S.C. § 1310 the issues of entitlement under 38 U.S.C. § 1151 and 38 U.S.C. § 1318 are moot, as the award of DIC pursuant to 38 U.S.C. § 1310 is the greater benefit. As such, entitlement pursuant to 38 U.S.C. § 1151 and 38 U.S.C. § 1318 will not be addressed further. Entitlement to service connection for the cause of the Veteran’s death. A veteran’s death will be considered as being due to a service connected disability when the evidence establishes that the service connected disability was either the principal or a contributory cause of death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312(a). A service-connected disability will be considered as the principal, or primary, cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). A contributory cause of death is inherently one not related to the principal cause. In determining whether the service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; or 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 C.F.R. § 3.312(c)(1); see also Gabrielson v. Brown, 7 Vet. App. 36, 39 (1994). A July 2013 autopsy report and the Veteran’s death certificate list the immediate cause of death as acute and chronic alcoholism. No contributory or secondary causes of death are listed on either document. At the time of the Veteran’s death, he was service connected for PTSD. The appellant primarily contends that the Veteran abused alcohol as a method of self-medicating his PTSD. The appellant submitted a detailed statement in July 2014, in which she testified to the fact that the Veteran routinely drank to excess due to his PTSD symptoms. In addition to this statement the appellant submitted statements from the Veteran’s friend and his sister. The Veteran friend stated that over the past 10 years the Veteran’s drinking had worsened significantly, and that the Veteran frequently struggled with depression. The Veteran’s sister testified to the fact that the Veteran struggled with depression following service and drank frequently to cope with it, as well as his other PTSD symptoms. The Veteran’s sister further stated that his drinking worsened significantly over time. These statements are competent as they testify to lay observable events and behaviors, and there is no evidence they are not credible. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, they are entitled to significant probative weight. A review of the Veteran’s post service medical records reflect periodic reports of drinking, as well as a gradual increase in the amount of alcohol consumption. An August 1991 VA examination showed the Veteran drank occasionally. A January 1992 VA examination and a December 1991 PTSD assessment show the Veteran was diagnosed with mild PTSD. A November 1993 PTSD VA examination showed the Veteran expressed feelings of on going sadness. He was unable to return to his construction job and had to take a desk job due to his injuries. He relived the land mine accident repeatedly and reported that certain triggers caused flashbacks. The examiner found the Veteran met the criteria for PTSD and might be at risk of developing a superimposed major depression. A March 1994 VA medical record shows the Veteran reported feeling depressed. He had no current thoughts of suicide because of his son. A March 1994 VA Persian Gulf Clinic medical record shows the Veteran’s primary concern was depression which centered around his experience of a close encounter with an exploding cluster bomb. The Veteran stated he could not seem to put it behind him. He had a very altered sleep pattern and poor self esteem. An examiner assessed him as having PTSD and depression. A March 1994 VA psychiatry initial assessment form shows the Veteran had had feelings of depression for three to four months. He reported decreased sleep and appetite, crying spells, and increased anxiety and social isolation. The Veteran felt helpless and hopeless. The Veteran indicated he had been drinking up to five cans beer daily for two weeks. He increased his consumption of alcohol to help with sleep and relaxation after using up his prescription medication. He thought about suicide often but had no plan. The examiner’s impression was major depression. An April 1994 VA mental health clinic evaluation form shows the Veteran had increased depressive feelings, increased anxiety and social isolation. He had decreased sleep and appetite, low self esteem, and low concentration. He had no suicidal intent, plan, impulsivity, or fantasies concerning suicide. He indicated he had always had mood swings. The Veteran admitted to drinking approximately a six pack of beer per night. The examiner’s assessment was major depression. A December 1995 VA medical record shows the Veteran had had depression since service and had not felt the same since service. He had been arrested on several occasions for disorderly conduct for bar fights. He would binge drank until blackout. He had no sense of fear and got involved in very risky conflicts. He reported nightmares, flashbacks, reduced sleep, repeated thoughts and images of the Gulf War mine explosion. The examiner found the Veteran had poor eye contact, depressed mood, and a depressed and anxious affect. The Veteran did not have homicidal ideations. He did have suicidal ideations, but no plan. The Veteran experienced auditory and visual hallucinations during flashbacks. His judgment was impaired while intoxicated. The examiner diagnosed moderate PTSD and alcohol dependence. The examiner recommended restarting anti depressants, out patient psychiatry, and alcohol treatment. A July 1997 VA medical record shows the Cage test was positive for alcohol abuse (i.e., episode of more than five drinks in a day), but Veteran did not feel alcohol was a problem. The Veteran was complaining about physical pains in the right leg and low back. A December 1998 patient questionnaire shows the Veteran admitted to drinking three to four alcoholic drinks weekly but did not think he should cut down on his drinking. A June 2000 VA medical record shows the Veteran was no longer taking Prozac and stated he could not tell the difference from being on the medication. He indicated he still felt he had some depression with thoughts generally on the darker side. He indicated he drank about one beer per week. June 2000 patient questionnaire shows the Veteran drank four drinks per week and thought he should cut down on his drinking of alcohol. A May 2002 VA medical record shows the Veteran had a history of depression. The Veteran stated that anti depression medication was not helping his depressed mood. He indicated that he had increased his alcohol intake to a couple of beers two to three times per week. A January 2012 VA medical record shows the Veteran complained of worsening depression, anxiety, and insomnia. He drank a pint of vodka daily and wanted to get help. June 2013 VA in patient treatment records show the Veteran had been admitted for alcohol withdrawal treatment from June 2, 2013 to June 14, 2013. He stated he had been drinking a fifth of vodka daily for ten years and that he usually drank to the point of blacking out. The Veteran also reported during this period of treatment that his alcohol usage was due at least in part due to his trouble sleeping. The records reflect repeated Axis I diagnoses of alcohol withdrawal delirium and alcohol dependence. The Board notes that VA has obtained several medical opinions in conjunction with the current appeal, specifically in March 2014, August 2014, November 2016, and August 2017. Each opinion stated that it was less likely than not that the Veteran’s PTSD materially contributed to the Veteran’s cause of death, specifically acute and chronic alcoholism. In support of these opinions, each examiner cited to the fact that none of the treatment records associated with Veteran’s alcohol use with his PTSD, and further that the Veteran would have been referred to substance abuse treatment if the alcohol abuse were related to his PTSD, which did not occur. The examiners also generally cited to the fact that the Veteran’s alcohol abuse developed well-after the trauma underlying his PTSD diagnosis. There is no evidence that the examiners in this case were not competent or credible, and therefore the opinions are entitled to probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Based on the foregoing, the Board finds that the evidence of record shows that it is at least as likely as not that the Veteran’s service-connected PTSD materially contributed to the Veteran’s cause of death. The Board notes that the VA opinions of record all state that it is less likely than not that there was a relationship, as the alcohol abuse developed well-after the stressor and treatment records do not indicate that the Veteran’s treating physicians found the PTSD and alcohol abuse to be causally related. However, the Board first notes that there is no evidence of any psychiatric treatment, or indeed treatment of any kind, for the period from 2002 to 2013 when the Veteran appeared for detoxification. The Board further notes that this gap in the Veteran’s records corresponds with the period when the lay statements of record indicate the Veteran’s alcohol use significantly worsened. The lack of treatment records corresponding to the period when the Veteran’s alcohol use significantly worsened undermines the VA examiner’s reliance on the fact that no treatment records reflect that the Veteran’s alcohol abuse and psychiatric disability were causally related. Further, the treatment records that are associated with the file reflect that the Veteran did report alcohol use to deal with symptoms of his PTSD, even if he did not report that he used it to medicate his PTSD specifically. In particular, the Veteran on several occasions endorsed drinking heavily in order to help with his chronic sleep disturbances, which was a symptom that was clinically associated with his PTSD. These records additionally reflect a gradual increase in alcohol consumption following the Veteran’s separation, and significant alcohol usage in approximately 1995. While no issues with alcohol were noted in 1993, subsequent treatment records and examinations reflect an increase in the amount of alcohol the Veteran was consuming on a weekly or daily basis. In sum, the Board finds that the VA treatment records noting an association between the Veteran’s alcohol use and symptoms associated with his PTSD, in conjunction with the lay statements of record concerning the Veteran’s use of alcohol as a coping mechanism for his PTSD symptoms, in particular his sleep impairment and depression, sufficiently establish that the Veteran’s PTSD materially contributed to his cause of death. As a service-connected disability materially contributed to the Veteran’s cause of death, service connection for the cause of the Veteran’s death is warranted. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. CHRISTOPHER A. WENDELL Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G.A. Flynn, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.