Citation Nr: 1307447 Decision Date: 03/05/13 Archive Date: 03/11/13 DOCKET NO. 06-28 247 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for the cause of the Veteran's death. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD S. M. Kreitlow INTRODUCTION The Veteran had active military service from October 1968 to April 1971. The appellant is the Veteran's surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The Board notes that the appellant's appeal was previously remanded in July 2008 and November 2010 for additional notice and development. At this time, the Board finds that the prior remands have been substantially complied with and that the Board may therefore proceed forward with adjudication of the appellant's claim. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). FINDINGS OF FACT 1. The Veteran died on November [redacted], 2004, due to cirrhosis of the liver resulting from hepatitis C. 2. During his lifetime, the Veteran was not service-connected for any disability. 3. The preponderance of the evidence establishes that the Veteran's hepatitis C was the result of his intravenous drug abuse. 4. The preponderance of the evidence fails to establish that, during his lifetime, the Veteran had an acquired psychiatric disorder (to include posttraumatic stress disorder (PTSD)) other than polysubstance abuse/dependence, or, that if he did, his intravenous drug abuse was proximately due to, the result of, or aggravated by, any such acquired psychiatric disorder. CONCLUSION OF LAW Service connection for the cause of the Veteran's death is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1310, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310, 3.312 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Notice and Assistance Requirements 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 and 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012) describe VA's duties to notify and assist claimants in substantiating a claim for VA benefits. In the context of a claim for Dependency and Indemnity Compensation (DIC) benefits, which includes a claim of service connection for the cause of the veteran's death, the United States Court of Appeals for Veterans Claims (Court) has held section 5103(a) notice must be tailored to the claim. Hupp v. Nicholson, 21 Vet. App. 342 (2007). The notice should include (1) a statement of the conditions, if any, for which a veteran was service connected at the time of his or her death; (2) an explanation of the evidence and information required to substantiate a DIC claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate a DIC claim based on a condition not yet service connected. Id. In the present case, notice was provided to the appellant in August 2005, prior to the initial agency of original jurisdiction (AOJ) decision on her claim. The Board finds that the notice provided fully complies with VA's duty to notify. Although this notice was provided prior to the Court's decision in Hupp, the Board notes that the Veteran was not service-connected for any disability during his lifetime, Therefore, the notice provided was sufficient because VA was not required to give the appellant notice of any service-connected disabilities. Likewise, the Board finds that the appellant has been afforded a meaningful opportunity to participate effectively in the processing of her claim. She was told that it was her responsibility to support the claim with appropriate evidence and has been given the regulations applicable to VA's duty to notify and assist. Indeed, the appellant has submitted evidence in connection with her claim, which indicates she has actual knowledge of the evidence and information needed to support the claim. Thus, the Board finds that the purposes behind VA's notice requirement have been satisfied, that VA has satisfied its "duty to notify" the appellant, and that any error in this regard is harmless. With respect to VA's duty to assist, VA is only required to make reasonable efforts to obtain relevant records that the veteran has adequately identified to VA. 38 U.S.C.A. § 5103A(b)(1). All efforts have been made to obtain relevant, identified and available evidence. The Board notes that, despite the appellant's reports of psychiatric treatment at the VA medical facility in "Brecksville." Multiple attempts were made to obtain those records, but the VA Medical Center in Cleveland (of which Brecksville is a Division) only provided treatment records from August 2001 to August 2003 and essentially none of those were for mental health treatment of the Veteran. VA notified the appellant of the evidence that it had obtained. Neither the appellant nor her representative has identified any evidence that has not been sought to be obtained and associated with the claims file. VA, therefore, has made every reasonable effort to obtain all records relevant to the appellant's claim. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. As the Veteran is deceased, a VA examination could not be obtained. The Board notes, however, that medical opinions were obtained in connection with the appellant's claim in November 2005, June 2011, April 2012, July 2012, and October 2012. The Board also notes that, in addition, the appellant submitted medical opinions in support of her claim dated in March 2010 and April 2010. Thus, the Board finds that VA has satisfied its duties to inform and assist the appellant at every stage of this case. Additional efforts to assist or notify her would serve no useful purpose. Therefore, she will not be prejudiced as a result of the Board proceeding to the merits of her claim. II. Analysis The appellant is seeking Dependency and Indemnity Compensation (DIC) based upon service connection for the cause of the Veteran's death. Dependency and indemnity compensation is payable to a surviving spouse, child, or parent either because of a service-connected death occurring after December 31, 1956, or pursuant to the election of a surviving spouse, child, or parent, in the case of such a death occurring before January 1, 1957. 38 C.F.R. § 3.5. Service connection may be established for the cause of a veteran's death when a service-connected disability "was either the principal or a contributory cause of death." 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312(a). See also 38 U.S.C.A. §§ 1110 and 1112 (setting forth criteria for establishing service connection). A service-connected disability is the principal cause of death when that 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 must be causally connected to the death and must have "contributed substantially or materially" to death, "combined to cause death," or "aided or lent assistance to the production of death." 38 C.F.R. § 3.312(c)(1). See generally Harvey v. Brown, 6 Vet. App. 390, 393 (1994). Therefore, service connection for the cause of a veteran's death may be demonstrated by showing that the veteran's death was caused by a disability for which service connection had been established at the time of death or for which service connection should have been established. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). In order to prevail on the issue of service connection there must be medical evidence of a current disability; medical evidence or, in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v. West, 12 Vet App. 341, 346 (1999). The determination as to whether these Hickson requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). In relevant part, 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability benefits. Medical evidence of a current disability and nexus is not always required to establish service connection. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) (which stipulates that, "although interest may affect the credibility of testimony, it does not affect competency to testify"). The evidence of record shows that the Veteran died on November [redacted], 2004, as the result of cirrhosis of the liver due to hepatitis C. See Death Certificate. The appellant has advanced several theories regarding how the Veteran's hepatitis C warrants service connection. Her initial argument is that the Veteran was exposed to hepatitis C while serving in Vietnam. She also argues that the Veteran's exposure to Agent Orange while serving in Vietnam is a cause of the Veteran's liver damage. Finally, she argues that the Veteran had a mental disorder that resulted from his military service which resulted in either his use of intravenous (IV) drug use or aggravation of pre-existing IV drug use. The medical evidence clearly shows that the Veteran was diagnosed as early as 1994 to have hepatitis C. A letter dated January 21, 1994, to the Veteran from the MetroHealth Medical Center Blood Bank indicates that blood tests for the hepatitis C virus antibody and the hepatitis B core antibody were positive, and the serum ALT (alanine amino-tranferase) was elevated. In addition, a confirmatory test for hepatitis C virus antibody also gave a positive result. This letter advised him that the presence of the hepatitis C virus antibody may indicate a past or present infection with the hepatitis C virus, and the presence of the hepatitis B core antibody indicated that he had hepatitis B in the past. In April 2002, the Veteran underwent a consultation with the VA GI Clinic at Brecksville. He reported being diagnosed with hepatitis C in 1994. He reported never having treatment for his hepatitis C. He reported having had fatigue but no skin, joint, or eye disease, no gastrointestinal bleed, no swelling of the belly and no jaundice. The Veteran reported that he believed he got hepatitis C in Vietnam through IV drug abuse. He reported his last IV drug abuse was in 1970. He denied snorting or smoking it. He also reported that he was a heavy alcoholic a few years ago but discontinued alcohol intake 20 years ago. It was noted that he has had major depression and was treated for it 18 years ago. He complained of present depression episodes but denied seeking help. He had no suicidal or homicidal ideations. He reported being treated by a private physician for his health problems at that time. The assessment was chronic hepatitis C, risk factor IV drug abuse in the 1970s. He was also assessed to have a history of suicide, depression and homicide and was referred to the Mental Health Clinic for psychiatric evaluation. July and August 2002 notes signed by a psychologist indicate the Veteran was a now show for multiple mental health appointments. Private treatment records from August 2001 until the Veteran's death in November 2004 demonstrate, however, that he did not seek treatment for his hepatitis C until April 2003. At that time, he reported being diagnosed with hepatitis C when he donated blood in 1989 and that he thought he contracted it in Vietnam. He denied a history of drinking or blood transfusion. He reported he was shot in Vietnam with superficial wound, no transfusion. The next related treatment note is from February 2004 when the Veteran had a consultation with Gastroenterology; however, there is an April 2004 treatment note that indicates earlier treatment but those records were not provided. The February 2004 gastroenterology consultation note indicates that the physician and Veteran carefully went through his past risk factors and the physician stated that there "literally were none of the typical risk factors. However, the patient on a number of times was shot with bullets in Vietnam that had passed through a number of individuals. Either that or perhaps some barroom brawls where he bloodied his knuckles might be where his hepatitis C came from. The patient for years drank a pretty steady alcohol intake and quit three to four years ago." The impression was that the Veteran had chronic hepatitis C and had full blown cirrhosis of the liver. It was noted that his serum albumin had dropped quite considerably for an unknown reason that had led to the development of leg edema and ascites. In March 2004, he was seen by a liver specialist at which time he complained of continued symptoms of right sided discomfort, feeling bloating in abdomen, leg swelling and possible ascites. Subsequent treatment notes continue to show the Veteran complained of abdominal bloating and discomfort/pain. In July 2004, he underwent exploratory laparoscopic surgery due to his continued right upper quadrant abdominal pain. The surgery demonstrated that his gallbladder was quite distended as well as omental adhesions to the gallbladder wall, and it was removed. It was also noted that he had portal hypertension and a distended stomach. After the surgery, the Veteran reported a great improvement in his abdominal pain as well as the edema in his lower extremities but reported new onset of edema of his genitalia. From this point on, however, the medical records indicate the Veteran's condition continued to worsen. On November 21, 2004, he was seen in the emergency room at Parma Community General Hospital with reports of bloody emesis. At the time, he was also hypotensive. He was in critical condition and, after being stabilized, was evacuated by air to University Hospitals of Cleveland. He was assessed to have a likely upper gastrointestinal bleed possibly from esophageal varices although last esophagogastroduodenoscopy (EGD) showed none. He continued to have increased abdominal pain and, on admission to intensive care unit, was noted to have an elevated white blood cell count. An EGD was performed showing four columns of grade III varices, one with probable "white nipple sign." There was active oozing versus reflux of blood from the stomach and the gastroesophageal junction. The fundus and cardia were completely obscured by a large blood clot. Visualized parts of the body of the antrum and the duodenum were grossly normal within limits of retained blood coating. F bands were placed on the esophageal varices with satisfactory results. On November [redacted], 2004, the Veteran was seen in consultation with the liver specialist for evaluation for a transplant who indicated that he had varicele bleeding now treated with bands and sepsis syndrome treated with antibiotics. He was later noted to have refractory hypotension as well as sepsis syndrome, and was found to not be transplantable at that time. The death note indicates the doctor was called to the Veteran's bedside because he had no spontaneous breathing. After assessing him, the Veteran was pronounced dead at 6:00 pm. Initially, the Board notes that it appears the appellant is claiming that the Veteran's hepatitis C was the result of exposure to Agent Orange while he was serving in the Republic of Vietnam. The Veteran initially claimed that his renal cysts with renal cell carcinoma are related to exposure to Agent Orange while serving in Vietnam. In some circumstances, a disease associated with exposure to certain herbicide agents will be presumed to have been incurred in service even though there is no evidence of that disease during the period of service at issue, unless there is affirmative evidence to establish that the disease is due to an intercurrent injury or disease. 38 U.S.C. § 1116(a); 38 C.F.R. §§ 3.307(a)(6), 3.307(d)(1), 3.309(e). A veteran who served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 U.S.C. § 1116(f). The Board notes that the Veteran's service records demonstrate that he served in the Republic of Vietnam from October 1969 to April 1970. Consequently, he is presumed to have been exposed to herbicides, including Agent Orange, during such service. 38 C.F.R. § 3.307(a)(6)(iii). The Board notes, however, that hepatitis C (or, in fact, any liver disease) has not been scientifically determined to be a disease associated with such herbicide exposure. Diseases recognized by VA to be associated with such exposure include: AL amyloidosis; chloracne or other acneform diseases consistent with chloracne; Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes); Hodgkin's disease; ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina); all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia); multiple myeloma; non-Hodgkin's lymphoma; Parkinson's disease; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e); 75 Fed. Reg. 53,202 (August 31, 2010). For purposes of this section, the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of Ischemic heart disease. 75 Fed. Reg. 53,202 (August 31, 2010) (to be codified as Note 3 in 38 C.F.R. § 3.309(e)). The Secretary of VA has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994). See also 61 Fed. Reg. 41,442, 41,449 and 57,586, 57,589 (1996). A list of specific conditions not having a positive association was recently published by the Secretary. See Notice, 75 Fed. Reg. 81,332 (December 27, 2010). Consequently, service connection for cirrhosis of the liver or hepatitis C (the causes of the Veteran's death) is not warranted on the basis of presumptive service connection by reason of exposure to herbicides while serving in the Republic of Vietnam. The Board further notes that direct service connection may be established if a claimant submits scientific or medical evidence to establish that the etiology of a disease not enumerated in 38 C.F.R. § 3.309(e) is more likely than not exposure to herbicides. In the present case, however, the appellant has not submitted any scientific or medical evidence to support her contention that exposure to Agent Orange either caused the Veteran's hepatitis C or had any effect on the Veteran's liver that may have hastened his death (as she appears to claim in her August 2009 statement that the Veteran's exposure to Agent Orange in Vietnam damaged his liver). Rather, the overwhelming medical evidence demonstrates that the cause of the Veteran's cirrhosis of the liver was his hepatitis C. Consequently, the appellant's statements alone against the contrary medical evidence are insufficient to establish that Agent Orange caused damage to the Veteran's liver resulting in the cirrhosis that caused his death. For these reasons, the Board finds that the evidence fails to establish that service connection for either cirrhosis of the liver or hepatitis C is warranted either on a direct or presumptive basis as due to exposure to herbicides, including Agent Orange, during the Veteran's service in the Republic of Vietnam. The Board must next consider whether there is any other basis for finding that the Veteran's hepatitis C or cirrhosis of the liver was due to his military service. With regard to service connection for hepatitis C, the Board notes that, in order for service connection to be established, there must be evidence that the Veteran was exposed to a known risk factor during service and that such exposure is the most likely cause of his hepatitis C. VA has recognized that risk factors for hepatitis C include intravenous (IV) drug use, blood transfusions before 1992, hemodialysis, intranasal cocaine, high-risk sexual activity, accidental exposure while a health care worker, and various kinds of percutaneous exposure such as tattoos, body piercing, acupuncture with non-sterile needles, shared toothbrushes or razor blades. VBA letter 211B (98-110) November 30, 1998. The appellant contends that the Veteran was exposed to multiple risk factors during his service in the Republic of Vietnam (e.g. see, August 2009 statement in which she states that he was exposed to a dirty scalpel as "everything" was dirty in Vietnam). The appellant's representative also argues possible in-service risk factors and points to evidence in support of these risk factors to include: a scalp laceration noted in a March 2010 physician's letter, a scalpel laceration to the left wrist which required sutures in January 1970, removal of a ganglion cyst from the right wrist in April 1970 with sutures (which may have caused percutaneous blood exposure); and removal of a small furuncle with sutures in November 1969. The representative also noted that a medical history during a dental visit in July 1970 shows the Veteran reported having been hospitalized in the last five years (although it does not indicate for what) and that the Veteran reported in August 1979, upon being hospitalized for a gunshot wound to the abdomen, being hospitalized about 10 years prior for tendon repair on the right forearm, which would place this hospitalization during the Veteran's military service. A review of the service treatment records demonstrate the following: (1) a November 8, 1969 sick call note indicating "suspected drug use last night;" (2) sick call notes from November 10th, 14th, 15th and 17th of 1969 showing treatment for cellulitis/boil/furuncle on the dorsum of the right hand for which sutures were removed on November 14th; (3) a January 5, 1970 sick call note indicating the Veteran cut his left wrist with a scalpel that was cleaned and sutured (it was also noted that he appeared lethargic and that there were apparent needle tracks on both antecubital fossa over the veins and he was referred for a psychiatric consultation); (4) a January 6, 1970 psychiatry consultation note indicating that the Veteran was well know to this clinic and that he was a chronic drug abuser who wished no treatment (it was also noted that he was not mentally ill and interview with psychiatrist revealed no psychosis and it was recommended he be given a general discharge); (5) a January 7, 1970 sick call note indicating the Veteran reported feeling much depressed after physical examination for administrative discharge; (6) a January 8, 1970 follow up note stating that, considering the Veteran's personality disorder, it was advised that he not be given any guard duty or any duty including holding weapons until his return to the States; (7) a January 30, 1970 sick call note indicating the Veteran reported doing better in the unit and that he did not seem depressed (he also reported he was on no drugs or pot now); (8) a March 26, 1970 sick call note indicating the Veteran hurt his left wrist and had a movable mass thought to be a ganglion and he was sent to the Orthopedic Clinic who confirmed it was a ganglion cyst but no treatment was necessary (see also April 3, 1970 note); (9) a June 1970 Mental Hygiene consultation note indicating the Veteran reported he had been on various drugs since age 16 and wanted off; (10) a July 25, 1970 sick call note in which it was initially noted that the Veteran complained of having cut his right foot with barbed wire in the Republic of Vietnam but the doctor's note indicates he injured the left foot, he was referred to Podiatry who saw him on the 28th and diagnosed plantar fasciitis in the left foot; (11) an October 7, 1970 sick call note indicating the Veteran complained of having different personal problems but not wanting to talk to anybody but the psychiatrist; and (12) a November 5, 1970 note indicating informal discussions with Veteran concerning personal affairs, present duties, drug use and future plans. Furthermore, the Veteran's service personnel records contain the report of a psychiatric evaluation conducted in February 1971 in contemplation of his separation from service due to unsuitability. The report of this evaluation indicates the Veteran reported that he joined the military in lieu of receiving a potential prison sentence for possession of narcotic agents. It was also noted that the Veteran stated rather well-crystallized negativistic and hostile attitudes toward the military, relating his inability to adjust to the military. He further stated he had been using various narcotic agents for the past four years and in particular noted his abuse of heroin. He stated he desired to be discharged from service so that he may seek treatment for his addiction. On interview, the Veteran stated, " I know I could do much better out of the Army. I've had enough of it. I just can't shape up. I want to go to the Phoenix House." It was noted that the Veteran had completed 10 years of schooling, describing himself as a poor student, demonstrating recurrent difficulty with authority. He stated that he had received more than 20 Articles 15s for multiple offenses (although the Board notes only 5 actual Article 15s are shown in the service personnel records). On mental status evaluation, there was no indication of psychotic conceptual disorganization, associational defects, hallucinatory behavior, delusional material, or cerebral dysfunction; however, the psychiatrist noted that he presented several facets of a characterological disorder. The impression was passive-aggressive personality, chronic, moderate; manifested by immaturity, poor stress/frustration tolerance, immature impulsive behavior, poor modulation of hostile impulses, drug abuse, recurrent difficulty with authority figures, and poor motivation for continued military duty. The psychiatrist indicated that there was moderate impairment for further military duty and that this was not in the line of duty but existed prior to service. The psychiatrist further stated that there were no mental or physical defects warranting admission to, or final disposition through, medical channels. The Veteran was psychiatrically cleared for any action deemed appropriate by command, including administrative separation. In a March 1971 memorandum, subject being "Elimination Action UP AR 635-212 Para 6B," it was recommended that the Veteran be eliminated from the service by reason of unsuitability. The reasons for recommended action were that (1) he displayed evidence of a character or behavior disorder as shown by the February 1971 psychiatric evaluation, and further counseling would be to no avail and rehabilitation efforts were not appropriate; (2) he had 3 AWOL's duration of 23 days; (3) DFR'd 1 time; and (4) 5 Article 15s. Furthermore, the service personnel records contain a statement written and signed by the Veteran stating his reasons for wanting out of the Army to include: (1) his mother was not working and his father was in the hospital; (2) his drug abuse since he was 16 years old; and (3) that he could not take any more of the Army, his "mind is not thinking right (straight) anymore." Finally, the Board notes that the Veteran's entrance examination from October 1968 showed no skin abnormalities. His separation examination from February 1971, however, noted that he had a scar on his left forearm and foot and tattoos on his left forearm and right upper arm. The Board notes that neither the clinical records nor the separation examination reports demonstrate the Veteran reported receiving gunshot wounds while in Vietnam; that he was treated for a gunshot wound, to include receiving a blood transfusion, while in Vietnam; or that he had residuals from a gunshot wound such as a muscle injury or a scar. Furthermore, the Board notes that the Veteran's military records do not demonstrate that the Veteran was ever in combat. It is clear that he was in Vietnam but his military occupational specialty (MOS) was Powerman and he was assigned to medical units (the 4th Medical Battalion and the 51st Medical Company) while in Vietnam. Moreover he was not receipt of any combat related medals, honors or awards. Consequently, the Board finds that the service treatment records show only the following possible risk factors: IV drug use, tattoos, the scalpel laceration to the left wrist in January 1970, and the reported injury to the left foot. There is no evidence to demonstrate that the Veteran had a laceration to his scalp or that he had tendon repair surgery to his right forearm while in service as claimed by the appellant and her representative. Furthermore, there is no evidence demonstrating that the Veteran ever received any gunshot wound while serving in the Republic of Vietnam. To assist in determining what the most likely risk factor was the cause of the Veteran's hepatitis C, two medical opinions were obtained. The first medical opinion was obtained in November 2005. In this opinion, a VA physician opined that it is more likely than not that the Veteran's hepatitis C virus was contracted from IV drug abuse that from a tattoo because the risk of contracting the virus from IV drug abuse is "much, much greater" than from a tattoo. The second opinion was obtained in February 2009 from a VA gastroenterologist. In summarizing the Veteran's medical history, the VA physician stated that the medical records during and after service clearly indicate that the Veteran was using IV drugs during and after his service. On separation, he was noted to have tattoos on each arm. The physician stated that the CDC recognizes risk factors, such as past behaviors/medical conditions that are associated with hepatitis C infections, which are: (1) persons who ever injected illegal drugs, including those who injected once or a few times many years ago; (2) persons who received a blood transfusion or organ transplant before July 1992; (3) persons who received clotting factor concentrate before 1987; (4) persons who were ever on long-term dialysis; (5) children born to HCV-positive women; (6) healthcare, emergency medical, and public safety workers after needle sticks, sharps, or mucosal exposure to HCV-positive blood; and (7) persons with evidence of chronic liver disease. Notably absent from the list are STDs (sexually transmitted diseases), any injury to the skin where human blood contamination of the object is undocumented, and tattoos. The physician stated that, although it is conceivable that risks such as tattoos and STDs may be responsible for some hepatitis C infections, the risk in general is low and methodologically strong observational studies have not shown a significant association. Furthermore, sexual transmission is more likely if the partner is hepatitis C positive. In rendering an opinion, the physician stated the following: (1) Any skin penetrating injury (whether self inflicted laceration with a scalpel or stepping on glass) is not a risk factor for hepatitis C, unless blood transfusion were necessary as a result. Then the identified risk is the blood transfusion, not the injury. There is no documentation that the Veteran received blood transfusions before 1992. (2) STD per se is not a recognized and independent risk factor for hepatitis C, unless sexual contact with a hepatitis C infected person is likely. There is no documentation that the Veteran was exposed to an infected individual. (3) In the presence of very strong risk factors such as IV drug use, all other presumed, unconfirmed and non-independent risks, such as tattoos and sexual exposure, become irrelevant. And (4) studies show that regular injection drug use over years is associated with hepatitis C infection in 70 to 90 percent of cases. In conclusion, the physician stated that, in the presence of continued IV drug use of many years, it is highly unlikely that the Veteran's hepatitis C is causally related to the injury to his left foot by stepping on glass during his service in June 1968; to the self inflicted wrist laceration in January 1970; and to presumed STDs documented in Veteran's chart in July and August of 1970. It is highly likely that the cause of the Veteran's death, hepatitis C, was contracted through IV drug use. The physician noted that this opinion was based upon a complete review of the claims file. In addition, the physician cited to two medical sources in support of the opinion: (1) the Frequently Asked Questions on hepatitis C web page from the CDC's website (accessed February 24, 2009); and (2) Theodore Sy and M. Mazen Jamal. Epidemiology of Hepatitis C Virus (HCV) Infection, Int. J. Med. Sci. 2006; 3(3): 41-46. In support of her claim for direct service connection for hepatitis C, the appellant has submitted two medical opinions dated in March and April of 2010. The March 2010 letter is from a physician from the Gastroenterology and Liver Disease practice at University Hospitals Case Medical Center in Cleveland, Ohio. This physician stated that he took care of the Veteran for end stage liver disease from hepatitis C and that this was the cause of his death. He opined that the Veteran likely contracted hepatitis C while in Vietnam when he suffered a severe gunshot wound and received blood transfusions. It was noted that the Veteran also had a scalp laceration which could have also been a potential source of his hepatitis C. He stated that he thought it is more likely than not that this was the cause of the Veteran's hepatitis C and eventually led to his cirrhosis and his eventual death. The April 2010 letter was from a physician who was the Director of the GI Division of The MetroHealth System. He stated that he treated the Veteran for numerous liver issues including hepatitis C which led to his cirrhosis. This physician stated that the Veteran had one major risk factor for contracting hepatitis C which was a blood transfusion after a gunshot wound in Vietnam. He further stated that the Veteran also on a number of occasions had been shot with bullets in Vietnam that had passed through a number of individuals. The physician stated that this also could have been how the Veteran contracted hepatitis C. The physician, therefore, opined that it is more likely than not that the Veteran contracted hepatitis C in the Armed Forces which ultimately led to his death after he developed cirrhosis. In determining the risk factor for the Veteran's hepatitis C, the Board initially finds that the two private medical opinions provided by the appellant dated in March and April of 2010 are based upon an inaccurate factual premise, in other words that the Veteran received gunshot wounds while serving in Vietnam. It is clear that the physicians' opinions are based solely upon the Veteran's reported history than on a review of past medical records. For example, the gunshot wounds relied upon were reported by the Veteran at the time of treatment with these physicians as seen in the private medical records in 2003 and 2004. More importantly, such reported gunshot wounds are clearly inconsistent with the contemporaneous medical evidence, in other words the service treatment records that, as discussed above, fail to show any report of, treatment for or residuals of gunshot wounds. Rather, the Board notes that post-service medical records from August 1979 demonstrate that the Veteran received a self inflicted gunshot wound to the abdomen. Given that the private treatment records from 2003 and 2004 show multiple misreports by the Veteran relating to the timing of events in his past (for example, at one time he reported being diagnosed with hepatitis C in 1989 and another time in 1995 when in fact he was diagnosed in 1994), the Board is inclined to believe that it is more likely the Veteran was reporting the 1979 gunshot wound when he reported receiving a serious gunshot wound in service. Furthermore, the private medical records show the Veteran denied any drug use. In other words, he failed to report his history of IV drug abuse, which is clearly established by the record. Consequently, the private medical opinions are further based upon an inaccurate premise because the private physicians were not aware of the Veteran's history of significant IV drug abuse. Thus, the Board finds that, as the private medical opinions are not based on an accurate factual premise, they have little probative value. Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005), citing Reonal v. Brown, 5 Vet. App. 458, 461 (1993) and Swann v. Brown, 5 Vet. App. 229 (1993) (stating that the Board is not bound to accept medical opinions that are based upon an inaccurate factual background); see also, Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (It is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion.). Furthermore, as to the March 2010 medical opinion that a scalp laceration could also have been a potential source of the Veteran's hepatitis C, as previously discussed, there is no record of report of or treatment for a scalp laceration seen in the Veteran's service treatment records. The Board grants that this may be the type of injury that could have been self-treated and thus there would be no record of it. Thus, assuming the Veteran's report of a scalp laceration in service was credible, the Board find that the medical opinion is speculative because it not stated in a definitive manner, using the words "could have." By using such words without supporting clinical data or other rationale, this opinion is simply too speculative in order to provide the necessary degree of certainty required for medical nexus evidence. See Bloom v. West, 12 Vet. App. 185, 187 (1999). The Board also finds that the probative value of this opinion is outweighed by the February 2009 VA physician's opinion that, in the presence of very strong risk factors such as IV drug use, all other presumed, unconfirmed and non-independent risks become irrelevant. Consequently, the Board finds that the most probative and persuasive evidence as to the cause of the Veteran's hepatitis C is the VA medical opinions that opine that his hepatitis C is most likely due to his IV drug abuse because it is the strongest risk factor compared to any of the others. Clearly, the February 2009 VA gastroenterologist's opinion weighs heavily in favor of finding that the Veteran's IV drug abuse is the cause of his hepatitis C as this physician clearly based the opinion on sound medical principles and supportive medical literature. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (It is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion.). Having found that the most likely cause of the Veteran's hepatitis C was his IV drug abuse, the Board notes that service connection cannot be granted for any disease resulting from drug abuse as drug abuse is considered willful misconduct. Generally, VA law and regulations preclude granting service connection for a disability that originated due to substance abuse, as this is deemed to constitute willful misconduct on the part of the claimant. See 38 U.S.C.A. § 105; 38 C.F.R. § 3.301(d); see also VAOPGCPREC 7-99, 64 Fed. Reg. 52,375 (June 9, 1999). The United States Court of Appeals for the Federal Circuit, however, held in Allen v. Principi, 237 F.3d 1368, 1381 (Fed. Cir. 2001), that there is a limited exception to this doctrine when there is "clear medical evidence" establishing that a claimed condition involving alcohol or drug abuse was acquired secondary to a service-connected disability, itself not due to willful misconduct. However, direct service connection may be granted only when a disability or cause of death was incurred or aggravated in line of duty, and not the result of the veteran's own willful misconduct or, for claims filed after October 31, 1990, the result of his or her abuse of alcohol or drugs. 38 C.F.R. § 3.301(a). The isolated and infrequent use of drugs by itself will not be considered willful misconduct; however, the progressive and frequent use of drugs to the point of addiction will be considered willful misconduct. Where drugs are used to enjoy or experience their effects and the effects result proximately and immediately in disability or death, such disability or death will be considered the result of the person's willful misconduct. Organic diseases and disabilities which are a secondary result of the chronic use of drugs and infections coinciding with the injection of drugs will not be considered of willful misconduct origin. See 38 C.F.R. § 3.301(d) (regarding service connection where disability or death is a result of abuse of drugs.) Where drugs are used for therapeutic purposes or where use of drugs or addiction thereto, results from a service-connected disability, it will not be considered of misconduct origin. 38 C.F.R. § 3.301(c)(3). The regulation further states that an injury or disease incurred during active military, naval, or air service shall not be deemed to have been incurred in the line of duty if such injury or disease was a result of the abuse of alcohol or drugs by the person on whose service benefits are claimed. For the purpose of this paragraph, alcohol abuse means the use of alcoholic beverages over time, or such excessive use at any one time, sufficient to cause disability to or death of the user; drug abuse means the use of illegal drugs (including prescription drugs that are illegally or illicitly obtained), the intentional use of prescription or non- prescription drugs for a purpose other than the medically intended use, or the use of substances other than alcohol to enjoy their intoxicating effects. 38 C.F.R. § 3.301(d). See also 38 U.S.C.A. § 105; 38 C.F.R. §§ 3.1(m). VA's General Counsel has confirmed that, for claims filed after October 1, 1990, payment of compensation to a veteran is prohibited for a disability that is a result of his or her own abuse of alcohol and drugs, and that direct service connection of a substance-abuse disability is precluded for purposes of all VA benefits, including dependency and indemnity compensation. See VAOPGCPREC 7-99 (1999), published at 64 Fed. Reg. 52,375 (June 9, 1999); VAOPGCPREC 2-98 (1998), published at 63 Fed. Reg. 31,263 (February 10, 1998). The Board finds that direct service connection for contraction of hepatitis C in service in this case is barred as a matter of law, as the Veteran's IV drug abuse in service amounts to willful misconduct. 38 C.F.R. §§ 3.301(c)(2), 3.301(c)(3). While the isolated and infrequent use of drugs by itself will not be considered willful misconduct, the progressive and frequent use of drugs to the point of addiction will be considered willful misconduct. 38 C.F.R. § 3.301(c)(3). The Veteran's service treatment records make it clear that he was a well-known chronic drug abuser (see January 1970 psychiatric consultation report) and that he refused drug treatment while in service. Moreover, at the time of his psychiatric evaluation in February 1971 for his pending administrative discharge, he acknowledged a history of pre-service, as well as in-service, drug use. He further reported that he chose to enter military service in lieu of a possible prison sentence for the possession of narcotic agents. Finally, in a statement written by the statement as to why he should be discharged from military service, he again admitted to using drugs since the age of 16. In addition, the Board notes that the Veteran's I drug abuse continued for many years after service. It is unclear as to when he stopped using IV drugs; however, it is clear that he was still using them when he was hospitalized at VA from October to November of 1983, which hospitalization resulted in a discharge diagnosis of dependence to opioids and alcohol. Although it is not possible to tell in this case when the Veteran may have contracted hepatitis C given his long history of IV drug abuse, it is clear that his IV drug abuse in service cannot be found to be isolated or infrequent. Consequently, his IV drug abuse amounts to willful misconduct, and service connection for any disability, including hepatitis C, which developed secondary to such IV drug abuse is barred as a matter of law. In conclusion, therefore, the Board finds that, even if the Veteran's hepatitis C was contracted in service, it is proximately due to or the result of the Veteran's willful misconduct in abusing IV drugs and service connection on a direct basis is not warranted. The Board notes, however, that payment of dependency and indemnity compensation is not barred if the substance-abuse disorder is found to be secondary to a service-connected disability. See VAOPGCPREC 7-99 (1999), published at 64 Fed. Reg. 52,375 (June 9, 1999); VAOPGCPREC 2-98 (1998), published at 63 Fed. Reg. 31,263 (February 10, 1998). In the present case, the appellant essentially contends that the Veteran had either PTSD or some other psychiatric disorder that either caused or aggravated his IV drug abuse that led to him contracting hepatitis C. Consequently, she is arguing that the Veteran's hepatitis C should be service-connected as secondary to a service-connected psychiatric disability. Initially, the Board notes that the Veteran filed a claim for service connection for PTSD in July 1983. By rating decision issued in March 1984, the RO in Cleveland, Ohio, denied service connection for a nervous condition, alleged PTSD. In doing so, the RO noted that the service treatment records are negative for treatment or diagnosis of a neurosis or psychosis, and there is no evidence that the Veteran acquired a neurosis or psychosis in service. Moreover passive-aggressive personality disorder diagnosed is a constitutional or developmental abnormality - not a disability under the law for which compensation is payable. As for dependence to opiates and alcohol, the RO stated that this is of misconduct etiology. As to PTSD, the RO found that this was not shown by the evidence of record. The Board agrees that the medical evidence of record at the time of the March 1984 rating decision failed to demonstrate that the Veteran was diagnosed with any Axis I acquired psychiatric disorder, to include PTSD, other than polysubstance abuse/dependence. The service treatment records demonstrate the Veteran was a known chronic drug abuser and he was discharged from service due to an assessed passive-aggressive personality disorder. There was only one note in the service treatment records from January 7, 1970 in which the Veteran complained of depression after undergoing physical examination for administrative discharge, but this was clearly episodic as a January 30, 1970 note indicates he was doing better and it was noted that he did not seem depressed now. It is noted that the Veteran continued in service until April 1971. The February 1971 psychiatric evaluation found the Veteran did not have evidence of psychotic conceptual disorganization, associational defects, hallucinatory behavior, delusional material, or cerebral dysfunction; however, there was evidence that there were several facets of a characterological disorder present. The first post-service medical evidence of any psychiatric problem is from August 1979 when he was treated due to a self inflicted gunshot wound to the abdomen. It was noted he was despondent about family problems, and was diagnosed to have a depressive reaction. He was noted to have improved in the three days he was seen by psychiatry during his hospitalization for the gunshot wound. (See private hospital records.) In October 1983, the Veteran was hospitalized at the VA Medical Center in Cleveland, Ohio, Brecksville Division, for having homicidal ideation against his wife. The treatment records indicate that he went into a drug induced rage because he believed she had cheated on him and tore up their home and destroyed her things. He came to the VA hospital for treatment on October 24th and was scheduled to be admitted for drug treatment a few days later but came in again on October 26th again reporting he wanted to kill his wife. It was noted, however, that he may have come in because she had filed a complaint against him for vandalism and the police were seeking to arrest him. Upon admission, he reported 21/2 years of excessive alcohol use and a 12 year history of heroin dependence. He claimed to have no memory of his recent aggressive behavior. He admitted to hearing his name being called by a deceased war buddy and claimed that he would frequently see shadows of people pass by him. He was admitted to the psychiatric ward for stabilization of his psychotic symptoms and abstention from drugs and alcohol. Although some psychotic symptoms were noted in a social worker's admission note, the physician's admitting note indicates the Veteran was not psychotic or showing any mood disorder during his interview. It is noted, however, that the Veteran admitted to continuous use of many street drugs and alcohol. A November 1, 1983 Acceptance Note shows the Veteran admitted that he started drinking alcohol when he was about 14 years old and using heroin when he was 15 until the time of his hospitalization, at which time he was using twice a day and drinking 12 to 24 beers a day. Physical examination was significant for recent and old needle marks in both upper extremities, more on the left. His mental status at that time showed he was neat and clean in appearance, affect appropriate, memory fair, no hallucinations, no delusions, and no suicidal or homicidal ideas. The assessment was that the Veteran had been using heroin and alcohol because of marital problems. The Veteran was discharged from the VA hospital and the drug program on November 28, 1983, due to violating the urine policy in that he had two "dirty" urine samples. On discharge, his diagnoses were dependence to opioids and alcohol and passive-aggressive personality. The Board acknowledges that these treatment records include notations that the Veteran made comments about Vietnam (and even at one point noted PTSD); however, it is noted that the Veteran consistently reported throughout this hospitalization that his anger had to do with his wife's believed infidelity and his feelings revolved around his marital problems and wanting to resolve the issues with his wife. These records do not set forth any report by the Veteran of any symptoms consistent with PTSD. Moreover, they do not demonstrate that the Veteran underwent specific evaluation for or was diagnosed to have PTSD. Rather, they demonstrate that, upon discharge, the Veteran was not diagnosed to have any Axis I psychiatric disorder other than his polysubstance abuse despite his having had noted psychotic symptoms upon admission, which the Board finds must have been drug-induced since they apparently resolved as he stopped reporting his audio and visual hallucinations shortly after starting treatment. (The Board notes that the above findings are supported by the IME opinion of Dr. R. L. Diamond, which is discussed in more detail later on in this decision.) The only other treatment records associated with the claims file are from the Brecksville Division of the VA Medical Center in Cleveland, Ohio, from August 2001 through August 2003, although the Board notes that the last actual treatment note is from April 2002 as the subsequent notes merely indicate the Veteran failed to show for anymore scheduled appointments. An August 2, 2001 Mental Health Clinic Outpatient Update note indicates the Veteran called in reporting that he had recently returned to Cleveland from Florida. He stated he was a patient in the TRANSCEND program in the mid-1980s but had not engaged in aftercare treatment for alcohol dependence or PTSD in many, many years. He stated he would like to re-engage in treatment and reported increase in PTSD symptoms such as irritability and isolation. He reported drinking alcohol for coping/self-medication. He was referred for a substance abuse intake. An August 21, 2001 General Medicine History and Physical note indicates the Veteran reported a past medical history of hepatitis C diagnosis in 1994; history of alcohol and drug abuse since 1968 in military; gunshot wound to abdomen in 1980s; and knee pain since 1990. Although the nurse's note shows a positive PTSD screen, the physician's assessment indicated that evaluation was negative for PTSD and depression. Furthermore, the Board notes that, despite it appearing the Veteran was referred to Mental Health for outpatient treatment, notes from June and August of 2002 indicate he failed to keep any of his appointments, including four prior appointments. In contrast, the appellant has submitted multiple statements in which she states that the Veteran had mental illness, to include PTSD, and that he underwent multiple periods of counseling, both inpatient and outpatient, at the VA in Brecksville. Although the appellant's statements are not the clearest in setting forth details relating to the Veteran's mental illness, his symptoms, and his treatment for this, the Board has been able to derive the following from those statements. In a September 2005 statement, the appellant stated that the Veteran had been treated at VA Brecksville for flashbacks. In an October 2005 statement, the appellant stated that the Veteran had "mental issues, had PTSD" and that his personality disorder left him most of the time in the psychiatric ward at Brecksville. In a January 2006 statement the appellant stated that the Veteran was constantly in the psychiatric ward and undergoing outpatient and inpatient counseling. In an August 2009 statement, the appellant stated that the Veteran was not a drug user while he was living with her for 25 years. He was clean as he had to be undergoing testing at University Hospitals to be a candidate for a liver transplant. She again states that the Veteran was in and out of the Brecksville psychiatric unit because he could not deal with simple things in life. He underwent counseling and psychiatric evaluation meaning he did not know reality from one day to the next. The appellant further states that sometimes the Veteran would state things he did in which he did not do. Finally she claims that the evidence submitted should be sufficient to grant her claim and that she does "this for him and all the Nam Vet's which still today are not at peace with all the nightmares and all the flashbacks of Nam! I know because I live this nightmare with him thru (sic) his eyes! I as well suffer from PTSD due to all of his suffering!" Finally, in a July 2010 statement, the appellant stated that she was the "normal one mentally speaking" in her marriage. She stated she was married to an "unstable" man. She related that the Veteran would "freeze" on walks as soon as he heard a chopper or loud noises. He felt unsafe, scared, but ready to do anything if he entered what she call his "Flashback Mode." She stated that once he went into that mode, he was a soldier that would kill and hurt if he thought he was back in Nam. She related that they did not celebrate Independence Day because of the loud noises from bombshells, fire crackers, and fireworks but instead stayed locked up inside their home with the air conditioning on trying to block the noise. She reported that many times she took the Veteran to the psychiatric unit at Brecksville. She stated he was not stable at times and went through counseling where they sat with others and spoke about Vietnam. Afterward he would be fine for a few weeks, but then the night sweats and bad dreams would begin again. She recalled an event that occurred in the mid 1980s during the middle of July in which one day she came home to find the Veteran in the center of the living room floor with his face dripping in sweat, dressed in fatigues and combat boots and with his dog tags on. He had this vine-like plant that she had hanging from the ceiling wrapped around him like he was hiding behind this big tree. She stated that he hid as soon as he saw her. He then got down and crawled up to her and pulled her down to the floor. He then took a knife that was from the kitchen and placed it on her throat. She stated she knew he was back in Vietnam. He then grabbed her hair and pulled her head toward him and said, "Shush. Don't say a word." Then he dragged her to the bathroom and he said something in a foreign language that she said was Vietnamese. She said she looked into his eyes and they were like night, no emotion. She then called him by a name that they called him in Vietnam and told him to calm down. He said, "Man they going to blow us. We got to go, man. These bastards going to blow us." She kept speaking to him and eventually her voice reached him and he came back. The Veteran started crying. She stated that she called their counselor at Brecksville that same day and that the Veteran was admitted to the hospital where he stayed inpatient for almost three months. Finally, she stated that she asked her two daughters to write and share their stories, but she did not ask her son because he was only 12 when the Veteran died. She stated that her son's room was filled with all kinds of military planes hanging from his ceiling and military books because that is all the Veteran would speak about to him, about war and fighting for your country. In addition to her statements, she submitted two other lay statements. One statement submitted in August 2009 is dated July 18, 1983, reportedly written by the Veteran. The Board notes that this statement is dated a mere four days after VA received the Veteran's claim for service connection for PTSD; however, it not a part of the claims file and it not noted as having been a part of the record considered at that time. The Board, therefore, questions the authenticity of this document as it is type written in its entirety and not signed by the Veteran, when everything he submitted in July 1983 in support of his claim was hand written. Nevertheless, the Board finds this statement to not be sufficiently definite to demonstrate he had PTSD. Essentially in this statement, the Veteran purportedly is informing whomever that there are prisoners of war (POW's) in America because they are mentally still in Vietnam trapped with the horrors of war that 19 year olds went through, which the VA calls PTSD. Thus, the letter states things in the general rather than specific to the Veteran. The second statement is a letter from one of the Veteran's daughters dated in August 2009. In this letter, the daughter stated that her father was a loving man but that sometimes he was not in a normal mental state. She stated that they could not sneak up on him at night as he would startle easy. She related an incident in which she once caught the Veteran listening to "Vietnam helicopter records" and she tapped him on the shoulder. He turned around fast and knocked her over, scared she was going to kill him. She reported that he was often somewhere else mentally. She further related that the Veteran always wanted her to pursue a life in the military and enrolled her in the Civil Air Patrol and made her participate in every event even though she was not really interested in it. She also stated that the Veteran wrote to the senior officers of the Civil Air Patrol a letter asking to be put on their staff and that he sent this letter to them every few months. She related another incident in which she woke up on night to her mom putting away a samurai sword from her bedroom and was told that the Veteran had put it under his pillow, transported again to Vietnam and that they were after him. She stated that they all walked on eggshells making noise when they walked near him so he knew they were there. Finally, she stated that many times she woke up at night and the Veteran was watching old war movies. To assist the appellant in developing this theory of entitlement for service connection, the Board remanded her appeal in November 2010 to obtain a medical opinion. In June 2011, after reviewing the claims file and electronic records, a VA psychologist gave an opinion that it is likely the Veteran had a mental disorder but, unfortunately, the exact nature of his mental health problems is a matter of speculation. He stated that the record clearly indicated he abused alcohol and heroin, which would have likely been diagnosed on Axis I as alcohol addiction and opiate addiction. There was no clear record of any other diagnosis on Axis I. However, Axis II was mentioned as the likely cause of his problematic behaviors. Although at this point in time it is a matter of speculation, Axis II issues fit the pattern of his behavior, including the suicidal behavior. There were no other mental health records found from the period between 1983 and his death in 2004. Since there was no clear diagnosis of any anxiety or depressive disorder, it is a matter of speculation as to whether his drug use was related or caused by any other putative mental health diagnosis. No records were found to suggest that anything aside from the drug abuse had any significant role in his death from liver disease. Therefore, the VA psychologist opined that it is unlikely that any other mental health diagnosis of on Axis I contributed substantially or materially to the Veteran's death. Based upon this opinion, the denial of the appellant's claim was continued, and her appeal returned to the Board. The Board determined that the June 2011 medical opinion was inadequate as it essentially states that an opinion as to whether the Veteran had a mental disorder for which he self-medicated would be speculative without a clear rational as to why an opinion could not be rendered. Thus, the Board requested an independent medical expert (IME) opinion to obtain a more clear and definitive medical opinion. The IME was asked to render an opinion as to whether it is at least as likely as not (i.e., at least a 50 percent probability) that the Veteran had a chronic psychiatric disability (to include, but not limited to, PTSD - but other than alcohol and substance abuse and a personality disorder) related to his military service. It was advised that, in rendering a diagnosis, the IME should take into consideration the lay statements submitted by the appellant and her daughter as to the Veteran's mental status, the medical evidence of mental health treatment both in and after service, and any VA and non-VA medical opinions of record. If the IME found the Veteran had a chronic psychiatric disability other than alcohol and substance abuse and a personality disorder that is related to his military service, then he/she should provide an opinion as to whether it is at least as likely as not that the Veteran's use of IV drugs was for therapeutic purposes or was the result of said chronic mental disorder. In an April 2012 medical opinion, Dr. W. B. Lawson from the Department of Psychiatry and Behavioral Services at Howard University opined that the evidence supports concluding that the Veteran likely had PTSD and perhaps depression that were in all likelihood service related. In setting forth his opinion, Dr. Lawson noted that, while the Veteran was stationed in Vietnam, he was not assigned to combat duties. Nevertheless, his wife and daughter, various medical contacts including two psychiatric admissions, and examinations in various treatment programs reported his flashbacks, re-experiencing, hyper-responsiveness to anything resembling the Vietnam experience, avoidant behavior and emotion numbing. He stated that combat experience is not required for PTSD and a perceived threat to life whatever the cause certainly could be. He certainly appeared to have been in or close to combat zones. Dr. Lawson also stated that the Veteran had many of the symptoms of major depression including sadness, difficult sleeping, loss of interest in his usual activities that he enjoyed and several episodes of what appeared to be self-injurious. Depression is often comorbid with PTSD but depressive symptoms are often another expression of drug abuse and withdrawal. As to the Board's second question, Dr. Lawson stated that the evidence that the Veteran's drug use was some sort of self-medication or a result of the PTSD or depression is not strong. He stated that the Veteran noted in his deposition before the Army Discharge Review Board that his drug abuse began at age 16, which was before he entered service. Moreover, Dr. Harry Murphy noted in his evaluation in 1971 that the Veteran joined the Army in lieu of receiving a potential prison sentence for possession of narcotic agents. Thus, Dr. Lawson opined that it is more likely that the Veteran's drug use is more related to his personality disorder, which appears to have antisocial features and which existed before his entrance into the service. Thus, he concluded that it is unlikely that his drug use was a result of any service-connected disorder. In response to this medical opinion, the appellant's representative argued that it did not address whether any service-connected psychiatric disorder aggravated a pre-existing substance abuse disorder, and this is a pertinent question which must be considered. The Board agreed and, in June 2012, requested a second IME opinion in which the Board asked whether it is at least as likely as not that the Veteran's service-related psychiatric disorders diagnosed by Dr. Lawson as PTSD and depression chronically worsened the Veteran's pre-existing substance abuse (specifically his IV drug use). In July 2012, a medical opinion was provided by Dr. R. J. Diamond from Wisconsin Psychiatric Institute & Clinics. Unfortunately, rather than answer the narrow question asked by the Board, Dr. Diamond proceeded to evaluate the question of whether the Veteran's death was related to his military service to include whether his PTSD could have been a significant contributor to his substance use, and therefore a significant contributor to his eventual death. In doing so, he noted the Veteran's military service, including his service in Vietnam and stated that his military records do not support any direct exposure to combat or to life-threatening trauma. However, he acknowledged that neither is required for a diagnosis of PTSD. Dr. Diamond stated that, in his review of the treatment records and other documentation that was made available to him, he specifically looked for evidence while the Veteran was alive of symptoms that would have supported a diagnosis of PTSD, or a significant change in life direction that would have supported this diagnosis. He stated that the documentation of either kind of support is very scant. He noted that there are very moving letters from both the Veteran's daughter and spouse describing clear symptoms of PTSD, but that both of these letters were written after his death and that there is no contemporaneous documentation provided of similar descriptions or concerns while he was alive. There is certainly no documentation of on-going patterns in the available documentation. Similarly, there is a single positive screen for PTSD done in the ambulatory care clinic of Vista VA center in Cleveland on August 21, 2001, and a phone call shortly before suggesting that the Veteran's PTSD symptoms had gotten worse and that he wanted to re-engage in treatment for this. He noted that there was no record made available to him that the Veteran had previously been in treatment for PTSD, and suggestion from other reviewers that he had not been in such treatment. There was also no mention that he followed up with obtaining such treatment after the August screen. On the other hand, Dr. Diamond stated that there was some support that the Veteran had provided inaccurate information to other medical providers, which makes the history that he provided suspect at least. For example, a letter from Dr. K. Mullin at Case Western supported VA benefits based on the possibility that the Veteran could have contracted the hepatitis C from "a blood transfusion after a gunshot wound in Vietnam." This physician's letter also cited the risk because "on a number of occasions was shot with bullets in Vietnam that had passed through a number of individuals." Dr. Diamond noted, however, that there was no documentation that the Veteran had been shot in Vietnam, or had been shot with bullets that had passed through other individuals or had obtained a blood transfusion. Dr. Diamond assumed that this fabrication was told to this doctor by the Veteran in an attempt to enlist some kind of support or sympathy, and is more in keeping with ongoing personality problems than with PTSD. Furthermore, Dr. Diamond noted that, during his Brecksville inpatient psychiatric admissions for substance abuse, the Veteran indicated that he had started using alcohol at 14 and heroin at 15. There was mention that he entered the Army in lieu of a sentence for drug possession. This would support that the Veteran's drug problem predated his admission to the Army. In the appeal presented by the appellant's representative in September 2010, it was suggested that the Veteran was "first suspected to have abused drugs in November 1969." The Veteran acknowledged having abused IV heroin well before entering the Army. This same report references treatment for PTSD that allegedly occurred at the VA Medical Center Brecksville. However, documentation of this treatment was evidently never found, and given the reliability of the VA electronic records system it is likely that no such treatment occurred. There was records from an admission to Brecksville October 26, 1983 when the Veteran was admitted for "severe marital problems, drug abuse, and threatening to kill his wife." During this admission, there was psychotic symptoms that seemed to clear rapidly but no symptoms that suggested PTSD. He was discharged from this admission for continued drug use while on the psychiatric unit. In conclusion, Dr. Diamond stated that, based on the documentation that was provided to him for this review, he believes that it is most likely that this Veteran was a troubled man with ongoing drug and behavioral problems before he entered the Army, and that these problems continued during his period in the Army and after his discharge. He saw no objective evidence that the Veteran had significant symptoms of PTSD noted in his complaints to physicians or noted by behavioral specialists, other than his one positive PTSD screen. He also was not impressed that the Veteran's life took a clear downward turn in his stability or ability to function. Thus, Dr. Diamond opined that it is less than 50 percent likely that the Veteran's hepatitis C was connected to PTSD or the Veteran's Army experience. The Board notes that, at this point, it now had multiple inconsistent medical opinions as to whether the Veteran had PTSD or some other psychiatric disorder related to his military service. In order to resolve those inconsistent opinions, the Board requested a third IME opinion in September 2012. In October 2012, the Board received a medical opinion from Dr. A. S. A. Meguid, an Assistant Professor of Psychiatry at Virginia Commonwealth University Medical Center. Dr. Meguid began by noting that the Veteran was in Vietnam from May 1969 to April 1970 with no reported combat experience or life threatening experience. He further notes that, as indicated in the records, the Veteran reportedly joined the military in lieu of receiving a potential prison sentence for possession of drugs (narcotics) (psychiatric evaluation of February 1971), he reported to his examiner in June 1970 that he had been using "drugs" since the age of 16, and he indicated to his evaluator during an inpatient psychiatric admission in October 1983 that he started using alcohol at age of 14 and heroin at the age of 15 and was still using both at the time of that admission, which was because of a threat to kill his wife, and marital and legal issues in the context of alcohol and heroin abuse. Based on this and other documentations in the records, Dr. Meguid stated that the Veteran's alcohol and illicit drug/heroin use (including IV drug use) obviously started prior to his joining the military and being in Vietnam, continued throughout his time in the military, and continued well beyond discharge from the military and most probably caused his hepatitis C that lead to liver cirrhosis and resulted in his death in November 2004 as indicated by different medical opinions in the record. Dr. Meguid further stated that the Veteran's behavior reported in the records prior to being in the military as evidenced by the circumstances of him joining the military as indicated above, his behavior while in the service with documented "20 Article 15s," reason for discharge from the military, and inaccurate information provided by the Veteran to medical providers at certain points (example: having blood transfusion because of gunshot wound while in Vietnam, which caused hepatitis C, per Veteran's report, with no objective evidence for that), leaves little doubt about the diagnosis of "Personality Disorder," which is documented in his records both while in the military and during his psychiatric hospitalizations years later (1979 and 1983). Dr. Meguid stated that, with the exception of a number of letters written by his widow and his daughter, following the Veteran's death, describing "PTSD" symptoms that the Veteran was suffering from; the Veteran's letter dated July 18, 1983 describing PTSD symptoms; and a single positive screen for PTSD in Cleveland in August 2001, there is no objective evidence in the records which would support that diagnosis, not to mention any evidence that the Veteran was treated for it at any time. This is somewhat odd and raises significant doubt about that diagnosis, given the fact that the Veteran had psychiatric evaluation Mental Hygiene Consultation Service Certificate of February 22, 1971 while in service and that diagnosis and its symptoms were never documented. Also, he had couple of inpatient psychiatric stays many years later (1979 and 1983) with no mention of diagnosis, and, even with hospitalizations of his neck problem in 2001, and for his liver condition in 2004, neither PTSD nor any other psychiatric diagnosis was listed as part of the Veteran's history. One would have expected to see objective evidence of that diagnosis at one point during the Veteran's life, especially with his widow mentioning in one of her letters (July 12, 2010) that she had to live with his PTSD symptoms for the 25 years of their marriage. Dr. Meguid further stated that, although the Veteran had a couple of psychiatric hospitalizations many years following discharge from the military, one of them (1979) was for a self-inflicted gunshot wound to the abdomen with a diagnosis of "Depressive reaction," there was no mention of any other Axis I diagnosis or documentation referring to a relationship of that incident to his military service. the other rather well documented inpatient psychiatric treatment of 1983 only lists the Veteran's diagnosis at the time of discharge as "Dependence to Opioids and Alcohol, and Passive Aggressive Personality." There has been no documented objective evidence of other psychiatric disorders during the Veteran's service in the military or after that. Based on the records provided to him, including the two prior IME opinions, Dr. Meguid's impression was as follows: 1. The Veteran suffered from alcohol and IV heroin abuse/dependence that started well before him joining the military and continued while in the service and for years after that. 2. The Veteran had a Personality disorder (Passive Aggressive per record) that predated him joining the military and continued throughout his life and affected his behavior, emotions, and relationship with people. 3. There is no objective evidence to support a diagnosis of PTSD or any other chronic psychiatric condition (other than alcohol and substance abuse and a personality disorder) related to the Veteran's reported service in the military. 4. Given that there is no objective evidence to support that the Veteran had any service-related psychiatric disorder (#3), then there is no evidence that any psychiatric disorder chronically worsened the Veteran's pre-existing substance abuse/dependence. The Board must evaluate this evidence in rendering a decision, including an analysis of the credibility and probative value of the evidence, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Moreover, the Board may not base a decision on its own unsubstantiated medical conclusions, but, rather, may reach a medical conclusion only on the basis of independent medical evidence in the record or adequate quotation from recognized medical treatises. Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, the Board must account for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Nevertheless, when, after considering all the evidence, a reasonable doubt arises regarding a determinative issue, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. While the Board may not reject a favorable medical opinion based on its own unsubstantiated medical conclusions, Obert v. Brown, 5 Vet. App. 30, 33 (1993), the Board does have the authority to "discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence," Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In evaluating the probative value of competent medical evidence, the Court has stated, in pertinent part: The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicator . . . . Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The Board may appropriately favor the opinion of one competent medical authority over another, provided that it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). A physician's access to the claims file and the thoroughness and detail of the opinion are important factors in assessing the probative value of a medical opinion. Prejean v. West, 13 Vet. App. 444, 448-99 (2000). The Board is not bound to accept an opinion based on history provided by the appellant and on unsupported clinical evidence. See Black v. Brown, 5 Vet. App. 177, 180 (1993). An opinion based upon an erroneous factual premise has no probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). After considering and weighing the above evidence, the Board finds the more probative and persuasive evidence to be the July and October 2012 IME opinions that found that the Veteran did not have PTSD or any other psychiatric disorder other than alcohol and drug abuse/dependence and personality disorder during his lifetime. The Board notes that the Court has held that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). As will be discussed in further detail below, the Board finds that these medical opinions are factually accurate, fully articulated, and based on sound reasoning unlike the other opinions. The June 2011 VA psychologist's medical opinion has already been determined by the Board to be inadequate as the psychologist essentially stated that any opinion given would be speculative without giving a clear rationale as to why an opinion could not be provided. Thus, there is no clear basis for the psychologist's final opinion that it is unlikely that any other mental health diagnosis on Axis I (meaning other than alcohol addiction and opiate addiction) contributed substantially or materially to the Veteran's death. Consequently, the Board finds that this medical opinion has no probative value. A medical opinion based on speculation, without supporting data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 5 Vet. App. 104, 145 (1999). Furthermore, the Board finds Dr. Lawson's April 2012 IME opinion to not be adequate because he fails to provide a clear rationale for his opinion upon which the Board can use to provide adequate reasons and bases. In rendering an opinion that the Veteran likely had PTSD or depression during his life related to his military service, Dr. Lawson cites to evidence consisting of statements from the Veteran's "wife and daughter, various medical contacts including two psychiatric hospital admissions, and examinations in various treatment programs reported his flashbacks, re-experiencing, hyper-responsiveness to anything resembling the Vietnam experience, avoidant behavior and emotional numbing." Dr. Lawson did not specifically reference the evidence that he was relying on in making this statement unlike the IMEs who provided the July and October 2012 opinions. The Board notes, as did the IMEs who provided the July and October 2012 opinions, that there is no medical treatment records in the claims file demonstrating any report of symptoms consistent with PTSD. Thus, although the Board can identify the statements by the Veteran's wife and daughter and the two psychiatric hospital admissions referred to as those from 1979 and 1983, it cannot identify any "examinations in various treatment programs" that report symptoms of PTSD. Nor can the Board determine what evidence Dr. Lawson relied upon in stating there is evidence that the Veteran had symptoms of major depression including sadness, difficult sleeping, and loss of interest in his usual activities that he enjoyed. As the evidentiary basis of Dr. Lawson's medical opinion is unclear to the Board, it must find that such opinion lacks probative value because the Board is unable to determine whether it is based upon a factually accurate basis or upon sound reasoning. Unlike the June 2011 and April 2012 medical opinions, the IME opinions from Dr. Diamond and Dr. Meguid provided in July and October 2012, respectively, are clearly based upon a full and comprehensive review of the record as not only do they set forth what they believe is the pertinent evidence with citations to the exact evidence relied upon, but also point out the lack of evidence that supports their opinions. Thus, the Board is able to clearly tell the evidentiary basis upon which their conclusions are based. Each physician discussed both the positive and negative evidence relating to the claim in rendering an opinion. For example, each physician at least references the lay statements provided by the appellant and her daughter (and Dr. Meguid even discusses the Veteran's August 1973 letter). Even though both physicians do not clearly state that they are finding that the objective evidence outweighs the lay statements in rendering their opinions, the inference is clear from their statements that they assigned more weight to the objective evidence or lack thereof relating to the Veteran's mental health than the lay evidence in rendering their opinions. Both physicians indicated that the lay statements were rendered after the Veteran's death, which the Board finds significant as it raises the inference that the physicians found the statements to be biased. Therefore, both physicians relied on the objective evidence of record and found this evidence to be more persuasive in determining whether the Veteran had a psychiatric disorder that could have either caused or aggravated the Veteran's IV drug use that resulted in his hepatitis C that led directly to his death. Thus, the Board finds the July and October 2012 IME opinions to be highly probative and very persuasive as to the question of whether the Veteran had a psychiatric disorder other than alcohol and drug abuse/dependence and a personality disorder during his lifetime. Both physicians opined that he did not and provide complete and comprehensive reasoning for their opinions unlike the two previous opinions obtained. In making this finding, the Board does not overlook the lay statements provided by the appellant and her daughter as to the Veteran's mental status during his life. The appellant and her daughter are competent to provide testimony concerning factual matters of which they have firsthand knowledge. Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Further, under certain circumstances, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Thus, the appellant and her daughter are able to provide testimony as to what they witnessed, such as symptoms the Veteran had or events that happened, and that the Veteran had some mental issues during his lifetime. Whether the Veteran had a psychiatric disorder meeting the criteria for a diagnosis of set forth is the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). Id. at 443.), however, is a determination "medical in nature" requiring medical expertise, and the evidence fails to show that either the appellant or her daughter have such expertise. See 38 C.F.R. § 3.159(a)(1) (Competent medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements or opinions). The Board does acknowledge that there is a notation in the 2003/2004 private medical records that the appellant is an LPN, which is a nursing license obtained after two years of training. The appellant, however, has not shown that she has any particular expertise in psychiatry in order to be competent to render a diagnosis of any psychiatric disorder, which she has by stating that the Veteran had PTSD. Thus, the Board finds that, in so far as the statements by the appellant and her daughter state that the Veteran had any specific psychiatric disorder, those statements are not competent medical evidence and have no probative value in determining whether the Veteran had a psychiatric disorder other than alcohol and drug abuse/dependence and a personality disorder. To the extent that those statements set forth what they witnessed as to the Veteran's mental status during his life, the Board finds that those statements are competent. The Board further notes that those statements are not inherently incredible. Furthermore, as to the daughter's statement, the Board does not find any reason to find it not credible. The probative value of her statement, however, is somewhat reduced by the fact that there is an inherent bias the statement as it was submitted in support of her mother's claim for compensation benefits. As for the appellant's statements, although most likely credible, the Board finds that their probative value is lessened by inconsistencies among the statements, as well as being inconsistent with other evidence of record. One inconsistency among the statements is in the appellant's report of how long she lived with the Veteran. The marriage certificate of record indicates the appellant and Veteran married in December 1984. Thus, they would have been married essentially for 20 years. The appellant, however, has stated inconsistently that she lived with or was married to the Veteran for 22 years (see September 2005 statement) and 25 years (see August 2009 and July 2010 statements). Such reports would have placed them together as far back as 1982 and 1979, respectively. If such was the case, then the appellant's statements that the Veteran never used alcohol or drugs while he lived with her are inconsistent with the 1983 VA hospitalization records for alcohol and opiate dependence. If she had known or lived with the Veteran in 1983 like her statements indicate, the Board finds it unlikely that she would not have know about his substance abuse and, therefore, her statements are either incorrect as to the timeframe she lived with the Veteran or she is not being fully forthcoming in saying that the Veteran was clean and sober for all the time she knew him. Furthermore, the Board notes that the timeframes given by the appellant would mean that she was with the Veteran when he was married to other women as shown by the record, which shows he was divorced in 1979 from Chris and divorced in 1983 from Anne. More importantly, although the record is unclear as to when the Veteran stopped using heroin as the last treatment of record for it was the October 1983 VA hospitalization, the more recent VA and private treatment records indicate the Veteran continued to use alcohol until at least 2001. The August 2, 2001, Mental Health Clinic telephone call note demonstrates the Veteran reported drinking alcohol for coping/self-medication. He reported having drunk "half a bottle of whiskey and rum over the weekend." A February 2004 private gastroenterology consultation note indicates the Veteran reported having drunk for years a pretty steady alcohol intake quitting three to four years ago. Such contemporaneous statements made by the Veteran in the context of seeking treatment carry more weight than the appellant's statements made in conjunction with seeking monetary benefits. Furthermore, the Board notes that, although the appellant consistently reported that the Veteran received frequent psychiatric treatment, both inpatient and outpatient, at the VA in Brecksville, no mental health treatment records except for those from 1983 were obtained despite multiple requests for such records. The Board specifically requested in its November 2010 remand that the AMC obtain the Veteran's psychiatric treatment records from the Brecksville VA medical facility for the period of December 1983 to November 2004 and that the VA facility should provide a negative response if records are not available. In response to the request, the AMC sent to the Cleveland VA Medical Center (of which Brecksville is a division) a request for these records. Such request stated that, if records have been retired, they must be recalled, and if records are destroyed or unavailable, to provide a negative response in writing to the AMC. In reply, the Cleveland VA Medical Center provided treatment records relating to the Veteran for the period of August 2001 to April 2002. The Board notes that these records were previously associated with the claims file in November 2005 and contained notes through August 2003; however, any notes subsequent to April 2002 were not treatment notes but essentially were notes indicating that the Veteran failed to show for appointments. Given the presumption of regularity, the Board has no choice but to accept that the records provided by the Cleveland VA Medical Center are all the records they have for the Veteran between December 1983 and November 2004. There is a presumption of regularity that applies to official acts, and "in the absence of clear evidence to the contrary, courts presume that they have properly discharged their official duties." Ashley v. Derwinski, 2 Vet. App. 62, 64 (1992) (citing United States v. Chemical Foundation, Inc., 272 U.S. 1, 14-15 (1926)); see also Thompson v. Brown, 8 Vet. App. 169, 177-178 (1995) (applying the presumption of regularity to notice of a Board decision). The appellant has been advised multiple times as to what VA treatment records have been obtained. She has not shown that there are other VA treatment records outstanding despite her statements to the contrary. In addition, the Board notes that the August 2, 2001, Mental Health telephone call note indicates the Veteran reported he had recently returned to the Cleveland area from Florida and yet the appellant has never indicated, nor does the record show, that the Veteran received any mental health treatment at a VA medical facility in Florida. Moreover, there is no indication in the record how long the Veteran lived in Florida thus casting doubt on the appellant's statements that the Veteran received near continuous (or at least frequent) mental health treatment in Ohio at the Brecksville VA facility. Given these multiple and significant inconsistencies in the appellant's statements in comparison with the evidence (or lack thereof) of record, the Board finds that the probative weight to be given her statements is lessened significantly. The Board does not find, therefore, the appellant's statements are persuasive to establish that the Veteran had any psychiatric disorder other than his alcohol and drug abuse/dependence and a personality disorder during his lifetime and that such psychiatric disorder either led to or aggravated his IV drug use that led to his contracting hepatitis C, which eventually led to his death resulting from cirrhosis of the liver. The Board notes that, although VA's system is not adversarial and VA has a duty to assist claimants in establishing their claims, "[i]t is the [claimant's] 'general evidentiary burden' to establish all elements of [her] claim, including the nexus requirement." Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed.Cir.2009). In addition, although VA is to afford the claimant the benefit of the doubt when the evidence is in relative equipoise, the benefit of the doubt doctrine is not concerned with the quantity of evidence arrayed on both sides of a material matter, but the relative quality and persuasive effect of that contrary evidence. See 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). In the present case, the Board finds that the preponderance of the evidence is against finding that the Veteran had a psychiatric disorder other than alcohol and drug abuse/dependence and a personality disorder during his lifetime. The Board find, therefore, that the Veteran did not have a psychiatric disorder that is subject to service connection. The probative and persuasive evidence fails to demonstrate that the Veteran had any psychiatric disorder other than his alcohol and drug abuse/dependence and a personality disorder that may have been related to his military service. As set forth above, the Veteran's IV drug abuse is considered to have been willful misconduct. Consequently, service connection for such is barred by law. See 38 C.F.R. § 3.301(c) and (d). As for the Veteran's personality disorder, such is explicitly excluded as a disability for VA compensation purposes. See 38 C.F.R. § 3.303(c) (congenital or developmental defects, refractive error of the eye, personality disorders and mental deficiencies are not diseases or injuries within the meaning of applicable legislation, and therefore cannot be service connected); Winn v. Brown, 8 Vet. App. 510, 516 (1996). The Veteran is, therefore, also barred under the law from obtaining service connection for his personality disorder. Thus, the Board concludes that service connection for the cause of the Veteran's death is not warranted on a secondary basis. In other words, the evidence fails to establish that the Veteran had a psychiatric disorder related to his military service for which service connection should have been established during his lifetime and that significantly and materially contributed to the cause of his death by either causing or resulting in his IV drug abuse or that aggravated his IV drug abuse thereby leading to his contracting hepatitis C, which resulted in the cirrhosis of the liver that caused the Veteran's death. In conclusion, the Board has found that presumptive service connection as due to exposure to herbicides while serving in the Republic of Vietnam is not warranted because hepatitis C is not an enumerated disease found to be associated to such exposure and the appellant has not presented any scientific or medical evidence to conclude otherwise. Furthermore, the Board has found that the preponderance of the evidence is in favor of finding that the most likely cause of the Veteran's hepatitis C was his IV drug abuse rather than any other potential risk factor. Having found that his hepatitis C is the result of IV drug abuse, which is considered willful misconduct, the Board found that direct service connection for hepatitis C is not warranted as it is barred by law. Finally, having found that the probative and persuasive evidence of record fails to demonstrate that the Veteran had any psychiatric disorder during his lifetime other than his alcohol and drug abuse/dependence and his personality disorder, service connection for hepatitis C on a secondary basis (i.e., that it is proximately due to, the result of or was aggravated by a service related psychiatric disability) is also not warranted. For the foregoing reasons, the Board finds that the preponderance of the evidence is against finding that entitlement to DIC benefits based upon service connection for the cause of the Veteran's death is warranted. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Service connection for the cause of the Veteran's death is, therefore, denied. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for cause of the Veteran's death is denied. ____________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs