Citation Nr: 1804928 Decision Date: 01/25/18 Archive Date: 02/05/18 DOCKET NO. 16-43 419 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Florida Department of Veterans Affairs ATTORNEY FOR THE BOARD T. Minot, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from November 2006 to June 2007, and from January 2010 to January 2011. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Board notes that the Veteran requested a Board hearing in September 2016. See VA Form 9 (September 2016). However, in November 2017 he submitted written correspondence withdrawing his hearing request. In a November 2017 Statement in Support of Claim, the Veteran raised the issues of entitlement to service connection for traumatic brain injury (TBI), headaches, and respiratory and gastrointestinal disorders, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness pursuant to 38 C.F.R. § 3.317. Effective March 24, 2015, VA amended its adjudication regulations to require that all claims governed by VA's adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. See 79 Fed. Reg. 186 (Sept. 25, 2014). The RO is hereby advised that the Veteran has articulated an intent to file a claim for these disabilities, and should take appropriate action. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, his obstructive sleep apnea was aggravated by his service-connected PTSD. CONCLUSION OF LAW The criteria for entitlement to service connection for obstructive sleep apnea on a secondary basis have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran contends that his obstructive sleep apnea was aggravated by his service-connected PTSD, to include as a result of weight gain precipitated by his PTSD medications. See Statement in Support of Claim (November 2017). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection may be granted on a secondary basis for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. VA outpatient records reflect that the Veteran underwent a sleep evaluation in July 2013, following which he was diagnosed with obstructive sleep apnea. A history of obesity and PTSD, among other disorders, was noted. Thereafter, the record contains both positive and negative evidence with respect to the Veteran's assertion that his obstructive sleep apnea was aggravated by his PTSD. In support of his claim, the Veteran has submitted multiple scholarly articles demonstrating an empirical link between psychiatric disorders and sleep disturbance, to include obstructive airway diseases such as sleep apnea. See, e.g., Sharafkhaneh et al., Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort, 28 Sleep 1405 (2005); Colvonen et al., Obstructive Sleep Apnea and Posttraumatic Stress Disorder among OEF/OIF/OND Veterans, 11 J. of Clin. Sleep Med. 513 (2015). He also submitted an article reflecting a link between psychiatric disorders and obesity. See Daniel E. Casey, Metabolic issues and cardiovascular disease in patients with psychiatric disorders, 118 Am. J. of Med. 15S (2005). Also of record is a January 2014 Disability Benefits Questionnaire (DBQ) completed by the Veteran's VA pulmonologist, Dr. Pereira. The report reflects that Dr. Pereira examined the Veteran, reviewed his medical history, and opined that it was at least as likely as not that his sleep apnea was "aggravated by and is secondary to his service-connected PTSD." By way of rationale, Dr. Pereira explained: Sleep disruption caused by OSA can exacerbate anxiety, mental acuity, and depression. In addition, [the Veteran's] PTSD sometimes makes it difficult for him to tolerate his CPAP and also makes it difficult for him to sleep at all, which further worsens his daytime excessive somnolence related to his OSA. His PTSD treatment has also included multiple medications that affect sleep and are known to worsen OSA, and are associated with Obesity which worsens OSA. Evidence of record that weighs against the Veteran's claim consists of August 2014, June 2016, and July 2017 VA medical opinions. The August 2014 opinion notes that according to the online journal UPTODATE, "the most important risk factors for obstructive sleep apnea (OSA) are advancing age, male gender, obesity, and craniofacial or upper airway soft tissue abnormalities." The author determined that, in light of the Veteran's high body mass index (BMI), "[h]is body habitus is most likely the major risk factor of his OSA." Notably, the author did not conduct an in-person examination and did not meaningfully address the Veteran's assertion of a causal link between sleep apnea and PTSD. The June 2016 VA medical opinion acknowledged that severe weight gain can be one of the many "risk factors" for developing sleep apnea. The author noted, however, that "PTSD, in and of itself, does not cause sleep apnea, as it does not cause changes in the upper airways to cause sleep apnea." The author acknowledged the comments made by the Veteran's pulmonologist in the January 2014 DBQ, but noted that such comments concerned mental health symptoms which would be beyond the scope of a practicing pulmonologist. Finally, the author stated: "Comments about true aggravation cannot be provided" given the "many other comorbidities this [Veteran] has." The July 2016 VA medical opinion notes the Veterans' contention that his PTSD medications caused his weight gain, which in turn caused or aggravated his sleep apnea. However, after reviewing the record and listing the relevant medications taken by the Veteran, the author indicated that it was unclear if these medications precipitated weight gain. The author then opined that, given the Veteran's "host of medical and mental health comorbidities that are quite complex and intertwined," it would be "mere speculation to specifically state his medications for PTSD caused his weight gain" or otherwise aggravated his sleep apnea. The Board finds that the evidence of record is in equipoise regarding whether the Veteran's PTSD aggravated his sleep apnea, including as a result of weight gain precipitated by his PTSD medications. As reported in the January 2014 DBQ, there appear to be multiple possible medical explanations as to why his PTSD and associated medications could exacerbate his sleep apnea. These findings are bolstered by scholarly articles, which the Veteran has submitted for the record. By contrast, the VA medical opinions discussed above are more tentative-finding only that it would be mere speculation to conclude that the Veterans' PTSD (including medications taken for his mental health symptoms) would aggravated his sleep apnea. (The August 2014 opinion did not meaningfully address the Veteran's contentions, and is therefore not probative.) It is well established that the Board may not refute expert medical conclusions in the record with its own unsubstantiated medical conclusions. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Thus, absent persuasive medical evidence actually denying a causal link between the Veteran's PTSD and his sleep apnea, the Board finds that the evidence, taken together, is at least in equipoise on this issue. Resolving reasonable doubt in the Veteran's favor, his claim will be granted. See 38 U.S.C. § 5107(b). ORDER Entitlement to service connection for obstructive sleep apnea, secondary to service-connected PTSD, is granted. ____________________________________________ YVETTE R. WHITE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs