Citation Nr: 18142076 Decision Date: 10/12/18 Archive Date: 10/12/18 DOCKET NO. 16-11 107 DATE: October 12, 2018 ORDER Entitlement to service connection for sleep apnea, including as secondary to service-connected major depressive disorder and PTSD, is denied. REMANDED The claim of entitlement to service connection for high blood pressure, including as secondary to service-connected major depressive disorder and PTSD, is remanded. The claim of entitlement to an initial rating in excess of 50 percent for major depressive disorder and PTSD is remanded. FINDINGS 1. Sleep apnea did not initially manifest in, and is not otherwise related to, the Veteran’s service. 2. The Veteran’s PTSD does not aggravate nonservice-connected sleep apnea beyond its natural progression. CONCLUSION OF LAW The criteria for entitlement to service connection for sleep apnea, including as secondary to service-connected major depressive disorder and PTSD, have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from July 1990 to July 1994. Entitlement to service connection for sleep apnea, including as secondary to service-connected major depressive disorder and PTSD The Veteran seeks service connection for sleep apnea on a secondary basis, as caused or aggravated by service-connected PTSD. Service connection may be granted on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a). Any aggravation of such disability must not be due to its natural progress. 38 C.F.R. § 3.310(b). Service connection may also be granted on a direct basis if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. However, here, the Veteran is not alleging that sleep apnea initially manifested in, or is otherwise related to, service, medical evidence establishes that it was first diagnosed nearly two decades after service, and no medical professional has linked the condition to service. Therefore, the Board finds that the preponderance of the evidence is against a finding that sleep apnea manifested in or is related to service as there is no competent evidence relating sleep apnea to service. The question for the Board is therefore whether the Veteran has sleep apnea that is due to or the result of, or aggravated beyond its natural progression by, his service-connected PTSD. The Board concludes that, while the Veteran has a current diagnosis of obstructive sleep apnea, and he is currently service connected for PTSD, the preponderance of the evidence weighs against finding that PTSD aggravates his sleep apnea beyond its natural progression. 38 C.F.R. § 3.310. VA treatment records show the Veteran was diagnosed with sleep apnea in 2012, two years before being diagnosed with any psychiatric disability. In 2015, in support of the assertion that a psychiatric disability aggravated sleep apnea, the Veteran submitted an article titled, “Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort.” That article, not specific to the Veteran, discusses a study that was conducted to determine whether psychiatric disorders are commonly associated with sleep apnea in Veterans Health Administration beneficiaries. The findings establish that sleep apnea is associated with a higher prevalence of psychiatric comorbid conditions, suggesting that patients with psychiatric disorders with sleep-disordered breathing should be screened for sleep apnea. Two medical professionals, Dr. H. Jabbour, M.D., and a VA examiner, have specifically addressed any association between sleep apnea and psychiatric disabilities, to include major depressive disorder and PTSD, in the Veteran’s case. In a July 2015 letter, Dr. Jabbour explained the nature of obstructive sleep apnea (disorder involving disturbed breathing most commonly during REM (rapid eye movement) sleep when REM muscles become paralyzed, and during REM sleep, decreased muscle tone of the airway is more likely to lead to complete upper airway obstruction), and effect of PTSD on sleep (PTSD patients have dysfunctional sleep mechanisms). Dr. Jabbour indicated that, although PTSD does not cause sleep apnea, because there is more REM sleep in PTSD patients and apnea episodes happen during REM sleep, PTSD might exacerbate the symptoms of the Veteran’s sleep apnea. Based on the nature of sleep apnea and the dysfunction caused by PTSD, Dr. Jabbour concluded that “we can argue that PTSD worsens sleep apnea.” Dr. Jabbour also explained that there are studies showing sleep apnea can worsen the symptoms of anxiety, depression, and anxiety-based disorders like PTSD. Based on those studies, Dr. Jabbour concluded that the Veteran’s sleep apnea is at least as likely as not aggravated by PTSD, that PTSD is at least as likely as not aggravated by sleep apnea, and that there is significant co-morbidity between sleep apnea and PTSD. In March 2017, a VA examiner reviewed the above noted article, Dr. Jabbour’s opinion, and the Veteran’s file. Based on that review, the examiner concluded that the Veteran’s sleep apnea was less likely than not due to or permanently worsened by a service-connected psychiatric disability. The rationale includes that: (1) PTSD does not cause sleep apnea; (2) Several researchers have found a coexistence or association between the two, but none has found a causal relationship; (3) Obstructive sleep apnea is caused by dysfunction of the muscles in the throat, which is not caused by PTSD or any other mental disorder; (4) Dr. Jabbour admits there is no evidence of a causal relationship; (5) There is also no evidence of record that any aggravation of the Veteran’s obstructive sleep apnea is beyond its natural progression; (6) The obstructive sleep apnea could aggravate the Veteran’s PTSD because PTSD affects the normal architecture of sleep, but the contrary does not occur. The article is somewhat probative in that it confirms there is an association between sleep apnea and psychiatric disorders, a fact with which Dr. Jabbour and the VA examiner agree. Its probative value is limited, however, as it discusses any association generally, not in the context of the Veteran’s case. The Board finds that the Dr. Jabbour’s opinion is minimally probative, certainly less probative than the VA examiner’s. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). First, it is partially based on the article, which does not refer to research establishing that a psychiatric disorder can aggravate sleep apnea. Second, it is partially speculative in nature, initially concluding that “we can argue that PTSD worsens sleep apnea,” later, with no further evidence or support, concluding that the sleep apnea is at least as likely as not aggravated by the Veteran’s PTSD. Third, even if it were definitive and consistent, it does not speak to the matter of whether, aggravated or not, any aggravation is beyond the natural progression of the sleep apnea. While the Veteran believes his service-connected psychiatric disability is aggravating his sleep apnea, his opinion is not competent or probative. He is competent to report having experienced worsening symptoms of sleep apnea and anxiety, as those symptoms are capable of lay observation, but the issue of what is causing the worsening is medically complex, requiring knowledge of and the interplay between sleep issues and mental health issues and an interpretation of diagnostic testing. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As the most probative evidence of record establishes that the Veteran’s PTSD does not aggravate his nonservice-connected sleep apnea beyond its natural progression, and research shows that sleep apnea aggravates PTSD, not vice versa, the Board concludes that the criteria for entitlement to service connection for sleep apnea, including as secondary to service-connected major depressive disorder and PTSD, have not been met. The Board finds that the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310. REASONS FOR REMAND Entitlement to service connection for high blood pressure, including as secondary to service-connected major depressive disorder and PTSD The Veteran seeks service connection for hypertension on either a direct basis, as related to, or initially manifesting in, service, or secondary basis, as related to, or aggravated by, service-connected PTSD or ankle and foot disabilities. There are VA and private opinions of record addressing these assertions, but none is adequate to decide this claim. In each case, the medical professional did not discuss the significance of the Veteran’s service medical records, which show the following: (1) a normal blood pressure reading of 120/62 on enlistment examination in July 1989; (2) blood pressure of 124/88 in July 1990, a reading the in-service provider noted was indicative of borderline hypertension; and (3) numerous elevated blood pressure readings taken thereafter, including 130/86 (11/91), 128/82 (2/92), 154/96 (12/93), 158/102 (2/94), 146/88, 150/88, 148/92, 156/84, 154/96, 147/90, and 127/91 (all 3/94). That information is critical as similar readings noted after discharge served as a basis for diagnosing the Veteran with hypertension. Entitlement to an initial rating in excess of 50 percent for major depressive disorder and PTSD is remanded. The Veteran seeks a higher initial rating for a psychiatric disability. He underwent a VA examination in June 2015, but since then, he has submitted private mental health treatment records that suggest a different picture of the disability. Those records include additional diagnoses of panic disorder and agoraphobia, which may or may not be part of the service-connected psychiatric disability, and additional psychiatric symptoms, including a thought deficiency. Because of these findings, another examination is needed to assess whether the Veteran’s psychiatric disability, which now includes major depressive disorder and PTSD, has worsened. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with a medical doctor for an opinion as to whether the Veteran’s hypertension initially manifested in service. The examiner should review the Veteran’s service medical records, which include the blood pressure readings noted above. Based on the review, the examiner should opine whether the Veteran’s hypertension at least as likely as not initially manifested in service or within one year following separation from service. If not, the examiner should opine whether the Veteran’s hypertension is due to, or aggravated by, the chronic pain caused by his service-connected ankle and foot disabilities. The examiner should provide rationale for the opinions. 2. Schedule the Veteran for a VA mental disorders examination. The examiner should review all pertinent evidence of record, including all records of the Veteran’s treatment by H. Jabbour, M.D., and then evaluate the severity of the Veteran’s service-connected major depressive disorder and PTSD. The examiner should record in detail the Veteran's history of mental health symptoms and employment. The examiner should then diagnose all psychiatric disabilities found on examination or which were diagnosed during the appeal, to include panic disorder and agoraphobia. Regarding each newly diagnosed disorder, the examiner should indicate whether it is related to, part of, or indistinguishable from, the Veteran’s service-connected major depressive disorder and PTSD. The examiner should opine regarding the levels of occupational and social impairment and should describe the symptoms resulting in those levels of impairment. The examiner should then indicate whether the symptoms of the Veteran’s service-connected psychiatric disability cause deficiencies in work, school, family relations, judgment, thinking and/or mood. The examiner should opine whether it is at least as likely as not that the Veteran is unable to secure or follow a substantially gainful occupation, consistent with his training and experience. If the Veteran is felt capable of work despite the service-connected disabilities, the examiner should state what type of work and what accommodations would be necessary due to the service-connected disabilities. The examiner should provide rationale for all opinions. Harvey Roberts Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. N., Counsel