Citation Nr: 18144956 Decision Date: 10/25/18 Archive Date: 10/25/18 DOCKET NO. 17-26 761 DATE: October 25, 2018 ORDER Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected posttraumatic stress disorder (PTSD) is granted. FINDING OF FACT The evidence is at least in equipoise as to whether the Veteran OSA is proximately due to his service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for OSA, to include as secondary to service-connected PTSD have been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.310(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1980 to April 2000. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected posttraumatic stress disorder (PTSD) The Veteran asserts that his sleep apnea was caused by his service-connected PTSD. The Veteran does not contend that his sleep apnea was incurred or aggravated during service and there is no evidence of sleep apnea or other sleep disorder in his service medical records. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, a service-connected disability. The Board concludes that the evidence is in equipoise as to whether the Veteran’s current OSA disability is proximately due to or the result of his service-connected PTSD. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310 (a). In a November 2015 private opinion, the Veteran’s physician stated that PTSD might not cause sleep apnea, but might exacerbate the symptoms because there was more REM sleep in PTSD and because the apnea episodes happened during REM sleep due to the decrease in the muscle tone and the airway. Therefore, the private physician argued that PTSD worsened sleep apnea; the private physician asserted that the Veteran’s PTSD and related sleep disorder might worsen his sleep apnea symptoms. The private physician further argued that on the other hand sleep apnea could worsen the symptoms of anxiety and depression according to a study at a sleep and wake center; therefore, since PTSD was an anxiety disorder it could be said that sleep apnea could worsen the symptoms of PTSD. There had been several studies that showed a reduction in nightmares in PTSD patients, when sleep apnea was treated. Additionally, the private physician referenced to a large cohort study, which concluded that the co-morbidity with depressive disorders was 21.8 percent, 16.7 percent with anxiety disorders, and 11.9 percent with PTSD, indicting a significant association when compared to the general population. Thus, the private physician concluded that it was as likely as not that the Veteran’s sleep apnea was aggravated by his PTSD. The private physician also concluded that it was at least as likely as not that the Veteran’s PTSD was aggravated by his sleep apnea and there was a significant co-morbidity between these two conditions. In a January 2016 VA examination, the examiner opined that the Veteran’s sleep apnea was less likely than not proximately due to or the result of the Veteran’s PTSD. The examiner reasoned that it was not found in the literature that PTSD caused sleep apnea. The examiner said that in uptodate.com, it was noted that risk factors for OSA were age, male gender, obesity and craniofacial or upper airway soft tissue abnormalities. Additionally, some studies included smoking, nasal congestion, menopause, and family history. Rates of OSA were also increased in association with certain medical conditions such as pregnancy, ESRD, CHF, chronic lung disease, and stroke. The examiner also said that at www.ncbi.nlm.nih.gov that there was an article in 2011 named “OSA in combat related PTSD.” The study showed that PTSD was not necessarily associated with a higher prevalence of OSA; however comorbid OSA could lead to an increase in PTSD complaints. Thus, the examiner concluded that what was found in the literature related to PTSD causing sleep issues was for sleep disturbance, not sleep apnea.   Accordingly, the Board finds that the opinions of record are afforded equal probative value and service connection for OSA secondary to PTSD is warranted. M. H. HAWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Saudiee Brown, Associate Counsel