Citation Nr: 18145696 Decision Date: 10/29/18 Archive Date: 10/29/18 DOCKET NO. 18-13 921 DATE: October 29, 2018 ORDER Entitlement to service connection for sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD), panic disorder with agoraphobia, and alcohol abuse, is granted. FINDING OF FACT It is as likely as not that the Veteran’s sleep apnea is caused by his service-connected PTSD, panic disorder with agoraphobia, and alcohol abuse. CONCLUSION OF LAW The criteria for service connection for sleep apnea, to include as secondary to PTSD, have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2002); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1985 to January 1990, and from February 1991 to March 1991. This matter is before the Board of Veterans’ Appeals on appeal from an October 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. Here, the Veteran argues that his sleep apnea is secondary to his service-connected PTSD. As will be discussed below, the Board is granting this claim because there is competent medical evidence indicating that it is as likely as not that the Veteran’s sleep apnea is secondary to his PTSD, panic disorder with agoraphobia, and alcohol abuse. Service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310 (a). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or aggravated by, a service-connected disease or injury. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) evidence that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service connected disability. With respect to evidence of a current disability, the Veteran was diagnosed with obstructive sleep apnea in June 2017. A current disability has therefore been demonstrated. With respect to evidence of a service connected disability, the record reflects that the Veteran was granted service connection for PTSD, panic disorder with agoraphobia and alcohol abuse effective August 23, 2012. A service connected disability has been demonstrated. As the record contains evidence of a current disability and evidence of a service connected disability, what remains to be established is whether the current disability was either (a) proximately caused by or (b) proximately aggravated by a service connected disability. The record reflects that the Veteran was afforded a Compensation and Pension examination in October 2017. Based on an examination of the Veteran, a review of the medical evidence of record, and a consideration of his complete medical history, the VA examiner ultimately determined that the Veteran’s sleep apnea “is less likely than not (less than 50% probability) proximately related to the Veteran’s post-traumatic stress disorder (PTSD), panic disorder with agoraphobia, and alcohol abuse.” Notwithstanding this opinion, the examiner noted that “[a]lcohol, sedatives and tranquilizers . . . promote sleep apnea by relaxing the throat.” The examiner concluded that the Veteran’s risk factors, including alcohol and sedatives, were more likely the cause of his sleep apnea. In August 2017, the Veteran submitted a letter and treatment records from a private psychiatrist, noting that the he had a confirmed diagnosis of sleep apnea. The psychiatrist opined that it was as likely as not that the Veteran’s sleep apnea is aggravated by his PTSD, with symptoms of anxiety, vigilance, and insomnia. In support of this opinion, the psychiatrist referenced a “study [that] concluded that the co-morbidity with Depressive disorders is 21.8%, and 16.7% with Anxiety disorders, and 11.9% with PTSD, indicating a significant association when compared to the general population.” Although the clinician noted that “neither diagnosis cause the other, the co-morbidity is quite high.” The examiner also noted that the anxiety the Veteran experiences from his service connected PTSD makes it difficult to wear the CPAP mask that has been proscribed for his sleep apnea. It was noted that the anxiety associated with his PTSD is aggravating his sleep apnea. The weight of the evidence supports a finding that there is a relationship between the Veteran’s sleep apnea and his service-connected PTSD, panic disorder with agoraphobia, and alcohol abuse. As noted above, despite the October 2017 VA examiner’s conclusion that the sleep apnea was less likely than not related to the service-connected PTSD, the examiner specifically found that the sleep apnea was caused by his risk factors including the Veteran’s medication (Trazodone) and alcohol abuse. However, the Veteran’s treatment records reflect that he is prescribed this medication specifically to treat his service-connected PTSD, panic disorder with agoraphobia, and alcohol abuse. Additionally, the VA examiner noted that alcohol use was a risk factor for the development of sleep apnea, but failed to recognize that the service connected condition includes “alcohol abuse.” Accordingly, it cannot be said that the VA examination report reflects a negative finding as to the causal relationship between the Veteran’s service-connected disability and his active service. Rather, this report tends to establish a nexus between the service connection PTSD, panic disorder with agoraphobia, and alcohol abuse and the medications prescribed for its treatment, and diagnosed sleep apnea. As such, and considering the positive opinion of the Veteran’s private provider, the Board finds that the evidence for and against the claim is at least in equipoise. When the evidence for and against the claim is in relative equipoise, by law, the Board must resolve all reasonable doubt in favor of the Veteran. See 38 U.S.C. § 5107 (2002); 38 C.F.R. § 3.102 (2016); see also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Therefore, the benefit of the doubt must be resolved in favor of the Veteran and entitlement to service connection for sleep apnea secondary to service-connected PTSD is granted. M. Donohue Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Mahlet Makonnen, Law Clerk