Citation Nr: 21004779 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 15-18 931A DATE: January 28, 2021 ORDER Entitlement to service connection for sleep apnea as secondary to posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT The Veteran’s sleep apnea is not shown to be proximately due to or aggravated by service-connected disability. CONCLUSION OF LAW The criteria for entitlement to service connection for sleep apnea as secondary to PTSD have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from April 1967 to January 1969 including service in the Republic of Vietnam. This matter comes before the Board of Veteran’s Appeals (Board) on appeal from a July 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In January 2020, the Board remanded the Veteran’s claim for further development. This matter is now returned to the Board for further decision. 1. Entitlement to service connection for sleep apnea as secondary to PTSD The Veteran contends that he has sleep apnea that was caused or aggravated by his service-connected PTSD. The Veteran was diagnosed with sleep apnea by a sleep study around 2001. See VA examination report, April 2011 at p.10. He is also presently service-connected for PTSD. A May 2019 VA medical opinion was obtained to address secondary service connection, but the examiner provided no rationale for the opinion. Therefore, the Board finds the May 2019 VA medical opinion to have low probative value. A May 2015 private medical opinion by Dr. H.S. shows he noted a review of some records and opined that the Veteran’s PTSD “aided in the development of and permanently aggravates his sleep apnea.” Dr. H.S. reasoned that an article, Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort, shows that a study found arousal-based mechanism initiated by PTSD that promotes the development of obstructive sleep apnea (OSA) in trauma survivors. Dr H.S. cited another study in the article as finding that with CPAP treatment, both OSA and PTSD symptoms decreased, as further evidence of comorbidity. See Article, Received September 2019 at p.4-5. Dr H.S. wrote “He told me there are times that he is unable to wear the CPAP mask due to his anxiety symptoms caused by PTSD.” A copy of the article cited by Dr. H.S. was posted to the file on September 19, 2019. The Board notes, however, that the authors of the study noted significant limitations, and their conclusions were far from definitive, particularly on the issue of causation and aggravation. For example, the authors noted that Klein (see footnote 12) reported no evidence of sleep disturbance when comparing a small sample of trauma patients with and without PTSD. Furthermore, Dr. H.S. made little association of the study findings to the Veteran’s case other than the contention that avoiding CPAP use was necessarily caused by PTSD and necessarily aggravated apnea. Furthermore, as discussed in detail below, several VA treatment records from the period on appeal, including multiple VA sleep medicine records, show the Veteran had excellent compliance with his CPAP machine, using it in 25 to 30 of the last 30 days. Thus, the Board finds that the assertion by Dr. H.S. that the Veteran is unable at times to wear his CPAP due to his PTSD is inconsistent with the Veteran’s own reports to multiple clinicians in the medical evidence of record; therefore, the Board finds this statement by Dr. H.S. to be not credible. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (the Board as fact finder is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. ); Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (The credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements). The Board further finds that the Veteran’s statements to his own treating providers at the VA medical center are particularly trustworthy as compared to his statements made to Dr. H.S. in requesting a medical opinion for purposes of this claim. Statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment. White v. Illinois, 502 U.S. 346, 355-56 (1991). A January 2020 VA medical opinion shows the examiner reviewed the claims file, including the May 2015 opinion by Dr. H.S. as well as the study cited by him. The VA examiner opined that the Veteran’s sleep apnea is less likely than not caused by his PTSD. The examiner reasoned that based on the medical literature in UpToDate and based on standard medical texts, there is there is no definite association between sleep apnea and PTSD, and PTSD is not a known risk factor for sleep apnea. The examiner noted that according to Clinical Presentation and Diagnosis of Obstructive Sleep Apnea in Adults (Kline, Lewis R.), risk factors for sleep apnea include older age, male gender, obesity, and craniofacial and upper airway abnormalities. The examiner noted that based on a review of literature, whether there is an increased prevalence of sleep apnea in PTSD patients is unclear. The January 2020 VA medical opinion did not, however, address aggravation. An August 2020 addendum from the same examiner shows the examiner was asked to address the article cited by Dr. H.S., as well as opine as to whether the Veteran’s sleep apnea was aggravated by his PTSD. The examiner opined it is not at least as likely as not that the Veteran’s sleep apnea is aggravated by his PTSD. The examiner acknowledged that the article or study cited by Dr. H.S. (associated with the file in May 2015) states that sleep apnea is associated with a higher prevalence of psychiatric comorbid conditions in Veterans Health Administration beneficiaries. The examiner explained this association suggests that patients with psychiatric disorders and coincident symptoms of possible sleep-disordered breathing should be evaluated for sleep apnea, but that there is no definitive relationship between sleep apnea and PTSD shown. Rather, the examiner explained it is merely a suggestion, not a definite association. The examiner further noted that a review of standard medical textbooks and UpToDate medical literature shows no definite association between PTSD and sleep apnea. The Board has also reviewed all of the other medical evidence of record. A July 2016 VA sleep medicine record shows the Veteran reported he loved his new CPAP machine and it felt great. See CAPRI, received June 2020 at p.501. He reported again at an October 2016 VA sleep medicine appointment that he continued to feel great using his CPAP. See CAPRI, received June 2020 at p.447. A May 2017 record shows he had good compliance with his CPAP machine, and that treatment options including positive airway pressure, weight loss, and oral appliances were discussed. See CAPRI, received June 2020 at p.407-408 of 517. March 2018 VA sleep medicine records show the Veteran was “doing very well” with his DreamWear CPAP machine and had “excellent compliance.” See CAPRI, received June 2020 at p.325 and 328 of 517. A July 2019 VA sleep medicine record shows the Veteran reported that his CPAP mask fit well and he used the CPAP for 30 of the last 30 days and that he felt refreshed from his sleep using the CPAP machine. It was noted that the Veteran was adherent to his CPAP therapy. See CAPRI, received June 2020 at p.179. VA primary care records dated in August 2018, October 2019, and January 2020 show the Veteran reported consistent use of his CPAP machine with improvement in his sleep quality. See CAPRI, received June 2020 at p.80, 147, and 283 of 517. An April 2020 VA primary care record shows the Veteran reported he uses his CPAP machine every night and finds it beneficial. See CAPRI, received July 2020 at p.38 of 121. An August 2020 VA sleep medicine record shows the Veteran used his CPAP machine for 25 of the last 30 days. There is simply no indication in the treatment records that the Veteran’s sleep apnea was caused or aggravated by his PTSD, or that he had problems with compliance using his CPAP machine due to his PTSD. See CAPRI, received August 2020 at p.21 of 22. The Board acknowledges that a July 2019 VA treatment record shows the Veteran requested to see a psychologist regarding sleep trouble due to his PTSD, and it was noted that he would be seen by Dr. J.S. See CAPRI, received June 2020 at p.179. A subsequent July 2019 VA psychiatry record shows Dr. J.S. noted the Veteran was referred for PTSD and sleep problems. See CAPRI, received June 2020 at p.179. He reported experiencing nightmares weekly or less. When asked about his present level of symptomatology, the Veteran reported his PTSD was not a problem at the moment, and denied any distress or impairment due to symptoms. When asked about his goals for therapy, he reported he had none. Dr. J.S. noted the Veteran was functioning quite well, but may wish to seek therapy in the future. In light of all the evidence of record, the Board finds the preponderance of the evidence is against finding that the Veteran’s sleep apnea was caused or aggravated by his service-connected PTSD. The Board finds the opinion of the January 2020 VA examiner, together with the August 2020 addendum, is the most probative medical opinion of record. The VA examiner provided a detailed rationale for the conclusions provided, and cited to medical literature. The examiner also discussed the May 2015 private opinion by Dr. H.S. and the medical article cited by him. As explained above, the opinion by Dr. H.S. cited in part to statements made by the Veteran that the Board finds to be not credible. Dr. H.S. relied greatly on the medical article discussed above, but did not explain how the studies in that article relate specifically to the Veteran’s case. Also, as noted above, the conclusions in the article were far from definitive. The VA sleep medicine treatment records show the Veteran has had excellent compliance with his CPAP therapy, and none of the records indicate any etiological link between the Veteran’s sleep apnea and his PTSD. The Board has also considered the Veteran’s own lay assertions in support of his claim. While he asserts herein that his sleep apnea is caused or aggravated by his PTSD, the Board finds these statements to be inconsistent with his own reports to his treating providers. A July 2012 private treatment record shows the Veteran asked his provider whether his sleep apnea was due to Agent Orange exposure in service (the provider noted there was no evidence of any relationship). See Records, April 2012 at p.3. Subsequent VA treatment records, discussed in detail above, show the Veteran reported to providers that he was doing well with his CPAP, that he had good compliance, and felt refreshed after sleeping. Despite several records of treatment of his sleep apnea in the record, none of these records indicate any relationship between the Veteran’s sleep apnea and his PTSD. To the extent the Veteran is shown to experience nightmares due to his PTSD, the Board finds that this symptom is already contemplated by his already service-connected PTSD, and there is no evidence that his nightmares caused or aggravated his sleep apnea. Therefore, the Board concludes the entitlement to service connection for sleep apnea is not warranted; as the preponderance of the evidence is against the claim, the benefit of the doubt rule is not for application. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Juliano, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.