Citation Nr: 21063616 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 19-06 840 DATE: October 14, 2021 ORDER Entitlement to service connection for obstructive sleep apnea, to include as secondary to a service-connected disability is denied. FINDING OF FACT The Veteran's obstructive sleep apnea is not shown to be caused or aggravated by any service-connected disability, to include posttraumatic stress disorder (PTSD). CONCLUSION OF LAW The criteria for entitlement to service connection for obstructive sleep apnea, to include as secondary to a service-connected disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty military service from September 1965 to January 1969, to include service in the Republic of Vietnam, for which he earned the Purple Heart citation. This matter was previously before the Board in March 2021, when it was remanded for additional development. Specifically, the Board directed that an addendum opinion or additional VA examination and opinion be obtained which addressed specific outstanding deficiencies in the VA examination and opinion of record. An addendum opinion was obtained in May 2021 which addressed the questions posed by the Board. The Board finds that the remand directives were satisfied and that no further development is required. Entitlement to service connection for obstructive sleep apnea, to include as secondary to a service-connected disability The Veteran seeks service connection for sleep apnea, which he asserts is the result of his PTSD from the Vietnam War. In support of this assertion, he has submitted copies of decisions issued by the Board in other appeals. He has also supplied medical research articles which discuss correlations between PTSD in combat veterans and sleep apnea. Generally, to establish a right to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). All three elements must be established by competent and credible evidence in order that service connection may be granted. Service connection is also provided for a disability which is proximately due to, the result of, or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310. VA has amended 38 C.F.R. § 3.310 to reflect that it will not concede aggravation unless certain additional conditions are met, to include an understanding of the baseline level of disability prior to any aggravation. 38 C.F.R. § 3.310 (b). In October 2015 the Veteran was evaluated for sleep apnea. (See Correspondence, 12/15/2020.) He reported symptoms of difficulty falling asleep, difficulty staying asleep, waking up frequently, snoring, non-refreshing sleep, daytime sleepiness, night sweats, restless sleep, restless legs, and dream-enacting behavior. The provider noted that the 2009 diagnosis of sleep apnea was confirmed, and that CPAP was the best treatment. A January 2016 treatment note from the sleep medicine provider noted that untreated sleep apnea may trigger PTSD-related nightmares. (See Correspondence, 12/15/2020.) The provider noted that evidence showed that sleep apnea can aggravate PTSD because chemicals released during apneic events activate the brain's fight or flight response. The provider stated that they were unaware of any rationale for finding that PTSD causes sleep apnea. A subsequent note indicated that, because of the chemical connection between sleep apnea and PTSD symptoms, it was very likely that treatment of obstructive sleep apnea would be beneficial in alleviating PTSD and mood symptoms over time. The Veteran has submitted several articles regarding the relationship between sleep apnea and PTSD. (See Correspondence, 12/15/2020; Third Party Correspondence, 01/13/2021.) These show that there is a higher prevalence of obstructive sleep apnea among veterans with PTSD than in the general population, which suggests that sleep disturbance is likely a bigger part of PTSD than previously known. PTSD is known to cause recurrent nightmares and difficulty sleeping as a result of insomnia. These also show that the exact relationship between the two conditions is not yet understood and it is not clear if the relationship is one of cause or aggravation or merely correlation. One study indicates that it is possible that an undiagnosed case of sleep apnea may predispose an individual to develop PTSD. A VA examination in August 2018 noted that the Veteran had been diagnosed with obstructive sleep apnea and was using a CPAP machine for the condition. (See C&P Exam, 08/08/2018.) He reported a history of fatigue and snoring. The examiner offered the opinion that the Veteran's obstructive sleep apnea was not due to his PTSD because PTSD is a mental health disability and does not cause airway obstruction. The American Academy of Sleep Medicine does not include PTSD in a list of causes or risk factors for sleep apnea. The examiner noted that the Veteran has two risk factors for obstructive sleep apnea: first, he is overweight or obese and, second, he has a high arched palate and a congenitally narrow airway. At the January 2021 Board hearing, the Veteran testified that his doctors had both told him they felt his PTSD was linked to his sleep apnea. The Veteran's representative conceded that for the most part, the documents have looked at the impact of sleep apnea on PTSD but emphasized that there is a relationship between the conditions. The representative also raised the issue of research on the relationship between obesity and sleep apnea, noting that the Veteran has also claimed service connection for diabetes mellitus, which is often linked to obesity. Finally, the representative raised the issue between rapid eye movement (REM) sleep and sleep apnea, including changes in the REM sleep patterns of individuals with PTSD. An addendum VA opinion was obtained in March 2021, which specifically stated that the Veteran does not have a diagnosis of diabetes mellitus, type II, but merely elevated glucose readings. (See C&P Exam, 03/30/2021.) Because there is not an official diagnosis of diabetes mellitus, type II, service connection cannot be granted for the condition and the impact of diabetes mellitus on obesity as a causal or aggravating factor for sleep apnea cannot be considered. An addendum VA opinion was obtained in May 2021 regarding the Veteran's claim of service connection for sleep apnea. (See C&P Exam, 05/17/2021.) The examiner provided the opinion that it is less likely than not (probability less than 50 percent) that the Veteran's obstructive sleep apnea was caused or aggravated by his PTSD. Obstructive sleep apnea is caused by soft tissues of upper airway blocking the air passages and can result from bony abnormalities such as smaller than usual passages of larger than normal soft tissue, including excess submucosal fatty tissues in obese people. While PTSD can cause insomnia and nightmares and chronic pain can interfere with sleep, PTSD does not cause physical abnormalities which result in obstruction of the air passages. The examiner considered the Veteran's concerns about REM sleep interruption and noted that this symptom is found to be related to both PTSD and sleep apnea but that it did not result in any physical changes to the airways. The examiner also considered the studies cited by the Veteran and noted that the causal relationship between PTSD and sleep apnea is actually the reverse of what has been claimed here: sleep apnea can aggravate PTSD by interfering with restorative sleep. However, sleep apnea is not shown to cause PTSD, there is merely a statistical correlation between those diagnosed with PTSD and those diagnosed with sleep apnea. The examiner noted that the Veteran's primary risk factors for sleep apnea are being male, being over 50 years of age, and being obese. After considering all of the evidence of record, with specific attention to the documents discussed above, the Board finds that the preponderance of the evidence is against the claim of service connection for sleep apnea. While the Veteran clearly has diagnoses of both PTSD and sleep apnea, the evidence does not show that the Veteran's PTSD has caused or aggravated his sleep apnea. The medical evidence of record makes it clear that sleep apnea is the result of physical anatomy, including smaller air passages and larger tissues which obstruct the air passages, and is not caused or worsened by mental health conditions such as PTSD. While there is literature and research showing that a high percentage of veterans with PTSD also have sleep apnea, the research indicates that it is more likely that sleep apnea aggravates PTSD rather than vice versa. The May 2021 VA addendum opinion considered all of the arguments about potential links which have been put forth by the Veteran and found that these are not supported by the medical research or literature of record. Notably, there is no medical opinion of record which specifically states that the Veteran's sleep apnea was caused or aggravated by his PTSD. For all of these reasons, the Board finds that the claim must be denied. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Cheryl E. Handy 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.