Citation Nr: 21073560 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 15-19 116 DATE: December 9, 2021 ORDER Entitlement to service connection for sleep apnea is denied. FINDINGS OF FACT 1. The Veteran sleep apnea did not manifest during active service and there is no indication that it is causally related to his active service. 2. The Veteran's sleep apnea is not caused or aggravated by his service-connected posttraumatic stress disorder (PTSD). CONCLUSION OF LAW The criteria for service connection for obstructive sleep apnea have not been met. 38 U.S.C. §§ 1110, 5107(b) (2018); 38 C.F.R. § 3.303, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served in the Army National Guard for an initial period of active duty for training (ADT) from January 1991 to April 1991, and had active service from February 2003 to July 2004, and from May 2007 to August 2008. This case initially came before the Board of Veterans' Appeals (Board) on appeal from a January 2013 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). In April 2021, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In August 2021, the Board remanded the claim to the Agency of Original Jurisdiction (AOJ) for additional development. The case has since been returned to the Board. Service Connection Sleep Apnea The Veteran maintains that his sleep apnea is secondary to his service-connected PTSD. During the April 2021 hearing, he testified that after he was deployed, he began having difficulties with PTSD and sleeping. He stated that his PTSD interrupted his sleep four or five times a week, and that it took him a while to lay back down and get back on his continuous positive airway pressure (CPAP) machine. He stated that he did not have any health problems prior to his deployment. The Veteran's service treatment records are unremarkable for any treatment or diagnosis related to sleep apnea. After the Veteran's deployment in September 2005, he reported that he still felt tired after sleeping. Later records indicated that he complained of having difficulty falling and staying asleep. After his first period of active service, an April 2006 VA treatment record noted he experienced loud snoring but had no history of apnea during sleep. The report of a May 2008 post-deployment health assessment indicated that the Veteran denied still feeling tired after sleeping. In July 2008, he reported that since he returned from Iraq in May 2008, he had problems with poor sleep, anger/verbal aggression, hypervigilance, and nightmares. He was eventually diagnosed with PTSD and was granted service connection for that disability in a July 2009 rating decision. Post service, a February 2012 VA treatment record indicated that the Veteran was referred for a sleep study. It was noted that he reported loud snoring, fatigue, and non-refreshing sleep. He stated that his symptoms began four years previously and became worse after his mother died. The sleep study confirmed a diagnosis of obstructive sleep apnea and began using a CPAP machine. In December 2012, a VA examiner opined that the Veteran's sleep apnea was less likely than not proximately due to or the result of his service-connected PTSD. The examiner noted that obstructive sleep apnea was a common disorder characterized by repetitive narrowing or collapse of the pharyngeal airway during sleep and was caused by anatomical variations in the craniofacial features and/or neck. The examiner indicated that obesity, alcohol use, and supine sleep position, among other things, could exacerbate obstructive sleep apnea, but that PTSD did not cause obstructive sleep apnea. The examiner noted that although several sleep disorders could be highly prevalent in PTSD, sleep apnea was not associated with a high prevalence of psychiatric comorbid conditions in veterans and that prevalence did not signify causative etiology. The examiner noted that in some scientific studies comparing standard polysomnography results, there were no differences in test results between subjects with PTSD and control subjects except an increased number of brief arousals from REM sleep being detected in subjects with PTSD. The Board notes that the VA examiner did not review the Veteran's claims file and did not address whether his service-connected PTSD aggravated his sleep apnea. Therefore, the opinion has limited probative value. In December 2013, the Veteran also submitted an article from http://ptsd.about.com. The article noted that a December 2010 study by Water Reed Army Medical Center indicated that two-thirds of veterans diagnosed with PTSD were found to also suffer from sleep apnea. It was noted that people with PTSD might be more likely to develop sleep apnea, but that it had not been explored by researchers. In March 2015, the AOJ forwarded the claims file to a different VA examiner for review of the claims file and an addendum opinion. The examiner reviewed the claims file and noted that medical literature did find that PTSD and obstructive sleep apnea were commonly found in the same persons, but that that there was no causal link noted, just an association. The examiner indicated that obstructive sleep apnea was caused by an anatomical narrowing of the upper airways and that PTSD did not cause that type of narrowing and that there was no scientific evidence showing that PTSD caused obstructive sleep apnea. Therefore, the examiner opined that it was less likely than not that the Veteran's obstructive sleep apnea was caused by his PTSD. The Board notes that the VA examiner did not address whether the Veteran's PTSD aggravated his sleep apnea. Therefore, the opinion has limited probative value in that regard. In August 2021, the Board remanded the claim to obtain an additional medical opinion to address whether the Veteran's service-connected PTSD aggravated his sleep apnea. In September 2021, a VA examiner reviewed the claims file and opined that the Veteran's service-connected psychiatric disability, to include depression, anxiety, and PTSD, did not cause or aggravate his obstructive sleep apnea. The examiner noted, as above, that obstructive sleep apnea was due to upper airway obstruction associated with apneic episodes and that there was no physiologic or anatomic mechanism by which psychological conditions could cause or aggravate obstructive sleep apnea, including medications used to treat psychological conditions. The examiner also stated that there was no evidence of aggravation of the Veteran's obstructive sleep apnea beyond its natural course due to any cause. The examiner noted that obstructive sleep apnea tends to progress over time, often requiring CPAP adjustments or changes in treatment modality. The examiner indicated that he had reviewed the medical literature and noted that some studies suggested a possible association between obstructive sleep apnea, PTSD, depression, and anxiety, but cause and effect, including aggravation, had not been accepted by the current, widely accepted, peer-reviewed medical literature. Therefore, examiner ultimately concluded that it was less likely than not that the Veteran's obstructive sleep apnea was caused or aggravated by his PTSD. In this case, the Board finds the most probative evidence weighs against the claim. Although the Veteran had sleep difficulties during service and was ultimately diagnosed with PTSD, the evidence does not indicate that sleep apnea manifested during active service. Obstructive sleep apnea was not diagnosed until February 2012, over three year after he separated from active service. In addition, the VA examiners opined that it was less likely than not that the Veteran's obstructive sleep apnea was caused by his service-connected PTSD. The September 2021 VA examiner also specifically address the issue of aggravation and opined that it was less likely than not that the Veteran's service-connected PTSD aggravated his obstructive sleep apnea. The September 2021 VA examiner based his opinion on the relevant medical evidence and lay statements, and he provided rationale for his opinion. Therefore, the Board finds that the September 2021 VA examiner's opinion significantly probative. Furthermore, there is no medical opinion to the contrary. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board has considered the December 2010 article submitted by the Veteran, which noted a high prevalence of sleep apnea in veterans with PTSD; however, the September 2021 VA examiner considered the medical literature, which suggested a possible association, and pointed out that but cause and effect, including aggravation, had not been accepted by the current, widely accepted, peer-reviewed medical literature. Furthermore, the article was not accompanied by a medical opinion of a medical professional and failed to demonstrate with any degree of certainty that the Veteran's PTSD caused or aggravated his sleep apnea. The Board has also considered the lay evidence of record. The Veteran is competent to describe what he has personally observed or experienced. However, the ultimate questions of diagnosis and etiology in this case extends beyond an immediately observable cause-and-effect relationship and are beyond the competence of lay witnesses. (Continued on the next page) Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to service connection for obstructive sleep apnea is not warranted. 38 U.S.C. § 5107(b) (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Mishalanie, 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.