Citation Nr: A21020136 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 210816-178559 DATE: December 16, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA), as secondary to the service-connected posttraumatic stress disorder (PTSD), is granted. FINDING OF FACT The evidence is in at least relative equipoise regarding whether the Veteran's OSA is caused or aggravated by his service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for OSA, as secondary to the service-connected PTSD have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1968 to October 1969. This appeal to the Board of Veteran's Appeals (Board) has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.§ 7107(a)(2). In seeking service connection for OSA, the Veteran contends that the disorder is secondary to his service-connected PTSD. The AOJ favorably found that the Veteran has a current diagnosis of OSA and that he is service-connected for PTSD. Service connection may be established on a secondary basis for a disability which is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 U.S.C. § 1110; 38 C.F.R. § § 3.303, 3.310. To prevail on the theory of secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). Regarding whether there is a nexus, in October 2019, the VA examiner opined that it was less likely than not that the Veteran's OSA was caused or aggravated by his service-connected PTSD. The examiner stated that, per the medical literature, the nature of the relationship between PTSD and OSA remained unclear. While various theories have been posed to account for this noted increase in comorbidity, no clear mechanism has been reliably established linking the two disorders. Given the current state of literature on this topic and continued ambiguity about relationship between these disorders, the examiner opined that it would be inappropriate to conclude that the Veteran's OSA was caused by his PTSD. In May 2020, the Veteran submitted articles that discussed the association between OSA and PTSD. One article stated that the severity of PTSD symptoms increased the risk of screening positive for OSA. Another study mentioned that PTSD could exacerbate sleep disorders and that OSA is associated with other comorbidities, to include PTSD. See May 2020 Correspondence. In June 2020, the Veteran submitted a private medical opinion, in which the physician opined that it was more likely than not that the Veteran's OSA was caused or aggravated by his PTSD. The physician cited a research article, which was also submitted by the Veteran and stated that research showed that 40% to 90% of veterans with PTSD also have co-occurring sleep disturbance, such as OSA. The physician noted that the classic predictors of OSA, such as old age and higher BMI, were not seen with this Veteran. See June 2020 Correspondence. In June 2021, the VA examiner provided a negative nexus opinion. The examiner explained that obstructive sleep apnea occurred when the muscles in the back of the throat relax too much to allow normal breathing. When the muscles relax, the airway narrows or closes as one breathes in and breathing may be inadequate, which can lower the level of oxygen in the blood. This pathophysiology of OSA explained why a mental health condition would not cause OSA (structural pathology). The examiner explained that the Veteran being overweight or obese, which could contribute to narrowing airways as a result, could be the more likely cause of his OSA. Obesity is the most single significant risk factor for sleep apnea. The examiner stated that the Veteran's PTSD was currently stable and controlled and that, therefore, no aggravation was found. After a thorough consideration of the evidence of the record, the Board finds that the evidence is at least in relative equipoise regarding whether the Veteran's OSA is secondary to his service-connected PTSD. The VA examiners have opined that his OSA is less likely than not secondary to his PTSD. While the medical literature was referenced by the examiners, they did not clearly reconcile the medical literature discussing a positive association with the relevant evidence of the record. The October 2019 VA examiner indicated that there was ambiguity regarding a known association between OSA and PTSD. Further, the June 2021 VA examiner did not fully explain why the Veteran's PTSD could not aggravate his OSA and simply concluded that his PTSD was currently stable. The Board acknowledges the June 2020 private medical opinion has some flaws as well. The doctor states that older age and higher BMI are factors that the Veteran does not have, while the medical records indicate that the Veteran has those factors. The medical literature submitted by the Veteran indicates that PTSD could be a risk factor for OSA and also that OSA could be a risk factor for PTSD. The Board acknowledges that significant time has been used to develop the evidentiary record in this matter in order to resolve the uncertainties. As the record stands now, there is evidence on the record for and against the claim. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the Board shall give the benefit of the doubt to the claimant. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In resolving reasonable doubt in favor of the Veteran, the Board finds that there is a nexus between the Veteran's OSA and his service-connected PTSD. Accordingly, the criteria for service connection for OSA, as secondary to the service-connected PTSD, have been met, and this appeal is granted. THERESA M. CATINO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Middleton, Associate 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.