Citation Nr: 21024204 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 15-34 984A DATE: April 22, 2021 ORDER Entitlement to service connection for sleep apnea is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran’s favor, the evidence of record is in relative equipoise as to whether his sleep apnea is aggravated by his service-connected PTSD. CONCLUSION OF LAW The criteria for entitlement to service connection for sleep apnea, to include as secondary to 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 in the United States Army from December 1965 to November 1967. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). This issue was previously before the Board in March 2019 and January 2021 and was remanded for further development, which has been completed. Beyond the above, it is valuable to note that the Veteran has been granted a total disability rating based on individual unemployability (TDIU) since October 2018. This is the only issue on appeal. The Veteran is seeking entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD. Sleep apnea is defined as transient periods of cessation of breathing during sleep. The two primary types are central sleep apnea and obstructive sleep apnea. See Dorland’s Illustrated Medical Dictionary, 118 (31st ed. 2007). Obstructive sleep apnea is defined as sleep apnea resulting from collapse or obstruction of the airway with the inhibition of muscle tone that occurs during REM sleep. Id. The Veteran is competent to report that he has difficulty sleeping. Additionally, the Veteran has a current disability of sleep apnea with a continuous positive airway pressure (CPAP) machine. See October 2019 Yale VA Clinic Outpatient Note. Here, it appears the Veteran’s central theory for entitlement to service connection for sleep apnea is one of secondary service connection. More specifically, he contends that his sleep apnea is proximately due to, or aggravated by, his service-connected PTSD. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection has been established for PTSD. The Board has considered the evidence of record and finds that the evidence of record is in relative equipoise as to whether the Veteran’s sleep apnea is aggravated by his PTSD. The evidence against the claim includes an August 2013, July 2013, May 2019, and February 2021 VA medical opinion. The August 2013 VA examiner opined that the Veteran’s sleep apnea was less likely than not incurred in or caused by military service and was not due to or the result of his PTSD. In reaching their rationale, the examiner, reviewed the Veteran’s file, test results, history provided, reviewed the medical literature, and examined the Veteran in person. However, the examiner merely noted there is medical literature in support of their opinion but did not explain further or cite to it and therefore, the August 2013 VA medical opinion cannot be afforded much probative weight. Again, in July 2013, the same VA examiner opined that sleep apnea is not caused by or a result of PTSD or the Veteran’s mental condition. The examiner also opined that the Veteran does not have PTSD. Because the Veteran was later diagnosed with PTSD, the July 2013 VA medical opinion does not hold much probative weight. A May 2019 VA examiner opined that the Veteran’s sleep apnea is less likely than not proximately due to or the result of the service-connected PTSD. In reaching their rationale, the examiner stated a causal relationship has not been established between sleep apnea and PTSD. However, the examiner referenced the Veteran’s obesity and noted both obesity and PTSD have been associated with sleep apnea, but only obesity has been established. The Board finds the VA examiner’s rationale on the relationship between sleep apnea and PTSD contradicts itself and therefore cannot be provided much probative weight. In February 2021, another VA examiner opined the Veteran’s sleep apnea was less likely than not incurred in or caused by military service and was less likely than not proximately due to or the result of the service-connected PTSD. The examiner noted the positive medical opinions provided by the Veteran but found there is no medial research noting that sleep apnea is directly linked or caused by PTSD. Clinically, obstructive sleep apnea is when muscles of the trachea relax and obstruct the trachea, causing a pause in breathing. Obstructive sleep apnea is not clinically linked or caused by PTSD and therefore the examiner opined that the Veteran’s current complaints of sleep apnea is less likely than not related to his PTSD. The evidence in favor of the claim includes October 2013, August 2018, and February 2020 private medical opinions. An October 2013 private physician reviewed the medical record and performed extensive testing on the Veteran. Given the Veteran’s PTSD, scores on his neuropsychological tests, history of sleep deficits, and history of sleep apnea, the physician opined that the Veteran’s sleep apnea is more likely than not related to his service-connected PTSD. In reaching their rationale, the physician cited and provided research literature on the connection between sleep apnea and PTSD. During an annual check-up from the Veteran’s sleep center in August 2018, a private physician opined that the Veteran’s sleep apnea is at least as likely as not related to his PTSD. In reaching their rationale, the private physician noted there is data suggesting a good association between the two conditions but did not provide citations to medical literature or any basis for the association. Therefore, the August 2018 private opinion cannot be provided much probative weight. Another private physician reviewed the Veteran’s sleep medicine records and personally performed a history and physical examination of the Veteran in February 2020. The private physician opined that it is at least as likely as not that the Veteran’s obstructive sleep apnea is related to his service-connected PTSD and exacerbates his PTSD. In reaching their rationale, the private physician noted that obstructive sleep apnea is a condition in which the upper airway collapses to block the airway, however, this is more than just anatomy, as the neuronal tone and arousal threshold are controlled by the central nervous system. Furthermore, the physician noted there is a significantly growing body of literature showing that obstructive sleep apnea is much more common in people with PTSD, as high as 50 percent in some studies. The physician also noted that the pathophysiology of this increased risk is yet to be elucidated, but may involve the increased arousal threshold in PTSD patients. Additionally, there is a growing body of evidence that shows untreated obstructive sleep apnea worsens quality of life and symptoms in PTSD patients and the use of a CPAP helps to reverse those deficits. In this regard, no one would suggest that PTSD “causes” sleep apnea. There is no basis in law or in medicine for such a finding. In this case, the only limited question is whether the PTSD aggravated the sleep apnea condition, nothing more. After a thorough review of the record, the Board finds the evidence to at least be in equipoise in this limited case as to whether the Veteran’s current sleep apnea is aggravated by his service-connected PTSD. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for sleep apnea is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. John J. Crowley Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Laura Cochran, 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.