Citation Nr: 21024498 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 17-64 546 DATE: April 22, 2021 ORDER Entitlement to service connection for sleep apnea, to include as due to service-connected posttraumatic stress disorder (PTSD) and/or medications taken for his service-connected disabilities is granted. FINDING OF FACT The probative and competent evidence of record shows that the Veteran’s sleep apnea is secondary to his PTSD, including the medications taken for his service-connected disabilities. CONCLUSION OF LAW The criteria for service connection for sleep apnea, to include as due to service-connected PTSD and/or medications taken for his service-connected disabilities have been met. 38 U.S.C. §§ 1155, 5107 (b) (2012); 38 C.F.R. §§ 3.102, 3.304, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1989 to June 1991, February 1997 to June 1998, and from June 1998 to June 2006. This matter comes before The Board of Veterans’ Appeals (Board) on appeal from a December 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the Veteran withdrew his hearing request in a June 2020 statement. Entitlement to service connection for sleep apnea, to include as due to service-connected posttraumatic stress disorder (PTSD) and/or medications taken for his service-connected disabilities Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1155; 38 C.F.R. § 3.303. Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310 (a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); Allen v. Brown, 8 Vet. App. 374 (1995). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (2012); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran has been diagnosed with sleep apnea that he asserts is related to his active duty service. Alternatively, the Veteran asserts that his sleep apnea is due to his service-connected PTSD and/or medications taken for his service-connected disabilities. Service treatment records show that in October 2005, the Veteran was seen for follow up of insomnia. The physician noted poor sleep architecture and psychological stress related to work and life transition. The Veteran was started on Ambien. In a May 2008 VA treatment record, the Veteran reported that he had a sleeping problem since deployment. In a June 2008 VA treatment record, the Veteran reported trouble sleeping (per war experience). Service treatment records also showed that the Veteran still felt tired after sleeping. A June 2016 VA treatment record noted a diagnosis of mild obstructive sleep apnea. In the December 2017 VA Form 9, the Veteran said that his sleep symptoms presented in 2005 and had been present ever since. He said prior to his formal obstructive sleep apnea diagnosis in 2016, he had been prescribed sleeping medication over the years. In an October 2019 disability benefits questionnaire (DBQ), a diagnosis of obstructive sleep apnea was noted. The examiner noted that the Veteran’s 2005 service treatment record deployment notes showed poor sleep architecture and insomnia related to stress, work, and life transition. The Veteran was on Ambien to assess if he could get a good night sleep; the results were “good,” and he was directed to mental health. The Veteran’s flight status was related to the mental health issue and the diagnosis was insomnia in the service treatment record. The examiner also noted a 2006 exit self-report of sleep disturbance under the mental health section. In a separate October 2019 opinion, the examiner opined that the Veteran’s sleep apnea was less likely than not related to service. The examiner reviewed the Veteran’s medical records and noted a diagnosis of obstructive sleep apnea in 2016 after a sleep study. The examiner said that the Veteran’s sleep apnea was a functional collapse during sleep of the velopharyngeal and/or oropharyngeal airway. Thus, the examiner opined that the Veteran’s sleep apnea was more likely due to his weight and aging, as sleep apnea was associated with age, gender, and obesity, which were all risk factors in the development of sleep apnea. The examiner reasoned that the Veteran’s obesity was documented in his VA records and the condition was mild. Review of the service treatment records noted sleep disturbance and/or insomnia related to anxiety in 2005; such mental health conditions could cause sleep disturbance, and commonly, insomnia. They were considered separate conditions from sleep apnea, which was a functional collapse during sleep of the velopharyngeal and/or oropharyngeal airway. In November 2020, the Veteran submitted medical journal literature dated May 2015, titled “Obstructive Sleep Apnea and Posttraumatic Stress Disorder among OEF/OIF/OND Veterans.” The Veteran also submitted medical literature dated August 1994, titled “Effects of sleep deprivation and sleep fragmentation on upper airway collapsibility in normal subjects,” and another article dated November 2016, titled “Sedation & Respiratory Depression.” In a November 2020 DBQ, the examiner opined that the Veteran’s sleep apnea was both caused and aggravated by his service-connected PTSD and chronic pain as well as his prescribed medications for his symptoms. The examiner noted that the Veteran was service connected for PTSD, degenerative disc disease of the thoracolumbar spine, left lower extremity radiculopathy, left shoulder pain, and left knee traumatic arthritis, among other conditions. The examiner noted the findings in the June 2016 PTSD VA examination, July 2016 shoulder and knee VA examinations, November 2016 back VA examination, June 2016 sleep study, and the October 2019 sleep apnea VA examination. The Veteran told the examiner that he had a difficult time getting to sleep at night due to his pain and racing thoughts, and he took a Benadryl nightly to fall asleep. The Veteran said when he did sleep, he would awaken several times with back pain, stiffness, nightmares, and anxiety; several nights per week his CPAP mask would contribute to his anxiety and he had to remove it to fall asleep. As a result of his broken sleep and inability to use his CPAP on a consistent basis, the Veteran remained excessively sleepy during the day, which resulted in sleepiness and fatigue causing him to nod off intermittently throughout the day. The examiner noted that the Veteran was 5’7” and weighed 195 pounds with a BMI of 30.5. The Veteran expressed that he was frustrated with his weight gain as he was always accustomed to staying in shape. However, he said that when his anxiety and depression symptoms increased, he would eat. He also said a lot of his medications affected his appetite and there were times he would not want to eat at all and other times he would engage in binge eating. Additionally, the Veteran said that he was very limited in his ability to move about due to his chronic pain issues and, because of this, he was unable to engage in any type of exercise routine. He admitted that even if he could, he lacked motivation and felt this had a lot to do with his depression, anxiety, and sleepiness. The examiner pointed to research which had shown PTSD and other psychiatric disorders were commonly associated with sleep apnea. The examiner further stated that frequent awakenings, in the case of the Veteran, due to back, shoulder, and knee pain, as well as nightmares and anxiety led to fragmented sleep. When sleep was fragmented, an individual was unable to proceed normally through sleep cycles. A study showed that sleep fragmentation led to a higher upper airway collapsibility, which could contribute to the pathogenesis of sleep apnea. Also, the Veteran’s prescribed medications for pain were all known to have significant sedating effects. Research showed all sedative drugs suppressed the central nervous system typically accompanied by a reduction in carbon dioxide responsiveness in the medullary respiratory center. The examiner stated that since sleep apnea itself was a serious disorder in which breathing was paused or shallow during sleep, the introduction of medication which resulted in respiratory pauses, irregular breathing and shallow breaths increased the risk for harmful respiratory events. The examiner concluded that based on the information within the Veteran’s claims file, medical research, and consultation with the Veteran, it was as likely as not that the Veteran’s service-connected PTSD, as well as pain and side effects of medications for his service-connected conditions leading to weight gain proximately caused his sleep apnea. The examiner stated that the impact the Veteran’s mental health had upon his ability to maintain uninterrupted sleep and adhere to prescribed CPAP therapy had aggravated his sleep apnea symptoms. Additionally, the examiner stated that the Veteran’s service-connected spine, shoulder, and knee conditions shared proximate cause of his sleep apnea due to the delayed sleep onset and fragmented sleep precipitated by these conditions. The 2019 examination for sleep apnea said that the Veteran’s sleep apnea was related to his obesity. The Veteran was noted to be obese and this would be a significant risk factor for sleep apnea. VA examinations had clearly shown that the Veteran’s spine, knee, and shoulder conditions precluded activity, which would allow the Veteran to engage in proper exercise for weight control resulting in his obesity. The Veteran’s mental health symptoms and prescribed medications for pain had also contributed to his ongoing weight issues. Therefore, the examiner partially agreed with the 2019 examiner’s opinion, but felt the limitations and medications from his service-connected conditions had resulted in his obesity. The examiner concluded that there were multiple risk factors for sleep apnea affecting the Veteran, namely PTSD, prescribed pain medications, and weight gain. These factors could not be differentiated or apportioned for causation. Overall, the Board finds that giving the Veteran the benefit of the doubt, his sleep apnea is related to his service-connected PTSD and medications taken for his service-connected conditions. Initially, the Board acknowledges that the October 2019 examiner’s findings for direct service connection are adequate because the examiner determined that the in-service reports of insomnia and sleep issues were related to his mental health condition. However, the Board finds that the October 2019 VA opinion did not address the Veteran’s secondary service connection theory specifically for his sleep apnea, not just general reports of sleep trouble. Although the Veteran may not have raised this theory at the time of the 2019 examination, the theory was still raised when the Veteran submitted the medical literature in November 2020. The Board notes that this information was readily available at the time of the October 2019 examination. Additionally, the examiner provided an opinion finding that sleep apnea was a functional collapse during sleep of the velopharyngeal and/or oropharyngeal airway. This opinion did not address any medical findings, such as the above, of the effects of sleep deprivation and sleep fragmentation on upper airway collapsibility in normal subjects as well as sedation and respiratory depression. Therefore, the Board finds the October 2019 opinion less probative. In contrast, the November 2020 opinion found that the Veteran’s sleep apnea is due to his his service-connected PTSD and pain medications taken for his service-connected disabilities. The Board finds this opinion highly probative because the examiner considered the Veteran’s claims file, medical research, and lay statements. The Board acknowledges that the Veteran experiences sleep problems associated with his PTSD; however, the Veteran’s sleep apnea diagnosis is distinguished from his PTSD sleep problems. Thus, in light of the probative and competent November 2020 opinion, the Board resolves reasonable doubt in the Veteran’s favor and herein grants service connection for sleep apnea. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Saudiee Brown 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.