Citation Nr: 21040348 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 17-56 135 DATE: July 3, 2021 ORDER Service connection for obstructive sleep apnea, as secondary to service connected posttraumatic stress disorder with major depressive disorder and alcohol use disorder (PTSD), is granted. FINDING OF FACT The Veteran's obstructive sleep apnea was caused by the service connected PTSD. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for obstructive sleep apnea, as secondary to service connected PTSD, have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310, 3.326. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran, who is the appellant, had active service from August 1994 to August 2002. This matter came before the Board of Veterans' Appeals (Board) on appeal from an April 2017 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. The Veteran testified at a May 2021 virtual Board hearing before the undersigned Veterans Law Judge. The hearing transcript has been associated with the record. The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). As the instant decision grants service connection for obstructive sleep apnea, which is a complete grant as to the issue on appeal, no further discussion of VA's duties to notify and assist is necessary. Service Connection for Obstructive Sleep Apnea, as Secondary to Service Connected PTSD, is Granted. Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Service connection may be granted for disability that is proximately due to or the result of a service-connected disability. An increase in severity of a non service connected disorder that is proximately due to or the result of a service connected disability, and not due to the natural progress of the non service connected condition, will be service connected. Aggravation will be established by determining the baseline level of severity of the non service connected condition and deducting that baseline level, as well as any increase due to the natural progress of the disease, from the current level. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995). Throughout the course of this appeal, the Veteran has sought service connection for obstructive sleep apnea as either directly related to service, or as secondary to service connected PTSD. At the outset, the Board notes that there is a current diagnosis of obstructive sleep apnea. Such diagnosis can be found in the report from an April 2017 VA sleep apnea examination and elsewhere throughout the record. Having reviewed all the evidence of record, lay and medical, the Board finds the evidence at least in equipoise on the question of whether the currently diagnosed obstructive sleep apnea was caused by the service-connected PTSD. Initially, the Board notes that negative VA direct and secondary service connection opinions were obtained in April 2017 and September 2019. Per the opinion reports, the VA examiners found it more likely than not that the obstructive sleep apnea was due to the Veteran's post-service weight gain. While the VA examiner in September 2019 did acknowledge that medical studies have shown a correlation between PTSD and obstructive sleep apnea, the VA examiner assessed that the medical literature did not support that there was a direct causal link between the two disabilities. As will be discussed in greater detail below, a positive private secondary service connection opinion was received in May 2021. Along with the opinion report, the private examiner submitted a summary of some of the relevant medical literature. Relevant to the negative VA opinions, per a medical journal article entitled Sleep Disorders in US Military Personnel: A High Rate of Comorbid Insomnia and Obstructive Sleep Apnea, the authors found that obesity and PTSD in combination are far more likely to cause sleep apnea then either condition alone. Further, the medical evidence showed that the effect of one of these conditions on obstructive sleep apnea could not be scientifically segregated from the other. Such a finding was supported by the fact that both PTSD (through its effect on the central nervous system) and obesity can cause the physical process that results in obstructive sleep apnea, the fact that treatment for sleep apnea often lessens the symptoms of both PTSD and obesity, and the fact that medical studies have shown that obstructive sleep apnea is three to four times more likely in young men with both a mood disorder and obesity, as opposed to just obesity. As the instant decision grants service connection for obstructive sleep apnea, which is a complete grant as to the issue on appeal, the Board finds remand for another addendum VA opinion considering the above medical journal study to be unnecessary at this time. VA received a private secondary service connection opinion in May 2021 from the Veteran's private physician of many years. Per the private opinion letter, the private physician reviewed the evidence of record and the relevant medical literature. The letter explained that over the years the private physician had taken a detailed history of in-service symptoms from the Veteran, to include persistent and loud snoring, daytime sleepiness, and gasping and choking for air when awakening. Further, the private examiner explained that the "continuous and emerging" medical literature supported a strong association between PTSD and obstructive sleep apnea, to include the fact that obstructive sleep apnea often appears as PTSD symptoms worsen. Based upon a review of the Veteran's records and the medical literature, the private physician opined that it was more likely than not that the obstructive sleep apnea was caused by, and first manifested following, the in-service stressors that subsequently resulted in a diagnosis of, and service connection for, PTSD. Along with the private opinion letter, the private physician submitted a "Summary of Studies Linking PTSD to Sleep Apnea." Per the medical literature cited, medical studies of veterans with PTSD showed increased rates of obstructive sleep apnea than the general population. Further, at least one study found "a bidirectional pathway in which [PTSD] sleep fragmentation had a negative effect on the human airway and increased susceptibility to the subsequent development of upper airway collapsibility." In other words, symptoms of PTSD have been found to cause the physiological effects that can result in obstructive sleep apnea. Following a review of the medical literature, in May 2021, a private examiner opined that it was more likely than not that the PTSD caused the subsequently diagnosed obstructive sleep apnea. The private examiner in May 2021 reasoned that following the manifestation of PTSD in service the Veteran began displaying symptoms of obstructive sleep apnea, to include snoring and cessation of breathing, which was later diagnosed as obstructive sleep apnea. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 118 (32nd ed. 2012) (apnea is "cessation of breathing" and obstructive sleep apnea is "sleep apnea resulting from collapse or obstruction of the airway with the inhibition of muscle tone that occurs during REM sleep.") The factual assumption of in-service onset of sleep symptoms is supported by the report from the April 2017 VA PTSD examination, which notes that the service treatment records showed that PTSD-related sleep symptoms first manifested during service. The private physician's findings (that in-service PTSD manifested as in-service sleep apnea symptoms) is supported by various lay evidence of record. At the May 2021 virtual Board hearing, the Veteran credibly testified that during service multiple servicemembers informed him that he had sleep symptoms of snoring and cessation of breathing during service. Further, in a February 2017 lay statement, a former servicemember, with whom the Veteran had been romantically involved, conveyed that during service the Veteran displayed sleep symptoms of snoring and cessation of breathing. To the extent that the Veteran's service treatment records are absent any notation of snoring or cessation of breathing during sleep, the servicemember noted that such sleep troubles would not commonly have been seen as a medical issue to be treated in service, but rather a personal issue to be dealt with by the Veteran. Further, in a December 2017 lay statement, the Veteran advanced not seeking treatment for sleep apnea symptoms during service because he was unaware that the in-service snoring and gasping for air were symptoms of a treatable disability, specifically, obstructive sleep apnea. In sum, a private physician in May 2021 opined that the medical literature supported that PTSD can be a causative factor in the development of obstructive sleep apnea, discussed in detail above, and, after reviewing the claims file, and based upon the private physician's history with the Veteran, found it was more likely than not that the Veteran's service-connected PTSD caused the currently diagnosed obstructive sleep apnea. Conversely, the VA examiner in September 2019 opined that the medical literature did not support a causative effect between PTSD and obstructive sleep apnea, but merely showed a correlation between the two disabilities. Further, both that VA examiner and a VA examiner in April 2017 opined that the obstructive sleep apnea was due to the Veteran's post-service weight gain. As the above discussed opinions appear to be adequate for VA rating purposes, it is not the Board's place to determine which examiner has correctly interpreted the medical literature, as both the positive and negative interpretations appear equally valid. Rather, the Board will find that the evidence is at least evenly balanced as to whether the Veteran's obstructive sleep apnea was caused by the service-connected PTSD. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, the Board finds that the criteria for service connection for obstructive sleep apnea, as secondary to service connected PTSD, have been met. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. J. PARKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Blowers, 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.