Citation Nr: 22015892 Decision Date: 03/20/22 Archive Date: 03/20/22 DOCKET NO. 12-10 173 DATE: March 20, 2022 ORDER Entitlement to service connection for obstructive sleep apnea as secondary to service-connected posttraumatic stress disorder (PTSD) is granted. FINDING OF FACT The evidence is in equipoise as to whether the obstructive sleep apnea was caused by PTSD. CONCLUSION OF LAW Resolving all reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for obstructive sleep apnea as secondary to PTSD have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2021). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from June 1969 to July 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision by a Department of Veterans Affairs (VA) regional office (RO). In September 2016, April 2019, December 2020, April 2021, and August 2021, the Board remanded the claim for further development. 1. Entitlement to service connection for obstructive sleep apnea Governing law and regulations Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active duty. See 38 U.S.C. § 1110. A disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary disorder, the secondary disorder shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). To establish service connection for a claimed disability on a secondary basis, there must be (1) medical evidence of a current disability; (2) a service-connected disability; and (3) medical evidence of a nexus between the service-connected disease or injury and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The United States Court of Appeals for Veterans Claims (the Court) has held that "[g]enerally, an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise is too general and inconclusive." Mattern v. West, 12 Vet. App. 222, 228 (1999) (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)). The Court has, however, also held that medical treatise evidence "standing alone, discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Wallin v. West, 11 Vet. App. 509, 514 (1998) (citing Sacks, 11 Vet. App. at 317). The United States Court of Appeals for Federal Circuit (the Federal Circuit) held that "[a] veteran with a competent medical diagnosis of a current disorder may invoke an accepted medical treatise in order to establish the required nexus; in an appropriate case it should not be necessary to obtain the services of medical personnel to show how the treatise applies to his [or her] case." Hensley v. West, 212 F.3d 1255, 1265 (2000). Analysis Various VA examination reports and VA treatment records reveal a diagnosis of obstructive sleep apnea. Therefore, Wallin element (1), current disability, is established. Service connection is in effect for PTSD. Thus, Wallin element (2), service-connected disability, is shown. Turning to medical nexus, there is conflicting medical evidence. A 2018 VA study titled Obstructive Sleep Apnea in Posttraumatic Stress Disorder Comorbid with Mood Disorder: Significantly Higher Incidence than in Either Diagnosis Alone showed a high prevalence of obstructive sleep apnea in psychiatric patients, particularly in those with PTSD and major depressive disorder and less so with bipolar disorder. The study also showed that there is a statistically significant increase in the incidence of obstructive sleep apnea in male veterans with either bipolar disorder with comorbid PTSD or major depressive disorder with comorbid PTSD. In a February 2019 written brief presentation, the representative cited an article from the National Institutes of Health (NIH) showing that there may be an increased prevalence of obstructive sleep apnea in individuals with major depressive disorder and in individuals with PTSD. A November 2019 VA PTSD examination report reveals that the examiner opined that it is less likely than not that the obstructive sleep apnea was proximately due to the service-connected PTSD. The examiner stated that PTSD does not cause obstructive sleep apnea. The examiner added that while obstructive sleep apnea can be co-morbid with PTSD, obstructive sleep apnea is not induced or caused by PTSD. A November 2019 VA sleep apnea examination report reflects that the examiner opined that it is less likely than not that the sleep apnea is due to or the result of the PTSD. The examiner stated that the current medical literature remains silent for any mechanism by which PTSD, a psychiatric disorder, may cause obstructive sleep apnea, an anatomically based disorder. The examiner noted that the NIH study cited by the representative does not establish direct cause and effect between PTSD and obstructive sleep apnea. In a February 2021 addendum to the November 2019 VA sleep apnea examination report, the November 2019 examiner again opined that it is less likely than not that the sleep apnea is due to or the result of the PTSD. The examiner reiterated that current medical literature remains silent for any mechanism by which PTSD, a psychiatric disorder, may cause obstructive sleep apnea. The examiner indicated that obstructive sleep apnea is caused by the muscles in the throat relaxing, which results in the airway being narrowed or closed and a momentary cut off of breathing. In an April 2021 written brief presentation, the representative cited "The Connection Between Sleep Apnea and PTSD", which was published at the Sleep Foundation's website in February 2021. The representative stated that the article notes that whereas only 17 to 22 percent of the general population have sleep apnea, 12 to 90 percent of people with PTSD have sleep apnea. The representative added that the article states that 69 percent of Vietnam veterans with PTSD show indications of PTSD. The Board notes that the Veteran served in the Republic of Vietnam. In a June 2021 addendum to the November 2019 VA sleep apnea examination report, the November 2019 examiner again opined that it is less likely than not that the sleep apnea is proximately due to the PTSD. The examiner noted that study published by the Sleep Foundation shows an increased risk of obstructive sleep apnea in veterans with PTSD but does not find causation. The examiner indicated that the NIH study finds that there is an elevated risk of obstructive sleep apnea with PTSD but no causation. In a November 2011 medical opinion, a VA doctor opined that it is less likely than not that the sleep apnea is proximately due to the PTSD. The clinician stated that while the current literature suggests that PTSD may play some role in obstructive sleep apnea, this conclusion is not definitive and that more research is needed. The physician cited a study of Australian Vietnam veterans with and without PTSD that shows no difference across all polysomnography parameters, include the diagnoses and severity of obstructive sleep apnea and periodic limb movements of sleep. The clinician added that this study reveals that Vietnam veterans with PTSD demonstrated an increased perception of sleep disturbances. The doctor discussed the study from the Sleep Foundation. The physician noted that the source study divides patients with obstructive sleep apnea with PTSD and without PTSD and that there was less adherence to use of a continuous positive airway pressure (CPAP) machine with PTSD patients compared to patients without PTSD. The clinician stated that the study does not indicate a stronger association and that it discusses less compliance with treatment. The doctor added that several statements in the article were not consistent with their sources. The doctor quoted a 2018 entry at the VA website "It is possible that PTSD and chronic arousal are related to OSA [obstructive sleep apnea] bidirectionally, as research has yet to definitely determine temporality." The physician noted that entry states that it is possible that the two disorders are related but that research has yet to definitely determine temporality. Given that the VA doctor who prepared the November 2021 medical opinion noted the possibility of a relationship between PTSD and obstructive sleep apnea and stated that the current literature suggests that PTSD may play some role in obstructive sleep apnea, the evidence is in equipoise as to whether the obstructive sleep apnea was caused by PTSD. Wallin element (3), medical nexus, is established. Therefore, service connection for obstructive sleep apnea by means of causation is in order. 38 U.S.C. §§ 1110, 5107. As the Board is granted service connection for obstructive sleep apnea as secondary to PTSD via causation, the Board does not have to address whether the sleep apnea began in service, whether the sleep apnea was aggravated by PTSD, and whether the sleep apnea is related to the service-connected lumbar spine disability and type II diabetes mellitus. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Cherry, 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.