Citation Nr: 22017456 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 17-26 099 DATE: March 25, 2022 ORDER Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected posttraumatic stress disorder (PTSD) with depression and adjustment disorder (psychiatric disorder), is denied. FINDING OF FACT The Veteran's OSA is not secondary to service-connected psychiatric disorder, and is not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for OSA due to service or service-connected psychiatric disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1967 to November 1969. Among his awards and decorations are the Vietnam Campaign Medal, the Combat Infantry Badge, the Purple Heart Medal, and the Bronze Star Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2019 and September 2021, the Board remanded this matter for further evidentiary development, to include obtaining an opinion addressing whether the Veteran's sleep apnea is caused or aggravated by his service-connected psychiatric disorder. The Board finds that there has been substantial compliance with the previous remand directive as an adequate medical opinion was obtained in October 2021. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002); Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for OSA, as secondary to service-connected psychiatric disorder. The Veteran contends that his OSA is secondary to his service-connected psychiatric disorderand submitted articles suggesting a possible connection between sleep apnea and his psychiatric disability. See Notice of Disagreement (NOD) (March 2017). The Veteran's representative reiterates the Veteran's contention, to include that his OSA is aggravated by his PTSD, and submitted a reference to a Journal of Clinical Sleep Medicine study regarding the risks of OSA and an association between OSA and PTSD. See Appellate Brief (December 2020). The Veteran's representative further contends that the "October 14, 2021, examiner expressed his medical opinion in a conclusory statement without any supporting rationale... [and] did not address the Veteran's contentions or the medical literature referenced by the Veteran." See Appellate Brief (December 2021). The Board notes that, although the Veteran's representative referenced laws regarding service connection on direct and chronic bases, no contention or argument regarding such theories of entitlement were provided. The Veteran's September 2016 fully developed claim for compensation identified the claimed disability as "sleep apnea (related to: PTSD Combat)." Additionally, the Veteran's March 2017 notice of disagreement (NOD) stated that he "did not seek treatment for Sleep Apnea while in the military as I did not suffer any symptoms." Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board's adjudication will consider only entitlement to secondary service connection. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. Here, the evidence shows that severe OSA was diagnosed in March 1992. Thus, the question is whether there is probative evidence that the Veteran's OSA is caused or aggravated by his service-connected psychiatric disorder. The Veteran's private treatment records show no etiology opinion for the Veteran's OSA. An October 2016 VA examiner opined that the Veteran's OSA is less likely than not proximately due to or the result of the Veteran's service-connected psychiatric disorder. The examiner reasoned that OSA is caused by an obstruction of the airway during sleep. The Board's February 2019 decision remanded the claim for an opinion on whether the Veteran's OSA was aggravated (i.e., permanently worsened beyond the natural progression) by his service-connected psychiatric disorder. An October 2019 VA examiner opined that the medical evidence is not sufficient to support a determination of baseline level of severity of OSA, but that regardless of an established baseline, it was less likely than not aggravated beyond its natural progression by service-connected psychiatric disorder. The examiner's rationale was as follows: Obstructive sleep apnea is caused by relaxation of the soft tissues of the throat during sleep leading to airway obstruction while sleeping that can cause apnea. This condition can be worsened in severity by such factures as weight, neck circumference, narrow airway, being older, smoking and anatomical problems of the nose. This condition cannot be aggravated by his PTSD. C&P Exam (October 2019). The Board's September 2021 decision remanded the claim for an opinion considering the relevant medical literature cited by the Veteran's representative following to the October 2019 medical opinion. An October 2021 VA clinician noted the review of medical literature from the Mayo Clinic's website, the Journal of Clinical Sleep Medicine referenced by the Veteran's representative, and an online article titled "Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort" by Amir Sharafkhaneh, MD, etal. The clinician opined that it is less likely than not that the Veteran's OSA is due to, or has been aggravated beyond its natural course, by his psychiatric disorder. The clinician's rationale was as follows: Though sleep disturbances such as insomnia are common with psychological conditions, they are mediated by the central nervous system and differ from the mechanism of OSA. OSA is due to upper airway obstruction associated with apneic episodes. There is no physiologic or anatomic mechanism by which psychological conditions can cause or aggravate OSA. This includes the medications used to treat related psychological comorbidities.... Studies have suggested a possible association between OSA, PTSD, depression and anxiety but cause and effect, including aggravation, has not been established in the current, widely accepted, peer-reviewed medical literature. C&P Exam (October 2021). Regarding the medical literature referenced in support of the claim, the clinician reasoned that the "studies cited above discuss the possible association between psychological comorbidities and OSA... [but the] authors drew no conclusion as to cause or aggravation." Id. The Board concludes that, while the Veteran has a current disability, the evidence of record persuasively weighs against finding that the Veteran's OSA is proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The October 2021 clinician's opinion is probative because it is based on an accurate medical history and provides a thorough explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Additionally, the provided opinion sufficiently informed the Board of the examiner's "judgment on a medical question and the essential rationale for that opinion." Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). The October 2021 VA opinion considered and discussed the physiologic effects of PTSD, to include medication prescribed for the treatment. Moreover, the clinician addressed the medical literature as directed and provided an adequate explanation as to why the literature does not support the claim. Notably, the other medical evidence of record also fails to support the claim. There was no indication of a psychiatric disability at the time OSA was diagnosed in 1992, and the Veteran's private treatment records continually showed negative psychiatric findings between 1992 and 2005. The first indication of depression symptoms comes from VA treatment records in 2008, approximately 16 years after his diagnosis of OSA. The fact that the Veteran's OSA was diagnosed in 1992 and his psychiatric disorder was diagnosed in 2008, tends to contradict the Veteran's contentions and indicate the lack of a causal relationship. The Veteran and his representative believe that the Veteran's OSA is proximately due to or aggravated beyond its natural progression by his service-connected psychiatric disorder. The Veteran and his representative in this case are not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and the interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran and his representative in this case because the record does not show that they have the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24 Vet. App. 428 (2011). Additionally, the medical literature submitted by the Veteran and his representative is insufficient to support a grant of secondary service connection. The articles referenced in the Veteran's March 2017 NOD discuss that OSA is a risk a factor for worsening PTSD, and that veterans with PTSD screen as high risk for OSA compared to non-veterans. However, showing that OSA is a risk factor for worsening or aggravating PTSD suggests that OSA worsens or aggravates PTSD, which is the opposite of the Veteran's contention that his PTSD worsens or aggravates his OSA. Moreover, showing that veterans with PTSD screen as high risk for OSA does not indicate a causal relationship between the Veteran's OSA and PTSD. It is noted that an association can arise between variables in the presence and absence of a causal relationship. By contrast, causation indicates that one event is the result of the occurrence of the other event. In other words, while the Veteran through his representative has provided evidence of an association between OSA and PTSD, he has not provided evidence of causation and it cannot be logically said that evidence of association tends to show causation. Consequently, the Board gives more probative weight to the October 2021 VA medical opinion and the private medical evidence showing the onset date of the Veteran's OSA decades prior to the onset of his psychiatric disorder. The Board denies the Veteran's claim for service connection for OSA, as secondary to service-connected psychiatric disorder. While a claimant is generally entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence, there is no such doubt to resolve in the Veteran's favor here. See Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021). KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Thaddaeus J. Cox, 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.