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Navigating the VA claims process to service-connect Sleep Apnea secondary to PTSD can feel like an uphill battle, but there’s a new strategy that could make the difference between an approval and a denial.
If you’re a veteran living with both Sleep Apnea and PTSD, you’re likely familiar with how these conditions can exacerbate each other, affecting every part of your life—from work to social relationships to overall well-being.
You’re not alone—medical research supports the connection between Sleep Apnea and PTSD, especially in veterans.
In this definitive guide by VA disability expert Brian Reese, we’ll explore the link between Sleep Apnea and PTSD, outline the crucial medical evidence you need for a successful secondary VA claim, and unveil a new strategy to help strengthen your case.
Table of Contents
4-Minute Video: *NEW TIPS* for Your VA Claim for Sleep Apnea Secondary to PTSD!
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Summary of Key Points
- Service-Connecting Sleep Apnea Secondary to PTSD: Navigating the VA claims process for secondary service connection can be challenging, but a new approach called the “DBQ/Nexus Combo” may improve your chances of a VA claim approval.
- Impact of Sleep Apnea and PTSD on Veterans’ Lives: Veterans living with both conditions often find that PTSD and Sleep Apnea worsen each other, affecting daily life, work, relationships, and overall well-being.
- Established Connection Supported by Research: Medical studies have demonstrated a significant connection between PTSD and Sleep Apnea, particularly among veterans, suggesting that PTSD can increase the risk and severity of Sleep Apnea.
- Crucial Medical Evidence for a Successful Secondary VA Claim: A formal Sleep Apnea diagnosis from a sleep study, evidence of service-connected PTSD, and a strong Nexus Letter linking the two conditions are mission critical. Adding a Disability Benefits Questionnaire (DBQ) for Sleep Apnea on-top, can make your claim “decision ready.”
What is Sleep Apnea?
Sleep Apnea is a common sleep disorder in which breathing repeatedly stops and starts during sleep. It occurs when the muscles in the throat relax too much, causing the airway to narrow or close and blocking oxygen flow. This interruption in breathing can last from a few seconds to a minute and may occur dozens or even hundreds of times per night, disrupting normal sleep cycles and leading to poor sleep quality.
There are three main types of Sleep Apnea:
- Obstructive Sleep Apnea (OSA): The most common form, OSA occurs when throat muscles relax excessively during sleep, blocking the airway. This can cause loud snoring, gasping, or choking sounds as the body struggles to breathe.
- Central Sleep Apnea (CSA): In this type, the brain fails to send proper signals to the muscles responsible for breathing. CSA is less common and may be associated with conditions affecting the central nervous system, like stroke or heart failure.
- Complex Sleep Apnea Syndrome: Also known as “treatment-emergent central sleep apnea,” this is a combination of OSA and CSA. This type is often diagnosed when someone with obstructive sleep apnea still experiences apnea episodes even after using CPAP (Continuous Positive Airway Pressure) therapy.
Symptoms of Sleep Apnea can vary, but commonly include:
- Loud snoring
- Episodes of stopped breathing during sleep (often reported by a partner)
- Gasping or choking sounds
- Excessive daytime sleepiness (EDS)
- Morning headaches
- Difficulty concentrating
- Irritability or mood changes
Risk Factors for Sleep Apnea include obesity, smoking, alcohol use, older age, and certain anatomical factors like a thick neck or narrow airway.
What is PTSD?
Post-Traumatic Stress Disorder (PTSD) is a mental health condition triggered by experiencing or witnessing a traumatic event. Veterans, first responders, and anyone who has gone through life-threatening situations, serious injury, or severe emotional distress can develop PTSD. The condition can manifest as intense anxiety, flashbacks, nightmares, and uncontrollable thoughts about the traumatic event.
PTSD symptoms fall into four main categories:
- Intrusive Thoughts: These include flashbacks, nightmares, and intense, distressing thoughts about the traumatic event. Intrusive memories can feel as if the event is happening again, causing extreme fear and anxiety.
- Avoidance: Individuals may go to great lengths to avoid people, places, conversations, or activities that remind them of the trauma. This avoidance can make daily activities challenging and limit personal relationships.
- Negative Changes in Thinking and Mood: This can involve feelings of hopelessness, detachment from loved ones, lack of interest in activities once enjoyed, and feelings of guilt or shame related to the traumatic event.
- Alterations in Arousal and Reactivity: People with PTSD may experience symptoms like hypervigilance, irritability, difficulty concentrating, trouble sleeping, and being easily startled. These reactions can lead to ongoing tension and restlessness.
Risk factors that increase the likelihood of PTSD include:
- Severity of the trauma
- Repeated exposure to trauma
- Lack of social support post-trauma
- History of mental health issues
- Family history of mental health conditions
- Military deployments, especially combat exposure
Sleep Apnea Secondary to PTSD: Is There a Connection?
Yes, there is a recognized connection between Sleep Apnea and PTSD, particularly in the veteran community.
Medical research and clinical observations have found that individuals with PTSD, especially veterans, have a significantly higher risk of developing Sleep Apnea compared to the general population.
PTSD affects how the brain and body respond to stress, sleep, and respiratory control, all of which can contribute to the onset or worsening of Sleep Apnea.
How PTSD Contributes to Sleep Apnea
Several underlying mechanisms link PTSD and Sleep Apnea, mainly involving the body’s stress response, changes in sleep patterns, and impact on respiratory function.
Here are some ways in which PTSD may lead to Sleep Apnea:
- Hyperarousal and Sleep Disruption: PTSD is characterized by a heightened state of arousal, which often makes it difficult for individuals to relax and achieve deep sleep. This disruption in sleep patterns, including frequent awakenings and reduced REM sleep, can increase the likelihood of developing obstructive Sleep Apnea (OSA).
- Impact on Respiratory Stability: PTSD-related stress responses may alter how the brain regulates breathing during sleep, contributing to apneas, or pauses in breathing. Studies suggest that the central nervous system’s hypervigilance in PTSD patients can lead to irregularities in breathing that worsen or cause Sleep Apnea.
- Chronic Stress and Inflammation: The chronic stress experienced by people with PTSD can lead to inflammation and muscle tension, including in the muscles that control breathing. This increased inflammation may impact airway stability during sleep, contributing to the collapse of the airway that defines obstructive Sleep Apnea.
Study #1: A Narrative Review of the Association between Post-Traumatic Stress Disorder and Obstructive Sleep Apnea
This review explores the link between PTSD and obstructive sleep apnea (OSA) and suggests a two-way influence between the conditions, meaning each one may worsen the other.
Here’s a summary of the main points:
- PTSD and OSA Connection: Veterans and others with PTSD are at higher risk for OSA than the general population. PTSD symptoms, like constant alertness and poor sleep, might lower the threshold for waking up due to mild airway blockage, increasing OSA episodes. Meanwhile, OSA causes interrupted breathing and reduced oxygen during sleep, which can lead to fragmented sleep and worsen PTSD symptoms like nightmares.
- Sleep Quality: OSA disrupts REM sleep (the deep sleep phase), which is important for processing emotions and memories. Interrupted REM sleep can worsen PTSD symptoms by intensifying nightmares and emotional distress.
- Benefits of Treating OSA: Treating OSA with positive airway pressure (PAP) therapy can reduce both OSA and PTSD symptoms, like nightmares and daytime fatigue. However, people with PTSD may find PAP treatment uncomfortable, so alternative treatments may be better for them.
- Treatment Implications: Treating sleep issues can improve PTSD symptoms, even if a person isn’t ready for traditional PTSD therapies. This approach may help more veterans, especially those uncomfortable with mental health treatment, to manage symptoms.
Study #2: Obstructive Sleep Apnea and Posttraumatic Stress Disorder among OEF/OIF/OND Veterans
This study examined the connection between PTSD symptoms and the risk of obstructive sleep apnea (OSA) in younger veterans from the Iraq and Afghanistan conflicts.
Here’s a simplified summary of the main points:
- Participants: The study involved 195 younger veterans with PTSD from Iraq and Afghanistan who were seen in a VA outpatient clinic.
- High OSA Risk: 69% of the veterans were considered high-risk for OSA, much higher than in general community studies.
- PTSD and OSA Link: Veterans with more severe PTSD symptoms were more likely to screen positive for OSA risk, especially for symptoms like snoring and fatigue.
- Unique Factors: Unlike typical OSA patients who are usually older or have a higher BMI, these younger veterans didn’t always show classic OSA risk factors, indicating that PTSD symptoms themselves may elevate OSA risk.
BVA Decision #1: Entitlement to service connection for obstructive sleep apnea, as secondary to posttraumatic stress disorder (PTSD), IS GRANTED
- Decision: The veteran was granted VA disability benefits for obstructive sleep apnea, linking it as a secondary condition to her service-connected PTSD. This means the VA acknowledged that her sleep apnea was caused or worsened by her PTSD.
- Background: The veteran served in the U.S. Navy from 1990 to 1995. She filed for sleep apnea benefits, claiming it was related to her PTSD.
- Medical Opinions: There were multiple medical opinions both for and against the connection between her PTSD and sleep apnea:
- Some VA examiners provided negative opinions but lacked supporting evidence or didn’t fully consider the veteran’s experiences.
- On the other hand, two private specialists (a psychologist and a psychiatrist) offered strong, evidence-backed opinions in support of the connection. They cited research showing how PTSD can disrupt sleep, increase stress, and lead to conditions like sleep apnea. They also ruled out other major risk factors, concluding that PTSD was the likely cause.
- Outcome: The Board sided with the positive private opinions, finding that the weight of the evidence supported a connection between the veteran’s PTSD and sleep apnea. The Board then approved the service connection for sleep apnea as secondary to PTSD, granting her benefits for this condition.
BVA Decision #2: Entitlement to service connection for obstructive sleep apnea as secondary to service-connected posttraumatic stress disorder (PTSD), IS GRANTED
- Decision: The veteran was granted service connection for obstructive sleep apnea as secondary to his PTSD. This means that the VA recognized that his obstructive sleep apnea was caused by or connected to his PTSD.
- Background: The veteran served actively in the military from June 1969 to July 1971. He filed for VA disability benefits for obstructive sleep apnea, claiming it was linked to his service-connected PTSD.
- Medical Opinions: Multiple medical opinions were reviewed, with conflicting views on the connection between PTSD and sleep apnea:
- Some VA examiners offered negative opinions, asserting that there was no direct causal link between PTSD and sleep apnea. These examiners argued that PTSD, a psychological condition, could not cause an anatomically based condition like obstructive sleep apnea. However, they acknowledged that PTSD and sleep apnea often occur together, even if one does not cause the other.
- Positive evidence came from studies showing an increased risk of sleep apnea in veterans with PTSD, such as a 2018 VA study that found higher rates of obstructive sleep apnea among individuals with PTSD and depression. Another study indicated that 12-90% of people with PTSD have sleep apnea, compared to 17-22% in the general population.
- Additional analysis noted that while these studies did not establish a definitive cause-and-effect relationship, they suggested a possible association between PTSD symptoms and sleep apnea. One VA doctor also acknowledged the possibility of a link, stating that PTSD-related chronic arousal might influence sleep disturbances.
- Outcome: Given the balanced (equipoise) evidence for and against the connection between PTSD and sleep apnea, the Board resolved reasonable doubt in favor of the veteran. They granted service connection for obstructive sleep apnea as secondary to his PTSD, awarding him the related VA disability benefits.
How to Prove Secondary Service Connection
To establish secondary service connection for Sleep Apnea secondary to PTSD, you must meet three key elements:
- Medical Diagnosis of Sleep Apnea: You’ll need a formal diagnosis of Sleep Apnea recorded in your medical records, confirmed by a sleep study, which can be from VA healthcare providers or private physicians. Having a recent diagnosis, ideally within the past 12 months, strengthens your case by showing the current status of your condition.
- Existing Service-Connected PTSD: Your PTSD must already be recognized by the VA as a service-connected disability. This establishes the foundational service connection needed to build the case that your Sleep Apnea is a secondary condition arising from PTSD.
- Medical Nexus Evidence Between the Two Conditions: A strong Nexus Letter for your secondary condition is crucial. This is an independent medical opinion from a qualified provider that states your Sleep Apnea is “at least as likely as not” caused or aggravated by your service-connected PTSD. A Nexus Letter that references medical studies or research supporting the link between PTSD and Sleep Apnea can greatly improve your chances of approval for a secondary service connection.
New Strategy to Service-Connect Sleep Apnea Secondary to PTSD
Remember this: MEDICAL EVIDENCE WINS VA DISABILITY CLAIMS!
Private medical evidence from experts is especially important for helping you prove secondary service connection.
Here’s a new strategy to strengthen your VA claim linking Sleep Apnea secondary to PTSD:
#1. Confirm a Current Diagnosis of Sleep Apnea via a Sleep Study
To support your VA claim, ensure you have a recent, documented diagnosis of Sleep Apnea confirmed by an official sleep study. This diagnostic report should highlight the type of Sleep Apnea and severity of your condition, which is crucial for establishing your case.
#2. Obtain a Disability Benefits Questionnaire (DBQ) for Sleep Apnea
A DBQ for Sleep Apnea, completed by a private healthcare provider, can greatly enhance your claim. This form provides a detailed breakdown of your diagnosis, including the frequency, severity, and duration of your Sleep Apnea symptoms, along with how they impact your daily life, work, and social interactions. By submitting a fully completed DBQ, your claim is marked “decision ready.” This often allows the VA rater to evaluate and potentially rate your claim without requiring a separate C&P exam, expediting the review process.
#3. Secure a Nexus Letter Connecting Sleep Apnea to PTSD
A Nexus Letter is a cornerstone for secondary VA claims. This letter, written by a qualified medical professional, should explain why it is “at least as likely as not” that your Sleep Apnea is proximately due to or aggravated by your service-connected PTSD. The letter should be evidence-based and reference relevant medical research or clinical findings, highlighting the ways PTSD can aggravate or contribute to sleep-disordered breathing. A Nexus Letter with high probative value can be the key to a favorable outcome on your claim.
The “DBQ/Nexus Combo” for Sleep Apnea Secondary to PTSD
This *Pro Tip* encompasses two critical pieces of medical evidence (used in tandem) to help you service connect Sleep Apnea secondary to PTSD.
We call it the “DBQ/Nexus Combo.”
We recommend you have a private healthcare provider complete a DBQ for Sleep Apnea and submit it and your Nexus Letter for Sleep Apnea secondary to PTSD with your VA Fully Developed Claim (FDC) online.
Why?
By using both at the time of claim submission, a VA Rater has all the information he/she needs to review and rate the claim.
Your VA claim is “decision ready,” and you might even be awarded VA disability benefits for Sleep Apnea secondary to PTDS without the need for a C&P exam.
What is the VA Rating for Sleep Apnea Secondary to PTSD
Sleep Apnea is rated under 38 CFR § 4.97, Diagnostic Code 6847.
The VA assigns ratings based on the severity of symptoms and the required treatment
VA ratings for Sleep Apnea secondary to PTSD range from 0% to 100% with breaks at 30% and 50%:
- 0% Rating: This rating is for veterans who have a diagnosis of Sleep Apnea but do not require continuous positive airway pressure (CPAP) or other breathing assistance. Symptoms might exist, but they don’t significantly impact daily functioning, work performance, or social interactions.
- 30% Rating: Veterans receive a 30% rating if their Sleep Apnea causes persistent daytime hypersomnolence (excessive daytime sleepiness). This level of impairment can lead to disruptions in daily life and challenges in maintaining regular activities due to fatigue and drowsiness.
- 50% Rating: A 50% rating is given to veterans who require a CPAP machine to manage their Sleep Apnea symptoms. CPAP therapy is typically prescribed when Sleep Apnea symptoms significantly interfere with quality of sleep, resulting in adverse effects on work, life, and social functioning. This rating acknowledges that the veteran’s condition requires ongoing treatment for effective management and to improve daily functioning.
- 100% Rating: The highest rating, 100%, is assigned for veterans with chronic respiratory failure due to Sleep Apnea, conditions involving carbon dioxide retention, or those requiring a tracheostomy. This rating reflects the most severe level of impairment, where Sleep Apnea severely impacts the veteran’s health and requires extensive medical intervention.
Did the VA Deny Your Claim for Sleep Apnea Secondary to PTSD?
Sleep Apnea secondary to PTSD claims are commonly denied, even with a Nexus Letter.
Here’s why these denials often happen and what you can do to improve your chances of winning your claim during the appeals process:
Reason #1: Lack of Evidence Showing PTSD Causes Sleep Apnea
One common reason for denial is that the VA claims examiner didn’t find enough evidence to show that PTSD causes Sleep Apnea.
While PTSD doesn’t directly cause Sleep Apnea, research supports a link where PTSD can make Sleep Apnea symptoms worse or more likely due to sleep disruptions and heightened stress.
Pro Tip: If your claim was denied due to lack of “causation,” check your VA decision letter. If you believe the decision was incorrect, filing a VA Higher-Level Review may be your next best step. Emphasize the aggravation aspect in your claim rather than causation, showing how your PTSD worsens Sleep Apnea symptoms.
Reason #2: Denial Due to Weight Gain or Obesity
Sleep Apnea is often associated with weight gain and obesity, which might be used to deny your claim if these factors were seen as unrelated to your service-connected PTSD.
However, weight gain may actually result from PTSD, particularly due to medications or lifestyle impacts from PTSD symptoms.
This is called the “intermediate step” principle for service-connection, where PTSD contributes to weight gain, which then aggravates Sleep Apnea.
To establish this, the following must be true:
- Your PTSD caused weight gain or obesity, potentially through side effects of medications or changes in lifestyle.
- This weight gain was a substantial factor in causing or worsening your Sleep Apnea.
- Your Sleep Apnea wouldn’t have developed if not for this weight gain linked to PTSD.
Pro Tip: If weight gain or obesity contributed to your Sleep Apnea, review your VA decision letter. You may consider explaining that your Nexus Letter showed that your weight gain or obesity resulted from PTSD, which aggravated your Sleep Apnea. Then submit a Higher-Level Review if you believe an error was made.
Reason #3: Missing Nexus Letter or DBQ for Sleep Apnea Secondary to PTSD
A Nexus Letter is a critical part of a secondary service connection claim, as it provides a medical opinion connecting PTSD and Sleep Apnea.
If you didn’t include a Nexus Letter or DBQ (Disability Benefits Questionnaire) with your initial claim, this could be why your claim was denied.
The Nexus Letter should:
- Be written by a qualified medical professional.
- Clearly explain that it’s “at least as likely as not” that PTSD contributed to or aggravated your Sleep Apnea.
The DBQ, completed by a healthcare provider, confirms the diagnosis and details the severity and impact of your Sleep Apnea.
Pro Tip: To make your claim stronger, submit a Nexus Letter alongside a DBQ for Sleep Apnea from a private healthcare provider. This “DBQ Nexus Combo” can make your claim “Decision Ready,” potentially eliminating the need for a C&P exam.
If you didn’t include these in your original claim, you can submit a Supplemental Claim with the Nexus Letter and DBQ for review.
If they were included but your claim was still denied, consider a Higher-Level Review to appeal the decision.
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About the Author
Brian Reese
Brian Reese is a world-renowned VA disability benefits expert and the #1 bestselling author of VA Claim Secrets and You Deserve It. Motivated by his own frustration with the VA claim process, Brian founded VA Claims Insider to help disabled veterans secure their VA disability compensation faster, regardless of their past struggles with the VA. Since 2013, he has positively impacted the lives of over 10 million military, veterans, and their families.
A former active-duty Air Force officer, Brian has extensive experience leading diverse teams in challenging international environments, including a combat tour in Afghanistan in 2011 supporting Operation ENDURING FREEDOM.
Brian is a Distinguished Graduate of Management from the United States Air Force Academy and earned his MBA from Oklahoma State University’s Spears School of Business, where he was a National Honor Scholar, ranking in the top 1% of his class.
