ANXIETY DISORDER

E. I. VELEZ · 2025 · Case ID: 25011081

MIXED

Summary

The veteran, who served from March 1976 to March 1980, had his claims for sleep disability, hypertension, and obstructive sleep apnea (OSA) reviewed by the Board of Veterans' Appeals. The Board granted service connection for insomnia, finding that the veteran and his witnesses credibly reported sleep disturbances with an in-service onset and continuity of symptoms, despite the lack of a formal in-service diagnosis. The Board applied the benefit of the doubt, resolving reasonable doubt in the veteran's favor due to the approximate balance of evidence. However, service connection for OSA was denied because the medical evidence did not support a diagnosis of OSA, and lay statements alone were insufficient to establish it, especially after the veteran's passing prevented further development. For hypertension, service connection was granted secondary to the veteran's service-connected right ankle and psychiatric disabilities. The Board found that while VA examinations were inadequate or did not specifically address the veteran's risk factors, the May 2020 opinion, which found a nexus to service-connected disabilities (NSAID and alcohol use), remained uncontradicted and raised reasonable doubt that favored the veteran. The Board noted that the legal standard requires only a contributory factor, not the sole cause, for secondary service connection.

Rationale

Competent lay reports of sleep disturbances with in-service onset and continuity; Treating providers diagnosed insomnia and prescribed medication; Benefit of the doubt applied due to approximate balance of evidence

Special Benefit

NO SPECIAL BENEFIT

Docket No.

16-37 195

Full Decision Text

Citation Nr: 25011081
Decision Date: 08/27/25 Archive Date: 08/27/25

DOCKET NO. 16-37 195
DATE: August 27, 2025

ORDER

Entitlement to service connection for insomnia is granted.

Entitlement to service connection for obstructive sleep apnea (OSA) is denied.

Entitlement to service connection for hypertension secondary to service-connected psychiatric and right ankle disabilities, is granted.

FINDINGS OF FACT

1. Resolving all reasonable doubt in the Veteran's favor, the weight of the competent evidence is at least in approximate balance that his insomnia began in service and continued since service.

2. The weight of the competent evidence is not at least in approximate balance or nearly equal that the Veteran was diagnosed with a separate and distinct disability of OSA.

3. The weight of the competent evidence is at least in approximate balance that the Veteran's hypertension is related to his service-connected right ankle and acquired psychiatric disabilities.

CONCLUSIONS OF LAW

1. The criteria for service connection for insomnia have been met. 38 U.S.C. §§ 1110, 1141, 5103, 5103A, 5107 (2024); 38 C.F.R. § 3.102, 3.303 (2025).

2. The criteria for service connection for OSA have not been met. 38 U.S.C. §§ 1110, 1141, 5103, 5103A, 5107 (2024); 38 C.F.R. § 3.102, 3.303 (2025).

3. The criteria for service connection for hypertension secondary to service connected right ankle and acquired psychiatric disabilities have been met. 38 U.S.C. §§ 1110, 1141, 5103, 5103A, 5107 (2024); 38 C.F.R. § 3.102, 3.303 (2025).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from March 1976 to March 1980. This matter came before the Board of Veterans Appeals (Board) on appeal from a March 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO).

Unfortunately, the Veteran died in June 2017 during the pendency of this appeal. The Veteran's surviving spouse has been substituted for the Appellant for his claim.

The Board remanded the issues on appeal for further development in April 2019, October 2020, January 2021, November 2022, and February 2025.

Service Connection

Service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay 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 present disability). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303(a).

VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. When the evidence is in approximate balance in the veteran's favor or nearly equal 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; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). If the evidence is not in approximate balance or nearly equal, the claim is to be denied. See Lynch v. McDonough, 21 F. 4th 776 (Fed. Cir. 2021).

1. Entitlement to service connection for a sleep disability, to include insomnia and OSA

At the outset, the Board notes that November 2020, June 2024, and November 2024 VA etiology opinions were deemed inadequate for rating purposes. See January 2021 and February 2025 Board Remands. As such, the Board will not consider the findings therein in the analysis below.

1. Entitlement to service connection for a sleep disability, to include insomnia and OSA

Service treatment records are silent for any complaints, diagnoses, or treatment of a sleep disability, though at his January 1980 separation examination, he endorsed symptoms of depression and excessive worry. An August 2011 VA treatment record indicated that the Veteran had nightmare/dream sleep attacks, a REM disorder with acting out in sleep, witnessed sleep apnea, and insomnia. He was prescribed trazadone specifically for sleep. In September 2011, the Veteran reported to his VA treating provider that he did not have sleep apnea or a sleep study, but he did have witnessed apnea, daytime sleepiness, and chronic fatigue.

In a March 2012 statement, the Veteran reported that he had been experiencing sleep and rage problems since March 1976. See March 2012 VA Form 21-4138, Statement in Support of Claim.

In October 2013, the Veteran's treating provider wrote that his sleep issues began in the 1970s while in service, but that he had used alcohol to sleep. The Veteran described sleep issues involving initial insomnia approximately 3 to 4 days per week, as well as middle insomnia.

The Veteran's friends and family submitted several October and November 2013 statements which attested to his mental health symptoms. Notably, one friend noted that she knew the Veteran since 1989 and lived with him for 5 years. She indicated that had noticed him awakening on high alert and agitated, fighting off unseen enemies, and having nightmares. The Board notes that the Veteran and his witnesses are competent to report lay-observable symptoms such as sleep disturbances and the time of its onset and affords such statements significant probative weight. See Layno v. Brown, 6 Vet. App. 465, 470 (1994).

A May 2015 VA psychiatric examination noted chronic sleep impairment and alcohol issues related to his now service-connected psychiatric disability. In April and August 2016 treatment notes, the Veteran reported that his knee pain and excessive phlegm interfered with his sleep and caused aspirations, as well.

A March 2022 VA etiology opinion noted that the record showed the Veteran had insomnia, but the examiner indicated that the etiology of this disability was out of the scope of his opinion as he was not mental health specialist. The examiner also found that the Veteran did not have a breathing related sleep disorder or a diagnosis of OSA prior to his death.

A March 2025 VA etiology opinion found that the record was silent for a diagnosis of OSA confirmed by a sleep study in the record, and therefore no nexus opinion was required. The examiner also indicated that an opinion regarding insomnia was outside the scope of his expertise as he was not mental health specialist.

A June 2025 VA etiology opinion found that the Veteran did not have a diagnosis of insomnia or other sleep disorder in the record. However, she also acknowledged that there were reports of sleep disturbances in the VA treatment records. She dismissed this evidence because it post-dated the Veteran's service. However, the competent lay reports regarding the onset and persistence of his lay-observable sleep symptoms cannot be disregarded merely because there is no evidence of an in-service diagnosis or contemporaneous medical evidence. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993); Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006).

The Veteran has consistently and competently reported that he began experiencing difficulty sleeping, staying asleep, and getting restful sleep during service. Both he and his witnesses endorsed the persistence of those symptoms after service and into the period on appeal. The Veteran's treating mental health providers diagnosed him with insomnia and even prescribed him medication to treat it. The Board cannot and will not discount this competent and persuasive evidence of a current diagnosis with an in-service onset and continuity of symptomology since. Any reasonable doubt on this matter must weigh in favor of the Veteran's claim. Thus, the Board finds that the weight of the competent evidence is at least in approximate balance that the Veteran's insomnia began in service and continued since service. Service connection for insomnia is therefore warranted.

However, the Board also finds that the medical evidence of record
, and getting restful sleep during service. Both he and his witnesses endorsed the persistence of those symptoms after service and into the period on appeal. The Veteran's treating mental health providers diagnosed him with insomnia and even prescribed him medication to treat it. The Board cannot and will not discount this competent and persuasive evidence of a current diagnosis with an in-service onset and continuity of symptomology since. Any reasonable doubt on this matter must weigh in favor of the Veteran's claim. Thus, the Board finds that the weight of the competent evidence is at least in approximate balance that the Veteran's insomnia began in service and continued since service. Service connection for insomnia is therefore warranted.

However, the Board also finds that the medical evidence of record does not support the conclusion that the Veteran had ever been diagnosed with a separate and distinct disability of OSA. VA treatment records do show complaints of sleep disturbances, witnessed apneas, and a diagnosis of insomnia. However, while the Veteran and his witnesses are competent to report the presence of such lay-observable symptoms, there is no indication that they had the training or expertise necessary to provide a competent opinion on whether these were associated with OSA specifically. See Layno, supra. A September 2011 VA treatment record notes that a sleep study consult referral was submitted, but the record is silent for any indication that the Veteran actually had a sleep study performed or that he was formally diagnosed with OSA. Both the March 2022 and March 2025 VA etiology opinions found that there was no diagnosis of OSA in the record. The March 2025 VA opinion specifically noted that the lay statements alone were not sufficient to provide such a diagnosis, as it needed to be confirmed by a sleep study. Unfortunately, due to the Veteran's passing, remand for the provision of a sleep study to resolve this outstanding medical question is not appropriate. As with all claims for service-connection, in the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection for OSA is therefore not warranted.

2. Entitlement to service connection for hypertension

Service treatment records show readings of high blood pressure, but no diagnosis of hypertension. See February 1976, November 1978, and January 1980 Service Treatment and Personnel Records.

A March 2010 VA treatment record documented that the Veteran had a standing diagnosis and related prescription for hypertension, but it is unclear at what exact date this diagnosis was officially rendered.

A May 2020 VA etiology opinion found that the Veteran's hypertension was less likely than not related to his service and/or service-connected disabilities. The examiner noted that the Veteran was taking nonsteroidal anti-inflammatory drugs (NSAIDs) to treat his service-connected right ankle disability, and that he had a history of daily alcohol use associated with his service-connected acquired psychiatric disability. However, he opined that "other" risk factors were more likely responsible for his development of hypertension. Not only did the examiner fail to identify the other risk factors, but he appears to be implying that the NSAID and alcohol use were among them. Furthermore, the Board notes that the Veteran's service and/or service-connected disabilities merely be a contributing factor, not that they be the most or only factor.

A November 2024 VA etiology opinion found that the Veteran's service-connected disabilities were less likely than not related to the Veteran's development of hypertension, but the examiner cited only to generalized statistics and medical literature to support this opinion without addressing any evidence specific to the Veteran. Therefore, the Board finds this opinion to be inadequate. See Bailey?v. O'Rourke, 30 Vet. App. 54, 60-61 (2018).

A March 2025 VA etiology opinion found that the Veteran's service-connected disabilities were not established risk factors for the development of hypertension and therefore could not have conferred any "significant" influence on its disease process. However, the Board again notes that the legal standard does not require that the Veteran's service and/or service-connected disabilities have a "significant" impact on the disease process, only a contributory one. The examiner also did not address the May 2020 opinion or the impact of his NSAIDs/alcohol use related to his service-connected disabilities. The fact that the right ankle and acquired psychiatric disabilities themselves does not address whether the treatment or symptoms associated with them may be related to or risk factors for the Veteran's development of hypertension.

As the only other etiology opinion of record is inadequate, the May 2020 opinion remains uncontradicted by the March 2025 opinion or other evidence of record. The May 2020 opinion itself raises reasonable doubt which must be resolved in the Veteran's favor
the Veteran's service and/or service-connected disabilities have a "significant" impact on the disease process, only a contributory one. The examiner also did not address the May 2020 opinion or the impact of his NSAIDs/alcohol use related to his service-connected disabilities. The fact that the right ankle and acquired psychiatric disabilities themselves does not address whether the treatment or symptoms associated with them may be related to or risk factors for the Veteran's development of hypertension.

E. I. VELEZ

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board E. Bock

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.

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