SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

WILLIAM H. DONNELLY · 2026 · Case ID: 26004497

MIXED

Summary

The Veteran served in the U.S. Army from October 1985 to November 1992. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2016 rating decision. The Veteran sought service connection for obstructive sleep apnea (OSA) and irritable bowel syndrome (IBS), claiming both were caused by his service-connected PTSD. The Board granted service connection for OSA, finding it proximately due to or the result of his service-connected PTSD. The Board denied service connection for IBS, concluding the Veteran did not have a current diagnosis of the condition during the appellate period. The Board found the Veteran's lay statements regarding IBS lacked probative value as he is not a medical expert and the record did not document a diagnosis. The Board also noted that while the Veteran's treating clinician opined a link between PTSD and OSA, it was not given probative weight due to lack of detailed rationale. However, the Board considered medical literature indicating a link between psychiatric conditions and OSA, ultimately finding service connection warranted in the absence of probative VA opinions to the contrary. The Board accorded no weight to VA examiner opinions that attributed OSA solely to obesity, finding they failed to address obesity as an intermediate step between PTSD and OSA. The Board also noted inconsistencies in some VA examiner opinions regarding aggravation, but found further remand unnecessary due to its own consideration of medical literature.

Rationale

Service-connected PTSD; Medical literature supports link between psychiatric conditions and OSA; No probative VA opinions to the contrary

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

17-65 830

Full Decision Text

Citation Nr: 26004497
Decision Date: 04/13/26 Archive Date: 04/13/26

DOCKET NO. 17-65 830
DATE: April 13, 2026

ORDER

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

Entitlement to service connection for irritable bowel syndrome (IBS) is denied.

FINDINGS OF FACT

1. The Veteran's OSA was caused by his service-connected posttraumatic stress disorder (PTSD).

2. The Veteran does not have a current diagnosis of IBS.

CONCLUSIONS OF LAW

1. The criteria for secondary service connection for OSA are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for service connection for IBS are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the U.S. Army from October 1985 to November 1992. These matters come to the Board of Veterans' Appeals (Board) on appeal from an October 2016 rating decision by the agency of original jurisdiction (AOJ) of the United States Department of Veterans Affairs (VA).

The Veteran testified at a June 2021 hearing held before a Veterans Law Judge (VLJ). A transcript of the hearing is associated with the claims file. The presiding VLJ is not available to participate in the adjudication of the claim, as required under 38 C.F.R. § 20.604, and so the Veteran was offered the opportunity for another hearing in July 2024. He did not respond, and so in accordance with the notice sent him, it is presumed he does not desire a new hearing.

In November 2021, November 2022, and December 2023, the Board remanded these matters for further evidentiary development. The matters are again before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998).

In December 2023, the Board also remanded the issue of entitlement to service connection for a headache disorder. In a December 2024 rating decision, the AOJ granted service connection for tension headaches. This action constituted a full grant of the benefit sought, and is no longer on appeal. Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997).

Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994).

In order to establish service connection on a direct basis, the record must contain competent evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection may also be warranted for disability proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). This permits service connection not only for a disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In the case of aggravation by a service-connected disability, a Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Id.; see also
, 1167 (Fed. Cir. 2004).

As the Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War, the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, are for consideration.

Under 38 C.F.R. § 3.317, service connection may be granted on a presumptive basis if there is evidence (1) that the claimant is a Persian Gulf Veteran; (2) who exhibits objective indications of chronic disability resulting from an undiagnosed illness, a medically unexplained chronic multisymptom illness (MUCMI) (such as chronic fatigue syndrome, fibromyalgia, or IBS) that is defined by a cluster of signs or symptoms, or resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either during active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2026; and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. §§ 1117, 1118; 38 C.F.R. § 3.317. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii).

In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the weight of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant.

Obstructive Sleep Apnea (OSA):

The Veteran contends that he is entitled to service connection for OSA. The Veteran asserts in his May 2016 Fully Developed Claim (VA 21-526EZ) and at the June 2021 Board hearing that his claimed OSA was caused by his service-connected PTSD. The Veteran is in receipt of a 50 percent rating for PTSD, effective July 14, 2010, and a 70 percent rating, effective August 16, 2016.

The evidence of record reflects that the Veteran's treating clinician submitted a letter on behalf of the Veteran dated May 2016 and associated with the claims file in December 2017. The clinician opined that it is at least as likely as not that the Veteran's OSA was aggravated by his service-connected PTSD, and that it is also at least as likely as not that the Veteran's PTSD was aggravated by OSA. The clinician indicated that sleep disruption caused by OSA can exacerbate mental health symptoms. It was further reported that the Veteran's PTSD sometimes made it difficult for him to tolerate his CPAP machine and for him to sleep at all, which worsened his daytime excessive somnolence.

The Board accords no probative weight to the opinion of the Veteran's treating clinician. The clinician did not indicate how the Veteran's PTSD made it difficult for him to tolerate his CPAP machine or affected his ability to sleep. To have probative value, a medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).

Pursuant to the Board's November 2021 remand, the Veteran was afforded a VA examination in March 202
machine and for him to sleep at all, which worsened his daytime excessive somnolence.

Pursuant to the Board's November 2021 remand, the Veteran was afforded a VA examination in March 2022. The examination report referenced the 2013 diagnosis of OSA, and use of a CPAP machine. The VA examiner opined that the claimed OSA is less likely than not proximally related to service-connected PTSD. The VA examiner reported that OSA is caused by the collapse of the soft tissues of the throat when sleeping, and that the most common cause of OSA is obesity. As the Veteran is classified as morbidly obese, the VA examiner indicated that such was the cause of his OSA. The VA examiner further opined that OSA was not aggravated by PTSD, and referenced VA treatment records dated January 2022 that noted the Veteran wore his CPAP three to four times per week, and denied symptoms of snoring, gasping, pausing, hypersomnia, or morning headaches with CPAP use.

Pursuant to the Board's November 2022 remand, a VA medical opinion was obtained in December 2022 by the same VA examiner. The VA examiner opined that while research has established a statistical comorbid association between PTSD and OSA, there is no established etiological basis for OSA to be due to PTSD. The VA examiner noted that the two disabilities share common symptoms of disrupted sleep patterns and non-restful sleep. The VA examiner further indicated that PTSD could interfere with sleep due to emotional and psychological issues, nightmares, and hypervigilance with easy arousal during sleep. The VA examiner reported that the pathophysiology of OSA is characterized by narrowing or collapse of the pharyngeal airway during sleep often due to excess weight and the aging process. As OSA is an obstructive process of the airway, it is not related directly or indirectly to PTSD as it would not result in such a pathology.

In a May 2023 addendum opinion, the VA examiner opined that while PTSD could affect sleep in that it can cause insomnia, difficulty falling asleep, and racing thoughts, the obstructive component of OSA may cause one to awaken. The VA examiner further opined that with OSA, one tends to fall asleep easily.

Thereafter, in August 2023, a VA examiner opined that the claimed OSA is less likely than not proximately due to or the result of the Veteran's service-connected PTSD. The VA examiner indicated that the two disabilities are not medically related, and that a review of medical literature failed to demonstrate a causal relationship.

Another VA medical opinion was obtained in August 2023. The VA examiner opined that OSA is less likely than not proximately due to or the result of PTSD. The VA examiner reported that the primary cause of OSA is obesity. The VA examiner indicated that the references to insomnia and racing thoughts by the prior VA examiner did not cause the Veteran to have interrupted breathing while he slept, as PTSD does not cause the collapse of the posterior throat while someone sleeps.

Pursuant to the Board's December 2023 remand, a VA examination was obtained in November 2024. VA medical opinions by a different VA examiner were also obtained that same month. The VA examiner opined that it is less likely than not that the Veteran's OSA was due to PTSD. The VA examiner noted that insomnia is not a sign of OSA and that they are mutually exclusive. The VA examiner reported that insomnia is a sleep disorder characterized by trouble sleeping, which may include difficulty falling or staying asleep. The VA examiner stated that by contrast, those with OSA have no trouble falling or staying asleep. The VA examiner reported that the medical literature did not support a mental disorder as causative or the potential for aggravation of the physiological condition of OSA, which is due to upper airway soft tissue abnormalities and or obesity. The VA examiner indicated that obesity is the best documented risk factor for OSA and that craniofacial and upper airway soft tissue abnormalities increase the likelihood of having or developing OSA. The Board notes that while the VA examiner opined that it is less likely than not that the Veteran's OSA
that insomnia is a sleep disorder characterized by trouble sleeping, which may include difficulty falling or staying asleep. The VA examiner stated that by contrast, those with OSA have no trouble falling or staying asleep. The VA examiner reported that the medical literature did not support a mental disorder as causative or the potential for aggravation of the physiological condition of OSA, which is due to upper airway soft tissue abnormalities and or obesity. The VA examiner indicated that obesity is the best documented risk factor for OSA and that craniofacial and upper airway soft tissue abnormalities increase the likelihood of having or developing OSA. The Board notes that while the VA examiner opined that it is less likely than not that the Veteran's OSA was aggravated beyond a natural progression by PTSD, she later opined the opposite in her report as the Veteran was unable to wear a CPAP needed to control his OSA.

Due to the internally inconsistent aggravation opinions of the November 2024 VA examiner, a VA medical opinion was subsequently obtained in January 2025 by a different VA examiner for clarification. The VA examiner opined that it is less likely than not that the Veteran's claimed OSA was aggravated beyond its natural progression by his service-connected PTSD or that his PTSD resulted in him not being able to use his CPAP mask. The VA examiner noted that such was not supported by the medical records. The VA examiner cited treatment records dated January 2022 that referenced the Veteran's use of a CPAP machine three to four times per week, and that the reason he might not use his machine was due to malfunction and not PTSD. The VA examiner further noted that equipment malfunction was noted on several occasions in the Veteran's records. The VA examiner further drew attention to treatment records dated September 2022 whereby the Veteran was asked to hold CPAP machine use due to nose bleeds.

The Board accords no probative weight to the opinions of the VA examiners of record. While the VA examiners attributed the Veteran's claimed OSA to obesity, they did not address whether obesity was an "intermediate step" between a service-connected disability and OSA. VAOPGCPREC 1-2017; Walsh v. Wilkie, 32 Vet. App. 300 (2020). Therefore, the opinions are not probative.

The Board finds, however, it is not necessary to reach the question regarding causation of weight gain, as service connection on a secondary basis may be awarded without such.

Further, a remand for an adequate VA medical opinion is not required, as the Board is also charged with knowledge of studies identifying a causal link between psychiatric conditions and sleep apnea. See, e.g., Leszek Kubin, Neural Control of the Upper Airway: Respiratory and State-Dependent Mechanisms. Compr. Physiol. vol. 6, 4, 1801-1850 (15 Sep. 2016); Rajesh Kumar, Neural Alterations Associated with Anxiety Symptoms in Obstructive Sleep Apnea Syndrome. Depress. Anxiety vol. 26, 5, 480-91 (2009). Both studies are readily available through the National Library of Medicine (https://www.nlm.nih.gov/). As such, the studies are constructively before the Board. See Euzebio v. McDonough, 989 F.3d 1305, 1321-22 (Fed. Cir. 2021). These studies indicate that psychiatric conditions result in changes to the neurochemical signals issued by the brain to assist in control of autonomous functions, to include the actions of throat muscles while sleeping.

In the absence of a probative examination and opinion, the remaining evidence of record favors the claim, and the weight of the evidence requires an award of service connection for OSA.

To be clear, the Board makes no finding concerning the etiology of obesity.

Irritable Bowel Syndrome (IBS):

The Veteran contends that he is entitled to service connection for IBS. The Veteran asserts in his May 2016 Fully Developed Claim (VA 21-526EZ) and at the June 2021 Board hearing that his claimed IBS was caused by his service-connected PTSD. The Veteran is in receipt of a 50 percent rating for PTSD, effective July 14, 2010, and a 70 percent rating, effective August 16, 2016. At the June 2021 Board hearing, the Veteran endorsed runny stools two to three times per day.

Pursuant to the Board's November 2021 remand, the Veteran was afforded a VA examination in March 2022. The VA examiner indicated that a review of the record did not document a diagnosis of an intestinal disorder. The Veteran reported that his stomach "rolls," which the VA examiner characterized as abdominal distension, as well as constipation. The Veteran also endorsed daily nausea, which did not affect his ability to eat. The Veteran noted that he smoked marijuana to help with pain symptoms but questioned whether this could cause nausea. The examination report indicated that continuous medication was not required nor did the Veteran have a surgical history for an intestinal disorder. The examination report further noted that the Veteran did not have episodes of bowel disturbance with abdominal distress, to include exacerbations or attacks, weight loss, malnutrition, serious complications, or other general health effects attributable to an intestinal disorder. The VA examiner noted that the Veteran also did not have a benign or malignant neoplasm or metastases associated with an intestinal disorder.

In conjunction with a VA Gulf War examination, the Veteran was afforded a subsequent VA intestinal disorder examination in May 2022. The VA examiner reported that the Veteran did not now have nor ever was diagnosed with an intestinal disorder. The VA examiner indicated that the Veteran endorsed chronic constipation but had canceled several colonoscopy appointments but intended to undergo one. The Veteran further noted that he followed no special diet or treatment, but had to always be aware of bathrooms. The VA examiner directed attention to a May 2022 abdominal X-ray that was assessed as normal with respect to the amount of fecal residue and showed no evidence of obstruction. The VA examiner also noted that diagnostic laboratory testing performed in May 2022 was normal. As with the prior March 2022 VA examination, the VA examiner indicated that the Veteran did not have episodes of bowel disturbance with abdominal distress, to include exacerbations or attacks, weight loss, malnutrition, serious complications, or other general health effects attributable to an intestinal disorder. It was noted that the Veteran did not have a benign or malignant neoplasm or metastases associated with an intestinal disorder. The VA examiner reported that there was no diagnosis of IBS, but that inflammatory bowel disease was not ruled out. He stated that if the Veteran underwent a colonoscopy and was evaluated by a gastroenterologist, such could yield a diagnosis of IBS or inflammatory bowel disease.

As the May 2022 VA examiner suggested that further testing was necessary, the Board, in November 2022, remanded the claim for another VA examination and medical opinion.

A VA medical opinion by the May 2022 VA examiner was obtained in May 2023. The VA examiner indicated that there was a lack of documentation of a gastrointestinal disorder or IBS. The VA examiner noted that a presumptive diagnosis of gastritis was made with caveats of a referral to gastroenterology for an evaluation to rule out inflammatory disease. He noted that the consultation was not accomplished by the Veteran. The VA examiner stated that there was no evidence of pathology for a gastrointestinal disorder or IBS on imaging, nor was there evidence of medications commonly prescribed to treat irritable bowel disorders. The VA examiner noted that there was also no mention of IBS or colitis in recent treatment records.

Thereafter, the record reflects that the Veteran failed to appear for a scheduled VA examination in August 2023. Contact history regarding the Veteran's availability, appointment notifications, and an appointment reminder were documented. Upon return of the appeal in December 2023, the Board again remanded the claim to provide the Veteran another opportunity to attend a VA examination.

The record subsequently reflects that the Veteran was afforded VA intestinal disorders and rectum examinations in November 2024. The Veteran reported that in the early 1990s, he experienced abdominal pain and constipation and was informed that he had gastrointestinal problems. He stated that he was diagnosed with IBS in 1993. The Veteran reported current symptoms of constipation as he had a bowel movement every two to five days, and abdominal distention. The Veteran reported that he took Maalox, Pepto Bismol, and Beano on an as needed basis. The examination report characterized the Veteran's lay symptoms as frequent episodes of bowel disturbance with abdominal distress. The examination report further indicated that the Veteran did not have exacerbations and or attacks of an intestinal disorder, anemia, or malnutrition. The VA examiner assessed the Veteran's general health effects attributable to an intestinal disorder as minimal to none. The VA examiner reported that there was insufficient evidence to render a diagnosis of IBS. The VA examiner referenced the Veteran's lay statements that he underwent a colonoscopy three years prior that yielded only benign polyps. The examination report noted that the Veteran also did not have chronic enteritis, functional digestive disorder, or other similar disorders. The examination report indicated that the Veteran did not take any daily prescribed medication for a gastrointestinal disorder. The VA examiner further reported that the Veteran did not have Crohn's disease, ulcerative colitis, undifferentiated form of inflammatory bowel disease, chronic enteritis, diverticular disease, history of intestine surgery, external intestinal fistulous disease, celiac disease, gastrointestinal dysmotility syndrome, visceroptosis, or tumors or neoplasms of the intestine.

The Board finds that the opinions of the VA examiners during the appellate period are entitled to probative weight, as the opinions considered and addressed the Veteran's lay statements, were based on the Veteran's treatment histories, and provided sufficient supporting rationales for the opinions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Further, there are no probative opinions to the contrary.

The threshold requirement for the granting of service connection is evidence of a current disability. In the absence of evidence of a current disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement in a claim of service connection of current disability "is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that a claimant may be granted service connection even though the disability resolves prior to the Secretary's adjudication of the claim." See McClain v. Nicholson, 21 Vet. App. 319 (2007).

Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; see also Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995).

Service connection for IBS is not warranted. The competent evidence of record does not reflect that the Veteran has a current diagnosis of IBS during the relevant period on appeal.

The Board notes that the Veteran is competent to report as to a condition within his knowledge and personal observation. Barr v. Nicholson, 21 Vet. App. 303, 308-310 (2007). The Board acknowledges the Veteran's lay reports at the June 2021 Board hearing and at VA examinations that he was diagnosed with IBS in the 1990s. However, mere transcription of medical history does not transform information into competent medical evidence. LeShore v. Brown, 8 Vet. App. 406 (1995). The record during the appellate period does not document a diagnosis of IBS. The Veteran is merely speculating as to whether he has a current diagnosis of IBS. As the Veteran is not shown to have appropriate medical training and expertise, he is not competent to render probative (i.e., persuasive) opinions on medical matters. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Bostain v. West, 11 Vet. App. 124, 127 (1998); Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Therefore, the Veteran's lay assertions in this regard have no probative
has a current diagnosis of IBS. As the Veteran is not shown to have appropriate medical training and expertise, he is not competent to render probative (i.e., persuasive) opinions on medical matters. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Bostain v. West, 11 Vet. App. 124, 127 (1998); Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Therefore, the Veteran's lay assertions in this regard have no probative value.

Therefore, the evidence of record does not reflect that the Veteran has a current disability of IBS, and the claim must be denied. In the absence of a current disability, service connection is not warranted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).

WILLIAM H. DONNELLY

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board G.A. Ong, 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.

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