Tips for Sleep Apnea Secondary to PTSD/Mental Disorder Claims

[dajoker12]

Moderator, you might want to Pin this somewhere, as this seems to be a recurring trend. 

I have given out this information to others, but I will post it here so that others can find it rather than searching through the forum.

First and foremost, claiming and getting sleep apnea secondary to PTSD or Mental disorder is not easy. I have personally seen more lost than won, however, it can be obtained and I myself have personally received it. 

If you had sleep apnea diagnosed while in active duty, it is usually a slam dunk........for the rest of those trying to get it, it could require a lot of work.  I suggest trying to get it both direct and secondary service connected.

It is easier to get sleep apnea as a direct service connection obviously, however, most Veterans do not get it diagnosed while in service. Best way to get that resolved is through buddy statements. I suggest getting 3-4 (I personally had 7-8) or more. Do not have them only say that they saw you snoring.......that is great and all, but that is not a symptom of sleep apnea.......it is incidental. They would need to say that they saw you gasping for air, choking, etc. Preferably roommates. If you were deployed, it would be easy to have many people saying that they saw/heard this as you would have more than likely been in an open bay setting at some point in time. You can also have your spouse write up a statement. This all needs to be during active duty periods of times and dates need to be included.  M21-1 reference III.iii.2.E.2.b "Types of Evidence VA May Use To Supplement or as a Substitute for STRs" allows for buddy statements to act as STRs for medical evidence.........if they are certified "buddy" statements or affidavits.............having them written on VA Form 21-4138 solves this issue as it has the appropriate verbiage written near the bottom. Under M21-1 reference III.iii.1.B.7.a and 38 CFR 3.200, it meets the certification criteria..........problem solved. From my experience, getting all of the buddy statements needed can take longer than you originally anticipate....plan ahead.

Now, for secondary criteria.

Have you ever been diagnosed with alcohol abuse (it is frequently written as "ETOH")? If so, has it been attributed to your mental disorder or did it exist prior to that and is it considered willful? If you have been diagnosed with alcohol abuse, and it is attributable to your mental disorder,  guess what, alcohol consumption is attributable to sleep apnea. 

would suggest that you start doing your own academic research. You might be able to locate peer-reviewed academic journal articles (those are the types of articles that you want to submit) through https://www.researchgate.net/. If not, another alternative is using a college database to search academic journals through. Ah, but you need to be a college student to use the database to search academic journals through. One might make an argument that you could register for classes at a local community college (you can even register online nowadays without even stepping foot on campus) and even register for "late start" classes, and have access to the aforementioned database immediately (hint hint, look in the academic journal Chest); one could easily find within a 60 minute search at least 5 appropriate and recent journal articles clearly establishing a link between specific mental disorders and sleep apnea; there is a clear link between PTSD, anxiety disorders, depression, and especially schizophrenia. One might make an argument that you could simply then disenroll from the classes that you enrolled in by the date specified in order to get a full refund, thereby being charged nothing. Save the academic journal articles as pdf files, and create a work cited page (bibliography) for them in APA format (google is your friend.)

You now have a choice...........

Submit your claim with the buddy statements, mental health notes from a private provider, and evidence that you have and go with either a VA exam or vendor exam (whichever is given) or you can get an IME and IMO from private providers. If go the latter route, I would schedule one with a sleep specialist, why, because sleep apnea is their specialty. Pulmonologists also fall within this scope as well, though I suspect that you will have better luck finding a sleep specialist believing there to be a link between mental disorders and sleep apnea. You will get a Sleep Apnea DBQ and an IMO. Make sure that you have your C - File first as an examiner is required to have access to it and state that they have seen it on the DBQ for it to acceptable proof to the VA.

I would also get one from your psychologists/psychiatrist (Make sure that they are a psychiatrist or a psychologist.....if a psychologist, they need to be PsyD or Ph.D., or under the observation of a Ph.D.). 

Make sure before you solicit those medical opinions, that you acquire "buddy statements" from 3-4 (or even more) people with whom you served. Roommates would be best, or people who slept in close proximity to you.........again, this is only if you believe that sleep apnea developed while you were in Active Duty service. Make sure that they are written on VA Form 21-4138. Make sure they say that they witnessed clear symptoms of sleep apnea i.e. gasping for air, choking sounds, moments where they visibly or auditorily could determine that you ceased breathing etc.

Remember, you will want the sleep specialist and the psych professional to have your academic journal articles and buddy statements.

Once you have all of them, solicit your medical opinions from the two aforementioned providers.

Ideally, you would love for the IMOs to say that they believe that you could be both direct service connected for sleep apnea or secondary due to mental disorder, possibly even say that the mental disorder and sleep apnea aggravate one another (which there is medical evidence to support.)

If you opt to go the route of getting the private IMO and IME, you will obviously submit those with your claim, and all medical records from private providers pertinent to sleep apnea and your mental health treatment, buddy statements, academic journal articles, and a nicely written statement written by yourself on a VA Form 21-4138 talking about the issue at hand and summarizing everything concisely. Mention everything that you are providing that you wont to be considered for the claim, and when the issue first manifested. 

[Fat]

I'm a little more inclined to file Sleep Apnea secondarily to Sinusitis or Rhinitis.

Literature supports the base line medical causation.

Finding a sleep doctor whom agrees with the theory, is willing to fill out an DBQ, and provide a nexus/IMO is the toughest part.

The actual sleep test results will speak for itself.

 

 

 

[USMC_VET]

On 2/24/2019 at 12:11 PM, vetquest said:

I would but I have been out 33 years.  Acquisition of buddy statements is impossible.

thats true. I just won my claim after getting a IMO from a Psychologist and Dr. Anaise that connected PTSD as aggravating my OSA (nightmares cause me rip the mask off about an hour after i fall asleep). First youll need to get a diagnosis/sleep study and a MEDICALLY ORDERED CPAP.  go to VA primary care and explain symptoms and ask for a sleep specialist/pulmonologist referral.  this alone doesnt win it it just provides the first part of the nexus. 

If you have a service connected disability that...
1) causes issues getting to sleep (insomnia, etc)

2) causes issues staying asleep (nightmares, regardless if you rip off the mask or not)
 

3) sleep long enough to get a good rest 

 

then you can make a aggravation/secondary claim that X service connected disability (PTSD, Tinnitues, ETOH abuse) makes your symptoms worse or makes the treatment of OSA impossible or difficult.  The IMO helps make that case medically, even though its saying exactly what you tell them youre experiencing.

[USMC_VET]

On 4/25/2019 at 2:04 PM, Mark D Worthen PsyD said:

That looks like very sound advice, dajoker12.

I have not yet seen scientific evidence that PTSD causes obstructive sleep apnea (I have read all the articles you posted), but:

(1) scientific evidence and legal evidence are not the same; and

(2) it could be that there is such a causal relationship but research has simply not identified it yet. 

There is also the question of aggravation, as you (dajoker12) discuss in your post. I think aggravation is more likely than causation. There has not been much research on the aggravation question, but a sleep medicine physician might (and I know some do) conclude that there can be such a relationship, i.e., that PTSD aggravates (exacerbates) Obstructive Sleep Apnea.

I wrote an article (blog post) a while back about mental disorders that are secondary to service-connected medical disorders and I emphasized the importance of specifically asking VBA to consider secondary service connection, and I offered some suggested language for veterans service officers. In my experience, sometimes VBA did not ask a C&P examiner to consider the aggravation question and the examiner did not think of it either (even though they should). Consequently, veterans who might have received disability benefits for a secondary condition did not. That's why I believe it's important to clearly and specifically ask VBA to consider secondary service connection when you file the claim.

I adjusted the wording of suggested language for veterans service officers to consider to fit the current topic, i.e., the PTSD ==> Obstructive Sleep Apnea relationship. 

This is a claim for obstructive sleep apnea that is proximately due to, or aggravated by, the veteran's service-connected posttraumatic stress disorder (PTSD). Please note that the veteran asks the Veteran Benefits Administration to:

1) First consider if the veteran's obstructive sleep apnea is proximately due to, or a result of, the veteran's service-connected PTSD.

2) If not, the veteran then asks VBA to consider if the veteran's service-connected PTSD has aggravated (increased the severity of) the veteran's obstructive sleep apnea beyond its normal course or progression. Allen v. Brown, 7 Vet. App. 439 (1995); Aggravation of nonservice-connected disabilities, 38 C.F.R. § 3.310(b).

Note that you should ask a veterans service officer, VA-accredited claims agent, or veterans law attorney about how to phrase questions since they know more about the topic than I do. What I wrote above is simply a suggestion to consider. 

~ Mark

I just posted about how i won my OSA secondary to PTSD for aggravation (my CFile request after this will provide more light on exactly what the rater decided but that will take awhile to get).

But in short because my nightmares from PTSD cause me to rip off my mask and not have great sleep generally this exacerbates the OSA symptoms and effects.  I had two psych exams and two (NP & MD) records reviews to wade through to get it along with two IMO's from a MD and psychologist.

[Riplip]

I know that this article is old but I have a referral to the sleep people at my local VA in 2 months. I have tinnitus, Sever hearing loss, anxiety and depression that I am service connected for. For years now I haven't felt like I sleep well and my wife typically has to leave the room when I'm sleeping. She doesn't think I stop breathing but I defenitely don't sleep well. I wake up all the time when my tinnitus decides to change pitchs and or my snoring wakes me up. I'll talk to the sleep people but would this be a sleep disorder? I don't think its apnea. Thank you