PTSD Is a Major Cause of Sleep Apnea in Obese Veterans

Many veterans suffer from obstructive sleep apnea (OSA)—a condition where breathing stops repeatedly during sleep. While obesity is often blamed, this explanation alone overlooks a crucial factor: Post-Traumatic Stress Disorder (PTSD). Mounting evidence shows that PTSD is not only linked to sleep apnea but plays a direct role in causing it, especially among veterans who are already at higher risk due to service-related conditions.

What Is Sleep Apnea—and What Causes It?

Sleep apnea happens when the airway becomes blocked during sleep. According to Dorland’s Medical Dictionary, this blockage results from the collapse of the airway and loss of muscle tone during REM sleep—the stage of deep dreaming when the body becomes temporarily paralyzed.

In most cases, two things must happen for OSA to occur:

1. A partially narrowed airway—often from obesity or other physical traits, like excess throat tissue.
2. A paralysis of muscles during REM sleep, including the tongue and throat muscles, which allows the airway to collapse entirely.

So, it’s not just about being overweight—it’s about how the brain regulates breathing and muscle control during sleep. This is where PTSD comes in.

How PTSD Triggers or Worsens Sleep Apnea

PTSD disrupts REM sleep, causing frequent nightmares, stress responses, and changes in muscle tone regulation. This disruption can paralyze the upper airway, making a full blockage more likely—especially in veterans whose airways are already partially narrowed due to obesity.

Veterans often experience sleep problems that civilians do not. And when conditions like PTSD affect how the brain controls REM sleep, the risk of developing obstructive sleep apnea increases dramatically.

The Science Behind It: What the Research Shows

Several large-scale studies back up the strong link between PTSD and sleep apnea in veterans:

1. VA Study of Over 4 Million Veterans (Sharafkhaneh et al.)

• Out of 4 million VA patients, 118,105 were diagnosed with sleep apnea.
• Of those with sleep apnea:
  • 21.8% had depression
  • 16.7% had anxiety
  • 11.9% had PTSD
• The connection between sleep apnea and psychiatric disorders was statistically significant at 99.999% certainty—a level of confidence that confirms this is not due to chance.

2. Study of Active-Duty Soldiers (Mysliwiec et al.)

• Evaluated 110 non-obese soldiers within 18 months of deployment.
• 62.7% had sleep apnea, 63.6% had insomnia, and 38.2% had both.
• 70% had at least one condition like PTSD, depression, TBI, or pain.
• Veterans with both insomnia and OSA had the highest rates of PTSD and other mental health issues.

3. PTSD Increases OSA Risk Even in Obese Veterans (Babson et al.)

• Reviewed records of 2.4 million obese veterans across 140 VA facilities.
• Found a much higher rate of OSA among those with PTSD or mood disorders compared to those without.
• Crucially, this higher risk existed even when BMI (body weight) was the same.
• Conclusion: PTSD and mood disorders increase OSA risk independent of obesity.

“Even when holding BMI constant, a significant relation emerged for mood disorders. This indicates that the association between sleep apnea and mood disorders is attributable, at least in part, to factors other than BMI.”
— Babson et al., published by the American Academy of Sleep Medicine

Why the VA’s Assumptions Are Flawed

The Board of Veterans’ Appeals (BVA) often assumes that obesity alone causes sleep apnea. But that view ignores the real-world evidence from veteran-specific studies. In the general population, about 12.5% of obese individuals have sleep apnea. But among veterans with PTSD, the rate jumps to 50% or more.

If obesity were the only cause, veterans with and without PTSD would have the same rates of sleep apnea. But they don’t—and that difference can only be explained by PTSD and other service-connected conditions.

Legal Implications: PTSD as a “Substantial Factor”

Under VA regulation 38 C.F.R. § 3.310, a service-connected condition like PTSD does not have to be the only cause of a secondary disability—it just needs to be a substantial factor. In legal terms, a condition is considered a substantial factor if:

• It contributes meaningfully to the outcome, and
• The harm would not have occurred without it.
  (See Shyface v. Secretary of Health & Human Services, 1999)

In veterans with both obesity and PTSD, both factors work together to cause sleep apnea. Therefore, PTSD meets the standard for being a proximate cause under VA law.

The Bottom Line

Veterans suffer from PTSD, mood disorders, and traumatic brain injuries at far higher rates than the general population. These service-related conditions do more than affect mental health—they directly contribute to physical disorders like sleep apnea.

Ignoring the role of PTSD in veterans with sleep apnea means ignoring both science and the law. Veterans deserve fair evaluations that recognize the real causes of their health conditions—not just those seen in civilians.