Sleep Apnea is a Unique Veteran Disease caused by PTSD and tinnitus and not only by obesity
For VA rating purposes, the veteran needs to show that he suffers from sleep apnea; whether of the obstructive type, central type or mixed type.
Dorland’s medical dictionary[1] defines sleep apnea as: “Sleep apnea resulting from collapse or obstruction of the airway with the inhibition of muscle tone that occurs during REM sleep.”
Obstructive Sleep Apnea (OSA) is caused by an airway blockage that occurs when the soft tissue in the back of the throat and primarily the tongue are paralyzed during REM sleep, collapse and block the airway. REM (Rapid Eye Movement) occurs during 25% of the sleep cycle. During REM the patient is dreaming, and with the exception of the eyeballs, the entire body is paralyzed. In a supine patient, the paralyzed tongue slips back and obstructs the airway.
A common misconception is that fat deposits in the neck cause obstructive sleep apnea. Clearly, by Dorland’s definition obstructive sleep apnea is a dynamic process and not a fixed mechanical obstruction. For this reason, sleep apnea patients experience little or no problems with their breathing or airway patency while awake. If they had mechanical obstruction of the airway they will be symptomatic when awake.
Obstructive Sleep Apnea is a Unique Veteran Disease
The VA expert, in his opinion, the obesity and only obesity causes obstructive sleep apnea, relied solely on the incidence of obstructive sleep apnea in the general public, where obesity and age are the main causes]. The major causes for OSA in veterans, however, are PTSD, mood disorder and tinnitus. These conditions are extremely common in veterans, but rather uncommon in the general public. For that reason, the VA must rely on the incidence of obstructive sleep apnea in the veteran population and not in the general population, where the relative incidence of PTSD is low, and the main cause of obstructive sleep apnea is then obesity.
A VA’s own website[2] reported that sleep apnea is more common in veterans suffering from PTSD than in the general population:
“Insomnia is one of the most common symptoms of PTSD, and has been reported to occur in 90-100% of Vietnam era Veterans with the disorder (McLay, Klam, & Volkert, 2010; Neylan et al., 1998). In the Millennium Cohort Study, an ongoing epidemiologic cohort study of military health, 92% of active duty personnel with PTSD, compared to 28% of those without PTSD, reported clinically significant insomnia (Seelig et al., 2010). As these studies indicate, insomnia is the norm for Veterans with PTSD…
It is important to be aware that insomnia and recurrent nightmares are often not the only sleep disorders that individuals with PTSD experience. There is growing evidence that this population also suffers from obstructive sleep apnea (OSA), a sleep-related breathing disorder, more often than the general population (Jaoude, Vermont, Porhomayon, & El-Solh, 2015).”
To illustrate this point, see a large VA study by Sharafkhanel[3] et al., Association of psychiatric disorders and sleep apnea in a large cohort. The authors of this study found that 50% of veterans suffering from obstructive sleep apnea suffered from mood disorder
“…reviewed the Veterans Health Administration data from 1998 to 2001 and identified patient records indicating sleep apnea and various psychiatric conditions. Out of 4,060,504 unique cases, 118,105 were identified as having sleep apnea (estimated prevalence of 2.91%). Psychiatric comorbid diagnoses in the sleep apnea group included depression (21.8%), anxiety (16.7%) and posttraumatic stress disorder (11.9%). Compared with patients not diagnosed with sleep apnea, a significantly greater prevalence (P < .0001) was found for mood disorders, anxiety, and posttraumatic stress disorder in patients with sleep apnea. The study concluded that sleep apnea is associated with a higher prevalence of psychiatric comorbid conditions in Veterans Health Administration beneficiaries…”
Most importantly the study determined that the association between obstructive sleep apnea and mood disorder was statistically significant with a certainty of 99.999%; this result could not have been obtained by chance.
This study only reviewed the veteran population from 1998 -2001; Veterans of the Iraq and Afghanistan wars were not included. Since then, thousands of veterans have been diagnosed with PTSD, mood disorder or tinnitus. The more recent studies including veterans of the Iraq and Afghanistan wars report the incidence of mood disorder in veterans suffering from OSA to be as high as 70%.
“In the study, Sleep Disorders in US Military Personnel: A High Rate of Comorbid Insomnia and Obstructive Sleep Apnea, Mysliwiec[4] et al. observed that sleep disturbances are increasing in frequency and are commonly diagnosed during deployment and when military personnel return from deployment (redeployment).[5] They evaluated 110 active duty soldiers referred to the sleep disorders clinic within 18 months of deployment. These soldiers were young (average age 33.6 years) and not obese. Overall, 62.7% met diagnostic criteria for obstructive sleep apnea (OSA) and 63.6% for insomnia. 38.2% had comorbid insomnia and OSA. The incidence of PTSD, TBI and mood disorder reached statistical significance when compared to control group. The study reports (emphasis added) [Exhibit 2]:
“In this study, we report that medical and psychologic comorbidities are frequent in military personnel referred for sleep disturbances, with 70% having at least one of the following: depression, mild TBI, pain, or PTSD, and almost one-half (47.3%) reporting two or more diagnoses…Patients with comorbid insomnia and OSA had the highest rates of depression, mild TBI, PTSD, and two or more diagnoses.”
The incidence of sleep apnea in veterans suffering from PTSD, TBI, and mood disorder is almost 10 times higher than the incidence of sleep apnea in the general population, and 3-4 times higher than the obese population.”
The BVA erred by looking only at the incidence and causes of Obstructive Sleep Apnea in the general public, where PTSD is relatively rare, and not at the causes of obstructive sleep apnea in the veteran population.
[1] Dorland, W. A. Newman 1864-1956. Dorland’s Illustrated Medical Dictionary. 28th ed. Philadelphia: W.B. Saunders Co., 1994.
[2] PTSD and Sleep. PTSD Research Quarterly, National Center for PTSD, Volume 27/No.4. ISSN: 1050-1835. 2016. https://www.ptsd.va.gov/publications/rq_docsV27N4.pdf
[3] Sharafkhaneh A, Giray N, Richardson P, Young T, Hirshkowitz M. Association of psychiatric disorders and sleep apnea in a large cohort. Sleep. 2005 Nov;28(11):1405-11. doi: 10.1093/sleep/28.11.1405. PMID: 16335330.
[4] Mysliwiec V, Gill J, Lee H, Baxter T, Pierce R, Barr TL, Krakow B, Roth BJ. Sleep disorders in US military personnel: a high rate of comorbid insomnia and obstructive sleep apnea. Chest. 2013 Aug;144(2):549-557. doi: 10.1378/chest.13-0088. PMID: 23681455; PMCID: PMC4694100.
[5] Peterson AL, Goodie JL, Satterfield WA, Brim WL. Sleep disturbance during military deployment. Mil Med. 2008;173:230–5