On this page
- Can PTSD cause sleep apnea?
- How VA decides sleep apnea secondary to PTSD
- VA rating for sleep apnea secondary to PTSD
- The C&P exam for sleep apnea secondary to PTSD
- Why sleep apnea secondary to PTSD claims get denied
- Nexus letter for sleep apnea secondary to PTSD
- Questions veterans ask about sleep apnea secondary to PTSD
- Sources
If your PTSD is service connected and a sleep study has diagnosed you with obstructive sleep apnea, you can claim the sleep apnea as secondary to the PTSD. It is the most common secondary claim tied to PTSD in the Board's 2021 to 2026 decisions, by a wide margin. It is also a claim VA denies often at first, because the link between a mental health condition and a breathing disorder is not obvious to every examiner. This page covers what the research says, how VA decides the claim, how it is rated, and what the Board's own rulings show about winning it.
Can PTSD cause sleep apnea?
The research shows a strong link, and the link runs in both directions.
- A 2017 meta-analysis of 12 studies (Zhang and colleagues, Sleep Medicine) found obstructive sleep apnea in 75.7% of people with PTSD using the broad threshold of 5 breathing events an hour, and in 43.6% using a threshold of 10. Veterans with PTSD differed significantly from nonveteran samples.
- A 2024 study of 181 male veteran twins (Shah and colleagues, JAMA Network Open) compared brothers with the same genes. In pairs where one brother had current PTSD, he had about 10.5 more breathing events per hour of sleep than his twin.
- A study of the Millennium Cohort, a large group of service members followed over time (Chinoy and colleagues, Sleep Health, 2022), found that PTSD predicted new sleep apnea and sleep problems predicted new PTSD.
- Among 159 Iraq and Afghanistan veterans screened at a VA outpatient PTSD clinic, 69.2% were at high risk for sleep apnea, and more severe PTSD symptoms raised that risk (Colvonen and colleagues, Journal of Clinical Sleep Medicine, 2015).
Why it happens is still being studied. The mechanisms medical opinions usually cite are hyperarousal and broken sleep, changes in how the airway behaves during sleep, and weight gain from PTSD itself or from the medications used to treat it. Not every study agrees: a 2011 Dutch study that compared veterans with and without PTSD on overnight sleep studies found no difference in sleep apnea. A careful opinion acknowledges that and explains why the link still holds for you.
How VA decides sleep apnea secondary to PTSD
Secondary service connection is in 38 CFR § 3.310. VA grants it in two ways:
- Caused by. Your service-connected PTSD caused the sleep apnea, at least as likely as not.
- Aggravated by. Your sleep apnea is worse because of the PTSD, meaning it would be less severe but for the PTSD (M21-1 V.ii.2.D). VA rates only the part above the baseline level of the sleep apnea before the aggravation, so the opinion should describe that baseline.
The claim needs three things in the file: a current diagnosis of sleep apnea from a sleep study, service-connected PTSD, and a medical opinion linking the two with reasoning. The first two are records. The third is where these claims are won or lost.
When weight gain is the link
Many sleep apnea secondary to PTSD claims run through weight. VA does not treat obesity as a disability on its own, but VA's General Counsel (VAOPGCPREC 1-2017) allows it to be a middle step: the PTSD or its medication caused weight gain, the weight gain was a substantial factor in causing the sleep apnea, and the sleep apnea would not have happened without the weight gain. The Court of Appeals for Veterans Claims built on that framework in Walsh v. Wilkie (2020), and since 2019 the Board has cited the General Counsel opinion in about 1 in 10 of its sleep apnea service connection decisions. An opinion on this theory has to answer all three parts. Claim Raven's guide to obesity as an intermediate step covers the rule in more detail. The Board has granted claims where the doctor did exactly that, for example:
"it was at least as likely as not that without his weight gain and obesity, the Veteran's OSA would not have occurred."
That is from Board citation A25000430, a grant. Board decisions are not precedential, but they show what the Board accepts.
VA rating for sleep apnea secondary to PTSD
Sleep apnea secondary to PTSD is rated the same way as any sleep apnea, under Diagnostic Code 6847:
- 100%: chronic respiratory failure with carbon dioxide retention or cor pulmonale, or a tracheostomy
- 50%: requires a breathing assistance device such as a CPAP machine
- 30%: persistent daytime hypersomnolence
- 0%: no symptoms, but a sleep study documents the disorder
Most veterans with a CPAP prescription land at 50%. The sleep apnea VA rating page covers what "requires" a CPAP means and the 2022 proposal to change these criteria.
VA rates the sleep apnea separately from the PTSD, because sleep apnea is a breathing disorder with its own code. The sleep problems that are part of PTSD itself, such as nightmares and trouble falling asleep, stay in the PTSD rating. The two ratings then combine under 38 CFR § 4.25. A 70% PTSD rating and a 50% sleep apnea rating combine to 85, which VA rounds to 90%.
The C&P exam for sleep apnea secondary to PTSD
VA usually orders an exam or a medical opinion for this claim. The examiner is asked whether your sleep apnea is at least as likely as not caused by your PTSD and, separately, whether the PTSD aggravated it. Both questions matter. An opinion that answers only the first one is inadequate under El-Amin v. Shinseki (2013), and the Board sends such claims back.
What the examiner looks at:
- Your sleep study and the date of your sleep apnea diagnosis compared with your PTSD history
- Your weight history and any medication that may have caused weight gain
- Other risk factors, such as age, neck size, smoking and alcohol use
- Whether you report symptoms such as gasping, choking or witnessed pauses in breathing
Unfavorable VA opinions on this claim often say sleep apnea is a physical problem of the airway and cannot be caused by a mental condition, or they blame weight without asking what caused the weight gain. The Board section below shows how often the Board sent these claims back because the VA opinion was not adequate.
Why sleep apnea secondary to PTSD claims get denied
When the Board denies this claim, it is almost always because it found the link between the PTSD and the sleep apnea not shown. The usual reasons:
- The only medical opinion is a negative VA opinion, and nothing in the file answers it.
- A private opinion states a conclusion with no reasoning, or does not address the other risk factors in your file.
- The weight gain theory is asserted, but no doctor connects the PTSD or its medication to the weight gain.
- No opinion addresses aggravation.
The Board section below breaks down the evidence that decided the grants and the denials.
Nexus letter for sleep apnea secondary to PTSD
A strong nexus letter for this claim does five things:
- States that the doctor reviewed your records, including the sleep study and your PTSD treatment history.
- Gives an opinion on causation: your obstructive sleep apnea is at least as likely as not caused by your service-connected PTSD.
- Gives a separate opinion on aggravation: your sleep apnea is aggravated by your service-connected PTSD, meaning it would be less severe but for the PTSD.
- Explains the reasoning in plain medical terms and cites the research, including what the research does not settle.
- Deals with your other risk factors directly. If weight is part of the picture, it answers the three weight gain questions above.
Where these opinions break down at the Board is predictable: no rationale, a conclusion with no reasoning behind it, an incomplete review of the records, or a specialty that does not fit the question.
Questions veterans ask about sleep apnea secondary to PTSD
Can PTSD cause sleep apnea?
The research shows obstructive sleep apnea is far more common in people with PTSD, a 2024 twin study tied PTSD to more breathing events per hour of sleep, and a large military cohort found each condition predicts the other. For a VA claim, a medical opinion has to apply that research to your own records.
What is the VA rating for sleep apnea secondary to PTSD?
The same as any sleep apnea under Diagnostic Code 6847: 0, 30, 50 or 100 percent. Most veterans who require a CPAP are rated 50 percent, and the rating combines with your PTSD rating.
Do I need a sleep study for this claim?
Yes. VA needs a current diagnosis of sleep apnea, and for sleep apnea that means a sleep study.
What if I gained weight from my PTSD medication?
That can support the claim through the weight gain path. A doctor has to say that the PTSD or its medication caused the weight gain, that the weight gain was a substantial factor in the sleep apnea, and that the sleep apnea would not have happened without it.
Can I file for sleep apnea secondary to PTSD before my PTSD is service connected?
Secondary service connection needs the PTSD to be service connected, so the sleep apnea claim depends on the PTSD claim. You can file both at the same time.
Sources
- 38 CFR § 3.310, secondary service connection; M21-1 V.ii.2.D, aggravation of a nonservice-connected disability by a service-connected one.
- 38 CFR § 4.97, Diagnostic Code 6847, sleep apnea syndromes; 38 CFR § 4.25, combined ratings table.
- VA General Counsel Precedent Opinion 1-2017 (VAOPGCPREC 1-2017), obesity as an intermediate step; Walsh v. Wilkie, 32 Vet. App. 300 (2020).
- El-Amin v. Shinseki, 26 Vet. App. 136 (2013), an opinion must address aggravation.
- Zhang Y, Weed JG, Ren R, Tang X, Zhang W. Prevalence of obstructive sleep apnea in patients with posttraumatic stress disorder and its impact on adherence to continuous positive airway pressure therapy: a meta-analysis. Sleep Medicine. 2017;36:125-132. PMID 28735910.
- Shah AJ, Vaccarino V, Goldberg J, et al. Posttraumatic Stress Disorder and Obstructive Sleep Apnea in Twins. JAMA Network Open. 2024. PMID 38913378.
- Chinoy ED, Carey FR, Kolaja CA, et al. The bi-directional relationship between post-traumatic stress disorder and obstructive sleep apnea and/or insomnia in a large U.S. military cohort. Sleep Health. 2022;8(6):606-614. PMID 36163136.
- Colvonen PJ, Masino T, Drummond SP, et al. Obstructive Sleep Apnea and Posttraumatic Stress Disorder among OEF/OIF/OND Veterans. Journal of Clinical Sleep Medicine. 2015;11(5):513-518. PMID 25665698.
- van Liempt S, Westenberg HGM, Arends J, et al. Obstructive sleep apnea in combat-related posttraumatic stress disorder: a controlled polysomnography study. European Journal of Psychotraumatology. 2011. PMID 22893807.
- Board of Veterans' Appeals citation A25000430 (granted). Board decisions are not precedential.
- Board figures on this page: Claim Raven's read of every Board decision from 2021 to 2026 that it holds, and of every decision since 1992 for the longer view. Citation shares count Board decisions since 2019 whose rulings all concern sleep apnea.