Have you even wondered if the sleep apnea that causes you to wake up feeling exhausted despite having had a full night’s sleep could be connected to your PTSD? New research suggests there is a strong connection. A recent study found that 69% of Vietnam veterans with Post-Traumatic Stress Disorder (PTSD) also had some form of sleep apnea. PTSD and sleep apnea would seem to go hand in hand. But does PTSD actually cause sleep apnea?

This article examines the relationship between PTSD and sleep apnea in depth. We also cover how veterans with service-connected PTSD can get benefits for sleep apnea, whether the sleep apnea was caused by PTSD or another health condition.

By way of introduction, we are The Rep for Vets, a national disability firm proudly advocating on behalf of veterans with PTSD and other service-connected disabilities. We’ve helped countless veterans across the country navigate the claims process and get the benefits they earned.

First, let’s cover the basics of sleep apnea — what sleep apnea is, why it’s considered a disability, what other health issues are associated with it — and then we’ll consider the connection between PTSD and sleep apnea.

What Is Sleep Apnea?

Sleep apnea is a potentially serious sleep disorder in which a person intermittently stops breathing throughout the night. This can be due to an obstructed airway, or it can have more of a neurological basis. We also see cases where other factors are at play.

Types of Sleep Apnea

The three main types of sleep apnea are:

Obstructive sleep apnea – This is the most common form. For any number of reasons, the throat muscles relax to the point where your airway is obstructed and you stop breathing.

Central sleep apnea – This form of sleep apnea is less common and occurs when signals from the brain to the muscles that control breathing aren’t firing properly.

Complex/mixed sleep apnea – This describes a bit of both obstructive and central sleep apnea.

What Are the Symptoms of Sleep Apnea?

When you hear the word ‘sleep apnea’ you probably think of someone who snores loudly in their sleep, not someone who experiences chronic heart failure. But complications from sleep apnea can be that dire. Some of the symptoms of sleep apnea include:

• Loud snoring
• Episodes in which you stop breathing during sleep (observed by someone else)
• Waking up gasping for breath
• Morning headaches
• Waking from a full night’s sleep feeling unrested

Two quick notes on these symptoms. 1) Not all people with sleep apnea snore, and not all people who snore have sleep apnea. 2) Many people who have sleep apnea don’t know it. Unless you wake up gasping for breath, you might not be aware that you stop breathing during your sleep.

Complications from Sleep Apnea

Any situation where you stop breathing for any period of time can cause potentially dangerous complications. Sleep apnea has been associated with the following complications:

• Daytime fatigue (hypersomnolence) and irritability
• High blood pressure (hypertension)
• Type 2 Diabetes
• Liver problems
• Respiratory failure
• Cor Pulmonale

Cor Pulmonale is a type of heart failure where the right side of the heart has to pump harder than the left side due to the high blood pressure that one develops from sleep apnea over time.

You might be surprised by the severity of some of these complications. We see type 2 diabetes on the list because sleep apnea increases your risk of developing insulin resistance. If you already have cardiovascular disease, apneas (temporary cessations) in your breathing during sleep can lead to a heart attack or stroke.

Risk Factors for Sleep Apnea – Who Gets It and Why?

PTSD – A study involving Iraq and Afghanistan veterans who visited a VA outpatient PTSD clinic found that 69% percent of them had a high risk for sleep apnea, and this risk increased with PTSD symptom severity.

Obesity greatly increases the risk of obstructive sleep apnea, due to excessive weight constricting the airway.

Toxic exposure, including Agent Orange exposure, burn pit exposure, and Gulf War Syndrome.

Smokers are 3 times as likely to have sleep apnea, due to the inflammation of the upper airway smoking causes.

Substance use – Alcohol, sedatives, and tranquilizers can worsen obstructive sleep apnea, while prescribed pain medicines can interfere with brain signals, causing central sleep apnea.

Existing medical conditions – asthma and other lung diseases, congestive heart failure, high blood pressure, type 2 diabetes Parkinson’s disease, polycystic ovary syndrome, hormonal disorders, and a prior stroke can all increase your risk.

Being male increases your risk factor two-fold.

Genetics could also be a factor. A naturally narrow airway, nasal congestion, a deviated septum, or a family history of sleep apnea can all increase your risk.

So How Does PTSD Cause Sleep Apnea?

There are a few theories out there, but the one that has a most traction takes into consideration the difficulty veterans with PTSD encounter when they are prescribed a Continuous Positive Airway Pressure (CPAP) therapy to treat their sleep apnea.

A CPAP machine is VA’s go-to treatment plan for veterans with sleep apnea. Diet, exercise, and stress reduction are also recommended. If you’ve never heard of it, a CPAP machine is basically a mask connected to a machine that you wear at night. If worn properly, the CPAP machine produces a continuous flow of air that keeps interruptions to your breathing to a minimum, allowing you to get a better night’s rest.

To be frank, CPAP machines aren’t hugely popular with veterans with PTSD. A survey found that only about half of veterans with PTSD use their CPAP machines at night, compared to 70% of veterans who aren’t battling with PTSD. The most common reasons vets gave for not using their CPAP machine, or only using it some of the night, were discomfort, nightmares, and feelings of claustrophobia.

Other researchers point out that people with PTSD often experience insomnia or frequent awakenings, which can reduce the secretion of growth hormones that help us fall asleep and stay asleep.

Teasing out cause and effect is a little tricky here, but these are the basic causes of the high prevalence of sleep apnea we see among the veteran population with PTSD.

If not treated, the conditions tend to reinforce one another. Sleep apnea further diminishes the quality of your sleep, while sleep deprivation and excessive daytime sleepiness can exacerbate your PTSD symptoms.

Getting Benefits for Sleep Apnea Caused or Aggravated by PTSD

If your service-connected PTSD has joined forces with sleep apnea to make it harder for you to get the rest you need to do your job, you should probably be getting disability benefits for both disabilities. You’ll hear this referred to as sleep apnea secondary to PTSD. Here, PTSD is the primary service-connected disability, and sleep apnea is the secondary service connection.

If you already had sleep apnea and the chronic stress and hyperarousal of PTSD caused the sleep apnea to get worse, you would also be able to make a secondary service connection. Generally speaking, it’s easier to win a sleep apnea claim if it is secondary to another service-connected disability.

Medication side effects is another way to get benefits for sleep apnea tied to PSTD or another condition. If a medicine you’re taking causes you to put on weight, which in turn causes you to develop obstructive or complex sleep apnea, you can make the secondary service connection that way.

As we briefly touched on earlier, sleep apnea could also be caused or aggravated by other diseases and conditions, including Parkinson’s, type 2 diabetes, heart problems, respiratory conditions from asthma to lung disease, hormonal disorders, depression, tinnitus, and many other conditions. You can get benefits for sleep apnea secondary to any of these diseases and conditions. See the Appendix at the end of this article for the full list of conditions that have been linked to sleep apnea.

What Evidence Do I Need to Present?

To make your case with the VA, you’ll need what’s known as a “nexus” letter from a doctor. A nexus letter is a letter simply states that your sleep apnea is as likely as not to have been caused by your service-connected PTSD, or another service-connected condition.

You’ll also need to be clinically evaluated by a VA physician. Even if you’ve already been diagnosed with sleep apnea by your regular doctor, the VA still requires a sleep study to be conducted. They want to confirm the diagnosis, and this is also how they determine your disability rating.

Tips During Your C&P Exam

Our advice to veterans who are wary about C&P exams is just to be honest and straightforward. If you were prescribed a CPAP machine and have had trouble adhering to CPAP therapy, let the doctor know. If you think your sleep apnea may be caused or exacerbated by your PTSD symptoms, it’s OK to say so. VA doctors don’t always see the big picture, so it doesn’t hurt to point out how you understand your health conditions to be related.

What Is the VA Disability Rating for Sleep Apnea?

The VA rates Sleep apnea in terms of percentage points, from 0% (acknowledging that you have sleep apnea but it doesn’t impact your ability to earn a living) to 100% (very disabling), with breaks at 10%, 30%, 50%, 70%, and 90%. These ratings are meant to capture the severity of your condition, and how much it affects your ability to work and take care of everyday life stuff.

Most sleep apnea ratings are in the middle range.

• A 30% rating describes someone who experiences excessive daytime fatigue, making it hard for them to concentrate on their work.
• A 50% rating describes someone who has the above symptoms and requires a CPAP machine to get a good night’s rest.
• A 100% rating is reserved for severe complications, such as sleep apnea-aggravated respiratory failure or Cor Pulmonale.

Calculating Your VA Rating for Sleep Apnea Secondary to PTSD

If you have more than one service-connected disability, the VA gives you a combined rating. Calculating your combined rating is a little more complicated than just adding the disability ratings together.

Let’s look at an example. Amy in Orlando is rated at 50% for PTSD and 50% for sleep apnea. That gives her a 100% rating, right? Not quite. Instead of adding the ratings together (that would be too easy!), the VA uses a ratings table to find the combined rating. Consulting the ratings table, we find that combing Amy’s 50% PTSD and 50% sleep apnea gives her a 75% rating.

The reason the VA uses a ratings table and doesn’t just add up percentages is because a person can’t be more than 100% disabled. If, for example, Amy had another 50% rating for a left knee injury, her combined rating would be 88%, not 150%. For more on how VA Math works, check out our article on How to Calculate Your VA Disability Rating. Or try our interactive VA Disability Calculator.