RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1201308 SEPARATION DATE: 20030801 

BOARD DATE: 20130125 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SPC/E-4 (44E/Machinist), medically separated for 
psychotic disorder. The psychotic disorder condition could not be adequately treated to meet 
the requirements of his Military Occupational Specialty (MOS). He was issued a permanent S3 
profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded no other 
conditions for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated the psychotic 
disorder condition as unfitting, rated 10%. The CI made no appeals, and was medically 
separated with a 10% disability rating. 

 

 

CI CONTENTION: “Still have problems with my condition.” 

 

 

SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 
6040.44, Enclosure 3, paragraph 5.e.(2) is limited to those conditions which were determined 
by the PEB to be specifically unfitting for continued military service; or, when requested by the 
CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings 
for unfitting conditions will be reviewed in all cases. The psychotic disorder condition, as 
requested for consideration meets the criteria prescribed in DoDI 6040.44 for Board purview. 
Any conditions or contention not requested in this application, or otherwise outside the Board’s 
defined scope of review, remain eligible for future consideration by the Army Board for 
Correction of Military Records. 

 

 

RATING COMPARISON: 

 

Service IPEB – Dated 20030626 

VA (2 Mos. Post-Separation) – All Effective Date NSC 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Psychotic Disorder 

9210 

10% 

Psychosis 

9210 

NSC 

20031002 

.No Additional MEB/PEB Entries. 

0% X # / Not Service-Connected x # 

 

Combined: 10% 

Combined: NSC 



 

 

ANALYSIS SUMMARY: 

 

Psychotic Disorder Condition. There was no known psychiatric history until CI was voluntarily 
admitted to the hospital 8 October 2002, for diagnostic evaluation of symptoms of hearing 
voices and other people’s dreams, that the days were “reruns” and that he could predict the 
future. Psychosis not otherwise specified (NOS) was diagnosed and he was discharged 
15 October 2002 on medication without a change in symptoms and followed as an outpatient in 
the mental hygiene clinic for continuing medication treatment and individual psychotherapy. 
During the MEB narrative summary(NARSUM) examination, 21 April 2003, 4 months prior to 
separation, the CI noted there had been little or no change in his presenting symptoms, and 
that he still experienced déjà vu, auditory hallucinations and feeling he could see the future. On 
mental status exam (MSE), the CI was appropriately groomed and dressed, alert and oriented 


to person, place, time and situation, and cooperative with the examination. Mood was “okay” 
with mood congruent, euthymic affect. Eye contact limited and he endorsed active auditory 
hallucinations and the ability to see the future but denied other types of hallucinations. Speech 
was normal to rate, rhythm, tone and volume, and thought processes were generally linear, 
logical and goal directed. There was no suicidal or homicidal ideation, and no evidence of 
paranoia, manic or obsessive-compulsive behaviors. Judgment was good, insight limited, and 
higher cortical function was normal. At the VA Compensation and Pension (C&P) mental 
disorder exam, on 13 September 2003, 6 weeks after separation, the CI denied impairments in 
social and occupational function and had not been in psychiatric treatment since discharge 
from the service. On examination, the CI was alert and oriented to person, place, time, and 
situation. There was no psychomotor retardation or agitation, no abnormal movements, 
thought process was coherent and logical, no looseness of association, no disorganized speech, 
no delusions or hallucinations, no phobias, obsessions or suicidal ideation. Mood was euthymic, 
affect appropriate. MSE was negative but based on the claims folder, the correct diagnosis was 
determined to be Psychosis NOS in total remission. His Global Assessment of Functioning (GAF) 
was noted to be 70 (mild symptoms). 

 

The Board directs attention to its rating recommendation based on the above evidence. There 
was no indication of any specific highly stressful event, therefore the Board concluded 
therefore that application of §4.129 is not applicable to this case. Both the PEB and the VA 
coded the CI’s condition as 9210, but provided different ratings. The VA denied service-
connection based on the C&P examination because no disability was shown at that time; citing 
no symptoms were present and the CI was not following any treatment. The PEB decided that a 
rating of 10% fit the profile description of mildly, transiently limiting occupational and social 
impairments. The GAF from the VA exam was assessed at 70, also placing this condition in the 
range of mild impairment. After due deliberation, considering all of the evidence and mindful 
of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to 
recommend a change in the PEB adjudication for the psychotic disorder condition. 

 

 

BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or 
guidelines relied upon by the PEB will not be considered by the Board to the extent they were 
inconsistent with the VASRD in effect at the time of the adjudication. The Board did not 
surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD 
were exercised. In the matter of the psychotic disorder NOS condition and IAW VASRD §4.130, 
the Board unanimously recommends no change in the PEB adjudication. There were no other 
conditions within the Board’s scope of review for consideration. 

 


RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of 
the CI’s disability and separation determination, as follows: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Psychosis Disorder Not Otherwise Specified 

9210 

10% 

COMBINED 

10% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120719, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 

 xxxxxxxxxxxxxxxxxxxxx, DAF 

 Acting Director 

 Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

(TAPD-ZB / XXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXXXXXXX, AR20130003961 (PD201201142) 

 

 

I have reviewed the enclosed Department of Defense Physical Disability Board of 
Review (DoD PDBR) recommendation and record of proceedings pertaining to the 
subject individual. Under the authority of Title 10, United States Code, section 1554a, 
I accept the Board’s recommendation and hereby deny the individual’s application. 

This decision is final. The individual concerned, counsel (if any), and any Members of 
Congress who have shown interest in this application have been notified of this decision 
by mail. 

 

 BY ORDER OF THE SECRETARY OF THE ARMY: 

 

 

 

 

Encl XXXXXXXXXXXXXXXXXXX 

 Deputy Assistant Secretary 

 (Army Review Boards)