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AF | PDBR | CY2011 | PD2011 00909
Original file (PD2011 00909.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    BRANCH OF SERVICE: Army
CASE NUMBER: PD1100909   SEPARATION DATE: 20090929
BOARD DATE: 20130410


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (92G/Cook), medically separated for schizoaffective disorder with elements of bipolar disorder (BPD). Although the CI did respond to treatment, it was not adequate to meet the requirements of his Military Occupational Specialty (MOS), he was not eligible to deploy on his medication regimen, and he was barred from access to weapons. He was issued a permanent S3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded schizoaffective/bipolar disorder as medically unacceptable and three other conditions as medically acceptable to the Physical Evaluation Board (PEB). The Informal PEB (IPEB) adjudicated the schizoaffective disorder with elements of BPD condition as the only unfitting condition, rated 10%. The CI initiated, but withdrew, an appeal to the Formal PEB (FPEB); he then was medically separated with a 10% disability rating.
CI CONTENTION: “Disparity of rating – VA rating 70% to US Army rating 10% disability. VA found that XXXXXXXXX suffers from PTSD, XXXXXX receives medications and counseling for PTSD but US Army did not rate XXXXX for PTSD.”


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 condition schizoaffective disorder with elements of bipolar disorder as requested for consideration meets the criteria prescribed in DoDI 6040.44 for Board purview and is addressed below. 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 20090803
 VA (1 Mos. Pre-Separation) – All Effective Date 20091028
Condition
 Code Rating Condition Code Rating Exam
Schizoaffective Disorder with Elements of Bipolar Disorder 9211 10% Post Traumatic Stress Disorder with Schizoaffective Disorder, Bipolar Type, and Cognitive Disorder 9211-9411 70% 20090923
Bilateral Tinnitus 6260 10% 20091029
↓No Additional MEB/PEB Entries↓
 0% X 1 / Not Service-Connected x 4
Combined: 10%
 Combined: 70%


ANALYSIS SUMMARY: The Disability Evaluation System (DES) is responsible for maintaining a fit and vital fighting force. While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition. The DES has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation nor for conditions determined to be service-connected by the Department of Veteran Affairs (DVA) but not determined to be unfitting by the PEB. However, the DVA, operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time. The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on severity at the time of separation.

Schizoaffective Disorder with elements of Bipolar Disorder Condition. The CI was initially seen by a social worker in the family advocacy clinic on 19 September 2008 for what appeared to be a walk-in appointment. The chief complaint was listed as “PTSD, R/O reported head trauma from a fall (4th grade with a six month hospitalization, right frontal and right side).” The note indicated that the CI referred himself for depression. The treatment plan on that date listed the problems as “possible head injury” and “possible PTSD.” The objectives in the treatment plan were to determine the diagnosis for each of the problems listed above. The diagnoses listed for coding included, partner relation (ship) problem; chronic posttraumatic stress disorder (PTSD); and head injury with intracranial hemorrhage. The CI was seen back in the Family Advocacy clinic on 26 September 2008 for an assessment that was performed by a psychologist. The chief complaint was listed as mood disorder of unknown etiology. The examiner noted that he had discussed the case with the social worker who initially saw the CI. The CI had completed a Minnesota Multiphasic Personality Inventory (MMPI) which profiled an individual who was experiencing a great deal of distress and a sense of alienation and detachment. The examiner further explained that this type of result suggests further evaluation for an underlying psychotic process. A rule out diagnosis of schizoaffective was made and later confirmed on further assessment.

The MEB narrative summary (NARSUM), dictated on 19 May 2009, documented that the CI had been assigned to the Warrior Transition Unit (WTU) since December 2008 and reported feeling stable for a few months. The CI stated that he was compliant with his treatment and that his counseling had “given him tools to help him deal with his anger and anxiety. He reported having fewer arguments with his wife. He also noted that he had gained twenty to thirty pounds since starting medications, but that he was watching his diet and working out regularly. The CI was working as a cook and assigned various administrative duties in his current assignment. The examiner reported that the CI had no difficulties with his work at that time. The CI expressed his desire to be medically separated, but that he hoped to remain in the area and find employment. The MEB psychiatry addendum, dictated 22 June 2009, documented that the CI was compliant with his treatment. He reported stopping Depakote in April due to weight gain, but he was taking Abilify. The CI reported some “mild irritability and some distrust of other” but felt his sleep and his speech had improved. The CI was functioning “adequately” in his WTB (Warrior Transition Battalion). There were no symptoms that interfered with activities. On examination, the CI was oriented to person, place, time, and purpose. He was adequately groomed and he had no evidence of pressured speech. The examiner noted that the CI’s thoughts were logical, but stated that the CI had “mildly tangential speech.” The CI had no clear delusions or hallucinations, although there was some suspicion of the motives of others. The CI was without suicidal or homicidal thoughts. The examiner reported no panic attacks reported or evident on examination. The CI endorsed brief periods of dysphoria (unhappiness) and anxiety which was much improved from his baseline.

A VA Compensation and Pension (C&P) psychiatric examination, performed 23 September 2009, 6 days prior to separation, reported that the CI received outpatient treatment for schizoaffective disorder, bipolar type, and PTSD. The examiner reported that the CI was not taking his medications (Depakote, Abilify). The CI reported that he was receiving individual psychotherapy. The effectiveness of the medication treatment was rated as “poor” and psychotherapy as “fair.” The CI reported panic attacks, sleep disturbance, paranoia, and restlessness. The CI rated his depression, anxiety, and irritability 0/10, on that date, but noted that there were times that he experienced anxiety 8/10 and irritability 10/10. The CI reported feeling depressed about once a week, sleeping about five hours a night with middle insomnia, having “dreams of car accidents,” and experiencing daily panic attacks when driving. The CI reported having “passive suicidal thoughts” weekly, when he is feeling down. The assessment of PTSD symptoms reported that the CI’s father died in a motor vehicle accident (MVA) when the CI was three years of age.

The CI also reported that he was engaged in combat (Iraq X2: 2005-2006 and 2007-2008) sustained combat wounds. The Board did not find records which corroborated that he was directly engaged in combat or that he sustained combat wounds. On examination, the CI was described as clean, neatly groomed, and casually dressed. His speech was spontaneous and he was cooperative, friendly, and attentive. His affect was reported as blunted. The CI was unable to complete serial sevens, but was able to spell the word “world” backwards (attention span). He was oriented to person, place, time, and place. The examiner reported that the CI had persecutory and paranoid delusions, such as, “worries he won’t fit in at a job, worries he will be judged, worried about his performance,” and stated “I still feel that people are out to get me.” The examiner further noted that the CI reported that an IED had exploded next to his truck and that he felt “fearful and really scared” and “thought he was going to die.” This reportedly occurred during the CI’s second deployment. The examiner noted that no testing for trauma exposure, interview-based diagnostic instrument for PTSD, or quantitative psychometric assessment of PTSD symptoms severity had been performed. The CI was given a diagnosis of PTSD, but noted that there could be overlap with the schizoaffective disorder; however, the “episodic nature of the patient’s bipolar symptoms and level of intensity and severity are more consistent with schizoaffective disorder.” The Global Assessment of Functioning (GAF) assigned at that time was a 35. The examiner stated that the CI had been unable to function in his work setting, maintained no social contacts, and experiences panic symptoms and passive suicidal thoughts weekly. A C&P general examination, 29 October 2009, a month following separation, reported that the CI was very pleasant, neatly groomed, and appropriately dressed for his appointment. The examiner reported that the CI was “an excellent historian, and recalls remote events and specific details easily.” The CI reported that his wife was managing most of his financial affairs but he did not mind. He reported that he expected to start a new job working at the VA “in a few days.” The examiner reported that the CI’s memory and speech were normal. His mood, affect, judgment, and behavior were normal. There were no hallucinations or delusions present and the CI had normal comprehension and average intelligence.

With regards to the traumatic brain injury (TBI), the examiner reported that the CI reported that he fell off the back of a moving truck and hit his head, losing consciousness for several hours. He reported staying in the hospital for a couple of days (he had previously reported being hospitalized for 6 months and variously reported his age at the time of the accident as 10, 11 or 12 to different interviewers; the Board also noted that this was not disclosed at accession). It is noted that the CI stated “he recovered from this accident without residuals.” The CI reported that his response to his current treatment was good and that he was having no side effects.

The Board directed attention to the rating recommendation based on the above evidence. It adjudged that this case did not meet the requirements for application of a retroactive Temporary Disability Retired List (TDRL) rating IAW VASRD §4.129. The psychiatric condition was determined to not be a result of a “highly stressful event” (as per §4.129). The Board noted that the PEB specifically addressed VASRD §4.129 and excluded it. It also noted that PTSD was entertained as a possible diagnosis early in the evaluation of the CI and excluded. The Board acknowledges that trauma exposure during combat was referenced, but not available in the evidence before it; and, could not be located after the appropriate inquiries. Further attempts at obtaining the relevant documentation would likely be futile and introduce additional delay in processing the case. The missing evidence will be referenced below in relevant context; and, it is not suspected that the missing evidence would significantly alter the Board’s recommendations. The Board noted the discrepancy between the MEB examinations, the VA psychiatry examination C&P, and the VA general C&P examination. The VA psychiatry examination was performed prior to the date of discharge while the CI had a duty assignment in his WTB. Also, the psychiatry C&P examination was significantly different than the general C&P examination and the previous outpatient mental health records. The Board noted the absence of evidence to support the reported combat wounds secondary to combat in Iraq. There were two pre-deployment health assessments and one post deployment assessment from 13 February 2006. There was no report of mental health issues, but there was a notation on the post deployment document that the CI had fear that he may be killed while deployed. The PEB adjudged the schizoaffective disorder with elements of bipolar disorder condition unfitting and coded it 9211 (schizoaffective disorder), assigning a 10% disability rating. The VA applied a combined code 9211-9411 (schizoaffective disorder-PTSD) with a rating of 70%. The VA apparently based this solely on the VA mental health C&P examination which is not consistent with the remainder of the record in evidence. The Board agreed that there was no evidence to support the 100% rating under the general mental health rating formula (total occupation and social impairment). There was, likewise, general agreement that the requirements for a 70% rating were not met. The CI was occupationally functional and there was not serious impairment in “most areas” to meet the rating criteria. Proximate to the time of separation, the CI’s occupation and social impairment had improved substantially; he did not have circumstantial speech, circumlocutory, or stereotyped speech, or panic attacks more than once a week. The Board noted the “panic attacks” reported in the C&P examination; however, the symptoms of anxiety was specifically related to driving and would be more consistent with a specific phobia. The Board agreed that the CI’s condition did not meet the criteria for the 50% rating using the formula for rating mental disorders. The Board deliberated on the 10% and 30% rating criteria. The Board majority agreed that the evidence of the CI’s condition supported transient social impairment of decreased efficiency and ability to perform occupational tasks and that his symptoms were controlled by medication. 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 obsessive compulsive 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 schizoaffective disorder with elements of bipolar disorder condition and IAW VASRD §4.71a, the Board by a vote of 2:1 recommends no change in the PEB adjudication. The single voter for dissent (who recommended code 9211 rated at 30%) did not elect to submit a minority opinion. 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
Schizoaffective Disorder with Elements of Bipolar Disorder 9211 10%
COMBINED
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20110821, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




         XXXXXXXXXXXX, DAF
         Acting Director
         Physical Disability Board of Review

SFMR-RB


MEMORANDUM FOR Commander, US Army Physical Disability Agency

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

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for
xxxxxxxxxxxxxxxxxxxxxxxxxxx, AR20130007440 (PD201100909)

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

xxxxxxxxxxxxxxxxxx
Deputy Assistant Secretary
(Army Review Boards)

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