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AF | PDBR | CY2012 | PD2012 01618
Original file (PD2012 01618.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    BRANCH OF SERVICE: Army
CASE NUMBER: PD1201618   SEPARATION DATE: 20080627
BOARD DATE: 20130411


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, SPC/E-4 (52C/Utility Equipment Repairer) medically separated for anxiety disorder. He first sought mental health care in 2007 following his second deployment to Iraq. He was initially diagnosed with schizoaffective disorder and posttraumatic stress disorder (PTSD). He improved with psychotherapy and medication, but was unable to meet the operational requirements of his Military Occupational Specialty (MOS) or satisfy general military requirements. He was referred for a Medical Evaluation Board (MEB); but, after an initial referral to a Physical Evaluation Board (PEB), his case was returned to the MEB for further evaluation and clarification of the final diagnosis. His final Axis I diagnosis was “anxiety disorder, not otherwise specified (NOS)” with an Axis II diagnosis of “personality disorder not otherwise specified with mild borderline, subclinical avoidance and possibly schizotypal features,” At that time he was issued a permanent S3 profile and referred back for completion of his MEB. Anxiety disorder was subsequently forwarded to the PEB as a medically unacceptable condition IAW AR 40-501; with no other conditions submitted. The PEB adjudicated anxiety disorder as unfitting rated 10%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD). There was also an entry on the PEB’s DA Form 199 stating, “condition is complicated by Axis II personality disorder which cannot be included in this evaluation for disability rating purposes per DoDI 1332.38.” The CI made no appeals, and was medically separated with a 10% disability rating.
CI CONTENTION: The CI elaborated no specific contention in his application.


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.” Also IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board’s role is thus 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 ratable severity at the time of separation. The rating for the unfitting psychiatric condition will be reviewed. 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 20080312
 VA (6 Wks. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Anxiety Disorder, NOS 9413 10% Schizoaffective Disorder w/PTSD* 9211* 50% 20080513
No Additional MEB/PEB Entries
 Other X 1 20080513
Rating: 10%
 Combined Rating: 60%*
Derived from VA Rating Decision (VARD) dated 20080802 ( most proximate to date of separation [DOS])
*PTSD removed from condition description and code by VARD dated 20100104, effective 20090716 (13 mos. post-separation).


ANALYSIS SUMMARY:

Anxiety Disorder. The CI returned from his last deployment to Iraq in November 2006. The first entry from behavioral health in the available service treatment record (STR) is an intake note from August 2007; although the record is clear that the CI underwent a psychiatric admission for suicidal ideation in May 2007, and the intake note lists current psychoactive medications. The earlier records were not felt to be probative enough to warrant the delay in attempting to locate them. His initial diagnosis in the available STR was “adjustment disorder, rule-out schizoid personality disorder”; although an Axis I diagnosis of anxiety disorder was also included. Early entries note auditory hallucinations which began after redeployment (in association with panic attacks); and, also documented a childhood history (age 9) of auditory hallucinations after his parents divorced (resolved in teens). The auditory hallucinations were treated in service with an anti-psychotic (risperidone) and resolved. The main thrust of treatment was psychotherapy focusing on panic attacks and anxiety symptoms, and no further hospitalizations were required. Psychological testing of November 2007 noted elevation across multiple scales, with an assessment, “individuals who score in this manner are chronically maladjusted.” PTSD was added to Axis I in December 2007 in a clinical psychologist’s note documenting “having physical reactions to a stressful military experience, avoided thinking or having feelings about a stressful military experience, loss of interest in things he used to enjoy, feeling distant/cut off from others, and being hypervigilant.” This was in the context of “being concerned about his upcoming deployment.” The January 2008 opinion of the MEB psychiatrist who re-evaluated the CI regarding his diagnosis (as per the Summary) is excerpted below.
I evaluated [CI] in early January and have discussed this case with [clinical psychologist associated with above entry] as well as also having reviewed both his [MEB] and neuropsychological testing. He currently denies any hallucinations. Interestingly, when he first presented to our clinic, he completed the PCL [military PTSD checklist], meeting criteria for a diagnosis of [PTSD] in all three categories, reexperiencing, avoidance and hyperarousal. His more recent score on PTSD checklist was 42 [cut-off for PTSD is 50]. [Name of same clinical psychologist] notes in group that he is quiet unless spoken to and predominantly will talk about his symptoms of anxiety and panic attacks. Indeed, it is during these attacks when he has the thoughts and/or hears voices telling him to hurt himself, or that other people are going to die, and there is nothing he can do about it. I feel these are rather consistent with the primary anxiety disorder and possibly better understood now having evaluated this service member and taking into consideration some contextual, cultural factors.
Neither the narrative summary (NARSUM) nor the psychiatric addendum elaborated the real time symptoms. Drug or alcohol use was denied, but social functioning was not elaborated. The CI remained compliant with outpatient therapy, and was still treated with Risperidone. The mental status exam (MSE) recorded an “anxious” mood and appearance, and affect was described as “constricted and narrow in range, and at times, flat.” To this was added, “this is not felt to be terribly unexpected given his baseline anxiety and his personality style.” There were no hallucinations, suicidal/homicidal ideation, or other acute features, and cognition was “grossly within normal limits”. The Global Assessment of Functioning (GAF) assignment was 58 (moderate range of impairment on that scale). Regarding functional status, the examiner stated, “When asked how his medical condition affected his ability to perform MOS-related tasks, he stated that he was generally uncomfortable around people he did not know and in crowds.” An updated commander’s performance statement documented, "[CI]’s performance in the WTU [warrior transition unit] has been good. He cooperates well with others and has not shown any forms of disrespect to anyone in any way. He works well independently and gets along with peers and subordinates."

At the VA Compensation and Pension (C&P) exam (6 weeks prior to separation), the CI related combat experiences that he had denied on his post-deployment questionnaires. He reported nightmares (none for past month, and currently sleeping well), intrusive thoughts (once per week), flashbacks (no comment on current frequency), increased startle response, guilt, and avoidance. These symptoms are not corroborated in concurrent STR entries, although they are not specifically denied. The CI also reported that he had heard voices as recently as a month ago, although the STR documented resolution ~5 months hence. Regarding social functioning, the VA examiner noted that “he is currently on terminal leave and spends his days trying to keep busy, exercising, and spending time with the family.” It was noted that he was having difficulty filling his “unstructured time,” not socializing with friends (noting that they were deployed), and that his relationship with his wife and stepdaughter were strained by his anger issues. Regarding occupational functioning, the examiner noted “his symptoms impact work performance because he had anxiety attacks at work and would hide it from his coworkers.” The VA psychiatrist’s MSE noted “depressed” mood and “flat” affect. It was otherwise normal. No active suicidal ideation or hallucinations were present. Cognition was normal. The GAF assignment was 48 (serious range of impairment on that scale). The Axis I diagnoses were schizoaffective disorder and PTSD, and no Axis II diagnosis of personality disorder was entered. The VA psychiatrist quoted VASRD §4.130 criteria for a 70% rating, “deficiencies in most of the following areas: work, school, family relations, judgment, thinking, and mood.”

The Board directs its attention to its rating recommendation based on the above evidence. It was first deliberated whether application of VASRD §4.129 was indicated in this case, as per DoD direction to the Board for PTSD and similar cases. In this case, the crux of the decision is whether the CI’s core pathology was PTSD precipitated by his deployments; or, whether it was predominantly the anxiety disorder and/or schizoaffective disorder which emerged in the aftermath of the deployments, but were not caused by them. Although there are different opinions from the service and VA psychiatrists in that regard, the action officer opines that the service opinion (as excerpted above) is more cogent and convincing. It is also relevant that in a follow-up VA psychiatric C&P evaluation (15 months post-separation), PTSD was removed from Axis I (replaced by anxiety disorder in addition to schizoaffective disorder) and “schizoid personality traits” was added to Axis II. All documentation agreed that the CI experienced auditory hallucinations for several years as a child during the stressful event of his parent’s divorce. His auditory hallucinations resolved only to recur upon return from his second deployment to Iraq. The CI completed a total of three “post deployment health reassessments” questionnaires which were reviewed by the Board; resulting in agreement that the CI did not meet Criteria A of the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria for PTSD. After deliberation, members agreed that, although some contribution of service stressors to the psychiatric condition was clearly present; the requisite §4.129 link that the condition occurred “as a result of” the stressors was not adequately satisfied. Therefore, the Board will consider only the VASRD §4.130 impairment present at separation for a single permanent rating recommendation.

Although no formal percentage deduction was applied by the PEB to arrive at its 10% determination, the PEB’s DA Form 199 language makes it clear that the PEB’s rating was likely tempered by the contribution from the unratable personality disorder. Members agreed that the PEB’s underlying assumptions were valid; i.e., that there was a distinct functional overlay from the personality disorder, and that the latter is not subject to service disability rating. All members agreed that it is impossible to clinically dissect the psychiatric impairment into ratable and unratable origins. Both DoDI 1332.38 (E2.1.1) and the VASRD (§4.22) require a degree of certainty for justifying such deductions that is not achievable in this case without undue speculation. Members thus agreed that its recommendation should concede the total §4.130 impairment in evidence as subject to service rating. All members agreed that none of the acute features characterizing the 70% rating description (§4.130) were met. The description for a 50% rating is “occupational and social impairment with reduced reliability and productivity”; referencing typical symptoms of flat affect, stereotyped speech, frequent panic attacks, deficits in comprehension and memory, impaired judgment, mood disturbance, and difficulty with establishing relationships. These criteria were arguably extractable from the prior to separation VA psychiatric evaluation; although, that is equivocal and requires a generous concession to reasonable doubt. Members furthermore agreed that there were significant probative value concerns related to the conflicting history as considered by the VA psychiatrist in his opinion; and, that the evidence recorded in the NARSUM, psychiatric addendum, STR, and commander’s statement is more internally consistent and of higher probative weight. With this conclusion in mind, deliberations moved to considerations for a 30% vs. 10% rating recommendation. The commander’s statement, always quite probative, would provide support for a 10% recommendation; as would the argument that the CI’s symptoms emerged in the context of apprehension when facing a third deployment – a service stressor that would not complicate his civilian transition. The latter conclusion was strengthened by his post-separation employment history. The facts that the CI’s satisfactory occupational functioning was facilitated by the protected environment of the WTU, that he continued to experience estrangement at work and friction with domestic relationships, that he remained dependent on potent psychotherapeutic medication, and that his symptom acuity remained fairly elevated; collectively outweigh the support for a 10% recommendation based on the evidence at the time of separation, however. After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the anxiety disorder.
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. As discussed above, PEB reliance on DoDI 1332.38 for rating the anxiety disorder was operant in this case and the condition was adjudicated independently of that instruction by the Board. In the matter of the anxiety disorder, the Board unanimously agrees that application of VASRD §4.129 does not attach; and, by a vote of 2:1, the Board recommends a disability rating of 30%, coded 9413, IAW VASRD §4.130. The single voter for dissent (who recommended no change in the PEB’s adjudication) 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 recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:
UNFITTING CONDITION
 VASRD CODE RATING
Anxiety Disorder, NOS (with Schizoaffective Overlay) 9413 30%
Rating
 30%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120912, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




         Physical Disability Board of Review


 SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB),


SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for AR20130009607 (PD201201618)


1. Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.

2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

         a. Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

         b. Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

         c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

         d. Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:




Encl                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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