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AF | PDBR | CY2012 | PD2012 01862
Original file (PD2012 01862.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:   CASE: PD1201862
BRANCH OF SERVICE: Army  BOARD DATE: 20130516
SEPARATION DATE: 20060128


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an Active Reserve 1LT/O-2 (15A00/B2 Aviation) medically separated for obsessive compulsive disorder (OCD) and major depressive disorder (MDD). He began to develop obsessive behavior 6 months post-tour and became increasingly compulsive with recurrent suicidal ideation and insomnia. The condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty. He was issued a permanent P2/S3 and temporary L3 profile and referred for a Medical Evaluation Board (MEB). The OCD/MDD condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded two Axis III and one Axis IV condition (hypertension, psoriasis and post-war stress-unrelenting symptoms- imminent end to military career) judged to meet retention standards. The PEB adjudicated the OCD/MDD as one unfitting condition, rated 10% referencing AR 635-40 and citing criteria of the DoDI 1332.39. The remaining Axis III conditions were determined to be not unfitting and therefore not ratable. The CI made no appeals, and was medically separated with a 10% disability rating.


CI CONTENTION: “Veteran received VA disability for PTSD, Obsessive Compulsive Disorder at 50% on 29 January, 2006. Army rated veteran 10% for Obsessive Compulsive Disorder/Major Depressive. Veterans affair service connected diagnosis: PTSD – 50%, Psoriasis – 0%, Knee – 0%, Tinnitus – 0%, Clavicle – 0%, Degenerative Arthritis Spine – 20%, Hypertensive Vascular – 10%. US Army discharged veteran with 10% for OCD. US Army did not include other diagnosis/symptoms.”


SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The ratings for unfitting conditions will be reviewed in all cases. The hypertension, and psoriasis conditions, as requested for consideration, meet the criteria prescribed in DoDI 6040.44 for Board purview; and, are addressed below, in addition to a review of the ratings for the unfitting OCD/MDD. The remaining conditions rated by the VA at separation and listed on the DA Form 294 are not within the Board’s 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 Board for Correction of Military Records.


RATING COMPARISON :

Service IPEB – Dated 20051104
 VA - (3 Mos. Pre/Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
OCD/MDD 9404 10% PTSD/OCD 9411 50% 20060417
Post-War Stress AXIS IV – Not Unfitting
Psoriasis AXIS III – Not Unfitting Skin Condition 7816 0% 20060505
Hypertension AXIS III – Not Unfitting Hypertension 7101 10% 20060505
No Additional MEB/PEB Entries
 Other x 4 20060505
Combined: 10%
 Combined: 70%
Derived from VA Rating Decision (VA RD ) dated 200 60821 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Obsessive Compulsive Disorder, Major Depressive Disorder Condition. The narrative summary (NARSUM) 20 June 2005 notes the CI was a helicopter pilot deployed in Iraq between April 2003 and July 2004, though he had been removed from flight duties and relieved as a platoon commander prior to deployment. While deployed he developed a generalized skin rash and shortly after began to have obsessions regarding “germs” and compulsions of frequent hand washing and bathing. The CI was able to complete his tour despite this behavior and returned to the US. Within the first 6 months after returning his obsessions and compulsions regarding cleanliness and orderliness became more severe. He spent hours per day washing his hands; cleaning his room; counting floor tiles; or counting the number of floors in a building. At the time of the NARSUM evaluation the CI was spending the entire day obsessing or performing his compulsions. Notes in the service treatment record (STR) indicate the CI first sought treatment for insomnia but on a follow-up visit 27 April 2005 reported difficulty with worsening OCD and posttraumatic stress disorder (PTSD) symptoms. He reported lying in bed, feeling “like something will come from above.” He reported anxiety about pictures not hanging straight and doors needing to opened and closed. He needed to fix the pictures multiple times per day, overused Lysol after every guest, and washed his hands constantly. A psychological evaluation 23 May 2005 noted that the CI reported coming under fire as well as frequent mortar attacks in base camp, though he denied being involved in direct combat in both post-deployment health assessments.

The CI reported symptoms of intrusive memories and nightmares related to combat; feelings of distress and heightened arousal; suspiciousness and hypervigilance;a pre-occupations with germs, cleanliness and order; he thought he could predict or alter the future based on his dreams or thoughts; he thought he sometimes heard someone calling his name or heard things hitting his house. He reported spending a great deal of time cleaning his house, washing his hands, bathing, and being fearful of touching things. The mental status exam (MSE) showed an anxious and depressed mood. The CI was fully oriented with normal speech and thought processes. The examiner noted suicidal ideation at times, without plans, and that the CI denied homicidal ideation, but had thoughts of harming his former commander. Standardized testing indicated severe depression and anxiety, and PTSD. He was referred to a psychiatrist, diagnosed with PTSD 26 May 2005 and started on antidepressant, and antipsychotic medications.

At the MEB exam, 20 June 2005, approximately 7 months prior to separation, the CI reported being depressed, having decreased appetite and interest in activities, decreased concentration, with difficulty sleeping for several months. He reported being intermittently suicidal, with specific suicidal thoughts at times like “stealing a helicopter and crashing it into a building,” but that that he would never act on them. He reported stress about not being able to fly anymore which he loved and had wanted to do all his life. He also reported feeling isolated upon his return and having nightmares and flashbacks about his deployment. The CI stated he had not had direct trauma in theater except for “being mortared frequently” and experiencing increased anxiety during the large number of convoys in which he participated. The MEB physical exam noted the CI had good family relationships with a mother, father, older brother, and half siblings. He was single. He reported drinking heavily following his return from deployment but had discontinued that seven to 8 months earlier. The MSE noted the CI was clean, well groomed, alert and oriented. He maintained good eye contact with slightly pressured speech. He appeared anxious and depressed. He denied any delusions or hallucinations, but did report nearly constant obsessions with contamination, orderliness, counting and sequencing. His thought process was linear and goal directed . The examiner noted his insight to be poor and judgment fair. The Axis I diagnoses were OCD and MDD, Axis IV diagnosis was post-war stress, unrelenting symptoms, imminent end to military career. The Global Assessment of Functioning (GAF) was estimated to be 55. (GAF- 60- 51 m oderate symptoms OR moderate difficulty in social, occupational, or school functioning in social, occupational, or school functioning. The a eromedical s ummary 20 June 2005, the same day as the MEB NARSUM, noted the same history and recommended that the CI be permanently disqualified from aviation duties due to his diagnoses of PTSD, OCD and Generalized Anxiety disorder (GAD) and the medications he required to treat them.

The PEB combined and adjudicated the OCD and MDD as one unfitting condition for rating . The Board noted that the CI contended PTSD which was not adjudicated by the PEB , in addition to OCD/MDD. PTSD was listed as a diagnosis on all treatment visits from 26 May 2005 up to and including the DD Form 2808 exam and the last visit on post prior to separation, which listed diagnoses of PTSD and OCD . The a eromedical NARSUM 20 June 2005 listed disqu alifying conditions of PTSD and OCD. Permanent profiles in the record 22 June 2005 and 11 July 2005 listed PTSD, OCD, and GAD . The Board upon review of the records unanimously agreed that the preponderance of the evidence supported that the CI was diagnosed with PTSD while on ac tive duty. The Board unanimously agreed that the CI’s PTSD was inextricably intertwined with the overall mental health imp airment due to a mental health disorder. The PEB rating, as noted above, was derived from DoDI 1332.39 and preceded the promulgation of the National Defense Authorization Act 2008 mandate for DOD adherence to Veterans Affairs Schedule for Rating Disabilities (VASRD) §4.129. IAW DoDI 6040.44 and DoD guidance (which applies current VASRD 4.129 to all Board cases), the Board is obligated to consider if the definition of §4.129 is met for any psychiatric condition resulting in medical separation; i.e., “a mental disorder that develops in service as a result of a highly stressful event.” Regardless of final PEB diagnosis, §4.129 does not specify a diagnosis of PTSD, rather it states “mental disorder due to a highly stressful event,” and its application is not restricted to PTSD. If the Board judges that application of §4.129 is appropriate, it must recommend a minimum 50% rating for a retroactive 6-month period on the Temporary Disability Retired List (TDRL). The Board must then determine the most appropriate fit with VASRD 4.130 criteria at 6 months for its permanent rating recommendation. The Board first addressed if the tenants of §4.129 (mental disorders due to traumatic stress) were applicable. The Board considered the evidence of traumatic stressor and the relationship of the mental health condition to the traumatic stressor. The CI noted stressors of frequent mortar fire and the increased anxiety during the many convoys in which he participated due to fear of improvised explosive devices. On both the post-deployment health assessments dated 28 March 2004 and 10 July 2004 the CI indicated yes to the question “did you ever feel that you were in great danger of being killed?” The Board majority determined that the CI’s mental health condition was due to a “highly stressful event” as used in the VASRD, and that application of §4.129 is appropriate in this case. IAW VASRD §4.130 a service member can only be provided a single disability rating for mental health disorder and all the noted diagnoses are subject to rating according to the same VASRD guidelines. The Board also noted that relative contribution to impairment from the CI’s OCD, PTSD, depression, and anxiety disorders diagnosed could not be separated, therefore the Board considered the mental health conditions together in its deliberations.

The Board reviewed to see if the rating criteria for a disability rating of greater than 50% for the 6 month TDRL period were met. Records available at the time of TDRL entry include the MEB NARSUM, aeromedical summary, both noted above, and post-separation VA treatment records. The VA treatment records indicated the CI was hospitalized for a mental disorder 8 March 2006, approximately 2 months post-separation, because his mother had contacted a social worker regarding concerns that the CI was isolated, depressed, manifesting aggressive behavior and making statements that concerned her that he might hurt himself. He was evaluated by a psychiatrist and voiced “fleeting” thoughts of harming himself or others, but the examiner noted no homicidal or suicidal plans. He did not have any delusions, or hallucinations; he was fully oriented. He was agitated, depressed, with impaired memory and concentration, but did have obsessions and compulsions. Judgment and insight were noted as poor. GAF was 30. (GAF- 30- 2 - Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment OR inability to function in almost all areas) . He was admitted to inpatient care to avoid worsening of his condition. At discharge 16 March 2006 his mental status was improved with no psychotic symptoms, improved mood and OCD symptoms, no suicidal or homicidal ideas (SI/HI) and improving judgment and insight. GAF was 50. According to the NARSUM, the CI was experiencing severe impairment due to obsessive-compulsive rituals described as spending all day performing various compulsions . He was depressed and intermittently suicidal as well as having sleep difficulties with nightmares and flashbacks. VA t reatment records indicate the CI experienced post-separation worsening and was hospitalized for a mental disorder 2 months post separation due to family concerns about suicide in particular and depression, impulse control and aggressiveness in general. He improved during the hospitalization and was discharged with an estimated GAF of 50. The Board agreed that the §4.130 criteria for the 30% rating were met and exceeded and deliberated between the 50% rating ( o ccupational and social impairment with reduced reliability and productivity) or the 70% rating ( o ccupational and social impairment, with deficiencies in most areas, such work, school, family relations, judgment, thinking, or mood). The Board opined that the CI’s mental health condition at TDRL entry most nearly met the 70% rating . After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 70% for the CI’s mental health condition at TDRL entry, coded as 9404 (OCD).

Records available proximate to the end of the 6 month constructive TDRL period included the first VA Compensation and Pension (C&P) exam and VA psychiatric treatment records around the 6 months post separation timeframe of August 2006. At the C&P exam 17 April 2006, approximately 3 months after separation, and a month post hospital discharge, the CI reported trouble sleeping with nightmares related to deployment, lack of concentration, anxiety, suspiciousness, and washing hands constantly. He talked about combat stressors described as daily mortar attacks and an accident involving harm to others. The VA examiner noted PTSD symptoms of recurring dreams, feeling or acting as if the traumatic event was recurring, efforts to avoid thoughts, or conversations associated with the trauma, concentration and sleep difficulties, exaggerated startle response. Family and social history was unchanged except the CI he had reported no friends and no leisure pursuits. The examiner noted a history of the CI trying to hang himself 3 weeks earlier after an argument with the neighbors due to loud noise. The exam noted the CI appeared disheveled with an anxious mood and a constricted affect. Attention, concentration, and orientation were normal. His thoughts were obsessive, but without delusions, or hallucinations. Judgment and insight were appropriate. The examiner noted that the CI washed his hands and bathed several times per day, arranged things around the house several times per day, and had poor impulse control. The examiner also noted no suicidal thoughts. The diagnoses were OCD and PTSD, GAF for each was 50. The CI was unemployed and the examiner opined it was due to the mental health (MH) effects and that the CI was severely impaired. The VA rated the CI’s MH condition of PTSD/OCD as 9411 at 50% based on this exam . At VA psychotherapy visit 22 June 2006 the CI reported going to visit his brother because he w as not doing anything at home. He wanted to get a job at an airport doing “anything . ” The CI verbalized that he was now able to be woken up by thunder and realize he was not in Iraq. He was still washing his hands frequently , but said he was “used to that . ” At a psyc hiatric evaluation 9 August 2006 , the CI reported feelings of persecution and having OCD. He reported nightmares , not about service related incident s , but described as not being able to read the c locks on a plane . He related an incident during deployment where , after a mortar attack, there was trembling , and a blackboard fell over on him and that he used to hear about things that happened to people because he was near a hospital. He reported hearing thunder and beco ming anxious with a rapid heart beat. On exam he was not ed to be depressed, anxious , without delusions but with obsessive -compulsi ve behavior; n o SI/HI were noted; mem ory , j udgment, and orientation were normal . Ins ight was noted as good. Diagnoses were a nxiety d isorder and OCD. GAF was 55 . At a psychiatric evaluation 15 August 2006 the CI had returned from visiting his brother , where he had expected to have more job options . He repor ted socializing with cousins, hearing a firecracker and becoming anxious; the cousins helped him calm down, but they left the pl a ce. On exam he was somewhat anxious and depressed; his answers were coherent without psychotic symptoms and he was fully oriented . The examiner noted good judgment and fair insight . On psychiatric evaluation 29 S ept ember 2006 the CI was unchanged. He was oriented, without suicidal thoughts, but longed to be back in the military as were his cousins, frustrated with the job prospects in the depressed economy. After his flu vox amine was decreased he was having increased compulsions. His medications were increased and continued. At a VA exam in a new location 7 April 2007, the CI reported anxie t y, depression and OCD. The examiner noted that the CI currently “ritualizes every day , ” characterized by counting, handwashing, and touching things. On exam the CI was described as friendly and interactive , but slightly irritable. He was well groomed , alert and oriented , w ith normal thoughts and no evidence of psychosis. His mood was euthymic (not up or down, even) The CI denied current SI/HI. The CI was employed at a home security company for 2 months. He reported that the he had repeated conflicts with superiors in any job since the military.

The Board directs attention to its recommendation for permanent rating at the time of removal from TDRL. In the 6 to 12 months post separation the records available indicate the CI’s mental health condition improved. The Board agreed that at the end of the 6 month TDRL period the CI met the 10% rating criteria IAW §4.130 and reviewed it to see if the next higher evaluation of 30% ( o ccupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks ; although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal ) was met. The CI, though still experiencing anxiety upon sounds he associated with war experiences, was able to realize he was not still in a combat situation and react appropriately. He was interested in obtaining a job, “anything” at an airport. He was socializing with family, feeling supported by them. He was not suicidal. His depression and anxiety were not as severe. He did continue with obsessive-compulsive behaviors on a daily basis. At the 6 months post TDRL entry the CI was not employed, but from the evidence in the record, it was due in part to the economy and not the CI’s mental health condition. Approximately 8 months after the end of the TDRL period he was employed, despite continuing with daily OCD behaviors. The stress and anxiety symptoms had significantly improved. Although the OCD, depression and anxiety symptoms persisted in the 6 months post TDRL re-evaluation window, the Board opined that the CI was significantly less impaired by them. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a permanent disability rating of 30% for the OCD/MDD condition at the end of TDRL.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that the hypertension and psoriasis conditions were not unfitting. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. 1) Hypertension. Notes in the STR indicate the CI was diagnosed with persistently elevated blood pressure (BP) without headaches or visual changes noted on 18 August 2005. An anti-hypertensive medication was prescribed. Five days of BP readings over a 2 week period from 20 September 2005 to 1 October 2005 showed a labile blood pressure with a median blood pressure in the borderline hypertensive category. There were no reported complications from this condition. 2) Psoriasis. The CI woke up with a rash in November 2004 that was itchy located on his chest, back and arms. The rash was recurring despite treatment. A biopsy of a skin lesion 8 September 2005 did not provide a definitive diagnosis and treatment continued with steroids without complete resolution. At the C&P skin exam 21 April 2006 the CI noted itching unrelieved by previous treatments. The VA exam showed a red rash around the waistline that covered less than 5% of the skin. The VA examiner listed a non-specific diagnosis of perivascular dermatitis and noted no impairment of the CI’s activities.

The hypertension and psoriasis conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards. All were reviewed by the action officer and considered by the Board. There was no performance based evidence from the record that either of these conditions significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions and so no additional disability ratings are recommended.


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 OCC/MDD condition, the Board recommends a disability rating as follows: the Board majority by a 2:1 vote recommends that application of §4.129 is appropriate, the single dissenting vote elected not to submit a minority opinion; the Board unanimously recommends placement on TDRL for a period of six months as required at 70%; and a final Service disability rating of 30% coded 9404 IAW VASRD §4.130. In the matter of the contended hypertension and psoriasis conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board, therefore, recommends that the CI’s prior separation be modified to reflect that the CI was placed on the TDRL at 70% for a period of six months and then permanently separated with a final disability rating of 30% 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 TDRL RATING PERMANENT
RATING
Obsessive-Compulsive Disorder/Major Depressive Disorder
 9404 70% 30%
COMBINED
 70% 30%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20121022, 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 AR20130012560 (PD201201862)


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 constructively place the individual on the Temporary Disability Retired List (TDRL) at
70% disability for six months effective the date of the individual’s original medical separation for disability with severance pay and then following this six month period recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30%.

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 temporary disability 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 day following the six month TDRL period.

         c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will account for recoupment of severance pay, provide 70% retired pay for the constructive temporary disability retired six month period effective the date of the individual’s original medical separation and then payment of permanent disability retired pay at 30% effective the day following the constructive six month TDRL period.

         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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