RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 
NAME:  XXXXXXXXXXXXXXXX                                                                 BRANCH OF SERVICE:  ARMY 
CASE NUMBER:  PD1200579                                                                   SEPARATION DATE:  20040411 
BOARD DATE:  20130125 
 
 
SUMMARY  OF  CASE:    Data  extracted  from  the  available  evidence  of  record  reflects  that  this 
covered individual (CI) was a National Guard Soldier, PFC/E-3(88M/Motor Transport Operator), 
medically separated for psychotic disorder, not otherwise specified (NOS).  The CI was admitted 
for psychotic disorder, NOS, in 2003 for paranoid ideation.  He responded well to treatment, 
but  did  not  to  meet  the  requirements  of  his  Military  Occupational  Specialty  or  retention 
standards.    He  was  issued  a  permanent  P3/S3  profile  and  referred  for  a  Medical  Evaluation 
Board (MEB).  The MEB forwarded psychotic disorder, NOS as an Axis I diagnosis, and medically 
unacceptable.  Asthma and hypertension, identified as medically acceptable Axis III diagnoses, 
were also forwarded by the MEB to the Physical Evaluation Board (PEB).  The PEB adjudicated 
the psychotic disorder, NOS, as unfitting, rated 10%, with application of the Veterans Affairs 
Schedule for Rating Disabilities (VASRD) and AR 635-40 B-107 para. (e.)  The PEB adjudicated 
the  asthma  and  hypertension  as  not  unfitting.    The  CI  made  no  appeals  and  was  medically 
separated with a 10% disability rating.   
 
 
CI CONTENTION:  The CI states: “I feel it was not rated properly due to my bipolar disorder and 
the  struggles  I  went  through  and  still  going  through.    I  was  not  in  my  right  mind  frame  but 
under heavy medication when I got the severence [sic] pay verses my %.  If I was in my right 
mind things would have went differently of it I [sic] had been able to comprehend.  I am asking 
the Army in which I love from myself being a soldier and knowing the values that we carry, I am 
asking for your help.  My condition has me currently taking about 10 different medication [sic] 
trying to help my problem of bipolar disorder.”  The CI also appended a two page letter.   
 
 
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 remaining conditions rated by the VA 
at separation 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 Army Board for Correction of Military Records.   
 
 
RATING COMPARISON:   
 

Service PEB – Dated 20031215 
Condition 
Psychotic Disorder, NOS 
Asthma 
Hypertension 
 
↓No Additional MEB/PEB Entries↓ 

Code 
9210 
Not Unfitting 
Not Unfitting 

Rating 
10% 

VA (3 & 4 Mos. Post-Separation) – All Effective Date—All NSC 
Condition 
Anxiety & Depression* 
Asthma 
Hypertension 
0% X 0 / Not Service-Connected x 10 

Rating 
NSC 
NSC 
NSC** 

Code 
9400 
6602 
7101 

Exam 
20040626 
20040706 
20040706 
20040706 

Combined:  Nothing 

 
Combined:  10% 
* VARD of 1/20/2012 service connected Bipolar Disorder w/Psychosis, 9432, rating it 70%, effective 6/23/11, combined 70%. 
**VARD of 7/19/2010 service connected hypertension, 7101, rating it at 0%, effective 4/12/04, the day after separation. 
ANALYSIS SUMMARY:   
 
Psychotic Disorder, NOS.  The CI was referred by a Chaplain for paranoid ideation and admitted 
on 17 June 2003, 10 months prior to separation.  He admitted and then denied drug abuse, but 
was positive for THC (a metabolite of marijuana) on a urine drug screen.  The Board noted that 
multiple subsequent drug screens in October of 2003 and April of 2004 were also positive for 
THC.    He  denied  a  personal  or  family  history  of  prior  mental  illness.    He  was  noted  to  have 
paranoia, confusion and questionable auditory hallucinations.  He responded well to an anti-
psychotic  with  resolution  of  symptoms  by  the  time  of  discharge.    He  was  thought  to  have 
marked  impairment  for  military  duty  and  definite  social  and  industrial  impairment.    The 
previous February, he had been seen for asthma and was noted to have been anxious about a 
new marriage and the use of a gas mask.  This was the only note referencing a mental health 
issue  prior  to  his  admission.    Following  his  discharge  on  11  July  2003,  the  next  documented 
mental health visit was on 20 October 2003 when the examiner noted an altered mental status.  
The CI was brought in by his mother due to “bizarre behavior.”  He had recently started dating a 
woman who reportedly abused illegal and controlled drugs and shared these with the CI.  He 
had stopped his anti-psychotic medication and noted that “the Lord keeps telling him things to 
do, that he’s suppose(d) to get out of the military…”  The examiner informed the mother that 
“1) he could be messing himself up w/ drugs; 2) it could be a form of schizophrenia or mental 
illness; 3) it could be a brain tumor; 4) it could be just him faking his behavior to try to get out 
of the military.”  He further wrote “When I said this he spoke up and said ’yep, that’s what I’m 
trying to do’.”  The next day he presented to the emergency room complaining of paranoia and 
was treated with Haldol (an antipsychotic) and Ativan (for sedation and anxiety) with symptom 
improvement.  Magnetic resonance imaging of the brain was unremarkable.  He was again seen 
on 21 November 2003 and it was noted that “nothing had changed.”  The last visit in the record 
prior  to  separation  was  15  April  2004.    The  CI  admitted  to  using  drugs  again,  but  declined 
rehabilitation.  At the MEB examination on 24 June 2003, 10 months prior to separation, the 
examiner  noted  a  history  of  psychotic  disorder  without  further  elaboration.    The  narrative 
summary dictated on 10 July 2003 by his treating psychiatrist the day prior to discharge from 
the hospital.  The history is above.  At the VA Compensation and Pension (C&P) examination 
performed  on  26  June  2004,  2  months  after  separation,  the  CI  reported  that  he  was  now 
divorced, but that he had not been happy in the marriage.  He also stated that he had used 
marijuana “off and on” while in the Army National Guard, but had not used it since separation.  
He denied a history of auditory hallucinations.  The examiner was of the impression that some 
of the CI’s symptoms could be related to the use of marijuana.  The CI stated that he was not 
taking any psychotropic medications or attending outpatient treatment.  He was working in a 
video store where he had been employed for 3 weeks.  He reported that he enjoyed attending 
church  and  exercising.    He  was  sleeping  well  and  had  a  good  appetite.    He  denied  sadness, 
depression, auditory or visual hallucinations, or anxiety.  On mental status examination, he was 
noted to be euthymic and appropriately dressed.  No hallucinations were in evidence and the 
affect appropriate.  He was alert, oriented and able to concentrate well with fair memory.  He 
denied  paranoid,  homicidal  and  suicidal  ideation.    His  Global  Assessment  of  Function  was 
assessed  at  70,  corresponding  to  mild  symptoms  or  mild  difficulty  in  functioning,  and  no 
psychiatric diagnosis was present.  Review of subsequent VA decisions shows that the CI was 
diagnosed with bipolar disorder on 13 July 2005, but that this was not service-connected to the 
in-service  diagnosis.    Service-connection  was  granted  for  bipolar  disorder  at  70%  disability 
effective 23 June 2011, over 7 years after separation.   

 
The Board directs attention to its rating recommendation based on the above evidence.  The 
PEB coded the condition 9210 for a non specified psychotic disorder and rated it at 10% for mild 
impairment  treated  with  medication.    The  VA  determined  that  there  was  no  mental  health 
disorder and did not grant either a rating or service-connection.  The Board noted that the CI 
was responding well to medications at the time of discharge from the hospital, 9 months prior 
to separation.  At a subsequent evaluation, the examiner could not determine the etiology of 
the problems and opined that drug abuse could be a factor as well as a desire for separation.  
The CI had positive drug screens for marijuana use on multiple occasions prior to separation.  
The  most  proximate  examination  to  separation,  the  C&P,  was  normal  and  the  CI  was  off  of 
medications and denied recent substance abuse.  After due deliberation, considering all of the 
evidence  and  mindful  of  VASRD  §4.3  (Resolution  of  reasonable  doubt),  the  Board  concluded 
that  there  was  insufficient  cause  to  recommend  a  change  in  the  PEB  adjudication  for  the 
mental health 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  although  it  noted  that the  PEB  also  cited  AR  635-40  B-107 para.  (e.).    In  the 
matter  of  the  psychotic,  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 
Psychotic  Disorder,  Not  Otherwise  Specified,  Manifested  by 
Paranoid Delusions 

VASRD CODE  RATING 
9210 
COMBINED 

10% 
10% 

 
 
The following documentary evidence was considered: 
 
Exhibit A.  DD Form 294, dated 20120603, w/atchs 
Exhibit B.  Service Treatment Record 
Exhibit C.  Department of Veterans’ Affairs Treatment Record 
 
 
 
 
 
 
 
 
 

 

           xxxxxxxxxxxxxxxxxxxx, DAF 
           Director 
           Physical Disability Board of Review 

 
 
 

SFMR-RB 
 
 
 
 
MEMORANDUM FOR Commander, US Army Physical Disability Agency  
(TAPD-ZB / xxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557 
 
SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for xxxxxxxxxxxxxxxx, AR20130002013 (PD201200579) 
 
 
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)