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AF | PDBR | CY2013 | PD-2013-01862
Original file (PD-2013-01862.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXX               CASE: PD-2013-01862
BRANCH OF SERVICE: ARMY           BOARD DATE: 20141104
SEPARATION DATE: 20041221


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard SPC/E-4 (95B/Military Police) medically separated for major depressive disorder (MDD). The condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent H2/S3 profile and referred for a Medical Evaluation Board (MEB). The posttraumatic stressed disorder (PTSD) and MDD were forward to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded one other condition (back problems) that was listed as an Axis III condition under the mental health (MH) DSM IV Axis description. The Informal PEB (IPEB) adjudicated the “posttraumatic stress disorder, major depressive disorder” conditions as unfitting rated at 10%, citing application of AR 635-40. The remaining back condition was determined to be not unfitting by the PEB. The CI non-concurred with the IPEB findings/recommendations and submitted a written appeal to the PEB to adjudge his back, neck and hearing loss conditions. The PEB affirmed the original IPEB findings therefore, the CI requested a Formal PEB (FPEB). The FPEB, citing the Veterans Affairs Schedule for Rating Disabilities (VARSD), determined that there was no evidence of specific traumatic events to support a diagnosis of PTSD, subsequently adjudicating only the MDD condition as unfitting, rated at 10%. The CI non-concurred with FPEB’s findings yet made no further appeal and was medically separated.


CI CONTENTION: “1) Rating of 10% received by DOD for Major Depressive Disorder, is below what should have been awarded. 2) Lower Back condition, should have been included and awarded 20% or more. 3) Both conditions were chronic in nature.”


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 PEB’s rating for the unfitting MDD condition is addressed below. Additionally the back condition is within the Board’s defined DoDI 6040.44 purview and is also addressed. 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.


R ATING COMPARISON :

Service FPEB (Admin Corr.) – Dated 20041024
 VA - (Exam ~ 6 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Major Depressive Disorder 9434 10% Major Depression w/Anxiety Features 9434 30% 20050618
Back Problems Not Rated Sacralization of L5; Degenerative Disc Disease and Degenerative Join Disease Thoracic Spine; L5-S1 Bulging Discs 5243 10% 20050601
Other x 0 (Not in Scope)
 Other x 7 20050601
Combined: 10%
 Combined: 40%
* Derived from VA Rating Decision (VA RD ) dated 200 50824 (most proximate to date of separation)


ANALYSIS SUMMARY:

Major Depressive Disorder Condition. During his 2003 deployment to Kuwait, the CI developed symptoms of anxiety, loss of appetite, sleep disturbance, depression and he was hospitalized, while in theater for suicidal ideations. The medical evacuation report, dated July 2003, noted he was overwhelmed by conditions and there was a language barrier. A diagnosis of MDD was rendered, citing symptoms consistent with a MDD diagnosis. The CI was transferred from Kuwait to Germany where he remained on inpatient status for 2 weeks. During the hospitalization, he reported he suffered from palpitations and shortness of breath. He had a history of having a murmur for years. He had a cardiac evaluation and a mitral valve condition was diagnosed. He was later transferred to Walter Reed Army Medical Center, Washington, DC; hospitalized for 2 days and discharged to home, August 2003, with diagnosis of adjustment disorder with mixed anxiety/depressed mood. The discharge summary documented that during his deployment the CI was retained with “the wounded soldiers,” while his unit “was sent forward” as well as seeing “soldiers wounded,” but was “unable to describe an exact precipitating event” that could be connected to the onset of his psychiatric symptoms.

The CI returned to Puerto Rico where he was referred to a 4-week partial-hospitalization day treatment program for his MDD. At the treatment program’s initial evaluation dated 19 August 2003, the CI reported that he had no symptoms of insomnia, low energy, poor concentration, decreased appetite or thoughts of suicide prior to his deployment to Kuwait and since that deployment, those symptoms had persisted.

The mental status examination (MSE) was significant for a blunted affect and passive suicidal ideation. The examiner rendered a diagnosis of major depression, severe single episode. The CI’s Zoloft (anti-depressant) dosage was increased and Klonopin (anti-anxiety) was continued. Upon completion of the treatment program, the CI was evaluated at Rodriguez Army Health Clinic, Puerto Rico on 4 October 2003, where he reported improvement but nonetheless he continued to experience depressed mood, anxiety, crying spells, flashbacks, nightmares, avoidance behavior and had increased startle reflexes. He also reported occasional thoughts of death, increased fear of being ill and auditory hallucinations. The CI continued with his medication regiment and talk therapy sessions for MDD at the Institute of Psychotherapy of Puerto Rico.

In October 2003 the CI was diagnosed with PTSD. A treatment note dated 9 December 2003; documents that the CI progression was thought to have been “suboptimal results with civilian psych team” and referred to the Roosevelt Roads Naval Hospital MH department for further treatment. During the MH evaluation dated 19 December 2003, the CI endorsed continued symptoms of anxiety and depression including nightmares, flashbacks, reliving, intrusive recollections from Iraq, disorientation, avoidance behaviors, anhedonia, social isolation, disrupted sleep, irritability, angry outbursts, crying spells, hyper-vigilance and increased startle response. The MSE was normal except for an anxious and depressed mood. The examiner rendered diagnoses of PTSD and major depressive disorder, single episode, mild. The CI was recommended for PTSD group therapy.

At the narrative summary (NARSUM) psychiatric addendum dated 19 April 2004, 8 months prior to separation, the CI reported continued psychotropic medication use and talk therapy every 2 weeks. He worked in a civilian job as an Administrative Officer at the Inter-American University of Puerto Rico. The MSE was significant for an anxious affect. The examiner rendered diagnoses of PTSD and MDD single episode, moderate symptoms. The Global Assessment of Functioning (GAF) score was 50 (moderate).

At the VA Compensation and Pension examination performed 6 months after separation, the CI reported 12 pounds weight loss in 3 months, due to poor appetite, poor sleep, anxiety, depression, irritability and destructive behavior. The MSE was significant for a depressed mood and blunted affect. The examiner noted that the CI exhibited good impulse control. The GAF score was 65 (mild). The examiner opined that based on the CI’s history, records and evaluations he did not fulfill diagnostic criteria for PTSD. The examiner stated that his symptomatology fulfilled criteria for the diagnosis of major depression; therefore a diagnosis of major depression with anxiety features was rendered.

The Board directs attention to its rating recommendation based on the above evidence. The PEB adjudicated the MDD condition as unfitting with a disability rating of 10% coded under 9434. The VA rated the major depression with anxiety features at 30% coded under 9434. The Board considered whether VASRD § 4.129, mental disorders due to traumatic stress, was applicable in this case. The Board noted that the CI was deployed to Kuwait, but there was no evidence or description of a specific stressor that precipitated the onset of the CI’s psychiatric symptoms. The Board determined that VASRD § 4.129 was not applicable in this case.

The Board then considered whether there was evidence for a higher than 10% rating IAW VASRD §4.130, General Rating Schedule for Mental Disorders. The Board noted that there were three consecutive hospitalizations for initial psychiatric stabilization in 2003, but no further psychiatric hospitalizations within 12 months prior to or post separation. The CI completed a 20-day intensive treatment program for depression. He continued with medication management and talk therapy every 2 weeks with partial remission of his symptoms. He was employed at Inter-American University in an administration position since 1990. The CI was married, although there were reports of marital stress due to his irritability and destructive behavior. His insight and judgment were not impaired. The Board determined that the evidence best supports a rating of 10% due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress.

Contended PEB Conditions. The Board then assessed the fairness of the PEB’s determination that PTSD was 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. The Board is mindful that the PTSD condition was profiled and referenced in the commander’s statement as a condition that impacts the CI’s duty performance as well as the CI attended group therapy sessions from October 2003 through January 2004 for PTSD. However, there was documentation of improvement of the CI’s PTSD symptoms with the exception of persistent nightmares, irritability and occasional auditory hallucinations. The Board also noted that the majority of the CI’s treatment notes proximal to separation, documented evaluation and treatment for his depression with anxiety condition. Furthermore the VA did not service-connect the CI’s PTSD diagnosis, citing that the CI’s social and industrial history, service treatment records and medical evaluations did not fulfill the diagnostic criteria for PTSD.

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 of not unfitting for PTSD.

The low back pain condition was listed on DA Form 3947 (MEB’s proceedings) as an Axis III diagnosis as well as the psychological NARSUM addendum dated 19 April 2004. 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. The lower back pain condition was not profiled or implicated in the commander’s statement. All available evidence was reviewed by the action officer and considered by the Board. There was no performance based evidence from the record that the lower back pain condition significantly interfered with satisfactory duty performance. After due deliberation, in consideration of the preponderance of the evidence, the Board concluded that the lower back pain condition did not rise to the level of unfitting 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 MDD condition, the Board unanimously recommends a disability rating of 10%, coded 9434 IAW VASRD §4.130. In the matter of the contended PTSD and low back pain conditions, the Board unanimously recommends no change from the PEB determination as not unfitting. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131002, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                                   
XXXXXXXXXXXX
President
Physical Disability Board of Review


 invalid font number 31502 SAMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


 invalid font number 31502 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXX, AR20150004689 (PD201301862)
 invalid font number 31502

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                                                  XXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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