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AF | PDBR | CY2013 | PD2013 00743
Original file (PD2013 00743.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1300743
BRANCH OF SERVICE: Army  BOARD DATE: 20131011
SEPARATION DATE: 20040728


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard SGT/E-5 (91W/Combat Medic), medically separated for anxiety disorder. The CI was activated for a deployment to Iraq in late 2003. During workups in preparation for deployment, the CI was hospitalized for exhibiting bizarre behavior. Upon his discharge, he was treated with psychotherapy and psychotropic medication; however his condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS). He was issued a permanent S3/L2 profile and referred for a Medical Evaluation Board (MEB). The anxiety disorder, characterized as “anxiety disorder, not otherwise specified (NOS)” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded “postoperative chronic low back pain” as not meeting retention standards. The PEB adjudicated “anxiety disorder, not otherwise specified (NOS)” as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The chronic low back condition was determined to be not unfitting . The CI made no appeals, and was medically separated.


CI CONTENTION: “Not all medical information was considered along with other information in medical records.”


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. In addition, the CI was notified by the Army that his case may be eligible for review of the military disability evaluation of his mental health condition in accordance with Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012 and whose mental health diagnoses were changed during that process. The CI is eligible for PDBR review of his conditions that were evaluated by the PEB . In accordance with Secretary of Defense directive for a comprehensive review of mental health diagnoses that were changed during the Disability Evaluation System (DES) process, the applicant’s case was reviewed with regard to mental health diagnosis change, fitness determination, and rating of unfitting mental health diagnoses in accordance with the Veterans VASRD §4.129 and §4.130. Accordingly, the rating for the unfitting anxiety disorder is addressed below. In addition, the board will address the contended chronic low back condition. 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 20040524
 VA – at Separation
Condition
 Code Rating Condition Code Rating Exam
Anxiety Disorder, NOS
 9413 10% Brief Psychotic Disorder 9210 50%* 20040727
Chronic Low Back Pain
 Not Unfitting Degenerative Disc Disease, Lumbar Spine 5242 10% 20040727
No Additional MEB/PEB Entries
 Other x 2 20040727
Combined: 10%
 Combined: 60%*
Derived from VA Rating Decision (VA RD ) dated 200 50912 ( most proximate to date of separation [ DOS ] ).
* VARD 200602028, (based on VA exam of 20051019 for DC 9210) lowered rating for DC 9210 to 10%, with combined disability lowered to 20% from 20060501


ANALYSIS SUMMARY:

Anxiety Disorder. The PEB rating, as described above, was derived from DoDI 1332.39 and preceded the promulgation of the National Defense Authorization Act 2008 mandate for DoD adherence to VASRD §4.129. The Board, IAW DoDI 6040.44 and DoD guidance (which applies to the current VASRD §4.129 to all Board cases as appropriate), must 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.” If the Board judges that application of §4.129 is appropriate, it will recommend a minimum 50% rating for a retroactive 6-month period on the Temporary Disability Retired List. The Board must then determine the most appropriate fit with the VASRD §4.130 criteria at 6 months for its permanent rating recommendation, based on the facts in evidence which are most probative for that interval.

On 26 April 2004, 3 months prior to separation, the psychiatric narrative summary (NARSUM) noted that the CI was brought in by his command to the psychiatric clinic for strange behavior. The following was reported: episodes of loud rambling, incoherent speech, emotional lability appearing to be angry, depressed, agitated, pacing, and having trouble sitting 2 months subsequent to activation. When the CI was initially interviewed, he stated he was “fighting for my rights,” but could not clarify, and when asked what he was fighting against, he responded “if I tell you then I’ve lost the battle.” He had trouble stating clearly what he meant and would become tongue-tied and confused. He had difficulty answering yes or no questions, and provided rambling, verbose narratives that did not directly relate to the questions. The CI felt people stayed away from him because he was “trying to be a better Christian,” and looked down on him because he did not drink or smoke like most of the other soldiers. He had no suicidal or homicidal ideations. During an 8-day hospitalization in the inpatient psychiatric unit, he was able to speak more calmly but still appeared very anxious. Additional history indicated that the CI had been promoted to NCO a few months prior and he had become extremely anxious once his unit had been activated and began to prepare for deployment. He became so anxious about being misunderstood by others that he felt he had to explain every detail of what he was saying. This became more complex when he began to feel that he had to explain his reason for having to explain, giving him an appearance of being tongue-tied and incoherent when he was experiencing severe anxiety. The CI had been in the National Guard for 6 years. He had previous deployments to Kuwait, Sinai, and Bosnia. His civilian job was cooking in a restaurant. He had a high school education without problems. The NARSUM examination showed that the CI was in distress despite an inappropriate grin, and frequently inappropriate affect. The CI had poor eye contact, fidgeted frequently in his chair, and his thought processes appeared to be rambling and difficult to track. The CI’s condition was described as improving with psychotherapy and medication. He had no further loss of behavioral or emotional control since hospitalization. He exhibited a moderate level of ongoing anxiety especially evident when he attended group therapy. The examiner diagnosed an Axis I anxiety disorder, NOS, manifested by excessive feelings of anxiety leading to loss of behavioral and emotional control, including incoherence, agitation and pacing, and labile affect; stressors: minimal, activation prior to deployment; predisposition: none known; impairment for military duty: marked; impairment for social and industrial adaptability: definite, due to obvious anxiety and discomfort in the presence of others, difficulty with speech, and visible behavioral changes. At the VA Compensation and Pension (C&P) exam performed on 27 July 2004, a day prior to separation, the CI denied any psychiatric problems. He showed some disorganization in his formal thought processes, he seemed guarded and suspicious, carefully weighing his responses, without evidence of significant anxiety. The CI showed euthymic mood, denied apprehension, stated he generally enjoyed life, and maintained a positive mood. He sat calmly in a relaxed posture, speech was not pressured or rapid, generally understandable, no rambling speech, no flight of ideas, and subtle indications of thought disorder, not grossly psychotic, showing idiosyncratic thinking pattern, some disorganization in his formal thought processes, ambivalence, and some guardedness. The CI reported no drug or alcohol problems, slept well, no excessive worry, showed no insight, questionable judgment, and low average intelligence. It appeared to the examiner to be likely long-standing personality characteristics; and that the CI was placed under pressure by promotion to NCO, and the preparation for wartime service greatly increased his stress and coping resources causing decompensation and psychotic behavior. He did not continue in outpatient treatment after the hospitalization and discontinued his medication (Effexor). It appeared to the staff psychologist examiner (Ph.D.) the stress was no longer as great, and the CI had essentially returned to baseline functioning still showing an idiosyncratic thinking pattern and some guardedness, he did not show any social impairment. The examiner opined that the records he examined were more suggestive of a brief psychotic disorder than an episode of severe anxiety, and if he was not exposed to significant stress, he may not exhibit signs of psychosis in the future. A Global Assessment of Functioning (GAF) score of 60 (moderate) was assigned. On 19 October 2005, at follow up C&P examination, 15 months after separation, the CI denied any mental health problems, specifically anxiety or depression, at the time of examination. He admitted he was treated as an inpatient for observation. There was no sleep impairment, no anhedonia, no suicidal or homicidal ideations, gained back lost weight with a good appetite, no hallucination, and no delusions. He was married for 6 years, looking for a job, and attending school at a state university. He completed house chores and occasionally visited relatives. The mental status examination revealed a neatly groomed individual, cooperative, rather vague, limited eye contact, some anxiety was noted, normal speech rate and rhythm, neutral mood, appropriate affect to content, logical and tight thought processes with no loosening of associations; no confusion, oriented in all spheres and normal memory. He denied hallucinations; no delusional material was noted and adequate insight and judgment was noted. The psychologist (Ph.D.) examiner noted no evidence for an axis I diagnosis, GAF 65 (mild), no gross impairment in social or vocational adaptability, and no evidence of any psychiatric disorder to preclude employment.

The Board directs attention to its rating recommendation based on the above evidence. The Board first deliberated whether the DoD mandate for application of VASRD §4.129 was appropriate. After lengthy deliberations, members concluded by a 2:1 vote that the preponderance of evidence did not support application of VASDRD §4.129. The Board next considered the VASRD diagnostic code 9413 (anxiety disorder, NOS) used by the MEB to refer to the IPEB, and the IPEB’s 10% rating upon discharge. This code is rated according to the VASRD general rating formula for mental disorders. The Board noted that the C&P examination performed a day prior to separation was most probative for adjudication, and the examination determined that the CI had returned to baseline functioning. The Board did not find evidence of flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships for a rating of 30% in the CI’s favor. The Board also considered VASRD diagnostic code 9210 (psychotic disorder, NOS [atypical psychosis]) used by the VA for a 50% temporary rating, and then reevaluated 13 months later for a 10% rating. Diagnostic code 9210 was rated using the same VASRD general formula as discussed above, and there was no avenue for a higher adjudication. Thus, changing the VASRD codes provided no rating advantage or disadvantage to the CI. The Board determined that no mental health diagnoses were changed during the disability evaluation process. 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 anxiety disorder, NOS condition.

Chronic Low Back Pain. The Board’s main charge with respect to this condition is an assessment of the fairness of the PEB’s determination that it was not unfitting. The Board’s threshold for countering Service 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 CI was found fully deployable on 7 October 2003, 9 months prior to separation, for intermittent LBP for which he took Naproxen. He passed the Army Physical Fitness Test on 29 October 2003, without an alternate event. There was no evidence of prior surgery by scar examination or X-rays. The orthopedic NARSUM addendum on 5 March 2004, found normal lumbar spine X-rays, ranges-of-motion flexion of 90 degrees (normal is 90), extension 15 degrees (normal 30), right and left flexion 30 degrees (normal 30), negative straight leg raise pain, normal deep tendon reflexes, normal sensation, and normal strength. The CI was able to run up to two miles with some muscle spasms afterwards. Additionally, he could walk and stand without difficulty; he had muscle spasms with lifting more than 25 to 30 pounds; pain with the rucksack, flak vest, and repeated bending. The CI was able to perform the technical aspects of his MOS without a problem. The commander’s statement on 8 March 2004 noted the CI performed exceptionally well as a 91W until he was no longer able to because of his back injury limiting heavy lifting; there was no evidence of any re-injury, or worsening of the condition while performing his MOS for 3 months prior to his mental health hospitalization found in the record. Members agreed was that there was no citable evidence which would challenge the PEB’s fitness conclusion; and, there were no clinical features, injuries, or specific functional limitations which would render the condition inherently unfitting. The Board concluded therefore that this condition could not be recommended for an additional disability rating.


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 anxiety disorder, NOS condition, IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended low back pain condition, the Board unanimously recommends no change from the PEB adjudication 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 recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION
 VASRD CODE RATING
Anxiety Disorder, NOS
 9413 10%
Low Back Pain
 Not Unfitting
COMBINED
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130529, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record





 SFMR-RB                                                                         


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


 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for AR20130019206 (PD201300743)
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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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