IN THE CASE OF:	  

		BOARD DATE:	    20 May 2014
	
		DOCKET NUMBER:  AR20140006646 


THE BOARD CONSIDERED THE FOLLOWING EVIDENCE:

1.  Application for correction of military records (with supporting documents provided, if any).

2.  Military Personnel Records and advisory opinions (if any).


THE APPLICANT'S REQUEST, STATEMENT, AND EVIDENCE:

1.  The applicant requests a review of the military disability evaluation pertaining to a mental health (MH) condition.

2.  The applicant states, in effect, the case file should be reviewed in accordance with the Secretary of Defense directive for a comprehensive review of members who were referred for a disability evaluation between 11 September 2001 and 
30 April 2012 and whose mental health diagnosis was changed during that process.

3.  The applicant submitted an application through the DOD Physical Disability Board of Review (PDBR) Mental Health Special Review Panel (SRP).

CONSIDERATION OF EVIDENCE:

1.  The PDBR SRP conducted a comprehensive review of the applicant’s submissions and records for evidence of inappropriate changes in the diagnosis of a mental health condition during processing through the military disability system.  

2.  The Department of Defense memorandum, dated 27 February 2013, directed the Service Secretaries to conduct a review of mental health diagnoses for service members completing a disability evaluation process between 11 September 2001 and 30 April 2012 in order to determine if service members were disadvantaged by a changed diagnosis over the course of their physical disability process.
3.  In the processing of this case, an advisory opinion was obtained from the PDBR SRP and the applicant was provided a copy.

4.  The applicant did not respond to the advisory opinion.  

DISCUSSION AND CONCLUSIONS:

1.  After a comprehensive review of the applicant’s case, the SRP determined by majority vote that the applicant’s prior Temporary Disability Retired List (TDRL) determinations should be modified (TDRL MH rating to a minimum 50 percent in accordance with (IAW) the Department of Veterans Affairs Schedule for Rating Disabilities (VASRD) Section 4.129). 

2.  The SRP considered the appropriateness of changes in the MH diagnoses, the appropriateness of the physical evaluation board (PEB) fitness determination for any MH condition and, if unfitting, whether the provisions of VASRD Section 4.129 were applicable.  The SRP further considered the fairness of disability ratings for MH conditions and made recommendations for these ratings IAW VASRD Section 4.130 (and VASRD Section 4.129 as appropriate).   

3.  The SRP considered the criteria for the diagnosis of Post-Traumatic Stress Disorder (PTSD) as specified in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) including:  the evidence for the stressor (criterion A), re-experiencing of the event (criterion B), persistent avoidance of stimuli associated with the trauma (criterion C), hyperarousal (criterion D), duration and onset (criterion E), or presence of clinically significant distress or impairment in social, occupational or other important area of functioning (criterion F).

4.  The SRP determined whether the initial diagnosis of anxiety, not otherwise specified (NOS) constituted a change in diagnosis or elimination of the diagnosis of PTSD.  With the exception of the unelaborated and uncorroborated entry of "delayed PTSD" as one of the flowsheet entries referenced above, there was no support to conclude that a diagnosis of PTSD was ever formally established during the applicant's active duty tenure.  There was not a preponderance of evidence in support for all of the DSM IV-TR criteria, and the medical evaluation board (MEB) psychiatrist's diagnosis of anxiety disorder, NOS was the only MH diagnosis underpinned by a comprehensive evaluation and sufficiently probative evidence.  The analysis by the end-TDRL psychiatrist establishing a progression from anxiety disorder, NOS to PTSD is a reasonable assumption, and was accepted as the conclusion of the SRP majority.

5.  The SRP noted the MH diagnosis was not changed during the TDRL processing through the Disability Evaluation System (DES), and the final DES determination at the end of TDRL was PTSD.  The progression of diagnosis to PTSD was not in evidence proximate to TDRL entry and therefore the applicant did not meet the inclusion criteria in the Terms of Reference of the MH Diagnosis Review Project.

6.  The SRP next addressed the application of VASRD Section 4.129 in its recommendations, noting that VASRD Section 4.129 did not specify a diagnosis of PTSD, rather it stated "mental disorder due to a highly stressful event."   Although there was an indication that domestic issues (the 2006 divorce) contributed significantly to the evolution of the anxiety condition, the SRP majority felt there was credible evidence that deployment-related stressors were a major factor.  The evidence shows the domestic stressor was raised as the primary substrate by the narrative summary (NARSUM) examiner (not a psychiatrist), the SRP majority felt the MEB psychiatric addendum and all of the follow-on VA psychiatrists linked only Criterion A operational stressors to the MH diagnosis and the domestic stressor(s) were not brought in. 

7.  The SRP noted that furthermore, if one accepted that the Service MH condition was evolving PTSD (final PEB diagnosis), it follows that the deployment stressors were strongly etiologic from the beginning; this was the accepted opinion of the SRP majority. 

8.  The SRP finally addressed the appropriateness of the final Service rating for the transitioned diagnosis of PTSD, based on VASRD Section 4.130 criteria, at the time of permanent retirement.  The SRP agreed that VASRD Section 4.130 criteria for a 50 percent rating, occupational and social impairment with reduced reliability and productivity (citing more acute symptoms than are present in this case) were not met.  The SRP thus deliberated a recommendation in support of the Service's 10 percent rating, for occupational and social impairment due to mild or transient symptoms which decrease work efficiency only during periods of significant stress, vs. a recommendation for a 30 percent rating, for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.'

9.  The SRP noted the applicant was not employed at the time of permanent retirement.  She was equivalently engaged as a student; which, coupled with her community and domestic functioning, supports a conclusion that she had no impairment impinging upon work efficiency or precipitating any intermittent 

periods of occupational incapacity.  The balance of the evidence and the probative psychiatrist opinions (predominantly medical, not psychiatric, impairment; examiner citing 10 percent criteria) lend more support for the 10 percent criteria than those for 30 percent.  The SRP consensus by majority opinion was mindful of VASRD Section 4.3 (reasonable doubt), that there was insufficient cause to recommend a change in the PEB's permanent rating for PTSD.  

10.  The dissenting member judged that reasonable doubt favored a 30 percent rating as school was not equivalent to work and the applicant displayed symptoms that would be likely to diminish occupational functioning.  Neither the dissenting member proposing no change from the Service TDRL, and permanent adjudications nor the member favoring a 30 percent permanent rating elected to submit a minority opinion.

11.  After deliberation, the SRP by a majority vote concluded that the preponderance of evidence supported a recommendation that the provisions of VASRD Section 4.129 should be applied for TDRL rating of the anxiety condition.  No SRP member judged that a rating higher than the VASRD Section 4.129 minimum 50 percent could be supported, and the dissenting member supported a 10 percent TDRL rating for anxiety disorder.

12.  The available evidence shows the SRP’s assessment should be accepted.  

BOARD VOTE:

____X____  ____X____  ___X_____  GRANT FULL RELIEF 

________  ________  ________  GRANT PARTIAL RELIEF 

________  ________  ________  GRANT FORMAL HEARING

________  ________  ________  DENY APPLICATION










BOARD DETERMINATION/RECOMMENDATION:

The Board determined that the evidence presented was sufficient to warrant a recommendation for full relief.  As a result, the Board recommends that all Department of the Army records of the individual concerned be corrected by modifying the applicant’s TDRL determination (TDRL MH rating to minimum 40 percent IAW VASRD Section 4.129).

UNFITTING CONDITION		
VASRD
CODE                
TDRL       RATING             
PERMANENT
RATING
Anxiety Disorder, NOS
9413
50%
---
Post-Traumatic Stress Disorder
9411
---
10%
Surgical Residuals, L4-5 Lumbar Disc Disease
5243
40%
20%
Neuralgia, Left Lower Extremity
8799-8720
20%
10%

COMBINED
80%
40%



      ___________X____________
       	   CHAIRPERSON
      
I certify that herein is recorded the true and complete record of the proceedings of the Army Board for Correction of Military Records in this case.


ABCMR Record of Proceedings (cont)                                         AR20040003532



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ABCMR Record of Proceedings (cont)                                  AR20140006646



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