BOARD DATE:	  25 June 2014

		DOCKET NUMBER:  AR20140008914 


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 unanimous vote that there should be no change of the applicant’s Temporary Disability Retired List (TDRL) diagnosis or Service rating determination.  

2.  The SRP considered the appropriateness of changes (if any) in the MH diagnoses, and provided remedial recommendations if it was judged that there were any elimination or unfavorable change in MH diagnosis by the Service.  The SRP further considered whether the provisions of the Department of Veterans Affairs Schedule for Rating Disabilities (VASRD) Section 4.129 were applicable to any unfitting MH condition (physical evaluation board (PEB) adjudicated or SRP recommended) and made rating recommendations in accordance with VASRD Section 4.130 (and Section 4.129 as appropriate).  

3.  The SRP considered the elimination or change in the diagnosis of Post-Traumatic Stress Disorder (PTSD), under the Term of Reference (TOR) of the MH Review Project, and applied the criteria of the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) (he 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), and presence of significant distress or impairment in social, occupational or other important area of functioning (criterion F)).

4.  The SRP first considered if the Service diagnosis of anxiety disorder constituted an unfavorable change in diagnosis or elimination of the diagnosis of PTSD.  It was clear that the service diligently considered an alternative diagnosis of PTSD, initially and following appeal.  The diagnosis of anxiety disorder was the only established MH diagnosis in the service treatment records (STR), thus there was no unfavorable change of diagnosis.  The SRP's charge was assessing the fairness of the service determination that criteria for the diagnosis of PTSD were not met, not whether an established diagnosis was eliminated.  Therefore, the applicant’s case did not meet the inclusion criteria in the TOR of the MH Review Project.

5.  The SRP agreed that DSM IV-TR Criteria A, D, E and F for PTSD were adequately supported by the evidence, and these criteria did not seem to be in dispute by either the service or the VA psychiatrists.  Both these psychiatrists and the MH clinical providers all opined that a significant driver of the applicant's symptoms was the underlying issue with perceived injustice and non-MH medical stressors, an opinion shared by the SRP.  These stressors would not qualify as Criterion A, and it was crucial to the diagnosis of PTSD that the combat related Criterion A stressors were themselves a major etiology of the symptoms and energized to the extent that they carried the sequelae of intrusive re-experiencing (Criterion B) and precipitated avoidant behaviors (Criterion C).  

6.  The VA and service psychiatrists provided comments that these manifestations were not endorsed by the applicant.  Although he did endorse them on the Behavioral Health (BH) questionnaires and the PTSD Checklist military version (PCL-M) responses, he did not do so in the context of directed interviews.  Symptoms of re-experiencing and avoidance were not mentioned in the service treatment records (STR) clinical notes, except in the 24 March entry described above, and this entry appeared to be in a PTSD template format, with the narrative elements stressing and elaborating the interpersonal conflicts with his unit.  With the exception of the last questionnaire, the above endorsements of Criteria Band C preceded the applicant's denial of them to the narrative summary (NARSUM) examiner.  The civilian psychiatrist provided no direct evidence for the presence or absence of Criteria Band C (or any of the others except E and F); and, his diagnosis of PTSD, although possibly accurate, was weakly substantiated.  The SRP agreed that the evidence from the psychiatric interviews which directly addressed the Criteria Band C questions was of the greatest probative weight, and the mitigating evidence as elaborated above was of a less convincing nature. 

7.  The SRP further agreed that an Independent Medical Review (IMR) by a third party psychiatrist, optional but not required by regulation, would have been helpful in this case.  By a preponderance of evidence, however, the SRP concluded that there was insufficient support for recommending a change in the Service MH diagnosis to PTSD, or for adding PTSD as an additional service diagnosis.  The SRP's role in evaluating the applicability of VASRD Section 4.129 to the Service MH diagnosis was obviously moot, having been incorporated by the Service/Integrated Disability Evaluation System (IDES) determination.

8.  The SRP turned to assessing the fairness of the service TDRL rating for the anxiety disorder.  The minimum 50 percent rating in accordance with (lAW) VASRD Section 4.129 was conferred, leaving the SRP to assess whether one of the higher ratings (70 percent, 100 percent) should have been recommended.  The VASRD Section 4.130 description for a 70 percent rating was occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, referencing typical symptoms of suicidal ideation, obsessional rituals, illogical speech, near continuous panic or depression, spatial disorientation, neglect of hygiene, and inability to establish relationships.  The SRP agreed that the requirements for a 70 percent rating were not met.  At the time of temporary retirement, the applicant remained occupationally functional; there was no serious impairment in most areas as dictated by the 70 percent rating description; and none of the exampled typical features were present.

9.  After due deliberation in consideration of the preponderance of the evidence, the SRP agreed, mindful of VASRD Section 4.3 (reasonable doubt), that there was insufficient cause to recommend a change in the PEB's TDRL rating for anxiety disorder, NOS.

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

BOARD VOTE:

________  ________  ________  GRANT FULL RELIEF 

________  ________  ________  GRANT PARTIAL RELIEF 

________  ________  ________  GRANT FORMAL HEARING

___X_____  ___X_____  __X___  DENY APPLICATION

BOARD DETERMINATION/RECOMMENDATION:

The evidence presented does not demonstrate the existence of a probable error or injustice.  Therefore, the Board determined that the overall merits of this case are insufficient as a basis for correction of the records of the individual concerned.  




      _________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)                                  AR20140008914



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