IN THE CASE OF:	  

		BOARD DATE:	  7 July 2015

		DOCKET NUMBER:  AR20150009675 


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 MH 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 MH 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 MH 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 recommended by unanimous vote that there should be no change in the applicant’s unfitting MH diagnosis, and that his prior determination be modified effective as the date of his prior medical retirement. 

2.  The SRP considered the appropriateness of changes in the MH diagnoses and physical evaluation board (PEB) fitness determination, and if unfitting, whether the provisions of the Department of Veterans Affairs Schedule for Rating Disabilities (VASRD) Section 4.129 were applicable and a disability rating recommendation in accordance with VASRD Section 4.130.  The evidence from available records documented that diagnoses of anxiety disorder, depressive disorder, and polysubstance dependence were rendered during the Disability Evaluation System (DES) process.  The SRP noted the DD Form 2808, prepared for the narrative summary (NARSUM), contained the diagnosis of post-traumatic stress disorder (PTSD), however, the NARSUM psychiatry addendum amended this to a diagnosis of anxiety disorder.  The SRP agreed the applicant appeared to meet the inclusion criteria in the Terms of Reference of the MH Review Project.

3.  The SRP noted the diagnosis of PTSD recorded on the DD Form 2808 was without supporting clinical documentation and evidence.  The SRP acknowledged the Department of Veterans Affairs (VA) Compensation and Pension (C&P) examiner’s assessment of PTSD in March 2010, 9 months prior to the NARSUM; however, the available records provided insufficient evidence to support a PTSD diagnosis at the time of medical retirement.  The psychiatry NARSUM examiner noted the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), diagnostic criteria for PTSD were not met.     A review of the record supported that Criterion B was not likely met and provided sufficient evidence that Criterion C was not met.  In order to meet Criterion B, there must be evidence demonstrating the presence of recurrent distressing dreams/intrusive thoughts of a specific traumatic event.  The SRP noted the applicant denied nightmares and intrusive thoughts in the 2005 Post-Deployment Health Assessment (PDHA), and in the 2008 PDHA, he said his PTSD-like symptoms were of minor concern. 


4.  The SRP noted that in the NARSUM the applicant stated that war gave him an adrenaline rush.  Taken in totality, there was insufficient evidence that Criterion B was met.  To fulfill the Criterion C, there must be evidence to demonstrate the presence of persistent avoidance behaviors, feelings of numbness/detachment from others, restricted range of affect, and sense of a foreshortened future.  During the NARSUM exam the applicant stated he had future plans to buy a house and although he had no plan to work, he indicated he could work if needed.  There was no mention of or indication of the presence of restricted range of affect.  At the C&P exam, he noted a friend who had been supportive, a good relationship with his cousin and a loving relationship with his girlfriend.  Although the C&P examiner indicated full criteria were met, it was not clear that Criterion C was met.  The SRP agreed that DSM-IV criteria for the diagnosis of PTSD were not met and that the PEB adjudication of unfitting anxiety disorder was supported by the evidence.

5.  The SRP concluded that the application of Section 4.129 was appropriate in this case and, accordingly, placed the applicant on a period of constructive Temporary Disability Retired List (TDRL) with a minimum rating of 50 percent in accordance with (IAW) Section 4.129 with reassessment after 6 months.  

6.  The SRP next considered if a rating higher than 50 percent was warranted at the time of entry on TDRL.  The next higher 70 percent rating required “occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood.”  Available treatment records at the time leading up to TDRL entry recorded no history of suicidal ideation; there were no psychiatric hospitalizations, no aggressive behaviors, no visits to the emergency room for MH issues, and no evidence of impairment in judgment or thinking.  The records demonstrated essentially normal mental status exams (MSEs) at the NARSUM and C&P mental evaluation.  The SRP concluded that there was insufficient reasonable doubt (IAW VASRD Section 4.3) for recommending a 70 percent TDRL entry rating.

7.  The SRP later undertook to determine a proximate source of comprehensive evidence on which to base the permanent rating recommendation.   The SRP reviewed the February 2011 C&P (MH Services) MHS Social Worker Exam for employability and review of symptoms, and noted that although this exam did not appear to meet the specification of a comprehensive source, it was appropriate to consider the clinical findings.  That exam recorded an essentially normal MSE; the applicant laughed and made jokes, he reported he had panic attacks once every 6 months that lasted for 30 minutes.  He had disturbed sleep, nightmares and reduced concentration.  He also reported he felt depressed, was fatigued and experienced lack of pleasure.  The applicant noted he had abused opiates and alcohol one month prior to the examination.  The examiner stated, “Much of his social and occupational impairment is due to the personality disorder and polysubstance dependence, rather than to PTSD.”  A Global Assessment of Functioning (GAF) of 60 (borderline moderate-mild) was assessed, and the examiner opined his condition had caused occupational impairment with “reduced reliability and productivity.”  Although the VA awarded a 70 percent rating, the examiner indicated a 50 percent level of disability. 

8.  The SRP noted there had been no psychiatric inpatient admission, no visits to the emergency room for his reported 30-minute long panic attacks, and no evidence of a legal history or report of physical altercations.  His GAF score had remained 60, and there was insufficient evidence that his condition had worsened in the 2 months since the NARSUM.  The NARSUM judged the condition met the 30 percent disability level.  The applicant expressed future plans to buy a house and indicated he felt he was employable.  The psychiatrist also noted that in spite of his substance abuse, he had maintained a 17-year history of consistent employment.  The SRP concluded his GAF score, MSE, and level of occupational impairment at the time of the C&P 2011 exam, and the NARSUM most accurately reflected the 30 percent level of disability. 

9.  After due deliberation considering all the evidence, the SRP unanimously agreed that the applicant’s record supported a permanent rating of 30 percent, but no higher, at TDRL removal.

10.  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 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 prior determination as indicated below:


UNFITTING CONDITION
VASRD CODE
TDRL RATING
PERMANENT RATING
Anxiety Disorder
9413
50%
30%
Left Knee
5003 (20%)
10%
10%
Right Knee

10%
10%
Right Ankle
5271
10%
10%

COMBINED (W/BLF)
70%
50%



      ____________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)                                  AR20150009675



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