RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD1300923
BRANCH OF SERVICE:  Army	BOARD DATE:  20140110
SEPARATION DATE:  20080619

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (11C10/Indirect Fire Infantryman) medically separated for psychosis and cognitive disorder.  The CI was air evacuated from Iraq in March 2007 after isolating himself and exhibiting odd behaviors.  A ruptured intracranial dermoid cyst was discovered in his left temporal lobe region following a Magnetic Resonance Imaging.  He returned to the U.S. for surgery and then was hospitalized for psychiatric care for 2 weeks in May.  Psychosis not otherwise specified was diagnosed.  Medications were used to treat the mental health (MH) conditions.  The MH condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS).  He was issued a permanent S4 and referred for a Medical Evaluation Board (MEB).  The MEB forwarded cognitive disorder not otherwise specified (NOS) and psychosis NOS as not meeting retention standards, while medial frontal lobe syndrome (MFLS) to ruptured intracranial dermoid cyst and depressive disorder were forwarded not as meeting retention standards IAW AR 40-501.  The Informal PEB (IPEB) adjudicated psychosis NOS as unfitting rated at 10%, citing criteria of Department of Defense Instruction (DoDI) 1332.38.  Due to the congenital origin of the dermoid cyst, the cognitive disorder associated with MFLS was determined to exist prior to service and was therefore not ratable.  The depressive disorder was found to be not unfitting and not ratable.  The CI appealed to the Formal PEB but then withdrew his demand for a formal hearing.  He was medically separated with a 10% disability rating.

CI CONTENTION:  The CI stated “I was at the time I got my rating of 10% in the army, I was very stressed and my thoughts were only to get discharged.  I had a chance to go get my rating up at 30% but I denied to do so.  Now, I am ready to take actions and am filling out this application.”

He also attached a one-page statement to his application which was reviewed by the Board and considered in its recommendations.

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 rating for the unfitting psychosis condition is addressed below; the cognitive disorder associated with MFLS, which was found to be congenital and therefore existing prior to service, was not ratable but will be addressed below; major depressive disorder, which was determined to be not unfitting by the PEB, is likewise addressed below.  No additional conditions are within the DoDI 6040.44 defined purview of the Board.  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 20080303	VA* - based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Psychosis NOS	9210	10%	Psychosis (Now Rated w/Cognitive D/O, Residuals of Brain Lesion (Claimed as Dermoid Cyst of Left Temporal Lobe, Cognitive Problems, Speech Problems, TBI, Depression)	8045-9210	10%**	STR*	
Cognitive D/O associated w/Medial Frontal Lobe Syndrome	8003-9326	---%					
Medial Frontal Lobe Syndrome 	Not Unfitting					
Depressive Disorder	Not Unfitting					
No Additional MEB/PEB Entries	Other x 3	STR*	
Combined:  10%	Combined:  10%**	
*Derived from VA Rating Decision (VARD) dated 20081006 most proximate to date of separation with service treatment records (STR) since CI did not report to VA examinations
**Rating increased to 70% via VARD dated 20090603 with C&P exams 20090427, 20090429 and 20090511; coded 9435-9210 with changed description.

ANALYSIS SUMMARY:

Psychosis NOS.  The CI was air evacuated to Germany from theater in March 2007 for observed symptoms of withdrawal, isolation, odd behaviors, mumbling to self and staring blankly at his hands for long periods with crying spells.  The narrative summary (NARSUM) noted he had been hospitalized psychiatrically for 2 days prior to being evacuated and diagnosed with psychosis NOS versus psychotic depression.  After arriving in Germany, imaging revealed a ruptured dermoid cyst.  Due to perceived difficulties with performing his activities of daily living (ADLs), the CI was admitted to inpatient psychiatry service (in Germany and at Walter Reed Army Medical Center) and diagnosed with psychosis secondary to dermoid cyst.  He was later transferred to US.  He underwent surgery to remove the cyst which involved the left temporal lobe and anterior/middle cerebral arteries.  Prior to surgery he was prescribed an antidepressant and an antipsychotic medication.  There was noted improvement in symptoms; the recommendation to discontinue the medications was made soon after surgery.  The CI underwent neuropsychological evaluation, 4 May 2007, with the finding of normal attention and memory and no gross impairment in executive functioning.  The psychologist concluded testing showed residual effects from the cyst but noted “he performed remarkably well cognitively given left brain surgery only 3 weeks earlier”.  At the neurology MEB consult, 8 May 2007, the neurologist noted the absence of psychotic symptoms and no behavioral problems in his unit.  The CI reported he no longer feels depressed and is in his usual state of health.  He denied symptoms suggestive of posttraumatic stress disorder (PTSD).  There was a question regarding baseline mental/emotional functioning.  Mental status examination revealed full orientation, flat affect, monotone speech, no spontaneous smile, no eye contact, and tangential thinking.  There was no evidence of psychosis.  Testing of frontal lobe inhibition ability was normal (go, no go), and naming skills, visuospatial, constructional praxis were all intact.  The neurologist diagnosed MFLS (apathy, impaired motivation, deficits of sustained attention and executive function, expressive aprosodia) and opined the CI failed retention standards under chapter 3-30j.

The NARSUM, 12 October 2007, recorded a pre-deployment history of depression.  (Cognitive disorder NOS recorded in the neurology MEB was noted as associated with frontal lobe syndrome and possible association with the cyst versus premorbid factors.)  For the condition of cognitive disorders due to a medical condition the CI was found to fail retention criteria, Ch. 3-34.  The NARSUM psychiatrist (CI’s treating psychiatrist) recorded the diagnoses of  psychosis NOS, depressive disorder NOS, and cognitive disorder NOS and opined the diagnosis of psychosis failed retention criteria, depressive disorder, met retention standards, and cognitive disorder, failed retention standards but the condition is associated with the ruptured dermoid cyst.  A global assessment of functioning (GAF) score of 60 was assigned.  The examiner recommended a trial of stimulant medication, and counseling.  The MEB forwarded the conditions of psychosis NOS, cognitive disorder NOS, and depressive disorder to the PEB.  The commander’s statement (CS), 4 December 2007, indicated the CI was Absent Without Leave (AWOL) for three weeks “but due to his cognitive disorder, he was unaware he was AWOL”.  The commander opined he lacks the mental capacity to perform the physical requirements to perform his MOS duties.

Psychiatry entry note, 8 February 2008, recorded the diagnoses of cognitive disorder NOS/frontal lobe syndrome (verbal paucity, poor initiation but ability to perform ADLs); history of psychosis secondary to dermoid cyst, resolved, off meds, history of depression, resolved off meds, and assigned a GAF of 60-65 with notation “likely at current baseline.”  The psychiatrist noted risk to self and others was low.  The CI had left the warrior treatment unit, apparently without permission, went home to his family in New York and remained.

One week later, the CI was evaluated by the Veterans Administration (VA) back in his home town.  He reported a 10-month deployment in Iraq as a gunner, patrolling, and said he never shot his weapon.  He reported good sleep and appetite, no suicidal or homicidal thoughts, is off medication and denied a depressed mood.  Mental status examination recorded anxious affect, poor eye contact, hypo verbal, low speech volume that was hesitant in fluency.  The examiner diagnosed frontal lobe syndrome with rule out of cognitive disorder NOS and noted the psychiatric diagnosis is not clear, depression and psychosis seems resolved; however, opined, the CI is not fit to serve in the military.  He was referred for a second neuropsychological evaluation.

On 3 March 2008, neuropsychology determined an average IQ; superior non-verbal intellectual functioning (120), and essentially no change from previous examination.  In March 2008, the PEB adjudicated the condition of psychosis NOS as unfitting and assigned a 10% disability rating.  Cognitive disorder was adjudicated as associated with MFLS secondary to the ruptured dermoid cyst, which was opined to be not compensable due to the cyst classified as a congenital lesion.  The depressive disorder was determined to meet retention standards.

The CI was non-attendant for the Compensation & Pension (C&P) examination.  On 6 October 2008, the VA used the STR and rated the diagnosis of psychosis at 10%.  The CI also claimed PTSD that was determined to be not service connected.

On 27 November 2008, 5 months after separation, the CI took an overdose of Tylenol in apparent suicide attempt.  He was upset with the noises from the neighborhood bar and began yelling at the crowd from his bedroom window.  The bar patrons started taunting him, he attempted to take a pair of scissors to confront them but his parents intervened.  He then took the overdose and 1-hour later he informed his parents of the overdose; he was taken to the hospital, treated and admitted to medical unit, and followed by psychiatry consultants.  Psychological testing on 17 December 2008 recorded a diagnosis of schizophrenia versus psychotic disorder due to general medical condition.  Post hospitalization note, 29 December 2008, recorded improvement in mood symptoms, noted stability of symptoms with medication, and recorded a diagnosis of “cognitive deficits NOS”, PTSD chronic, with a rule out of psychotic depression.

The Board directs its attention to the rating recommendation based on the evidence just described.  The PEB’s rating of 10% coded 9210.  Likewise, the VA assigned a 10% evaluation coded 8045-9210 for psychosis associated with brain lesion.  3 June 2009, approximately 1-year after separation, the VA increased disability rating to 70% for the conditions of psychosis with cognitive disorder and residuals of brain lesion (claimed as dermoid cyst, cognitive problems, speech problems, traumatic brain injury (TBI) and depression) coded 9435-9210.  The Board first unanimously agreed that VASRD §4.129 was inapplicable in this case in the absence of a highly stressful causative event.  The Board noted the assigned GAF of 60, borderline between moderate and mild impairment, and a GAF of 60-65 (mild) recorded by the same examiner more proximal to separation.  The service records demonstrated no hospitalizations beyond initial presentation of symptoms leading to the discovery of the ruptured cyst, no episodes of suicidal ideations, and no visits to the emergency room prior to separation.  At the time of separation the Board agreed that the §4.130 threshold for a 50% rating (occupational and social impairment with reduced reliability and productivity) was not approached.  The deliberation settled on arguments for a 10% versus a 30% permanent rating recommendation.  The Board considered the criteria for a rating of 30%, which requires “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks”.  The CI was briefly hospitalized psychiatrically, placed on antipsychotic medication and was discovered to have a brain lesion.  There were no further psychotic episodes post surgery and no additional psychiatric hospitalizations prior to separation, and no emergency room visits for MH issues.  In the February 2008 note, the treating psychiatrist stated the psychosis condition had resolved and the CI was off medications and a GAF of 60-65 (mild) was assigned.  The CS did not implicate a psychiatric disorder.  The commander stated the CI forgets to set his alarm or forgets about formation itself.  “He does not maintain an acceptable level of attention and concentration to carry out instructions without being told a number of times to do so”.  VA psychiatry treatment post hospitalization entry, 29 December, 2008, reported the applicant was unemployed and was hospitalized 5 months after separation for overdose of Tylenol in a suicidal attempt.  It is not clear if this represented a mood or psychotic episode; however, it was noted the CI had not taken his medications in the 4 months after separation.  The CI was taking psychotropic medications at the time of the December evaluation, was stable with noted improvement in symptoms and no evidence of psychosis.  No further hospitalizations were recorded.  The 30% rating is difficult to support given that there is no documentation that psychotic symptoms interfered with daily functioning, and there was no evidence of occupational or social impairment due to psychosis.  The 10% description, “occupational and social impairment due to mild or transient symptoms which decrease work efficiency only during periods of significant stress, or; symptoms controlled by continuous medication,” more accurately reflects the CI’s condition at separation.  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 psychosis disorder NOS condition.

Contended PEB Conditions.  The other condition forwarded by the MEB and adjudicated as not unfitting by the PEB was depression.  The condition of cognitive disorder NOS associated with MFLS was adjudicated and determined to be not compensable.  The Board’s first charge with respect to the conditions is an assessment of the appropriateness of the PEB’s fitness adjudications.  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.

Depression.  Available treatment records recorded a past history of depression with one entry recording a pre-deployment history of depression.  The medication profile of June 2007 recorded a diagnosis of a major depression and the psychiatric NARSUM recorded an episode of acute depression in March or April 2007 (pg. 54); however, there were no evidence in the clinical record of an Axis I diagnosis of depression.  Psychiatrist note, dated 8 February 2008, noted “history of depression, resolved off meds.”  Depression was not implicated in the CS, on the permanent profile or noted as failing retention standards.  The condition was reviewed by the action officer and considered by the Board.  There was no indication from the record that this condition significantly interfered with satisfactory duty performance.  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 for the contended condition of depression; and, therefore, no additional disability ratings can be recommended.

Cognitive Disorder associated with MFLS.  The contended condition of cognitive disorder associated with MFLS was adjudicated by the PEB as not compensable secondary to the condition of ruptured dermoid cyst.

Available treatment records suggested this condition was determined to be the direct result of the ruptured dermoid cyst.  Neurology MEB consult, 8 May 2007, noted the region of the brain potentially involved with the cyst included the medial frontal lobes, medial temporal lobes, and orbitofrontal regions.  Damage to structures in these regions could possibly result in deficits in behavioral/emotional functions, e.g., flat affect, apathy, and other symptoms associated with MFLS.  The neurologist opined, injury, whether by the ruptured cyst or by post-surgical changes to these areas, could explain the cognitive deficits.  Neuropsychological testing showed mild impairment of verbal recall and timed verbal fluency and no impairment in executive functioning or complex problem solving.  The neuropsychologist opined the CI’s problems on tasks were consistent with the location of the cyst and neurosurgery.  Although the condition of cognitive disorder NOS was implicated in the CS and on the permanent profile; and the condition of MFLS was not implicated or profiled, there was no indication that these conditions would be separately unfitting in the absence of the ruptured dermoid cyst.  The Board acknowledged that dermoid cyst is a congenital condition derived from skin cells during formation of the neural tube (first few weeks of gestation); and existed prior to entry; but undertook a careful review of the record to determine if the condition was permanently aggravated by service under VARSD code 8003.  The Board searched for evidence of residuals beyond the psychosis and determined there was not sufficient evidence to support the condition was permanently aggravated by service.  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 determination for either contended conditions, and therefore, no additional disability ratings can be 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.  In the matter of the psychosis disorder, NOS, and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended major depression, the Board unanimously recommends no change from the PEB determinations as not unfitting.  In the matter of the contended cognitive disorder with MFLS, and IAW DoDI 1332.38, E3.p4.5.2.2.2., and E3.p4.5.6, the Board unanimously recommends no change from the PEB determination of not compensable based on the conditions being a direct result of the ruptured intracranial dermoid cyst.  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	
Psychosis Not Otherwise Specified	9210	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130625, 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 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXX, AR20140005214 (PD201300923)

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