RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1301054
BRANCH OF SERVICE:  Army	BOARD DATE:  20140325
Separation Date:  20051231

SUMMARY OF CASE:  The available evidence of record indicates this covered individual (CI) was an active duty SPC/E-4 (92G/Food Service Specialist) medically separated for a mental health (MH) condition.  The CI complained of chest pain, dizziness, sweating, nausea, vomiting and anxiety attacks.  The condition could not be attributed to any organic source and could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty (MOS), so she was referred for a Medical Evaluation Board (MEB).  The condition was characterized as “undifferentiated somatoform disorder” and forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501, with no other conditions identified by the MEB.  The Informal PEB (IPEB) adjudicated “undifferentiated somatoform disorder” as unfitting but indicated that it existed prior to service (EPTS), so the PEB gave no rating.  The CI did not concur, demanded a formal hearing with personal appearance and appointed counsel, but did not submit a written appeal.  The Formal PEB (FPEB) adjudicated the same unfitting condition as described by the IPEB, but indicated that there was no evidence that it was EPTS and rated the condition at 10%.  The CI concurred with the results of the FPEB and was medically separated.

CI CONTENTION:  “Service connection for posttraumatic stress disorder PTSD with somatoform disorder features is granted with an evaluation of 50 percent effective Nov 5, 2008.  Pending the decision diagnosed from 01/01/2006.”

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 applicant.  The ratings for conditions meeting the above criteria are addressed below.  In addition, the Secretary of Defense directed a comprehensive review of Service members with certain mental health conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The applicant was notified that he may meet the inclusion criteria of the Mental Health Review Terms of Reference.  The mental health condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may be eligible for future consideration by the Board for Correction of Military Records.

In accordance with DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to review of medical records and evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.  Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

RATING COMPARISON:

Service FPEB – Dated 20051129	VA - (3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Undifferentiated Somatoform Disorder	9423	10%	Somatoform Disorder	9421	0%	20060324	
No Additional MEB/PEB Entries	Other x8	20060315	
Combined:  10%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20060617.

ANALYSIS SUMMARY:

Undifferentiated Somatoform Disorder.  The CI developed symptoms of chest pain, sweating and shortness of breath (SOB) while she was in Iraq in 2003.  The Behavioral Health examiner documented the CI had a 2-year history of unexplained SOB and chest pains; a cardiopulmonary work-up had been negative.  The CI endorsed 7 out of the 13 symptoms listed for panic attacks in the Diagnostic and Statistical Manual of Mental Disorders; pounding heart, sweating, SOB, chest pain, abdominal distress, feeling unsteady or light headed and hot flashes.  The examiner noted that psychological testing was marginally valid because the CI attempted to place herself in an overly positive light, minimizing faults and denying psychological problems.  She exhibited reports of physical distress, low frustration tolerance and easily became irritable and frustrated.  The examiner diagnosed somatization disorder.  The CI underwent a complete cardiopulmonary workup which revealed mild mitral valve prolapse (MVP) on echocardiogram (EKG).  The CI was started on a beta blocker medication for control of cardiac symptoms.  She was also evaluated with a cardiac exercise stress test that was stopped due to mild chest tightness, but there were no EKG changes and the CI performed up to 12 metabolic equivalent of tasks (METs).  The MEB narrative summary exam completed approximately 6 months prior to separation noted the CI had experienced a bad episode of chest pain, sweating and SOB one and one half months prior to this exam while she was out driving.  She also reported sweating, nausea, vomiting and anxiety attacks.  The examiner noted the CI expressed concern that she had not been told what was wrong with her and because she still had chest pain.  The examiner diagnosed somatoform disorder as manifested by various somatic complaints before the age of 30 that may have required medical attention with no medical explanation; marked impairment for further military duty, and mild impairment for social and industrial adaptability and not EPTS.  The Global Assessment of Functioning (GAF) was recorded as 75 (no more than slight impairment in social, occupational, or school functioning).  The commander’s statement indicated the CI’s medical condition prevented her from performing MOS duties and because she had blackouts with physical exertion, she posed harm not only to herself but to soldiers that depended on her to be coherent.  The CI was given a permanent S3 Profile for undifferentiated somatoform disorder.  A Behavioral Health addendum completed after the IPEB referenced “anxiety” attacks that occurred about 5 to 6 times during the past 18 months.  Based on an interview and a review of psychological testing, the examiner diagnosed an undifferentiated somatoform disorder.  The examiner further noted the CI had bad menstrual cramps at the age of 14, thought she had arthritis in her knees because of knee pain, and complained of lower back pain, diarrhea, nausea, menses and blackouts and therefore indicated the condition had existed prior to service.  The examiner documented marked impairment for further military duty and mild impairment for social and industrial adaptability.  The VA Compensation and Pension (C&P) exam accomplished approximately 2 months after separation documented that whenever the CI experienced chest pain, she would lay down for a while and it would subside, and also that she had ongoing memory problems.  The examiner noted the CI did not believe her symptoms were psychiatric but she accepted that diagnosis.  The examiner also noted continued chest pain, difficulty sleeping, mild memory difficulties and that the diagnosis of somatoform disorder was made by a psychiatrist.  The CI’s mental status exam was normal and the examiner diagnosed a somatoform disorder; a GAF of 75 was assigned (no more than slight impairment in social, occupational, or school functioning).  The CI was engaged to be married and was unemployed at that time but was planning on beginning school to become a billing clerk.

The Board directs attention to its rating recommendation based on the above evidence.  The SRP determined no MH diagnoses were changed to the applicant's possible disadvantage in the disability evaluation process, so this applicant did not meet the inclusion criteria in the Terms of Reference of the MH Review Project.  The FPEB coded the undifferentiated somatoform disorder as 9423 (the code for undifferentiated somatoform disorder) and rated 10%.  The FPEB stated that there was no evidence that the condition was EPTS.  The VA coded the somatoform disorder as 9421, somatization disorder and rated at 0%, specifically citing “…this condition is currently not causing impairment in a social or occupational setting.”  Documentation throughout the service treatment record (STR) consistently diagnosed the CI with a somatoform disorder.  Both the MEB and C&P examiners diagnosed a mild to slight impairment in social and industrial adaptability.  The Board reviewed the criteria for the next higher 30% rating and determined the CI did not manifest criteria required for that rating.  STR documentation indicates the CI also had MVP that could have been responsible for some of the symptomology.  While not in the scope of this Board, the MVP was discussed due to a commonality of symptoms, and it is medically reasonable to attribute the CI’s chest pain, SOB, dizziness and palpitations to mild MVP.  The Board considered the option of basing its rating recommendation on those symptoms, but the results of her cardiac stress test (achieving 12 METs of exercise) would also result in a rating of 10% under VASRD code 7000 (valvular heart disease), which would confer no benefit to the CI.  The Board recognized that there is documentation that the CI’s condition worsened remote from separation, but that was out of the Board’s scope for adjudication. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the FPEB adjudication for the undifferentiated somatoform disorder.

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 that any prerogatives outside the VASRD were exercised.  In the matter of the undifferentiated somatoform disorder, and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends no recharacterization of the disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130723, 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 XXXXXXXXXXXXXXXXXX, AR20140011460 (PD201301054)

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						     

CF: 
(  ) DoD PDBR
(  ) DVA