RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2014-00227
BRANCH OF SERVICE:  Air force	SEPARATION DATE:  20090831

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Security Forces Journeyman, medically separated for “anxiety disorder, not otherwise specified (NOS),” with a disability rating of 10%. 

CI CONTENTION:  The applicant was not evaluated for her PTSD condition.  The applicants complete submission is at Exhibit A.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20090812	VARD - 20100330  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Anxiety Disorder NOS	9413	10%	PTSD also claimed as Anxiety D/O  and Depression	9411	50%	20100323	
PTSD	Cat II					
Personality Disorder NOS	Cat III	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Anxiety Disorder NOS Condition.  According to service treatment records, the CI deployed to Iraq from July 2007-November 2007 and to South America from February 2008-March 2008.  On a post-deployment questionnaire in October 2007, she endorsed depression, a feeling of being in great danger of being killed, and interested in help for stress, emotional, alcohol or family problem.  Symptoms worsened in January 2008.  Enlisted Performance Report for the period from July 2006 - March 2008 rated her as “truly among the best” and recommended promotion, noting she was a standout community mentor and combat proven.  She was first seen by a psychologist on 27 March 2008 for an intake interview one day prior to deployment.  She claimed she had PTSD but the examiner opined she did not meet criteria for PTSD and diagnosed her with anxiety disorder NOS and cleared her for deployment.  Military One Source referred her to a private psychiatric group on 11 April 2008 and she reported combat exposures, symptoms of anxiety, near daily flashbacks of events in Iraq and South America, and heavy drinking since her return from South America.  The psychiatrist diagnosed PTSD and a personality disorder.  Despite receiving therapy and medication, her condition worsened and she was admitted to a psychiatric inpatient unit on 22 April 2008 for 6 days and diagnoses of depression NOS, PTSD by history, and rule out (r/o) major depression were rendered.  She returned to outpatient follow-up with the private providers and received weekly counseling and took medications for sleep and for depression/anxiety.  She denied a pre-military diagnosis or treatment of mental illness.  Psychological testing June 2008 suggested extreme exaggeration of symptoms but significant dread about a return to Iraq.  Diagnoses of anxiety disorder NOS, malingering, provisional, and r/o major depression were rendered.  She was referred for a Medical Evaluation Board.
 
The narrative summary (NARSUM), dated January 2009, noted the CI was restricted from all weapons-bearing duties, removed from worldwide qualified status, but continued in her primary duty in training exercises.  She reported separation anxiety in childhood and recurrent nightmares 2-3 times per week of people trying to kill her.  She was raised by her grandmother who died when she was 7 and was then raised until 15 by her mother who she identified as emotional and physically abusive and neglectful.  She denied suicide attempts or ideation.  She had returned to school to pursue a physical therapy degree.  Mental status exam (MSE) was notable for an anxious and sad mood with a limited affect.  Diagnoses of anxiety disorder NOS and personality disorder NOS were rendered with a Global Assessment of Functioning (GAF) of 60 (moderate bordering on mild impairment, symptoms).  The examiner noted the CI did not meet full criteria for PTSD due to a lack of flashbacks or specific avoidance.  Social and industrial impairment related to anxiety disorder was rated as mild.

The commander’s statement noted the CI was not able to perform her primary military duties due to her prescribed medications and restrictions that would not allow her to carry a weapon.  A Letter of Evaluation, dated July 2009, disagreed with her overall performance assessment for the period through March 2009, noting that she met the standard but did not “clearly exceed” the standard.  Her performance reflected only additional duties and not her performance in primary duties. 

At the VA Compensation and Pension (C&P) exam performed 7 months after separation, the CI reported she goes to counseling once per week or every other week and was not taking any medications because she could not pay for it.  She reported sexual abuse by an uncle but no intrusive memories or nightmares.  She reported getting into trouble for yelling at people and “anger problems” resulting in extra duty assignment while in the military.  She was not working but had completed a work study since her discharge and has missed work 2-3 days per week.  She was attending school full-time but missing classes 3 times per week due to fatigue, anxiety, or irritability.  She was interested in walking, shopping and watching television.  She denied close friendships and had not attended a party in 3 months.  MSE revealed an irritated mood.  A diagnosis of PTSD was rendered with a GAF of 50 (moderate impairment, symptoms.)

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating, coded 9413 (anxiety disorder) while the VA adjudicated the condition as PTSD, coded 9411 and assigned a 50% disability rating.  The MEB forwarded anxiety disorder NOS and PTSD as medically unacceptable and not existing prior to service (EPTS) but the final PEB (FPEB) adjudicated anxiety disorder NOS as unfitting in Category I, but assigned a Category II designation for PTSD as EPTS, without service aggravation.  The PEB noted that the CI “probably had PTSD as a child due to significant trauma, ”and noted the CI’s mother reported the CI had received psychiatric treatment on several occasions prior to entry on active duty, and that there was no indication that PTSD was combat-related.  The PEB acknowledged the CI had experienced combat exposures but was not diagnosed with PTSD by military providers as a result.  Personality disorder NOS was assigned a Category III designation because it is a condition not separately unfitting, compensable or ratable.  Pre-separation evidence of PTSD was lacking.  

Disability associated with any psychiatric condition, regardless of the diagnosis or multiple diagnoses, is subsumed under a single rating using the same criteria IAW VASRD §4.130.  The Board first considered if application of VASRD §4.129 with a constructional 6 month (50% minimum) period on the Temporary Disability Retirement List (TDRL) was indicated in this case (per Board directive from DoD).  The PEB did not apply 4.129 without explanation.  However, Board members agreed that the provisions of VASRD §4.129 were applicable in this case, noting the association with combat experiences impacting her current symptoms and the absence of military records that confirm a mental health diagnosis existed upon entrance into military service.  Symptoms of anxiety and depression were first documented after Iraq redeployment and appeared to be exacerbated by fear of further deployment to Iraq, resulting in hospitalization.  The Board then considered if there was evidence for a §4.130 rating higher than the minimum mandated 50% at time of TDRL placement.  The Board unanimously agreed that the §4.130 criteria for a rating higher than 50% were not met near the time of separation, and therefore the minimum 50% initial TDRL rating is applicable.  

The most proximate source of comprehensive evidence on which to base the permanent rating recommendation in this case is the VA C&P examination performed 7 months after separation.  There was no relevant VA outpatient or civilian provider evidence providing psychiatric details during the 6-month interval.  The C&P examination indicated she met criteria for PTSD.  She was unemployed but enrolled in school full-time and not attending many classes due to mental health symptoms.  She remained in counseling but could not afford medication.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 50% for 6-months of constructive TDRL and a 10% permanent rating for the anxiety condition.  

BOARD FINDINGS:  In the matter of the anxiety disorder NOS condition, the Board unanimously recommends a disability rating of 50%, coded 9413 IAW VASRD §4.129 for 6 months from the time of discharge consistent with a constructive period of TDRL and then a permanent separation rating of 10% IAW VASRD §4.130.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Anxiety Disorder NOS 	9413	50%	10%	
RATING	50%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131230, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00227.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings