RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00369
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20080528

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Air National Guard E-6 (Fire Protection Craftsman) medically separated for anxiety disorder.  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty.  He was issued a permanent S4 profile and referred for a Medical Evaluation Board (MEB).  Anxiety/post-traumatic stress disorder (PTSD) was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated anxiety disorder, associated with post deployment stress symptoms and depressive disorder as unfitting, rated 10% with cited application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  He was given a higher rating for his condition by the VA.  His complete submission is at Exhibit A.

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 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 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:

IPEB - Dated 20080408	VA* - based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Anxiety Disorder…	9413	10%	PTSD with Depression	9411	NSC	20060821	
Other MEB/PEB Conditions x 0	Other x 7	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20070123 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Anxiety Disorder, associated with PTSD Symptoms and Depressive Disorder.  Service treatment records show that the CI served on active duty in the Air Force from September 1999 to July 2006.  He was deployed twice to Afghanistan and had combat exposure both times.  He received the Combat Action Medal.  The CI had been in good emotional health until fall of 2002, 6 months after return from his first combat deployment.  In the January 2004 Pre-Deployment Health Assessments (PDHA), the CI reported receiving mental health care during the previous year.  He reported combat exposures during his first deployment but did not seek MH care until October 2003 when he was diagnosed with depression and placed on a temporary S4 profile, restricting night duty and responding to emergency calls.  The Post-Deployment Health Assessment (PDHA) dated in June 2004, documented he did not see someone wounded, killed, or dead, did not discharge a weapon, but felt in great danger of being killed.  He reported after redeployment he had symptoms of depression, nightmares of being killed in combat, irritability, decreased social connections, and avoidance of war coverage.  He received a diagnosis of PTSD by January 2005.  His service treatment records documented a diagnosis of major depressive disorder (MDD) and insomnia, treated with psychotropic medications and psychotherapy in 2004 and 2005.  During two MH visits between 2004 and 2006, the CI reported overwhelming anxiety spectrum problems in the context of family separation and acute environmental stressors.  He was honorably discharged from active duty in July 2006, later enlisted in the Air National Guard (ANG) and was medically separated in May 2008.

At the VA Compensation and Pension (C&P) exam dated 23 August 2006, 21 months before separation from the (ANG), the CI reported he was feeling better since his switch from active duty to the Guard.  He felt he did not need help at the time.  His MH problems had not occurred in 2 months and he was not receiving treatment for psychiatric problems. . He was working for 2 months and had a good relationship with the supervisor.  He also had good relationship with his wife and other family members.  His mental status exam (MSE) was unremarkable.  A diagnosis of depression NOS, resolved, was rendered with a Global Assessment of Functioning (GAF) of 85 (absent or minimal symptoms).  The examiner noted he did not meet criteria for PTSD.  The VARD determined that service connection for PTSD with depression was denied.

After enlisting in the ANG, the CI attended air traffic controller training from January 2007 to April 2007.  MH notes dated 18 June 2007 indicated he visited the emergency room (ER) with complaint of severe anxiety (with panic features) and depression triggered by viewing a combat video during training.  He mental health condition led to a permanent S4 profile in August 2007.  He was seen by a psychiatrist on 03 October 2007 (8 months pre-separation) for his first MEB mental health consultation.  The CI reported his anxiety level increased because he thought his activation for training was a prelude to another deployment.  He admitted he had minimized his symptoms when evaluated by the VA.  The CI also reported he continued to have nightmares of his experiences in Afghanistan, slept poorly, checked locks at this home at night, and had an overriding sensation of impending doom.  He had never needed or received MH treatment prior to entering the active duty Air Force and his deployments.  His MSE was unremarkable.  A diagnosis of anxiety disorder NOS with post-traumatic, generalized anxiety and obsessive compulsive features was rendered with a GAF of 51 (moderate symptoms, impairment).  The psychiatrist opined the origin began in fall 2002 with severe impairment for social and vocational adaptability.

A psychiatric nurse practitioner provided medication management from October 2007 to January 2008 and he reported an improvement in anxiety.  The commander’s statement (02 February 2008) noted his condition did affect his ability to satisfy duty requirements.  The second MEB consultation or narrative summary (NARSUM) dated 04 February 2008, 4 months pre-separation, noted the CI was working full time with an insurance company since October 2007.  He was working with a long-time friend who had become his boss which left him feeling micromanaged.  He enjoyed a number of activities that included working with at-risk youth and church activities.  He reported chronic self-esteem problems, a variable energy level, and difficulty concentrating.  He did have recent suicidal ideation without a plan but no current suicidal thoughts.  He was taking a small dose of medication for anxiety and a medication for sleep.  He had been married 7 years and had a child.  The MSE was essentially normal.  A diagnosis of anxiety disorder in partial remission and depressive disorder NOS was rendered, both with a date of origin in 2004.  His global assessment of function (GAF) was 70 (transient symptoms, slight impairment.)  Stressors were identified as two deployments to Afghanistan.  The psychiatrist opined he appeared stable and made no clinical recommendations.

Post-separation military treatment facility notes from 23 June 2008 to 17 September 2008, noted the CI was compliant with medication management and individual therapy.  He was taking classes at the college level and spending time with his son.  He denied suicidal and homicidal ideations, was not hospitalized and condition was recorded as stable.  An independent medical opinion (IMO) dated 18 October 2009 concluded that anxiety, PTSD with depression, and depression were diagnosed during active military service.  VARD dated 26 April 2010 assigned a rating of 30% for PTSD (claimed as depression and anxiety) effective 2 December 2008 based on C&P exam dated 02 April 2010.

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 (PTSD) but not service connected (NSC).  Based on a PTSD exam dated 02 April 2010 and the findings of an IMO reviewer, the VA granted service connection and assigned a disability rating retroactive to December 2008.  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 (Mental disorders due to traumatic stress) with a constructional 6 month (50% minimum) period on the Temporary Disability Retirement List (TDRL) was applicable in this case.  The PEB did not apply §4.129, claiming the condition was not the direct result of armed conflict or caused by an instrumentality of war.  However, Board members agreed that the provisions of §4.129 were applicable in this case, noting the association with combat experiences impacting his current symptoms.  The Board then considered if there was evidence for a §4.130 (General rating formula for mental disorders) rating higher than the §4.129 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 Board next considered the CI’s permanent rating recommendation.  Based on the second NARSUM exam and post-separation military treatment notes, all Board members agreed the §4.130 rating was minimally present at the time of TDRL removal.  This evidence showed the CI worked full-time, took classes, remained active in his community, and maintained good working and family relationships.  The last military provider note, dated 17 September 2008, described his symptoms as stable and improving.  His condition remained most appropriately supported at the 10% rating level by the continued use of medications.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board recommends a 6-month retroactive TDRL rating of 50% and no change in the PEB adjudication for the permanent medical separation rating of 10%

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 in this case that any prerogatives outside the VASRD were exercised.  In the matter of the anxiety disorder NOS condition, the Board unanimously recommends an initial Temporary Disability Retirement List (TDRL) rating of 50% for a period of 6 months, in retroactive compliance with VASRD §4.129 followed by no change to the previously assigned permanent rating of 10%.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

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

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140105, 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

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00369.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your records to reflect placement on the Temporary Disability Retired List without change to your assigned disability rating and separation with severance pay, upon final disposition.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

								XXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachments:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR
DFAS-IN