RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00585
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20150317
SEPARATION DATE:  20061020

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Master-at-Arms) medically separated for a mental health (MH) disorder.  The disorder could not be adequately rehabilitated to meet the requirements of her Rating.  She was placed on limited duty and eventually referred for a Medical Evaluation Board (MEB).  The MH disorder, characterized as “obsessive-compulsive disorder” and “posttraumatic stress disorder” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded one other condition (fibromyalgia) for PEB adjudication.  The Informal PEB adjudicated the mental disorder as unfitting and rated it at 10%.  The remaining condition was determined to be Category III, not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in her application.

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/Naval 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 IPEB – Dated 20060707	VA - (20 Months Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Obsessive Compulsive Disorder	9404	10%	Posttraumatic Stress Disorder	9411	50%	20080529	
Posttraumatic Stress Disorder	Category I- related					
Other x 1 (Not In Scope)	Other x 16	
Combined:  10%	Combined:  80%	
Derived from VA Rating Decision (VARD) dated 20080929 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Obsessive Compulsive Disorder (OCD)/Posttraumatic Stress Disorder (PTSD).  The psychiatric narrative summary (NARSUM) documented that the CI first sought MH treatment in August 2005.  At the time of her presentation she endorsed multiple anxiety symptoms, including poor sleep, panic attacks at least once weekly, anxiety and depressed mood.  An MH entry dated 26 August 2005 recorded the diagnosis of OCD with traits of PTSD and panic attacks.  Much of this evaluation was not among the record in evidence; therefore, the genesis of the PTSD diagnosis was not clear at this point.  The CI participated in regular OCD group therapy, had individual therapy and took psychotropic medications.  The CI also participated in specific therapy for her PTSD symptoms (Eye Movement Desensitization and Reprocessing [EMDR]) reportedly from childhood trauma.  Treatment records documented that following disclosure of sexual harassment there were increased incidents of cutting behavior to relieve stress, and episodes of dissociation.  Psychiatry entry dated 10 April 2006, 4 months prior to separation, documented the CI’s report of two events that had contributed to her MH conditions.  The CI reported that she had been subjected to inappropriate comments by males on her job and was among one of 5 women out of 100 individuals.  She did not find the males comments unusual for men to discuss; however, in September 2003 one of the men (reservist) had been relentless in his pursuit of a date with her and she consistently refused; however, while on guard duty, the reservist grabbed her by the shoulders and pinned her down and began to kiss her.  A patrol car drove up and he stopped.  The CI stated she had not revealed the incident because she assumed she would not be believed.  The psychiatrist stated, “It is medically contraindicated for her to return to security given her abuse history in light of the inappropriate comments and advance that she endured while working in security.”  The following month during a therapy session, the CI reported increased intrusive memories and nightmares since disclosing sexual assault, and noted disclosure had triggered other childhood memories.  The therapist documented dissociative episodes since elementary school; however, the CI had indicated an exacerbation of episodes in the last several weeks with daily or every other day cutting behaviors.  Therapist note dated 5 June 2006 documented improvement in anxiety symptoms with medication, and no nightmares, and minimal dissociation, and although intrusive memories had continued they had not bothered her as much.  The psychiatry NARSUM on 23 June 2006, documented diagnoses of OCD, PTSD, social phobia, and fibromyalgia; and noted she took medication that helped to improve some of her symptoms.  The examiner noted that the first 4 months of MH treatment had focused on OCD symptoms; however, there was no progress, until after she disclosed “horrendous childhood abuse.”  The examiner documented that the CI reported symptoms consistent with PTSD which had begun in 2003, and once she had reported her PTSD symptoms, treatment was focused on PTSD rather than her OCD.  The examiner stated after beginning specific trauma treatment (EMDR) related to childhood trauma, the CI stopped cutting, her mood improved, her dissociative episodes decreased and she did not have panic attacks.  She had improved and was returned to security duty; however, once she returned she began to decompensate and her symptoms worsened.  She began to cut and dissociate again, and had panic attacks and flashbacks.  The examiner then acknowledged the CI’s report of the September 2003 incident involving the reservist and sexual advances made by a male friend, and the temporal relationship to the CI’s deteriorating condition.  The psychiatrist documented that the CI had minimized the importance of these events “but the dates clearly support the role the harassment by the reservist and the advances by her friend played in her progressive decompensation.”  Mental status exam (MSE) recorded depressed mood and flat and depressed affect.  The CI had frequent dissociative episodes throughout the examination.  There was no evidence of psychosis, or suicidal or homicidal ideation, and the examiner noted inability to fully assess judgment due to the presence of dissociation.  The physician documented that the OCD symptoms was present since childhood; however, panic attacks, fear of leaving home, and other PTSD symptoms were not present prior to service.  However, there had been reported episodes of sexual abuse and verbal abuse and neglect during childhood.  The psychiatrist diagnosed chronic PTSD, delayed onset, and noted the condition had not existed prior to service (EPTS), and documented precipitating stressor of sexual harassment.  This condition resulted in severe impairment for the military manifested by an inability to “perform duty due to persistent anxiety, panic attacks, and inability to focus due to constant dissociation with flashbacks.”  The examiner stated, the CI was incapable of sustaining an 8-hour daily work schedule due to both her physical and psychiatric limitations.  The psychiatrist also opined that the psychiatric condition had caused severe interference with social adaptability due to flashbacks and dissociation as well as obsessive rituals.  The diagnosis of OCD was opined to be service aggravated but EPTS.  The examiner noted that although the CI had returned to her previous employment at the hospital she had not returned to her previous level of functioning.  Her fibromyalgia condition severely impacted her sleep, and prolonged standing increased her fibromyalgia related pain.  She was constantly checking her filing which was an added OCD issue for her.  The psychiatrist documented a Global Assessment of Functioning (GAF) score of 30-35 (some impairment in reality testing or communication).  The VA Compensation and Pension mental evaluation, approximately 5 months after separation, did not document any in-service stressor for PTSD, and the examiner attributed all of her PTSD symptoms to childhood abuse.  Her PTSD and OCD symptoms had not improved.  She had continued her medication and participated in weekly individual therapy.  The examiner noted that her symptoms had not required visits to the emergency room or psychiatric hospitalization.  The MSE documented anxious mood and affect, distractibility, history of hallucination (hearing her mother’s voice), and no impairment in judgment.  A GAF of 50 (serious) was recorded; and the examiner opined that the psychiatric symptoms cause occupational and social impairment with reduced reliability and productivity.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition of OCD at 10% using VASRD code 9404, noted that the condition was EPTS; and opined that the condition of PTSD was related to the OCD.  The VA rated the condition of PTSD at 50% using VASRD code 9411 (childhood origin).  The Board acknowledged that the PTSD was subsumed under the OCD diagnosis, and therefore, both conditions were taken into account under the 4.130 rating.  The Board first noted that the provisions of §4.129 were appropriately not applied.  There was insufficient evidence that the condition diagnosed as PTSD had been the result of an in-service related event; and the diagnosis of PTSD accompanied and was subsumed by the unfitting OCD diagnosis, making the PTSD condition not the primary unfitting MH condition.  The Board next considered if there was evidence for a §4.130 rating higher than 10% at the time of separation.  The higher 50% rating criteria requires evidence of “Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work relationships.”   Although, the NARSUM examiner opined that concentration problems contributed to the CI’s work impairment, there was insufficient evidence to support the 50% level of disability.  The CI reported panic attacks; however, frequency was not documented and there were no recorded visits to the emergency room for any MH symptoms, and no hospitalizations.  The majority of the MSEs in the 6 months prior to separation documented adequate judgment, absence of impairment in thinking, stable moods, and no suicidal or homicidal ideations.  The Board then settled on the 30% versus 10% criteria.  Board members agreed the evidence clearly reflected the 30% level of disability.  After due deliberation, and in consideration of all the evidence and VASRD §4.3 (reasonable doubt), the Board recommends a 30% permanent disability rating for the condition of PTSD. 

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 obsessive compulsive disorder condition, the Board recommends a disability rating of 30%, coded 9404 IAW VASRD §4.130.  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; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
OCD with PTSD	9404	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140120, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
		   DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref:   (a) DoDI 6040.44
       (b) PDBR ltr dtd 31 Jul 15 ICO XXXXXXXXXXXXXXX
       (c) PDBR ltr dtd 31 Jul 15 ICO XXXXXXXXXXXXXXX
	 (d) PDBR ltr dtd 24 Jul 15 ICO XXXXXXXXXXXXXXX
	 (e) PDBR ltr dtd 31 Jul 15 ICO XXXXXXXXXXXXXXX
	 (f) PDBR ltr dtd 11 Aug 15 ICO XXXXXXXXXXXXXXX
	 (g) PDBR ltr dtd 27 Jul 15 ICO XXXXXXXXXXXXXXX
	 (h) PDBR ltr dtd 14 Aug 15 ICO XXXXXXXXXXXXXXX

1.  Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (h).

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 40 percent disability rating (increased from 20 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 40 percent disability rating (increased from 20 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effective date of discharge.

     g. XXXXXXXXXXXXXXX, former USN: Placement on the Temporary Disability Retired List (TDRL) for six months at time of discharge with a 60 percent disability rating; following the TDRL period, placement on the Permanent Disability Retired List with a 40 percent disability rating. 

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.