RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-00895
BRANCH OF SERVICE:  Army                                                                  SEPARATION DATE:  20071115	

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Infantryman, medically separated for “Psychotic Disorder” with a disability rating of 10%.  

CI CONTENTION:  The CI contends he “was not properly diagnosed at time of separation.”  The CI’s 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 - Dated 20070713	VARD - 20080408	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Psychotic Disorder	9210	10%	Schizophrenia	9204	70%	20071114	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY: 

Psychotic Disorder Condition.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), symptom onset for this condition began during his second Iraqi deployment in November 2006.  The CI initially reported that he “did not feel like himself” and the command reportedly noticed early in the deployment that his performance had declined from a baseline high level of functioning.  This was attributed to discovering that his friend had committed suicide prior to the deployment.  The CI began having feelings of guilt secondary to the belief that he could have prevented the suicide if he had given his friend his telephone number.  The CI initially sought help through religion, and was spending excessive amount of time in the Chapel.
Given he was not improving, the CI was referred to mental health (MH) for an evaluation.  On 22 December 2006, he reported to the MH clinician that his chief stressor was that he was not able to spend enough time at church due to his work load.  He reported symptoms of insomnia, hyper-religiosity and bizarre thoughts.  He reportedly made an impromptu statement that he was sorry for all he had done and that “It is too late…it is happening tonight.”  When asked for clarification, the CI stated he was referring to “the rapture.”  He also reportedly believed the world was ending that night.  The CI also noted that he had witnessed his father’s suicide by hanging at age 9.  Due to lack of improvement, the CI was medically evacuated to Germany for hospitalization, and subsequently to the inpatient psychiatric ward in a US military hospital on 29 December 2006.  The Hospital discharge summary indicated the CI was discharged 1 week later.

The discharge summary recorded that he was evacuated from Iraq secondary to bizarre behavior and labile mood symptoms associated with learning of a friend’s suicide.  It was noted that while he was briefly observed by the inpatient unit in Germany, he had appropriate interactions and behaviors and had not required any medication.  The summary documented that on arrival to the military hospital, the CI related that he believed his problems were the sole result of “grief” and that he suffered no mental illness.  It was noted that he had not only lost his friend to suicide but was also going through a divorce.  The psychiatrist noted that it was determined that he had delusional thinking during his Iraq deployment, but that it had cleared up briefly after arriving in Germany.  Since being in the current inpatient unit, there had been no further evidence of psychosis.  It was noted that he interacted well with staff and fellow patients and was an active participant in group and individual therapy.  The diagnoses of brief psychotic disorder, resolved, and schizotypal personality traits were recorded.  The psychiatrist noted that he had no medications prescribed at any time prior to or during admission and that none were indicated.  

The CI was hospitalized for a second time, 1 day after discharge.  The discharge summary dated 23 January 2007 noted the CI was admitted on 10 January as a voluntary patient, due to threatening self-harm, and passive suicidal ideation (SI).  He was living in the Barracks at the time.  The CI denied history of depression, and denied all symptoms related to a mental illness.  He reportedly stated that “everything is fine, there is nothing wrong with him.”  His mental status examination (MSE) recorded he was hypervigilant, was somewhat hallucinatory and paranoid, his thoughts were disorganized and he appeared to have been responding to internal stimuli (voices).  The CI was prescribed medication and reportedly responded well.  At discharge it was noted that he was much improved, less paranoid, was sleeping better, and his thoughts were more organized.  The diagnosis of bipolar disorder was assessed, and a Global Assessment of Functioning (GAF) score of 59 (cusp of moderate and mild) was recorded.  

The NARSUM (psychiatric) was accomplished on 20 February, 3 weeks post hospitalization and 9 months prior to separation.  At the NARSUM, the CI reported he had no problems during his first 2005 deployment and had “enjoyed” deployment.  He recalled one particular incident involving a vehicle borne improvised explosive device (VBIED) and noted “he didn’t think anything of it”.  However, an acquaintance had developed PTSD symptoms associated with the VBIED and subsequently had a medical board.  He noted he re-deployed with his unit and did well, but in August and September 2006 he learned that the Soldier who developed PTSD from the VBIED had committed suicide.  He acknowledged that this Soldier had not been a close friend, but he had in part associated the death with his father’s suicide.  The CI was not in Iraq at the time of the Soldier’s death and noted that he took the death hard.  He was deployed again in October 2006 and developed psychotic symptoms, stating that he had become “very religious”.  He described auditory hallucinations, felt that God was talking to him, and his work performance declined.  MSE noted a flat affect, and no other abnormality.  The CI noted that he desired to remain in the Army, but acknowledged that he was not yet at 100%.  The psychiatrist diagnosed psychotic disorder, not otherwise specified (NOS), and recorded marked impairment for military duty.  A GAF of 45 (serious symptoms/impairment) was assessed.  The treatment records going forward indicated nearly complete resolution of symptoms.  

The Psychiatry treatment entry dated 9 May 2007, recorded the diagnosis of undifferentiated schizophrenia in remission.  It was noted that the CI was doing “very well” and that he needed to remain on the single medication prescribed for psychosis.  A Neurology entry dated 11 July 2007 noted that the CI had a psychotic reaction while in Iraq after several “extreme” stressors, however, he was currently “back to his premorbid baseline”.  The neurologist indicated that the CI’s wife was in attendance to the appointment and agreed that the CI was back to his premorbid baseline, and was not on any medication.  The neurologist also stated that he had met with the CI several times over the past few months and had not seen any evidence of a thought disorder or psychotic symptoms.  On 17 August 2007, the neurologist prepared a memorandum “To Whom It May Concern”, stating he had not witnessed any psychotic behavior or evidence of a thought disorder during CI’s visit to the Air Force neurology clinic.  The neurologist further opined he saw no reason to restrict the CI’s use of firearm.  

On 15 October 2007, 1 month prior to separation, the CI presented to MH with the report that he had gone to the emergency room (ER) that morning after he had a disagreement with his wife which caused his “different personalities” to have significant conflict.  He denied SI and homicidal ideation (HI).  He reported that he had multiple personalities that he has had since about the age of 9 after his father’s suicide.  The psychologist noted the absence of any reference to multiple personalities in the service treatment records.  It was also noted that the CI had not been on medication since March 2007.  His GAF score was recorded at 41-45 (serious symptoms).  He was seen again by the same psychologist on 28 November 2007 at which time he had restarted his medication and noted that the medication was beneficial in helping him control symptoms.  The CI noted that his alternate personalities had not caused him problems since restarting his medication.

The VA Compensation and Pension (C&P) mental exam was accomplished on 16 November 2007, the day following separation.  The psychiatrist indicated that the CI had intermittent auditory and visual hallucinations with delusions and religiosity.  It was noted that he had not had any hospital admission for his condition, nor had he sought treatment in the ER since 2007.  He had continued to take his antipsychotic medication.  The examiner noted that the CI stated that he was working and his job title was “Infantry”.  He noted he had not lost any time from work.  MSE recorded flat affect that was somewhat blunted, and although it was documented that he was fully oriented, and had normal communication and speech, the examiner wrote that he “showed difficulty understanding complex commands.  He is frequently distracted by hallucinations”; however, no explanation for these observations was recorded.  It was noted there was absence of suspiciousness, hallucinations, and delusions during the examination.  His thought processes were appropriate and judgment was not impaired.  SI and HI was absent, and he denied a history of panic attacks, but noted mild impairment in memory.  The psychiatrist diagnosed schizophrenia, in partial remission and assigned a GAF of 50-55 (moderate).
  
The Board directed attention to its recommendations based on the above evidence; and, first considered whether the provisions of VASRD §4.129 for any “mental disorder that develops in service as a result of a highly stressful event” were not applicable to this case.  The record clearly demonstrated that the CI’s symptoms begun prior to his deployment, and it was clearly documented his decline in performance was associated with the suicide of his friend.  

The PEB rated the condition of psychotic disorder NOS, coded 9210 at 10%.  The VA rated the condition diagnosed as schizophrenia, coded 9204 at 70%.  Board members agreed that at the time of separation, the VASRD §4.130 threshold for a 10% rating was met.  The Board considered the 30% rating which requires evidence that his condition caused “Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks chronic sleep impairment, mild memory loss.  

The Board noted that at the time of the NARSUM, the CI was taking an antipsychotic medication and a mood stabilizer; he denied all symptoms but noted that he was not yet at a 100% of his baseline.  However, 4 months later at his neurology appointment, the CI, with his wife, indicated he had returned to full baseline functioning.

The NARSUM noted his military duty impairment was marked and he had a GAF of 45 which connotes serious symptoms, however, this exam was 9 months prior to separation.  The C&P exam documented a stable clinical picture, however, with some inconsistent findings as noted above.  Although the documented findings of the C&P suggested significant impairment in functioning, it was noted that the CI had no visits to the ER, was not hospitalized psychiatrically, had no panic attacks, and had no psychotic symptoms during the examination, and his judgment was not impaired.  The only symptoms documented as present during the exam was his flat affect, and mild difficulty with concentration.  The statement that the CI showed difficulty understanding complex commands was not consistent with the absence of delusions, and absence of suspiciousness, and no observed hallucination.  He was fully oriented, and had no communication or speech abnormalities.  These negative findings do not support the likelihood of disturbance in cognitive functioning to the extent of having difficulty understanding complex commands.  Indeed, the psychiatrist noted that his condition was in partial remission, and assigned a moderate GAF score.  The Board agreed the findings at the C&P exam were not documented in any of the service treatment record and therefore did not likely reflect his true clinical picture.  

The Board reviewed the clinical notes in the 6 months prior to separation. All indicated his condition was stable and or in full remission.  It was noted that he had a trial off medication and developed symptoms that responded well upon re-starting medication. 

The Board considered absence of hospitalization in the 9 months prior to separation, absence of ER visits related to MH condition in the 9 months prior to separation, (although he presented one morning secondary to conflict with wife and symptoms not related to his psychosis), and the Commander’s Statement (CS).  The CS noted that the CI performed normal duties that were required of him, such as charge of quarters, and had a normal 8-10 hour duty day.  No MH symptoms were documented.  The Board also noted that his auditory hallucinations did not lead to any negative consequences such as aggression, irritability, confrontations.  Demonstrated impairment in judgment was absent.  There was no evidence that his thoughts disturbed his thinking, mood, sleep, appetite, energy, or behavior.  At the time of separation, his symptoms had improved with medication.  All Board members agreed, based on the evidence in the record, the 30% rating criteria was not supported.  The record demonstrated that his condition was best reflected in the 10% disability rating.  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 psychotic disorder NOS condition.

BOARD FINDINGS:  In the matter of the psychotic disorder not otherwise specified condition 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.  
The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140128, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXX, AR20160009940 (PD201400895)

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:
						         
Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA