RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX	CASE:  pd-2014-01065
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20150520
SEPARATION DATE: 20061013

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Boatswains Mate) medically separated for anxiety.  The condition could not be adequately rehabilitated to meet the physical requirements of her Rating or satisfy physical fitness standards.  She was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The “anxiety state, unspecified” condition was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “anxiety disorder, not otherwise specified” as unfitting, rated 0% with likely application of Veterans Affairs Schedule for Rating Disabilities (VASRD).  The PEB also adjudicated one additional condition of “cluster C traits” determined as Category II, contributing to the unfit condition.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Anxiety and the inability to stand greatly reduces the number of jobs I qualify for.”

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 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 20060710	VA* – 1 Month Post-Separation	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Anxiety Disorder, not Otherwise Specified	9413	0%	Anxiety Disorder With Syncope	9413	10%	20061122	
Cluster C Traits	Category II	No VA Placement	
Other x 0 (Not In Scope)	Other x 6 	
RATING:  0%	COMBINED RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20070328 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Anxiety Disorder, Not Otherwise Specified (NOS).  The narrative summary (NARSUM) notes the CI was referred for evaluation of recurrent episodes of syncope (fainting) over the previous 3 years.  Notes in the service treatment record indicate that between May and December 2005 the CI experienced multiple syncopal episodes while standing for a period of time, frequently at morning inspection.  The fainting was associated with brief loss of consciousness at times but not associated with headaches, chest pain, numbness or tingling, or seizure activity.  The CI reported other incidents of feeling lightheaded and dizzy with “butterflies” in her chest.  If she sat for a period at the beginning of the symptoms, they would pass.  She was referred to cardiology for evaluation and was placed on a 6-month period of LIMDU for syncope and lightheadedness.  A comprehensive cardiovascular evaluation for syncope was unremarkable.  At the tilt table testing, the CI manifested severe anxiety with hyperventilation and feelings of claustrophobia at the beginning of the test and was then referred to mental health (MH) for evaluation of anxiety as the potential cause of the symptoms.  A neurology evaluation was reportedly unremarkable and magnetic resonance imaging of the brain was normal.  At the psychology evaluation on 23 January 2006, the CI reported a lifelong history of social anxiety that was steadily worsening in public situations, sometimes including panic attacks, with lightheadedness, difficulty breathing, palpitations, flushing, sweating, de-realization, and feeling like she was going crazy.  The CI related that she “always had a problem with anxiety” and there was a family history of anxiety on her mother’s side of the family.  The CI also related some post-traumatic stress type symptoms related to a childhood abuse incident.  The CI denied significant alcohol or drug abuse.  The mental status examination (MSE) noted the CI was anxious, irritable, and tearful, with a self-reported mood of “OK,” without thought or speech abnormalities, cognitive deficits, or evidence of delusions, hallucinations, or suicidal ideation.  The MH examiner remarked that although syncope was not a classic panic disorder symptom, there was strong evidence that the CI’s syncope was related to anxiety symptoms.  The Axis I diagnosis was anxiety disorder, NOS and Axis II diagnosis was “Cluster C” traits (anxious, fearful cluster, includes avoidant, dependent, and obsessive-compulsive traits).  The Global Assessment of Functioning (GAF) was 60 (on the cusp of mild and moderate impairment range), with the highest GAF in the past year estimated to be 65 (mild impairment range).  The MH examiner summarized that the CI had “moderate personality pathology” and “severe anxious symptoms.”  The CI participated in individual psychotherapy sessions, but repeatedly declined psychotropic medications and was not compliant with other behavioral treatment recommendations.  At all psychology sessions the CI’s MSE was noted to be the same, with an anxious affect and an otherwise normal exam with a GAF of 60 reported.  At the LIMDU re-evaluation performed by the cardiologist on 12 April 2006, the CI reported that there had been weekly episodes of pre-syncopal symptoms, but she was able to abort the syncope if she sat down with the onset of symptoms.  Return to duty was recommended from a cardiology perspective, but a MH opinion was advised before doing so.  The CI was granted a waiver for all physical readiness assessment events 2 days later due to the syncopal symptoms and at the visit the CI indicated syncope occurred once every 2 weeks.  On the DD Form 2697, Report of Medical Assessment, the CI noted, “I pass out so I work on shore duty.”  The non-medical assessment (NMA) on 26 June 2006 noted the CI was working out of her specialty, but did not miss work, and although the CI was not worldwide assignable, the NMA indicated she did have potential for continued service in her present physical/mental condition.

At the MEB NARSUM examination on 22 May 2006, 5 months prior to separation, the CI reported multiple current personal and occupational stressors.  The MEB NARSUM MSE was identical in wording to that of the initial psychological evaluation 9 months prior to separation.  The Axis I diagnosis remained anxiety disorder, NOS and Axis II Cluster C traits, with a GAF of 65 (mild impairment range).  The examiner noted the presence of severe anxiety symptoms.  The MH examiner noted that the “disability may have existed prior to entry…and is considered to have been mildly aggravated while on active military duty.”
The CI did not attend a scheduled VA Compensation and Pension (C&P) psychiatric examination on 28 November 2006.  At the VA C&P general medical examination on 22 November 2006, a month after separation, the CI reported heart palpitations and syncope due to anxiety.  She reported daily palpitations and intermittent syncope two to three times per year, mostly associated with prolonged standing.  There was no functional impairment reported due to the palpitations, but she could not perform jobs which required prolonged standing.  The physical exam was normal.  The CI also performed an exercise treadmill test (ETT), commonly referred to as a “stress test,” at this exam and successfully completed it, exercising for 9 minutes and reaching a level of exertion routinely associated with strenuous physical activity without complications.  The CI’s mental status was noted as normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the anxiety disorder, NOS as an unfitting Category 1 condition and rated 0%, coded 9413 (anxiety disorder, NOS).  The PEB also adjudicated the Axis II Cluster C traits as a “related category 2 diagnosis.”  The original VARD, based upon service medical records and the C&P general medical examination, also coded the anxiety condition as 9413, but rated 10%.  The Board deliberated the rating of the MH condition IAW VASRD §4.130.  Members agreed that the evidence did not support rating 50% or higher because there was no evidence of total occupational and social impairment, psychotic features, suicidal ideation, frequent (weekly or more) panic attacks, or other features characteristic of the disability associated with the 50% and higher ratings.  The deliberation settled therefore on arguments for a 10% (occupational and social impairment due to mild or transient symptoms which decrease work efficiency … only during periods of significant stress, or; symptoms controlled by continuous medication) versus a 30% (occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks) permanent rating recommendation.  The Board noted that the MEB NARSUM examiner indicated the CI presented with “severe anxiety symptoms” yet noted a GAF of 65, which is specified as “some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well.”  The Board agreed that a level of work inefficiency resulted from the reported symptoms; the CI was restricted from duty onboard ship and also from all physical readiness testing due to her anxiety-related physical symptoms.  However, there was no documented evidence of work impairment within the limits of these restrictions as indicated by the NMA, which also indicates that there were no documented “intermittent periods of inability” relative to occupational capacity as specified in the 30% rating criteria.  The 10% rating description under §4.130 is a fit with the documented level of social and occupational functioning, which showed impairment limited by the physical sequelae of the anxiety disorder.  The CI’s symptoms were improved following medical evaluation and limited psychotherapy, following which the CI developed the capacity to abort syncope which was the most problematic outcome of her anxiety symptoms.  The CI was not taking any medications for the anxiety disorder or syncope while in service and did not report any medication or treatment at the post-separation C&P exam.  The Board also noted that the CI was able to successfully complete an ETT at the C&P exam -- a strenuous physical activity performed while standing.  The Board determined that based on the evidence in record, the CI’s symptoms could be fairly characterized as “mild or transient” at the time of separation.  The Board noted the PEB adjudicated “Cluster C traits” as a “related category 2 diagnosis”.  Personality traits are the combination of characteristics and qualities that form an individual’s character and are not routinely associated with functional impairment and are therefore not eligible for separate disability rating.  Additionally, the Board notes that IAW VASRD §4.130 only one MH disability rating can be provided based upon total occupational and social impairment.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the anxiety disorder condition, coded 9413. Board members received additional information from the CI; subsequently the Board considered this new information and determined it had no additional probative value to change the prior recommendation.
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 condition, the Board unanimously recommends a disability rating of 10%, coded 9413 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, effective as of the date of her prior medical separation:

CONDITION	VASRD CODE	RATING	
Anxiety Disorder, Not Otherwise Specified	9413	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140218, with attachments
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 23 Nov 15 ICO XXXXXXXXXXXXXXXXXXXXX   	 
      (c) PDBR ltr dtd 23 Nov 15 ICO XXXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 19 Nov 15 ICO XXXXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 19 Nov 15 ICO XXXXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 19 Nov 15 ICO XXXXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 18 Nov 15 ICO XXXXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 23 Nov 15 ICO XXXXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 19 Nov 15 ICO XXXXXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 19 Nov 15 ICO XXXXXXXXXXXXXXXXXXXXX
	(k) PDBR ltr dtd 19 Nov 15 ICO XXXXXXXXXXXXXXXXXXXXX
      (l) PDBR ltr dtd 18 Nov 15 ICO XXXXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (l) are approved.

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

     a. XXXXXXXXXXXXXXXXXXXXX former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXXXXXXXX former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXXXXX former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXXXXX former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     e. XXXXXXXXXXXXXXXXXXXXX former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXXXXXXXX former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

     g. XXXXXXXXXXXXXXXXXXXXX former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

     h. XXXXXXXXXXXXXXXXXXXXX former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

     i. XXXXXXXXXXXXXXXXXXXXX former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     j. XXXXXXXXXXXXXXXXXXXXX former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

     k. XXXXXXXXXXXXXXXXXXXXX former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.
     
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.

	XXXXXXXXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)