RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXX	                              	CASE:  PD-2014-01860	
BRANCH OF SERVICE:  AIR FORCE	 SEPARATION DATE:  20060622		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Basic Trainee, medically separated by the Formal Physical Evaluation Board (FPEB) for “pain disorder,” “posttraumatic stress disorder [PTSD],”and “adjustment disorder” rated at 10%, Category II and Category III, respectively, with a disability rating of 10%. 

CI CONTENTION:  “Please review all conditions.”  The applicant’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 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 20060614	BASED ON STR FROM VA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain Disorder	9422	10%	Psychiatric Condition Claimed as PTSD, Adjustment Disorder and Major Depression	9411	NSC	STR	
PTSD	9411	CAT II					
Adjustment Disorder w/Depressed Mood	CAT III					
Other x 0 (Not in Scope)	Other x 2	
Combined:  10%	Combined:  0%	

ANALYSIS SUMMARY:  

Pain Disorder Condition.   The narrative summary (NARSUM), psychiatric addendum noted the CI underwent laparoscopic appendectomy on 8 October 2005.  After her discharge, she began to complain of constant abdominal pain, with worsening pain after receiving steroid injection at the incision site for suspected neuropathic pain.  Despite physical therapy, 30-day convalescent leave, and aggressive pain management, her pain was not alleviated.  On 16 January 2006, the CI was seen in the emergency room for diarrhea and vomiting, and 2 days later she was seen in the surgery clinic.  On 2 February 2006, the CI was referred to the pain clinic and was started on steroid injections, an antidepressant (for neuropathic pain), an analgesic patch, and oral narcotic agent.  In March 2006, she was admitted overnight to the inpatient psychiatry unit after expressing homicidal ideations.  The CI reportedly stated she had been intensely frustrated by her pain and the likelihood of being separated from the service.  She had attempted to contact her parents via telephone and was unable to reach them.  She indicated she was also frustrated with her roommate and stated she wanted to “smother” the roommate and felt “murderous rage” toward “everyone else.”  

At the psychiatric addendum on 7 April 2006, the CI reported she was unhappy with the service and believed that her surgery was not done correctly, nor her aftercare.  She felt stressed that she may not be able to continue in the service and blamed the service for her current troubles.  The CI reported since her surgery she has experienced feelings of depression, irritability, sleep issues (due to pain and frustration), and decreased interests, concentration, and appetite.  She reported a history of childhood sexual abuse at the age of 6 by an 8-year-old cousin, and noted she had rare nightmares from that experience and no other problems associated with the abuse.  She denied a significant past psychiatric history but noted she had seen a therapist once during childhood.  Her current medications included an anti-epileptic medication for pain management, one narcotic agent, an anxiolytic medication for abdominal muscle spasms, and an analgesic patch.  The CI discontinued the anti-depressant medication that had been prescribed for neuropathic pain due to the sedative side effect.  Mental status examination (MSE) was unremarkable.  The diagnoses of adjustment disorder with depressed mood, pain disorder associated with psychological factors, and PTSD, with delayed onset, “manifested by experience of trauma (physical abuse by father in childhood), re-experiencing in dreams and through psychological reactivity…” were rendered.  The PTSD was recorded as EPTS and not service aggravated.  The examiner recorded a Global Assessment of Functioning (GAF) score of 50 (moderate), and recommended regular psychiatric outpatient care, and care from pain specialist.  The examiner documented under the adjustment disorder with depressed mood diagnosis, that the CI’s symptoms “have endured for several months and meet criteria for major depressive disorder.”  The examiner noted that the pain disorder had caused mild impairment for further military duty and mild impairment for civilian social and industrial adaptability.  There were no mental health records or evidence that the CI participated in mental health treatment.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the conditions of PTSD associated with pain disorder, as EPTS, not service aggravated, CAT II, and the adjustment disorder with depressed mood as CAT III.  The Board noted the 10% rating entered on Form 356 (PEB), for the condition diagnosed as PTSD, CAT II, EPTS, and concluded based on the recorded remarks contained therein, the rating entered likely reflects an administrative error.  The FPEB adjudicated the condition of pain disorder, coded 9422, and rated at 10% for mild social and industrial adaptability impairment.  PTSD remained a CAT II, EPTS condition, and adjustment disorder with depressed mood, CAT III.  The adjustment disorder is not a physical disability and is not ratable IAW DoDI 1332.38 (in effect at the time). The VARSD requires that all mental health condition be rated IAW §4.130 (schedule of ratings for mental disorders) and is based on impairment independent of diagnosis.   The VA did not service-connect any of the claimed conditions.  All Board members agreed that the provision of §4.129 were not applicable in this case.  The Board considered if there was evidence for a §4.130 rating higher than 10% at time of separation.  The higher 30% rating is for “Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).”  The NARSUM noted that the CI’s abdominal pain resulted in her inability to stand or sit for prolonged period; the psychiatric NARSUM recorded only mild impairment for further military duty due to pain. There was no documentation in the clinical records of episodes of incapacitation, reduced work schedule, or specific impairments in occupational or social functioning that resulted in impairment at the 30% disability level. The Board considered the absence of panic attacks, memory impairment, visits to the emergency room for psychologically based condition, suicidal ideation, and no history of mental health treatment.  Although the recorded GAF indicated a moderate degree of symptoms or impairment, the MSE was unremarkable.  There was no additional information that addressed occupational or social impairment in evidence.  After deliberation, board members agreed that there was insufficient evidence to support the higher rating of 30%.  The Board agreed with the PEB’s adjudication that the PTSD was EPTS, and not ratable.  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 pain disorder condition.  

BOARD FINDINGS:  In the matter of the Pain Disorder condition and IAW VASRD §4.129, the Board unanimously recommends no change in the PEB adjudication.  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140501, 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 XXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-01860.

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,

Attachment:
Record of Proceedings 
 
cc:
SAF/MRBR