RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-02428
BRANCH OF SERVICE:  Army	 Separation Date:  20070409

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Track Vehicle Repairer) medically separated for a psychotic disorder.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent S4 profile and referred for a Medical Evaluation Board (MEB).  The “brief psychotic disorder” and “right knee pain, possible Osgood-Schlatter disease (medically acceptable)” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “psychotic disorder, not otherwise specified (NOS)” as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  “Please consider all conditions.”

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. In addition, the Secretary of Defense Mental Health Review Terms of Reference directed a comprehensive review of Service members with certain mental health (MH) conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The MH condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.

RATING COMPARISON:  

IPEB – Dated 20070403	VA* - (~6 Yrs. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Psychotic Disorder NOS	9210	10%	Bipolar Disorder, Intermittent Explosive Disorder and Brief Psychotic Disorder with Auditory Hallucinations	9432	Not Service Connected (NSC)	20130807	
Right Knee Pain …	Not Unfitting	No VA Placement	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0	
RATING:  10%	RATING:  NSC	
*Derived from VA Rating Decision (VARD) dated 20130824 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Psychotic Disorder NOS Condition.  The CI had auditory hallucinations for a week beginning on 3 October 2006.  He was given a permanent S4 profile for psychotic disorder with additional restrictions of no access to weapons, no deployments and no access to classified information.  He was psychiatrically hospitalized from 11 to 17 October 2006.  On admission, the CI was anxious and scared about his command auditory hallucinations.  He was given medication to decrease the hallucinations and anxiety and to promote sleep.  He refused to take anymore antipsychotic medication after the first two doses during the first day of his admission.  The CI spoke to his father, who had a Bipolar disorder and advised him not to take the recommended medications.  

The Narrative Summary (NARSUM) exam was conducted about 5 months prior to separation while the CI was an inpatient.  It documented that the CI reported voices that told him to hurt or kill others but that he had been able to control his behavior and not act out violently.  He denied visual, tactile, olfactory and gustatory hallucinations.  The psychiatrist noted that the review of symptoms was negative for depressive or anxiety disorders.  The mental status exam (MSE), which was conducted after the cessation of auditory hallucinations on 16 October 2006, demonstrated that the CI was oriented to person, place and time, and memory, and that concentration and cognition were intact.  Mood was good; affect was congruent although somewhat flattened, but stable.  The CI’s thought process was devoid of suicidal or homicidal ideations.  His judgment and insight were fair, with impulse control being fair to good.   The examiner noted that the CI’s illness lasted less than a month without any significant premorbid personality or predisposing factors, except for genetic predisposition.  The CI planned on working in a family business upon discharge from the Service.  The examiner diagnosed Axis I:  Brief psychotic disorder, with a marked degree of military/psychiatric impairment and a mild degree of impairment for social and industrial adaptability.  The Axis IV diagnosis was stress during advanced individual training (AIT).  The Global Assessment of Functioning (GAF) was 65 (in the mild symptom range or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships).  The examiner opined that the CI’s prognosis was guarded, given the CI’s propensity toward a psychotic decompensation during times of stress and his biologic predisposition.  The psychiatrist noted functional limitations due to an inability to be placed in stressful situations and be deployed, and that he should not have access to weapons, ammunition or classified material.  

A psychiatrist note in February 2007, approximately 2 months prior to separation, documented that the CI requested a 4-day pass to visit his fiancée.  The CI was compliant with his medications for psychosis and for sleep respectively (Quetiapine and Trazadone) and was working on-post.  The CI denied any suicidal or homicidal ideations and there were no further psychiatric hospitalizations.  The MSE demonstrated a euthymic mood with fair impulse control.  He was deemed to not be a suicide or homicide risk.  

There was no VA Compensation and Pension (C&P) exam proximate to separation.  The CI’s original VA claim for benefits was in 2012.  The CI did not present for a scheduled VA exam in 2013 because he was incarcerated at the time.  A VA psychiatric consult in September 2012 (over 5 years remote from separation) indicated the CI had continuing MH symptoms with diagnoses of “bipolar disorder, type I with past history of psychotic symptoms.” The CI reported losing custody of his child, a pending divorce, and difficulty maintaining employment due to mental health symptoms and anger issues.  History included a psychiatric hospitalization in 2008; poor compliance with medication; and reported multiple episodes of depression with vegetative symptoms, manic episodes, and incidences of specific suicidal thoughts in 2006 and 2008.  He reported a suicide attempt in 2006 when he tried to crash his car.  The VA denied service-connection due to a lack of treatment records or a VA exam and granted 9432 (as bipolar disorder, intermittent explosive disorder and brief psychotic disorder with auditory hallucinations) for treatment purposes only.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the Psychotic Disorder, NOS condition, as 9210, rated at 10% including a statement that “Soldier is not able to carry or fire his assigned weapon and remains at high risk for relapse, as he has a strong family history of psychiatric difficulties.”  The Board adjudged that there was no traumatic stress or highly stressful event for application of VASRD §4.129 (mental disorders due to traumatic stress).  The Board considered rating IAW VASRD §4.130 and deliberated between the 10% rating criteria of “Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication” versus the 30% rating criteria of “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).”  

The CI had auditory hallucinations and initially responded well to psychiatric hospitalization and medications.  The STR evidence was scant.  Approximately 2 months prior to separation, the CI was compliant with a psychiatric medication regimen and was working full duty days; however, the NARSUM was written while the CI was hospitalized and the single pre-separation psychiatry note was for a pass and included scant MH evaluation details.  That assessment may not have indicated long-term occupational and social functioning.  Although the VA treatment note was remote from separation, it provided historical information concerning occupational and social functioning proximate to separation.  The CI had a second psychiatric hospitalization approximately a year after separation. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the mental health condition.  

Contended PEB Conditions.  The contended condition adjudicated as not unfitting by the PEB was right knee pain.  The Board’s first charge with respect to this condition is an assessment of the appropriateness of the PEB’s fitness adjudications.  The Board’s threshold for countering fitness determinations is preponderance of the evidence but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The CI reportedly developed right knee pain during basic training.  All right knee X-rays were normal.  The CI did not show for his orthopedic appointment and an internal medicine specialist noted painful motion of the right knee with full range of motion (ROM).  The examiner noted “Osgood Schlatter like pain” and prescribed medication for inflammation/pain, however, the CI was not put on a lower extremity profile.  The knee condition was not implicated in the commander’s statement and was not judged to fail retention standards.  The right knee pain was reviewed and considered by the Board.  There was no indication from the record that this condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the right knee pain contended condition; and, therefore, no additional disability rating can be recommended.  

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 psychotic disorder NOS condition, the Board unanimously recommends a disability rating of 30%, coded 9210 IAW VASRD §4.130.  In the matter of the contended right knee pain condition, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Psychotic Disorder NOS 	9210	30%	
RATING	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140505, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXX, AR20160004498  (PD201402428)

1.	Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re­ characterize t+++e individual's separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual's original medical separation for disability with severance pay.

2.	I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

a.	Providing a correction to the individual's separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

b.	Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with [severance pay] [Reserve retirement].

c.	Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

d.	Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.	I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure CF:
( ) DoD PDBR ( ) DVA