RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02446
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060202

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Radio Operator, medically separated for “narcolepsy,” with a disability rating of 10%.  

CI CONTENTION:  The CI requests consideration of all conditions.  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 based upon a 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 - 20051027	VA* - (~7 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Narcolepsy	8108	10%	Narcolepsy…	8108	60%	20060912	
Anxiety Disorder	Not Unfitting	PTSD with Major Depressive Disorder (Claimed as Anxiety Disorder)	N/A	30%	20060912	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Narcolepsy Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) psychiatric narrative summary (NARSUM), the diagnosis of narcolepsy without cataplexy (sudden and transient episode of loss of muscle tone) was established in May 2005 by sleep study after the CI reported a brief history of excessive daytime sleepiness and nocturnal insomnia, and multiple “black out spells.”  Prior to the onset of black out spells, (later found to be sleep attacks) the CI first mentioned daytime sleepiness in July 2003, and feelings of “spacing out.”  On one occasion, he fell asleep while driving and had an accident.  At the time he was taking antidepressant medication and it was believed this was the cause of his complaint.  

While deployed to Iraq in 2004, he began to experience hypnogogic and hypnopompic hallucinations (dreamlike state), and had multiple bouts of sleep paralysis consistent with narcolepsy.  He also began falling asleep while driving trucks and suffered from insomnia.  In March 2005, he was evacuated from Iraq for evaluation of his symptoms of possible narcolepsy and hallucinations.  These hallucinatory events were noted to have occurred during periods of sleep deprivation.  In addition to hallucinations, he had violent behavior during sleep, including one event when he choked a bunkmate.  He was amnestic for such events which raised the questions of seizures.  His EEG and MRI were normal.  

The hallucinations were treated successfully with antipsychotic medications and sleep.  The narcolepsy was treated with medications and produced dramatic improvement.  However, due to his history of occasional black-outs it was recommended that he not drive, carry or fire a loaded weapon, or be assigned to areas where access to continual medical services was not accessible.  Additionally, he must be allowed time to sleep from 2200-0600 every day with no night duty.  Therefore, he was referred to the MEB.  

At the MEB NARSUM dated 5 August 2005, the CI noted that the tactile and visual hallucinations had not recurred in the past 3 months even after discontinuing the antipsychotic medication.  It was noted that prior to the CI’s narcolepsy symptoms, he was being treated for anxiety, and his anxiety symptoms were now mild.  The psychiatrist noted that the CI’s conditions of narcolepsy and anxiety worsen his prognosis by complicating treatment of both, since the anxiety medications tended to worsen daytime sleepiness and medications to treat narcolepsy could worsen anxiety symptoms.  The mental status examination was unremarkable.  The diagnoses of narcolepsy and anxiety disorder were assessed with a Global Assessment of Functioning (GAF) score of 70 for some mild symptoms.  The examiner noted that the condition of narcolepsy failed to meet retention standards IAW AR 40-501, Chapter 3-30.  

On 2 February 2006, the day of separation, the CI presented to the local VA outpatient MH clinic for medication refill.  It was noted that he was still taking the medication for narcolepsy and was not taking the antipsychotic medication, or medication for sleep.  The examiner indicated that his condition of narcolepsy was in remission.  Treatment records going forward did not reflect any reports of black-outs in the 12 months after separation.  However, the VARD noted a VA Compensation and Pension (C&P) examination was performed in September 2006, 7 months after separation.  It was noted that the CI reported “multiple daily black-outs or naps, and hypnagogic and hypnopompic hallucinations.  A history of intention tremors was also noted.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB applied the VASRD directive to rate narcolepsy as epilepsy: petit mal, under the general rating formula for minor seizures (8911) at 10%.  The VA rated the condition under the same code at 60% for “an average of at least one major seizure in 4 months over the last year, or 9-10 minor seizures per week”, which likely reflected the CI’s report of daily black-outs or naps.  The higher rating of 20% requires evidence of at least one major seizure in the last 2 years or at least two minor seizures in the last 6 months.  The Board noted the absence of black-out episodes in the year before separation; however, considered the episode documented in the medical evacuation record that the CI had a witnessed attack in 2005, supported the justification of a 20% rating.  There is no evidence to support the higher 40% rating which requires five to eight minor seizures per week.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the narcolepsy condition.  

Contended PEB Condition:  Anxiety Disorder, NOS.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not implicated in the commander’s statement or judged to fail retention standards.  Although the condition was profiled two months prior to the NARSUM, there was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the narcolepsy condition, the Board recommends a disability rating of 20%, coded 8108 IAW VASRD §4.124a.  In the matter of the contended anxiety disorder NOS condition, the Board recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Narcolepsy 	8108	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140513, 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 XXXXXXXXXXXXXXXXXXXXX AR20160016866 (PD201402446)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

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.   

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:

CF: 
(  ) DoD PDBR
(  ) DVA