RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		PD-2014-02470
BRANCH OF SERVICE:  Army
DATE PLACED ON TDRL:  20040520  	            DATE REMOVED FROM TDRL:  20080616

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Active Reserve E5, Personnel Services Specialist, medically separated from the Temporary Disability Retired List (TDRL) for “schizophrenia” with a disability rating of 10%.

CI CONTENTION:  The applicant contends her schizophrenia condition continues to worsen.  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 – 20060609 /20080324	VARD – Failed to Present	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Schizophrenia, Paranoid Type	9203	30%	10%	Schizophrenia, Paranoid Type	9203	No Claim	NSC1	
COMBINED RATING: 30% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	
1. Condition service connected and rated 0% per 20111017 dated VARD, ~3 years post-TDRL removal

ANALYSIS SUMMARY:

Schizophrenia, Paranoid Type.  The Medical Evaluation Board (MEB) rebuttal narrative summary (NARSUM) examination dated 26 November 2003 (6 months pre-TDRL placement) documented the CI was assigned to the Active Guard/Reserve (AGR) program in January 2003.  She was stressed over her lack of training and perceived excessive criticism by supervisors.  By June 2003, she began to see a psychologist for stress management.  She filed a complaint against her commander for harassment and attempted to file a complaint with the EEOC, but was told she had insufficient cause.  She presented to the emergency department (ED) on 22 October 2003 with complaints of being drugged in her sleep with injected heroin.  She had signs of delusions (a witch possessed her since age 9), paranoia, and thought insertion (“the witch talks through her.”)  She was transferred to the inpatient psychiatry unit 23 October 2003.  She refused medication and had never been previously hospitalized.  She reported past suicidal ideation after an alleged rape at age 9.  The rape was not corroborated.  Her commander noted she had been a “trouble troop” since May 2003, having difficulty following orders.  Her mother noted that she had been well prior to January 2003.  The mental status examination (MSE) noted mood was “worried, with ideas of reference (the belief that routine things have strong personal significance), insight was poor and she displayed paranoid delusions.  She remained fixed and focused on her delusions while refusing medication due to paranoid ideation.  She had limited interactions with other patients, stating she just needed time to clear her thoughts.  A diagnosis of paranoid schizophrenia was rendered with a Global Assessment of Functioning (GAF) score of 30 (behavior influenced by delusions or hallucinations, serious impairment, inability to function in almost all areas.)  She was discharged 4 November 2003.

The commander’s statement noted the CI “was mentally incapable of performing her duties, consistently failed to keep up with all her responsibilities and received multiple complaints from the soldiers regarding her job performance.”  He further remarked that her “performance continued to deteriorate in her day-to-day duties, she chronically failed in her duties and performance in the unit has been very poor and should not be considered for future promotions and assignments.”

The TDRL evaluation dated 09 June 2006 (25 months pre-TDRL removal) documented the CI was receiving follow-up care at the VA intermittently with partial compliance.  She has refused antipsychotic medications due to fear of side effects but did participate in a support program from September to December 2005 to assist her with life and social skills and vocational rehabilitation.  She was homeless and unemployed during this period.  She lived alone and maintained a relationship with her mother and sisters.  She had not been hospitalized, had not attended school or been able to maintain any consistent employment.  MSE showed blunted affect, chronic paranoia and suspiciousness, partial insight and moderate depression for about one week per month.  

A follow-up psychiatric note, dated January 2008, noted the CI had paranoid and persecutory ideation less frequently than before and in a transient episodic fashion.  She denied auditory hallucinations for the past month.  The previous follow-up entry recorded nightmares of being chased and people trying to hurt her as well as ideas of reference and paranoid ideation around strangers.  She had an online boyfriend. 

The TDRL evaluation dated 11 February 2008 (4 months pre-TDRL removal) documented intermittent follow up at the VA about once every 6 months.  She appeared for appointments but did not take psychiatric medications or participate in counseling.  Her last appointment was January 2008 and minimal or equivocal indications of a psychotic disorder were present.  She had enrolled in a home study program (online) to become an electrician and had completed a one course module, attended church twice per week, and played the piano during church.  She reported she was working as an administrative assistant at a restaurant for 3 months and there were some problems getting along with other employees and her supervisor.  She had not been hospitalized.  She denied psychiatric symptoms and MSE was normal.  A diagnosis of schizophrenia, paranoid type in full remission was rendered.  The examiner noted an evolution from psychosis in 2004 to negative symptoms in 2006 to the appearance of normal function in 2008 at the time of interview.  
The CI failed to report to the VA Compensation and Pension (C&P) Mental Disorder examination dated 26 August 2008 (2 months post-TDRL removal).  The next C&P Mental Health examination dated 16 November 2011 (approximately 4 years post-TDRL removal) documented diagnoses of anxiety disorder and schizotypal personality disorder with a GAF score of 61 (mild symptoms, impairment.)  The examiner noted symptoms were not severe enough to interfere with occupational and social function or to require continuous medication.  She reported she had been married for 6 months but was separated since August 2011.  Her mother accompanied her to the evaluation.  She attended church weekly and got along with others, including family and friends.  She played her keyboards, read, studied and did household chores.  She played music, dined out and went to movies.  She was taking undergraduate classes while working for a Master’s degree at a nearby university part-time.  She worked at the university 20 hours per week for 2 years and worked at night in a manufacturing job about 25 hours per week as needed.  She was having conflicts with a co-worker in her day job.  Records noted she did not take psychotropic medication from 2008 to 2011 and did not seek MH treatment.  She was currently taking a medicine for depression since May 2011.  

The Board directed its attention to its rating recommendation based on the above evidence.  At TDRL placement, the PEB rated the schizophrenia condition at 30%, coded at 9203 while the VA noted no claim was made.  The Board next considered whether the provisions of VASRD §4.129 were applicable for the unfitting MH condition.  Regardless of final PEB diagnosis, §4.129 does not specify a diagnosis of PTSD, rather it states “mental disorder due to a highly stressful event,” and its application is not restricted to PTSD.  Members agreed that the requisite §4.129 link that the condition occurred “as a result of” in-service stressors was not adequately satisfied; and therefore concluded that application of §4.129 was not appropriate in this case.

Regarding the rating at the time of placement on TDRL, Board members considered if there was evidence to support a rating higher than the 30% assigned by the PEB.  The §4.130 criteria for the 30% rating are “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.”  The next higher 50% rating requires “occupational and social impairment with reduced reliability and productivity.”  A 70% rating requires “occupational and social impairment, with deficiencies in most areas.”  The Board considered that since the initial hospitalization, the CI had not been mentally capable of performing her duties, noting there were many complaints and performance was very poor.  Upon discharge from the hospital the CI received a GAF score of 30, connoting deficiencies in most areas.  The Board agreed there was evidence of chronic mental instability affecting all areas of function and were consistent with a 70% rating.  

As regards to the permanent rating recommendation, the Board considered if a rating higher than the PEB’s 10% rating was warranted.  The 10% rating specifies “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.”  Previous psychiatric follow up notes within 2 months prior to the second TDRL evaluation document episodic paranoid and persecutory ideation, ideas of reference, and auditory hallucinations.  The Board noted that the CI had finally achieved 3 months of employment a few months prior to TDRL removal.  Board members agreed her symptoms were mild or transient.  The Board agreed the CI more appropriately met criteria for a 10% disability rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a TDRL placement rating of 70% and permanent disability rating after removal from TDRL of 10% for the paranoid schizophrenia disorder.

BOARD FINDINGS:  In the matter of the paranoid schizophrenia disorder, the Board recommends by a majority vote an initial TDRL rating of 70% at TDRL placement in compliance with VASRD §4.130; and a 10% permanent rating at TDRL removal IAW VASRD §4.130. The single voter for dissent recommended re-characterization and did not elect to submit a minority opinion.  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 her prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Schizophrenia, Paranoid Type	9203	70%	10%	
RATING	70%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140513, 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 XXXXXXXXXX, AR20160007499 (PD201402470)

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  constructively place the individual on the Temporary Disability Retired List (TDRL) at 
70% disability rather than 30% for the period May 20, 2004 to June 15 2008 and then following this period no recharacterization of the individual’s separation or modification of the permanent disability rating of 10%.

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 day of this memorandum:

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

	b.  Providing orders showing that the individual was separated with a permanent combined rating of 10% effective the day following the TDRL period with no recharacterization of the individual’s separation.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will provide 70% retired pay for the temporary disability retired period effective the date of the individual’s original medical separation and then payment of permanent disability retired pay at 10% effective the day following the TDRL period.  

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