RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02611
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041217
DATE PLACED ON TDRL:  20041218	DATE REMOVED FROM TDRL:  20080108

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve O4, Adjutant General Corps, medically separated from the Temporary Disability Retired List (TDRL) for “major depressive disorder…” with a disability rating of 10%.  

CI CONTENTION:  “Please consider 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 – 20041008/20071101	VARD - 20050514	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Psychosis, Not Otherwise Specified/Major Depressive Disorder	9210/9434	30%	10%	Psychotic Disorder (claimed as Depression and Stress)	9210	10%	50%	
COMBINED RATING:  30% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  10%→50%	

ANALYSIS SUMMARY:  

Psychosis NOS/Major Depressive Disorder Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s Psychosis NOS/Major Depressive Disorder (MDD) condition began around May 2004 after several stressors, including: pending divorce, recent death of her nephew, estrangement from her family, work issues and a custody battle.  She had been in the service for 17 years but stated her symptoms had begun sometime while assigned to a duty station in Virginia, had persisted after her move to the area in July 2003 and had worsened over the past 2-3 weeks due to the death of her nephew.  A command-directed evaluation was recommended due to concerns regarding her odd behavior and potential workplace violence.  She thought her phone was tapped, made vague threats of violence against a specific person, and became non-productive at work.  She had become paranoid and believed others were out to harm her, had memory problems and panic attacks. The CI was admitted to inpatient psychiatry from 3 June 2004-7 June 2004 with a diagnosis of possible major depression or possible bipolar disorder with psychosis.  She was seen as an outpatient but stopped taking her anti-depression medication due to breastfeeding.  She was admitted again to inpatient psychiatry on 25 August when she appeared guarded, paranoid, and stated, “I have a computer chip in my brain.”  She was non-compliant with treatment, refusing medications and groups.  Lab studies were negative.  She started breaking things and threatened suicide, resulting in a transfer to another psychiatric inpatient unit on 1 September 2004.  The MEB forwarded psychotic disorder for PEB adjudication.  

The MEB NARSUM examination on 7 September 2004, performed on her day of hospital discharge and 3 months prior to separation, noted complaints of a fixed delusion related to the ability of computers to control her mind and emotions and movement of her face.  She accepted anti-psychosis medication and was compliant with treatment.  The inpatient psychiatrist noted she had been mentally ill for a minimum of 3-6 months.  Mental status exam (MSE) at discharge showed a relatively stable mood but the delusion remained and appeared unshakeable.  The diagnosis was psychosis NOS with a Global Assessment of Functioning (GAF) score of 60-65 (moderate-mild.)  The examiner noted her denial of acute delusional ideation but opined she was trying to appear more well than she was.  

At the 8 February 2006 VA Compensation and Pension (C&P) evaluation, performed 14 months after separation, the CI reported inpatient psychiatric hospitalization around Christmas 2004 because she “broke up, yelled and was ‘going crazy.’”  She reported she had been blamed for the death of her nephew because he had overdosed on her pain medication during a visit.  She was re-hospitalized in inpatient psychiatry in June 2005 for anxiety after complaining of trouble breathing.  She checked out against medical advice but was re-admitted August 2005 after her sister found her non-responsive sitting in her car.  She had not eaten or talked for several weeks.  She was released in September and reported she was currently taking medications as prescribed and meeting regularly with a social worker.  She reported occasional delusional thinking and symptoms of depression.  Her older daughter lived with her and her younger daughter was in protective custody, living with her sister.  CI watched television but was seeking employment through vocational rehabilitation.  She had not worked since separation and her sister helped her with finances.  

The first TDRL evaluation, dated 13 March 2006 and conducted by a psychiatrist, provided more detailed data regarding hospitalizations.  She had threatened her mother and her daughter in December 2004, 2 weeks post-separation, and was hospitalized for 2 weeks.  She received a diagnosis of paranoid schizophrenia.  At the second hospitalization of 11 days she was unresponsive upon admission, was treated with an anti-psychosis and an anti-depression medication.  She endorsed feelings of paranoia.  She was living with her children and with her sister and had been working for a month in a temporary office and clerical job as long as she took her medication.  According to an addendum 1 month later, she was not taking any medications.  She was retained on TDRL due to her inappropriate affect and confusion.  

The second TDRL evaluation, dated 11 October 2007, noted diagnosis of MDD with psychotic features in full remission for 1 year with a GAF score of 75 (mild and transient symptoms, impairment).  She had been attending appointments with a psychiatrist once every 3 months and was also receiving therapy services through social work until 10 months previous when it was determined she no longer needed therapy.  Records showed no symptoms of depression or psychosis and no medication changes in the past year.  She was taking an anti-depression medication and an anti-psychosis medication and a medicine to counter side effects daily.  She was employed with an insurance company full time since her last TDRL evaluation and was in a supervisory position.  She felt she was doing well emotionally and had no mood changes for the past year.  She denied all symptoms of psychosis, depression and anxiety.  She spent most of her recreational time with her children and would like to return to the military.  MSE showed some mild anxiety but no delusions or suicidal ideation.  The psychiatrist noted she had a history of minimizing her symptoms and opined partially that was what was going on at the time, noting the mild anxiety.  

At the 9 April 2008 VA Compensation and Pension (C&P) evaluation for mental disorders, performed 3 months after separation from TDRL, it was noted that the CI had been recently hospitalized 25 December 2007 and discharged on 2 January 2008.  Medications were changed to include injection of an anti-psychosis medication every 2 weeks.  She had also returned to counseling with a social worker.  She had stopped her medications prior to the hospitalization.  She could not seem to recall details of the hospitalization.  Psychiatric notes used the words “catatonic” and “unresponsive.”  Electronic medical records used the words “mute and despondent.”  Records suggested things had not gone well with her sister at a holiday party that precipitated the onset of symptoms.  She reported she worked full time doing mostly clerical duties such as filing, a job below her skill level, as she had a Master’s Degree in Software Engineering.  She felt a higher level of employment would exacerbate her condition.  She reported she had a hard time expressing herself at work and communicated better over the phone.  She stated she was “hard to understand” face to face but could not explain what she meant.  Discussion suggested she had word finding difficulties or phrased sentences awkwardly.  She reported significant fatigue after work and often went to bed with her clothes on.  Diagnoses of psychotic disorder NOS and MDD in remission were rendered with a GAF score of 49 (serious symptoms, impairment) based on social and occupational functioning.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the psychosis NOS/MDD condition 30%, coded 9210/9434 (psychosis/MDD) at the time of TDRL placement, citing a “definite” rating.  The VA rated the psychotic disorder (also claimed as depression and stress) condition 10%, coded 9210 (psychosis NOS) at the time of TDRL placement, based on the medical service records up to separation, citing symptoms controlled by continuous medication.  

Application of VASRD §4.129 is considered by the Board for all cases of service connected psychiatric conditions resulting in separation; but, all members agreed that the ‘highly stressful event,’ requisite for §4.129, was not satisfied in this case.  The Board then considered if there was evidence for a §4.130 rating higher than the 30% assigned by the PEB.  The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication,” for a 30% rating is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks,” while criteria for a 50% rating requires “occupational and social impairment with reduced reliability and productivity.”  

The PEB rating was based on the CI’s condition at the time of discharge from her second inpatient psychiatric hospitalization in the 6 months prior to separation.  Compliance had been difficult to achieve due to the paranoid and delusional features of her illness.  She reported that symptoms had been present for possibly a year but were markedly increased by the death of her nephew.  Her paranoid delusions resulted in tense relationships in the workplace and non-compliance with group therapy and medication recommendations during her hospitalizations.  Furthermore, the CI was hospitalized for the third time 1 week after separation, in part confirming the psychiatrist’s suspicion that she was not as well as she appeared to be at the NARSUM examination/discharge.  Board members agreed there was strong evidence of reduced reliability and productivity in the months prior to separation, meeting criteria for a 50% rating.  

The second TDRL examination represented that the CI was doing well emotionally, employed full time in a supervisory position for the past year, and taking medication for major depression disorder with psychotic features.  She had not been in therapy for 10 months and denied symptoms of psychosis and depression.  The examiner noted some inappropriate behavior during therapy and expressed suspicion she was not as stable as she appeared, though assigning a high functional score.  The C&P examination reported the CI was hospitalized 2 weeks prior to TDRL removal.  She was receiving injectable anti-psychosis medications since she had stopped oral medications, had a clerical level office job below her skill level due to inability to work at a higher level in her area of computer software, had difficulties communicating though was well-liked, and had an abnormal MSE, showing evidence of depression, psychosis and trouble with word-finding and language expression.  

The Board noted the CI was working and living with family for the past year, was still significantly impaired, and symptoms were not transient or mild since she required hospitalization prior to permanent removal.  The Board determined that the 30% rating better fit the disability in evidence at TDRL removal.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a TDRL placement rating of 50% and permanent disability rating after removal from TDRL of 30% for the Psychosis NOS/MDD disorder.  

BOARD FINDINGS:  In the matter of the Psychosis/MDD disorder, the Board recommends a rating of 50% at TDRL placement in compliance with VASRD §4.129, as DOD directed, and §4.130; and a 30% permanent rating.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Psychosis/Major Depressive Disorder	9411/9434	50%	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140524, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20160016879 (PD201402611)

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 the 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.

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