RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02809
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20080722

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Information Systems Technician, medically separated for anxiety 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 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 - 20080205	VARD - 20080820	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Anxiety Disorder not Otherwise Specified	9400	10%	Anxiety Disorder, Not Otherwise Specified	9413	30%	20080122	
Pyschogenic Hyperventilation	Cat III	No VA Placement	
 Tourette’s Syndrome	Cat III	No VA Placement	
Scapulothoracic Bursitis Corresponding to the Infraserratus Bursa of the Right Shoulder	Cat III	Subscapular Bursitis With Impingement Syndrome, Right Shoulder	5201-5203	10%	20080219	
Bursitis	Cat III					
Chronic, Stable Granulomatous Lung Disease Likely Secondary to Histoplasmosis	Cat III	Asthma, Chronic Stable Granulomatous Lund Disease…	6602	Deferred	20080219	
Mild Sleep Apnea	Cat III	Sleep Apnea	6847	50%	20080219	
Tic, Convulsive	Cat III	Tic Disorder	8103	NSC	20080122	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 5 	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Anxiety Disorder Not Otherwise Specified (NOS).  The final psychiatric narrative summary (NARSUM) was conducted in November 2007, 8 months before separation, and the original psychiatric addendum was accomplished approximately 4 months prior.  It was noted that in January and February 2002, the CI underwent multiple evaluations in response to his report of problems with sleep and breathing. He had pulmonary function studies and histamine challenge test in effort to diagnose asthma.  His symptoms were thought to be psychogenic and thus he was referred to psychiatry.  The record noted the CI underwent a psychiatric evaluation in May 2002 and was provisionally diagnosed with psychological factors affecting medical illness versus undifferentiated somatoform disorder versus anxiety disorder NOS.  It is not clear if he had any prescribed treatment at that time.  In July 2002, the CI underwent sleep studies, had a methacholine challenge test, MRI/MRA, and chest CT.  Pulmonary noted that his breathing complaints could not be explained by any pulmonary, CNS, or musculoskeletal condition. The CI was also evaluated by the ear, nose and throat specialist for possible mild sleep apnea and was noted to have enlarged inferior turbinate.  Since medication management was not successful, surgery was performed in October 2003.  A second sleep study in June 2003 demonstrated mild sleep apnea; however, he was unable to tolerate CPAP and an oral appliance was prescribed.  In 2004, the CI transferred to another base and had another pulmonary evaluation because he reportedly felt his prior evaluation had been incomplete.  He also underwent consultations with gastroenterology, and neurology.  In July 2005, he underwent esophageal dilation due to abnormal stricture noted on swallow study.  In 2006, he transferred to another worksite where he continued to seek out medical attention.  He requested further workup for his condition.  A psychological treatment note dated 31 July 2006 noted that he had a history of two psychological evaluations prior to his third one in July 2006.  He noted that he had received relaxation training and noted some benefit. The psychologist noted the CI reported breathing problems since 2001 when he was diagnosed with walking pneumonia.  He noted that he continued to believe that his lungs had not healed from the pneumonia.  The psychologist deferred diagnosis on Axis I and II, and noted that the CI was psychologically fit and suitable for full duty.  

The CI continued to report issues with sleep, and breathing problems, therefore, in late November 2006, his internist referred him to psychiatry for an evaluation.  His chief symptoms at the time were difficulty sleeping, feelings of panic when in spaces where he felt like he could not escape, and some problems with breathing.  He was prescribed an antidepressant medication and within 2 months he self- discontinued the medication due to nausea and general ineffectiveness.  His antidepressant medication was switched and he continued to report mild sleep disturbance and some mild agoraphobia.  Treatment records demonstrated that he participated in individual psychotherapy and was trained in relaxation techniques.  Treatment entry dated 16 July 2007 recorded the CI’s request for relaxation CDs. The therapist noted that the CI had not been a consistent participant in treatment and recommended he practice the techniques for relaxation taught in therapy, 4 times daily.  His MSE noted he was mildly anxious with a mildly constricted affect.  Insight was noted to be poor with fair judgment.  He was also observed as guarded and suspicious.  Treatment record demonstrated that the CI was assessed with several physical and mental diagnoses over the years.  He had a medical history of hypogonadism, gynecomastia, esophageal stricture, status-post dilation, psychogenic hyperventilation, mild sleep apnea, chronic stable granulomatous lung disease, opined to be “likely secondary to histoplasmosis”, and subscapular bursitis.

At the final psychiatric NARSUM, the examiner noted the history of generalized anxiety disorder and the previous diagnosis of anxiety disorder.  The CI indicated his anxiety problems begun 5-6 years ago when he fell down a “ladderwell” and had a rib injury.  He has had breathing difficulty for years related in part to his history of asthma and in part to being overweight.  The examiner noted some inconsistency between the reported history provided by the CI and the medical record.  The examiner opined that the CI may have somatic delusions, demonstrated by   CI’s strong belief he had fluid in his lungs, despite absence of clinical evidence.  The examiner noted that the CI had multiple intrusive thoughts and ideas in regard to his health.   He appeared “genuinely convinced that fluid regularly accumulates in his lung, and that if he does not perform particular movements, such as flinging his arm upward in the air to move his ribs outward to release a pressure valve, and making a sudden series of gasping intakes of air, that he will be unable to obtain air.”  The psychiatrist noted that although the CI’s anxiety was primarily concerned with somatic issues, he also had more general anxiety issues.  He felt anxious, tense, and had fears of crowds and social situations, and had severe panic attacks.  These problems with anxiety had worsened in the past year.  The examiner documented missed scheduled mental health appointments, appointments that the CI attended but left after seeing the intern and prior to seeing the attending psychiatrist, and showing up at the wrong time for appointments.  He had antipsychotic medications prescribed to target obsessive compulsive symptoms and somatic delusions, and medication to treat his anxiety.  Treatment response had been minimal.  It was noted that he had a history of suicidal ideation (SI) without plan or intent.  The CI had not been hospitalized psychiatrically.  The CI was married and was having new financial difficulty.  He got along well with his wife; however, there had been recent difficulty due to his hypogonadism and the uncertainty of their future (infertility issues).  At the time of the NARSUM, the CI was taking an antidepressant, an anxiolytic and an antipsychotic medication.  It was noted that he had never been in combat, but had served in a combat zone while deployed onboard various ships.  MSE recorded normal motor activity except when he lift his right shoulder and made a loud breathing/coughing sound every minute or so even while in the middle of a sentence.  It was noted that when distracted he could control the abnormal motor behavior.  His speech was pressured at times and rapid when he noted to be anxious about a topic.  His mood was anxious and frustrated and his affect was congruent to his mood and demonstrated “slight” lability.  He had somatic preoccupation but not evidence of psychosis.  Judgment was intact and there was no evidence of impairment in memory, concentration, or intellect.  The diagnoses of obsessive compulsive disorder, GAD, hypochondriasis and tic disorder were assessed with a Global Assessment of Functioning (GAF) score of 50 (moderate symptoms) was recorded.  The psychiatrist documented the CI’s condition had severe impairment on military functioning and that his obsessions and anxiety concerning his health caused him to be unable to focus on his work, and his compulsions and or tics drew attention to himself and made it difficult for others to work.  The initial psychiatric NARSUM was conducted by a different psychiatrist who diagnosed anxiety disorder NOS.

The VA Compensation and Pension (C&P) mental examination was accomplished 6 months before separation.  That examination documented a 5 year marriage with no children and noted that the CI and his wife got along well for the most part.  The examiner noted the absence of a history of violence, suicide attempts, or use of alcohol or drugs.  He had some friends outside of his home but his social interactions was limited.  He did attend church.  There had been no psychiatric hospitalizations and the CI noted that he was not in therapy and was taking an antidepressant and an anxiolytic medication.  He continued to report ongoing anxiety and breathing difficulties.  His MSE was unremarkable with the exception of an anxious mood.  Of note, abnormal motor behaviors that were recorded in the NARSUM MSE was not documented in this exam.  However, the examiner noted that his MSE did demonstrate that the CI was “obsessed with his medical conditions”.  The examiner noted the CI had no report of panic attacks.  The diagnosis of anxiety disorder NOS was recorded with a GAF of 65 (mild).  The psychiatrist opined the CI’s problems with occupational functioning were secondary to decreased concentration and poor social interactions.  The examiner further opined that his mental condition had caused reduced reliability and productivity in his occupational and social functioning.  Treatment records for this condition was silent from January 2008 until July 2008.  Treatment entry dated 7 July 2008 indicated the CI had panic attacks but had no recent visit to the emergency room (ER) related to his attacks.  The CI reported no significant improvement in his symptoms, but the examiner opined there had been some improvement since he had no recent visits to the ER.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition of anxiety disorder NOS, at 10% coded 9400 (GAD).  The VA granted a 30% disability rating for the condition of anxiety disorder NOS, coded 9413 (anxiety disorder NOS).  The Board first considered if the provisions of §4.129 were applicable.  All Board members agreed that the preponderance of evidence did not support the application of §4.129.    The higher rating of 30% requires evidence of “Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks” 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 examiner, 8 months before separation, noted that the CI had chronic sleep impairment, panic attacks, delusional thinking, and anxiety symptoms.  It was opined that his level of disability for continued military service was severe.
However, there were no reports of recent suicidal ideation, and no history of hospitalizations, but he reportedly had frequent visits to the emergency room related to panic attacks. Frequency of these attacks and ER visits were not documented.  The commander’s statement of record was too remote for consideration (14 months before separation).  The MSE at the NARSUM demonstrated issues with mood, affect, speech and behavior; however, there was no evidence of impairment in memory, or judgment, and although delusional thinking was demonstrated, frank psychosis was absent.  His MSE at the C&P examination was normal except for an anxious mood, and obsessive thinking related to his belief he had medical issues not addressed.  He reported chronic sleep impairment, and panic attacks were not recorded.  The psychiatrist opined he had occupational impairment due to decreased concentration and poor social interactions.  The Board noted that the record demonstrated that he had continued to have panic attacks in the month of separation, and despite efforts to treat his anxiety, the last 2 treatment entries noted his condition had not improved.  All Board members agreed, the CI’s condition at the time of separation was more than transient or mild, and was not controlled by continuous medication.  The Board concluded his condition most closely reflected the 30% level of impairment.  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 anxiety disorder NOS condition, coded 9400.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the conditions of psychogenic hyperventilation, Tourette’s syndrome, scapulothoracic bursitis corresponding to the infraserratus bursa of the right shoulder, chronic, stable granulomatous lung disease likely secondary to histoplasmosis, mild sleep apnea, tic, convulsive, and bursitis were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The   Tourette’s syndrome, scapulothoracic bursitis corresponding to the infraserratus bursa of the right shoulder, chronic, stable granulomatous lung disease likely secondary to histoplasmosis, mild sleep apnea, tic, convulsive, and bursitis conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.   All were reviewed and considered by the Board.  Although the condition of psychogenic hyperventilation was profiled in 2006, this condition was likely related to the diagnosed anxiety disorder, and thus was considered in that rating.  The record demonstrated absence of physiological medical explanation for this condition.  There was no performance-based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance at separation.   

After due deliberation, and 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 any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the Anxiety Disorder NOS condition, the Board unanimously recommends a disability rating of 30%, coded 9400 IAW VASRD §4.130.  In the matter of the XX condition and IAW VASRD §4.71a, the Board unanimously or majority recommends no change in the PEB adjudication.  In the matter of the contended psychogenic hyperventilation, Tourette’s syndrome, scapulothoracic bursitis corresponding to the infraserratus bursa of the right shoulder, chronic, stable granulomatous lung disease likely secondary to histoplasmosis, mild sleep apnea, tic, convulsive, and bursitis conditions, 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.  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	PERMANENT RATING	
Anxiety Disorder Not Otherwise Specified	9400	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140528, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 21 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX 
	(c) PDBR ltr dtd 03 May 16 ICO XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 24 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 17 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 15 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 13 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 13 Apr 16 ICO XXXXXXXXXXXXXXXXXXXX
	(k) PDBR ltr dtd 15 Apr 16 ICO XXXXXXXXXXXXXXXXXXXX
	(l) PDBR ltr dtd 22 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (l) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 50 percent disability rating (increased from 10 percent) effect date of discharge. 

     b. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effect date of discharge. 
 
     c. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
     
     d. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge.

     e. XXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 40 percent disability rating (increased from 10 percent) effect date of discharge. 
 
     f. XXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge. 

     g. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge.

     h. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge.

     i. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge.

     j. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 40 percent disability rating (increased from 20 percent) effect date of discharge.

     k. XXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge.

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.

	XXXXXXXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)