RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03053
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080818

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

CI CONTENTION:  The source of the CI’s seizures was never identified.  The applicant’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 - 20080430	VARD - 20091022	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Anxiety Disorder	9413	10%	PTSD with Severe Anxiety Disorder	9413-9411	NSC	STR	
Pseudoseizures	Not Unfitting	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  According to service treatment records (STR), the CI was deployed to Iraq from November 2005-November 2006.  At Post Deployment Health Assessment (PDHA) in March 2007, she endorsed nightmares, avoidance, hypervigilance, detached feelings, loss of pleasure, and depression over the previous month.  Neurology summary, dated October 2007, noted the CI may have had a pseudoseizure related posttraumatic stress disorder (PTSD), that most of her medical pathology was related to PTSD, and recommended she be medically retired.  A psychology consult, dated 15 February 2008, 6 months prior to separation, the CI self-referred because her panic attacks were so bad.  There was no prior history of psychiatric diagnosis and treatment. She reported traumatic stressors in her deployment, including being part of a response and casualty recovery team.    She reported being on missions all the time for 18 hours a day. The response team also performed route clearance. She also had nightmares about being in Iraq and the people who died. Her platoon got hit with an IED two weeks after they got into country, and 5 personnel in her battalion was lost.   She also had nightmare about being the only female on a forward operating base with more than 300 Iraqis.  She had her first panic attack 10 days after redeployment and her first pseudoseizure occurred when she went on block leave.  The CI reported she has nightmares every night and 3-4 times per week about Iraq.  With a sleep aid, she slept 4 hours per night, was extremely hypervigilant and easily startled.  She had intrusive thoughts of Iraq and had difficulty remembering parts of her experiences in Iraq.  She was no longer outgoing or participated in outdoor activities and had friends drive her to work since she would only drive short distances when familiar with the route.  She was taking a medication for depression, a medication for anxiety 3 times per day and a sleep aid.  Her baby was born 3 weeks premature and weighed 3 pounds.  Panic attacks declined because she didn’t go anywhere.  Mental status exam (MSE) noted an extremely anxious mood, speech so rapid she was asked to slow down, and tearfulness.  She had poor tolerance of stress.  Thought process was clear and she denied homicidal/suicidal ideation.  A diagnosis of PTSD with severe panic attacks was rendered with a Global Assessment of Functioning (GAF) score of 50 (serious bordering on moderate symptoms, impairment.)  She was issued a S3 profile and referred for MEB.  The February 2008 commander’s statement noted the CI continued to be treated for treated for PTSD and her duty performance was satisfactory but she was unfit for combat.  Her first line supervisor indicated that she did not have discernible psychological conditions that would prevent her from military service outside of combat branches, and that she could work independently and maintains appropriate  relationships with her peers and superiors.  

The March 2008 narrative summary (NARSUM) identified the primary medical condition as PTSD with severe panic attacks.  She reported she continued to have 3-4 panic attacks per week, despite medications as identified above.  The symptoms were mostly work-related, specifically with military triggers and she had learned how to calm herself.  The attacks lasted up to an hour.  She still had sleep difficulty.  She reported anxiety with any soldiering activity or military association with flashing lights and mild noises the most common triggers.  Military functional activities were not significantly affected by her psychiatric condition.  A diagnosis of PTSD with severe panic attacks was rendered.  The examiner noted she failed to meet retention standards based on this diagnosis.  The April Warrior Transition Unit Commander’s statement noted the CI did not work an 8-hour work day due to her PTSD.  The CI’s Platoon Sergeant submitted a letter in support during the MEB process of her combat exposures, including casualty recovery, IED route clearance, disposal of unused explosive devices and home raids.  Post-deployment she was very agitated in Army associated situations. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a rating of 10% under a 9413 code (Anxiety disorder), originally diagnosed as PTSD but claiming no PTSD stressor was verified and anxiety was related to health conditions.  The VARD identified the mental health condition as PTSD with severe anxiety disorder under 9411-9413 code as not-service connected (NSC) because she failed to appear for the VA C&P examination.  The Board noted the absence of documentation to relate the CI’s symptoms to a physical medical condition, the absence of pre-deployment psychiatric history, and the confirmation of combat exposures by the Platoon Sergeant.  Disability associated with any psychiatric condition, regardless of the diagnosis or multiple diagnoses, is subsumed under a single rating using the same criteria IAW VASRD §4.130 general rating formula for MH conditions.  The Board agreed the CI met criteria for 4.129 due to combat exposures and then considered if there was evidence for a §4.130 rating higher than the §4.129 minimum mandated 50% at time of TDRL placement.  The Board agreed that the §4.130 criteria for a rating higher than 50% were not met near the time of separation.  The most proximate source of comprehensive evidence on which to base the permanent rating recommendation in this case is the psychological examination and NARSUM exam performed 5 months before separation.  There was no other relevant VA outpatient or civilian provider evidence providing psychiatric details during the 6-month interval.  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.”  She reported she was taking medications for anxiety and depression and panic attacks had declined.  The Board agreed the 10% rating was appropriate.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 50% for 6-months of constructive TDRL and a 10% permanent rating thereafter for the anxiety condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that pseudoseizure was 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.  At the NARSUM examination, the CI reported she blacked out in front of her parents and had what was described as seizure-like motions and had no memory of the event.  An electroencephalogram (EEG) in April 2007 was negative.  Her most recent episode was in January 2008 and reportedly related to a panic attack.  Neuroimaging in February 2008 was negative.  Final assessment by neurology noted the pseudoseizures or syncopal episodes was related to PTSD and panic attacks.  No further neurological evaluation was indicated.  The pseudoseizure condition was 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.  There was no performance based evidence 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 any of the pseudoseizure contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the anxiety disorder condition, the Board unanimously recommends a disability rating of 50%, coded 9413 IAW VASRD §4.129 for 6 months from the time of discharge consistent with a constructive period of TDRL and then a permanent separation rating of 10% IAW VASRD §4.130.  In the matter of the contended pseudoseizure 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.  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	
Anxiety Disorder	9413	50%	10%	

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20140622, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160011105, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to constructively place Ms. Robinson, Mary on the Temporary Disability Retired List (TDRL) at 50% disability for six months effective the date of her original medical separation for disability with severance pay and then following this six month period no recharacterization of your separation or modification of the permanent disability rating of 10%.  Enclosed is a copy of the Board's recommendation and record of proceedings for your information.

The constructive TDRL period will result in an adjustment to your pay providing her 50% retired pay for six months from the date of your original medical separation and then no recharacterization of your separation or modification of the permanent disability rating of 10% following the constructive six month TDRL period

The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to the pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted. Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,