RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX 	CASE:  PD-2014-03145
BRANCH OF SERVICE:  aiR FORCE  	
DATE OF PLACEMENT ONTO TDRL:  20010623 
DATE OF REMOVAL FROM TDRL:  20030406

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Offensive Avionics Systems Apprentice) removed from the Temporary Disability Retired List and medically discharged for paranoid schizophrenia, rated at 20%.

CI CONTENTION:  The CI requests the Board consider all conditions.  His 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 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:  

SAFPC – 20030113	VA Rating Decision1 - 20011003	
TDRL Placement – 20010623	Code	Rating	Condition	Code	Rating
Proximate	
Condition		TDRL
Placement	TDRL Removal			TDRL2
Placement	TDRL3 Removal	
Paranoid Schizophrenia	9203	30%	20%	Paranoid Type Schizophrenia	9203	100%	100%	
Left Shoulder, Axis III		NA	NA	S/P Subluxation, Left Shoulder	5201	20%	20%	
Other x 0 (Not in Scope)	Other x 3	
RATING:  30% → 20%	RATING:  100%	
1. Most proximate to TDRL Placement
2. Rating derived from C&P exam dated 20010913, ~2.5 mos. post-TDRL placement 
3. Rating derived from VARD dated 20041108 stating future exam was not necessary and 100% rating continued 

ANALYSIS SUMMARY:  

Paranoid Schizophrenia.  The CI began the MEB process during his 2-week psychiatric in-patient treatment.  The discharge summary documented that prior to hospitalization he was being treated with talk therapy for panic attacks with agoraphobia.  On 28 March 2001, his therapist referred him to the family practice clinic for medication and he was prescribed Ativan and Paxil, which were not helpful.  All treatment entries from the psychologist documented an absence of past mental health history.  On 1 April 2001, the CI presented to mental health accompanied by his wife, and reported disturbance in mood (angry, retaliative), and memory loss.  His wife reportedly stated she had noticed a change in his personality and he had been “more preoccupied over the week.”  He was having angry thoughts related to his supervisors and co-workers.  On 2 April 2001, the CI was referred to the in-patient psychiatry unit for diagnostic evaluation and treatment.  At the time of admission, it was noted that he had difficulty with his supervisor; he felt he was being treated unfairly.  His wife reportedly had concerns about his condition because he had begun pacing and mumbling to himself.  The CI reported symptoms suggestive of anxiety, such as, feeling nervous, shaking, sweaty palms, and increased heart rate.  He also reported paranoid ideations and believed he was being watched and scrutinized by random people.  As a result he avoided the public whenever he could.  He reported to hear voices commanding him to become aggressive; he coped with the voices by withdrawing, and sitting without responding.  He also at times verbally responded saying, “No, I won’t.”  While on the unit, he continued to have command hallucination, and tactile hallucinations (odd bodily sensations like something is crawling on him).  He had voices urging him to perform sexual acts and he had fears of being homosexually approached.  The CI also reported symptoms of ideas of reference, believing that the television and the radio are relaying messages specifically for him.  He had depressive symptoms and sleep disturbance.  The CI underwent psychological testing that concluded he was suffering from “early schizophrenia.”  He was started on antipsychotic medication and briefly followed out-patient.  He was discharged with the diagnosis of paranoid schizophrenia (early in the course of illness) with a Global Assessment of Functioning (GAF) score of 58 (moderate).  The examiner noted that the CI was competent at discharge but was only “somewhat employable.”  The MEB narrative summary (NARSUM) dated 17 April noted the diagnosis of paranoid schizophrenia.  It was not clear if there was a psychiatric addendum; however, the author of the NARSUM recorded that his psychiatric symptoms were controlled with medication and that voices were not present.  His affect was documented as flat, and there were no other recorded mental status elements.  The CI was placed on the TDRL in June 2001.  Treatment entry dated 17 August 2001 recorded the CI’s assessment as worse, noting he was constantly getting into arguments, was suspicious and paranoid, and he still had hallucinations.  The psychiatrist increased the antipsychotic medication (Risperidone) to 8mg daily (high dose).  

The VA Compensation and Pension (C&P) mental exam was accomplished 3 months post-TDRL placement.  The examiner noted that the CI’s wife reported he had paranoid thinking “for a good while.”  She believed his thinking reflected his personality, but overtime she began to believe he was not normal.  They could not go outside or go to a mall.  They stayed together in a dormitory and were fairly isolated.  They had not yet married and stayed pretty much to themselves.  No visitors ever came to their home.  Since TDRL placement, the CI’s illness continued.  Approximately a month after TDRL placement, he had an incident in a Blockbuster store where he became very angry and his wife had to remove him from the building out of fear that something bad might happen.  His wife said he scrubs his face frequently and he said it is because he has a sense that there is some “stuff” on his face and he has to wash it frequently.  He lives with his wife and 7 month old daughter.  He does not sleep well.  MSE noted he demonstrated initial hostility towards the examiner, but by the end he demonstrated depression when describing his illness.  There was no impairment in thought processes or communication, although the psychiatrist wrote, “He is too paranoid and delusional to be logical.” The CI was not suicidal or homicidal, and did not display obsessive or ritualistic behaviors other than the repeatedly washing of his face.  The examiner noted his personal hygiene was maintained and he was fully oriented.  It was opined that the CI did not sleep well due to the schizophrenia and that his judgment was impaired and cannot be relied upon.  He was deemed not competent for VA purposes.  A GAF score of 40 (some impairment in reality testing or major impairment in several areas) was recorded.  The examiner documented that the CI was not employable and noted that he would not be able to maintain employment even if he secured it due to his illness.

At the TDRL removal exam, approximately 15 months post-TDRL placement, the physician noted the CI was in treatment for his condition and had continued to take 8mg of risperidone, as well as gabapentin and klonopin.  He had not required in-patient hospitalization during the TDRL period; however, he reported frequent auditory hallucinations and paranoid delusions.  He lived with his parents, remained married and his wife was 6 months pregnant.  He was unemployed and his social interactions remain limited due to his paranoia.  MSE recorded a blunted affect, and no other abnormality; however, judgment was recorded as “grossly intact.”  The examiner recorded the diagnosis of schizophrenia, paranoid type “as evidenced by auditory hallucinations, paranoid delusions, social and occupational dysfunction, with continuous signs for some time now.”  A GAF score of 51-60 (moderate) was documented.

The Board directed attention to its recommendations based on the above evidence but first considered whether the provisions of VASRD §4.129 for any “mental disorder that develops in service as a result of a highly stressful event” were applicable to this case (as mandated by DoD).  The Board unanimously agreed that VASRD §4.129 was not applicable in the absence of a highly stressful causative event, but that placement on the TDRL for stabilization was appropriate.  The CI continued to have symptoms and was still in need of further stabilization.  At the time of TDRL placement, the PEB rated the condition of paranoid schizophrenia coded 9203 at 30%.  Likewise, the VA used the same code; however, granted a 100% disability rating.  All members agreed that at the time of placement of the TDRL, the VASRD §4.130 threshold for a 30% rating was met.  A higher rating of 50% requires “occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.”  The Board noted the NARSUM was primarily accomplished while the CI was on the in-patient unit (2 months before TDRL placement), and although he was noted to have improved, the in-patient psychiatrist suggested occupational impairment reflective of the 50% criteria (reduced reliability and productivity), stating, that the CI is “somewhat employable.”  He is seen in the MH clinic a month prior to TDRL and reported poor family relationships, constant arguments and was having significant hallucinations and paranoid that everyone is against him.  Three months into the TDRL, the C&P examiner documented “He is too paranoid and delusional to be logical,” and his judgment is impaired and cannot be relied upon.  He doesn’t leave home, and is too paranoid for outside activities and friendships.”  He was deemed mentally incompetent; however, the examination supported the 70% level of disability (impairment in thinking, judgment, family relations, mood, with impaired impulse control [blockbuster incident], persistent delusions and hallucinations, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships) and not total impairment at the 100% level.  The commander’s statement (undated) stated, “The effects of his illness, coupled with his past confrontations with co-workers, prevent him from performing his assigned military duties.” After considerable deliberation, Board members agreed, at the time of TDRL placement, his condition was most closely reflected in the 70% disability level (occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood).  
The Board next directed attention to the permanent rating recommendation based on the evidence described at TDRL removal.  The PEB rated the condition at 30%; however, deducted 20% for “contributing factors.”  As noted above, the CI appealed and the rating was increased to 20%, less 10% for contributing factors.  Members then turned to deliberation of whether the PEB’s deduction for the condition that was determined by the PEB and upheld by the SAFPC as “existed prior to service, with service aggravation” was appropriately applied to the Board’s recommendation.  The PEB’s AF Form 356 rationale for the initial determination is excerpted below.

The IPEB notes member's medical condition is essentially unchanged since being placed on the TDRL but the IPEB notes new information that the member exhibited symptoms very early on at basic training.  The predominance of medical evidence would indicate that member’s condition was a natural progression of a pre-existing condition and appropriate deductions have been taken.  Recommends discharge with severance pay with a disability rating of 10% IAW DOD and VASRD guidelines.

SAFPC agreed that the condition was EPTS but with service aggravation.  The PEB’s AF Form 356 rationale for the initial determination is excerpted below.

The board opines that there is now clear evidence the member’s psychiatric symptoms began within a short period of time following his entry on active military service, and well within the 180 days referenced in DOD instruction 1332.39 regarding conditions which existed prior to military service (EPST).  However, the Board considered the plausibility of an influence of unique environmental factors on the member’s medical condition…and opines that application of service-aggravation to the member’s EPTS, paranoid schizophrenia, which went largely undetected at the time of his attendance at basic military training, is a more appropriate course of action.  The Board finds the member unfit and recommends his separation with severance pay with a 20% disability rating, which acknowledges the member’s current 30% disability rating, but with application of a 10% rating reduction for an EPTS factor.
All members agreed that the PEB’s deduction could not be conceded for application to the Board’s recommendation for the following reasons.  First of all, the underpinning for the condition being EPTS, on which the deduction hinges, is overly tenuous.  Although SAFPC summarized that the CI had early symptoms that begun in basic training where he “began to think in a funny fashion,” and began to notice that there were “differences in his behavior,” and the in-patient psychiatrist commented that the CI has had a history of hearing voices for longer than 2 years, there was no documentation that he had been diagnosed or treated for a mental illness prior to the psychologist’s diagnosis of panic attacks in March 2001, nearly 3 years after entry.  The in-patient psychiatrist did not document a pre-existing mental health condition or treatment for any mental health issue prior to service.  The DD Form 214 recorded active duty entry date of August 1998.  He first sought MH treatment on 9 March 2001 at which time no psychiatric diagnosis was made, and his MSE was normal.  He reported no changes in sleep or energy, and had a few symptoms of depression.  His GAF score was 70 (mild); 2 weeks later he was diagnosed with panic disorder with agoraphobia (20 March 2001).  Secondly, at the TDRL exam, the psychiatrist recorded premorbid personality and predisposition: “NO”, and made no mention of a pre-service mental condition.  The record noted the CI graduated high school a year prior to joining the service and completed a year of college in an engineering curriculum.  There was no indication from the record that he showed any signs of mental illness prior to service.  He did not undergo any command directed mental health evaluation at any time.  He sought mental health treatment independent of any recommendation from leadership.  No such input from a psychiatric examiner that his condition was EPTS is in evidence; thus the Board could not fairly speculate that the nature of the symptoms observed prior to a mental health evaluation represented an EPTS condition.  Medical literature supports the concept of a prodromal phase of schizophrenia; however, acknowledges that the report of prodromal symptoms is generally not recognized until the diagnosis has been made.  Oftentimes prodromal symptoms when present will precede the first psychotic episodes by days, weeks, or months, but not by years.  The CI’s wife indicated he began pacing and mumbling to himself in the days prior to hospitalization.  This observation could qualify as prodromal symptoms (unusual behavior but not grossly organized) since these behaviors were in close proximity to the onset of an identified psychotic process.  However, the literature notes that much of what is theorized about the prodromal phase has relied on retrospective recall, thus, reliability and validity is uncertain.  

Having concluded that no deduction should be applied, members turned to deliberation of a fair rating (IAW VASRD §4.130) of the overall psychiatric disability in evidence at separation.  The CI continued to suffer auditory hallucinations and delusions of paranoia.  He had not been hospitalized nor was there evidence of emergency care; however, he remained isolative and spent little to no time out of the house.  He continued to have difficulty with sleep, and although judgment was recorded as “grossly intact”, his treating psychiatrist noted in the record 7 months prior to the TDRL examination, that the CI has had “recent contact with the police, extremely paranoid, does not eat, cannot concentrate, just sits in his apartment.”  He was not feeling safe in his home and was planning to leave home and move in with his family due to stressors in his home (spouse left him to join service, could not deal with him).  Three months later his spouse assaults him.  The Board considered the evidence and noted that although his condition did not appear improved in regards to his symptoms, his overall condition may have improved somewhat as demonstrated by absence of psychiatric hospitalizations and emergency room visits, and suicidal and homicidal ideations.  The Board acknowledged the report of legal contact with the police; however, noted the absence of documented legal prosecution, charges, or arrest.  The record did not indicate that he had ever been charged with domestic violence but did in fact note that he had been a victim.  There were no recorded incidents where he was unable to control impulses or demonstrated severe impairment in judgment.  The record demonstrates that he had difficulty in adapting to stressful environment, and remained socially isolated and was not employed, and this was likely due to the severity of his illness; however, Board members agreed, there was insufficient evidence to support a 70% rating, and therefore, the Board agreed the condition at TDRL removal supported the 50% level of disability for “occupational and social impairment with reduced reliability and productivity.”

BOARD FINDINGS: In the matter of the paranoid schizophrenia condition, the Board majority recommends a disability rating of 70%, coded 9203 at TDRL placement and a permanent disability rating of 50%, coded 9203 IAW VASRD §4.130.  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 his prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Paranoid Schizophrenia	9203	70%	50%	
RATING	70%	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 201340625, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-03145.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.  I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.

The office responsible for making the correction will inform you when your records have been changed.  Corrected documents will involve a retirement order to place you on the retired rolls by reason of physical disability and, if appropriate, a new DD Form 214, Certificate of Release or Discharge from Active Duty.  Once you receive these documents, you may proceed to the nearest military personnel flight to secure a military identification card for you and any eligible dependents.

If you require assistance for matters not involving military pay actions, please contact the PDBR Intake Unit at Randolph AFB, (210) 565-3256.  Any inquiry concerning your pay may be addressed to DFAS – Indianapolis Center, Department 3300 (ATTN:  Correction of Records/Claims), 8899 East 56th Street, Indianapolis IN 46249-3300.

Sincerely,

Attachment:
Record of Proceedings 

cc:
SAF/MRBR
DFAS-IN