RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03177
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20011109

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Security Forces Journeyman, medically separated  for “panic disorder with agoraphobia”, 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 - 20010904	VARD - 20020711	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Panic Disorder w/Agoraphobia	9412	10%	Panic Disorder w/Agoraphobia and Depression	9412	100%	20020510	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:  

Panic Disorder w/Agoraphobia Condition.  Service treatment records (STR) noted the CI reported his panic attacks began in 1998.  He reported during the NARSUM, dated June 2001, that his first panic attack occurred during basic training in February 1998 when he was preparing for an inspection.  He began to experience nausea, shortness of breath, sweating, chest discomfort, tingling in his hands, and increased heart rate.  In summer 1999, he sought treatment from a psychiatrist and was placed on medication for anxiety and for depression/anxiety with some benefit.  When he stopped the medication, the panic attacks returned.  He was admitted to the hospital after an emergency room (ER) visit for a panic attack in December-January 2001.  Cardiac evaluation was negative.  Weapons-bearing and driving privileges were suspended.  He had 4-5 panic attacks per week with stomach distress and lost consciousness during a “severe” panic attack while on duty.  He had delayed sleep onset, low energy and difficulty concentrating.  

The narrative summary (NARSUM) noted the CI was highly motivated for treatment and was compliant with treatment.  He was taking two medications for anxiety with swift improvement.  Psychotherapy included cognitive and behavioral strategies to manage anxiety.  Since the first attack any new situation had the potential to trigger a panic attack.  He remained at home when not required to leave his home and at intake was leaving home once every 3 weeks.  Leaving a situation could reduce the intensity of the attack.  Panic attacks reduced to weekly during the first week of treatment and to 4-5 during the next 3 months with lower intensity and better ability to manage and prevent full panic attacks.  He was more outgoing socially and remained in treatment.  He still had mild anxiety due to job related stressors.  He was single and not in a relationship.  Mental status examination (MSE) showed sporadic anxious affect.  A diagnosis of panic disorder with agoraphobia, improving was made with a global assessment of function (GAF) score of 70 (mild symptoms, impairment.)  A S3 profile was recommended.  The examiner noted the CI had a 3-4 year history of severe panic attacks with occasional syncopal episodes and a fair prognosis if he could maintain his progress with treatment support.

The commander’s statement, dated July 2001, noted the CI had not performed full duties since January 2001 because his condition and medication prohibited him from bearing firearms.  He had two medical appointments weekly but his duty performance and motivation level was high.  He was willing to accept cross-training into a new field and retention was recommended. Psychiatric addendum, dated August 2001, noted there was no evidence of a diagnosable condition prior to enlisting in service.  His initial panic attack occurred during an inspection.  

He appeared in the ER In August 2001 with a panic attack, reporting he had left his meds at another base.  A few days later he was aero evacuated after an evaluation for panic attacks.   He reported irregular heartbeat, lightheadedness, numbness in hands/feet and sometimes vomiting with diarrhea in severe cases.  He was taking a medication for depression/anxiety daily and a medicine for anxiety if he felt the onset of an attack.  He could drive.  With medication the attacks lasted 5-10 minutes but without medication they lasted several hours. 

At the VA Compensation and Pension (C&P) General exam, performed six months after separation, the CI noted he sprained his right ankle in February 2000 in Kuwait after he fell off an all-terrain vehicle and fell 10 feet vertically.  The vehicle landed on his right ankle.  He reported rapid heart rate that began in 2000, occurring 2-3 times per week.  He had attacks with a rapid heart rate, sweating, shortness of breath, dizziness, and nausea.  He also had a perioral numbness and numbness in fingers and toes.  The episodes occurred at rest and during sleep but occur more often if he is in a stressful or confined situation.  These panic attacks occurred 1-2 times per week, lasting 20 minutes to 20 hours.  Sometimes he could not leave the house because the sensations lasted most of the day.  At age 14 he had an episode of loss of consciousness after playing three soccer games in extreme heat.  He lived alone and was single.  He was working as an investment and insurance broker, visiting people in their homes.  Symptoms hindered his employment and one every week or two, could not leave the house due to panic attacks.  He did his own cooking and cleaning.  He watched television and liked movies, went bowling once a month, played pool and threw darts once per week with friends, and liked to box twice a month.  He was taking three medications for panic disorder.  Diagnoses included panic attacks, vasovagal fainting, and cyanosis with blue fingernails that occurred during panic attacks.  

At the VA Compensation and Pension (C&P) MH examination performed 6 months after separation, the CI reported minor problems with anxiety after his return from Kuwait.  He was supposed to return to Kuwait and was in training in Nevada when he awoke to a fast heartbeat, felt lightheaded, got sick, and blacked out.  He currently had 3-4 panic attacks per week.  He lost his last job because of this and had applied to other jobs but was not hired.  He was unable to get other jobs after he informed employers of his condition.  He had tried working for himself but it was not going well.  He became depressed and angry.  He lost control of his schedule due to the panic attacks and their unpredictability.  He was more comfortable working from home due to his agoraphobia.  He was not sure how he would survive and had no money in the bank.  It was difficult to motivate himself and worked out of his house about 3-4 hours per day.  MSE showed an inappropriate affect e.g. laughed while describing thoughts of cutting his wrists.  He described himself as “the most depressed I’ve ever been.” Diagnoses of panic disorder with agoraphobia and depression NOS due to panic disorder were rendered with a GAF of 45 (serious symptoms, impairment.)  The examiner opined he was “far more impaired than that suggested by discharge documentation.  He is exhibiting profound social and industrial impairments.  He remained in psychiatric care but medications were not controlling his symptoms.

The Board directed its attention to its rating recommendation based on the above evidence.  Both the PEB and the VA used the same coding, 9412 (panic disorder and agoraphobia) to identify the CI’s condition but the PEB rated it at 10% due to mild social and occupational impairment while the VA rated it at 100% citing deficiencies in most areas of social and occupational functioning.  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 (member consensus was) that the ‘highly stressful event’ requisite for §4.129 was not satisfied in this case.  The Board considered if a rating higher than 10% was warranted at the time of separation.  Deliberation settled on arguments between a 10% and 30% rating.  The §4.130 criteria for a 10% rating is “Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.”  A 30% rating requires “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.” 

The NARSUM examination noted the CI was having only mild symptoms and was doing well with medications.  Panic attacks had reduced to 4-5 in 3 months with lower intensity and better ability to manage and prevent attacks.  He was socially more outgoing and had mild anxiety related to job stressors.  The GAF score of 70 reflected mild symptoms.  The commander noted high duty performance and motivation.  An emergency room visit 3 months prior to separation noted a return of symptoms in the context of not taking his medicines.  With medication the attacks lasted a few minutes versus without medications, attacks lasted several hours. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the panic disorder with agoraphobia condition.

BOARD FINDINGS:  In the matter of the panic disorder with agoraphobia condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140610, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record
SAF/MR
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-2014-03177.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings