RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03497
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060308

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E-4 (Administrative Specialist) medically separated for anxiety disorder.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent P2S3 profile and referred for a Medical Evaluation Board (MEB).  The “anxiety disorder” condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated the anxiety disorder as unfitting, rated 10%.  The CI made no appeals and was medically separated.

CI CONTENTION:  He requested all conditions be considered.  His complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  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/Naval 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:

IPEB – Dated 20060210	VA* - (~4 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Anxiety Disorder…	9413	10%	Post-Traumatic Stress Disorder 	9411	30%	20051122	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 8	
RATING:  10%	COMBINED RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20060407 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  

Anxiety Disorder Condition.  The first Axis I psychiatric diagnosis documented in the service treatment record (STR) was in January 2005, at which time the CI was diagnosed with “post-traumatic stress disorder” (PTSD) and started on antidepressant medication.  There were frequent follow-up appointments with psychiatry during early 2005 whereby the CI endorsed horrific combat activities while deployed in Iraq and Afghanistan with multiple “near-miss” death experiences and the killing of other troops that were close to him.  His mainstay treatment remained with general individual counseling and medications.  There were no inpatient psychiatric hospitalizations nor prolonged incapacitating episodes dealing with a psychiatric condition.  In August 2005, the CI was permanently profiled with a diagnosis of severe and chronic PTSD and was referred to an MEB.  The commander implicated the proscribed profiled restrictions as the basis for the CI being incapable of reasonably performing his MOS duties.

At the psychiatric narrative summary (NARSUM) examination 24 October 2005; 4 months pre-separation, the CI’s chief complaint was, “I can’t sleep, I am very anxious, I’m depressed.”  The clinical status of the CI as described by the MEB psychiatrist is summarized in the following excerpt from the examination:

“He has become more verbal, less depressed and less explosive. He is still very sensitive to pressure.  He is able to work most days… He continues to have anxiety when driving but is able to function in this area…His sleep pattern is more normal but is still disrupted 2-3 times a week with dreams of a disturbing nature… His prognosis is good but he will continue to need medication and continued therapy for his still unstable reaction to the PTSD symptoms already described. This will be for an indefinite time.”

Active psychiatric symptoms recorded in the NARSUM were consistent with PTSD-specified criterion to include feelings of intense fear, helplessness, horror and rage, event recollection/dreams; all resulting in intense distress upon reminders of his deployed experiences.  Additionally, he endorsed hyper-arousal symptoms of disrupted sleep, outbursts of anger, difficulty concentrating, and being hyper-vigilant with an increased startle response.  Suicide and/or homicidal ideations were not present.  The MEB psychiatrist’s Axis I diagnosis remained chronic PTSD and his Global Assessment of Functioning (GAF) was 60; indicating moderate impairment.

At the VA psychiatric Compensation and Pension (C&P) examination 22 November 2005; 3 months pre-separation, the CI again reported horrific combat exposures while deployed.  His mental status examination (MSE) was detailed and normal excepting an anxious affect and some depression.  His diagnosis remained PTSD and his GAF was listed at 80; indicating transient symptoms that are expected reactions to psychosocial stressors.

The case file also contained three memoranda (dated 10 November 2005, 30 November 2005, 3 February 2006) sent from the PEB to the commander of the military treatment facility (MTF) where the CI’s MEB was performed.  The subject for each correspondence was entitled Discontinuance of Physical Evaluation Board Proceedings Pertaining to [the CI].  The first memorandum was a request for the demographics of the CI’s deployed (in-theater) commander, first sergeant, or first line supervisor in an attempt to contact them for verification of the CI’s combat exposure as detailed in the NARSUM.  The second memorandum was a request for psychiatry to review the accuracy of the prior PTSD diagnosis after contact with the CI’s in-theater commander and first line supervisor did not support and even contradicted the CI’s report of combat stressors.  The last memorandum again requested a psychiatric review of the prior diagnosis after the CI’s peers were also unable to provide credible information regarding the CI’s reported combat stressors.  The last correspondence noted, “In the absence of credible corroboration, it appears that some other diagnosis may be more appropriate.”  In response to the three memoranda from the PEB, a letter from psychiatry dated 06 February 2006 clearly stated that the appropriate diagnosis in this case should be modified to anxiety disorder, not otherwise specified (NOS).
The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA diagnosed differing mental health (MH) conditions of anxiety disorder and PTSD with VASRD impairment ratings of 10% and 30%, respectively.  Disability associated with any psychiatric condition, regardless of the diagnosis, is subsumed under a single rating using the same criteria IAW VASRD §4.130.  Neither the PEB nor the VA elected to apply VASRD §4.129, with its minimum rating and stipulation for a follow-up evaluation within 6 months, to the CI’s unfitting MH condition.  The first question that came before the Board was whether the CI’s MH condition (anxiety disorder) met the §4.129 definition of “a mental disorder that develops in service as a result of a highly stressful event that is severe enough to bring about the veteran’s release from active military service.”

The Board placed great probative value in the PEB’s negative verification of the CI’s reported stressful combat exposures and concluded that the requisite §4.129 link that the condition occurred “as a result of a highly stressful event” was not satisfied.  The Board also considered that the VA did not apply §4.129 to the CI’s initial rating, thereby reflecting their opinion that the §4.129 criterion threshold was not met as well.  The Board therefore will consider only the VASRD §4.130 impairment present near separation for a single rating recommendation.

Absent evidence of panic attacks greater than once a week, the 50% impairment criteria under §4.130 was not supported.  The deliberation settled on arguments for a 10% versus a 30% impairment rating.  All members agreed that in this case, examination probative value was not overwhelmingly applied to either the NARSUM or the C&P for both exams were detailed and in close or nearly equal proximity to the date of separation.  The Board majority agreed that despite the CI having a persistence of described symptoms, the evidence of overall improvement as noted by being less depressed, less explosive, with a more normal sleep pattern, coupled with a 20 point increase in GAF to that of transient impairment remained consistent with a 10% impairment rating.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority agreed that a disability rating of 10% for the anxiety disorder condition was appropriately recommended in this case.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the anxiety disorder condition, and IAW VASRD §4.130, the Board majority recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  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 20140417, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB				
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 XXXXXXXXXX, AR20160004396 (PD201403497)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA