RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03673
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20030406 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Unit Supply) medically separated for a brief psychotic disorder.  The condition could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty (MOS).   She was issued a permanent S3 profile and referred for a Medical Evaluation Board (MEB).  “Brief psychotic disorder” and “paranoid personality traits,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “brief psychotic disorder, in remission with continuous medication” as unfitting, rated 0%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI requested a Formal PEB (FPEB) but later withdrew this request and was medically separated.  

CI CONTENTION:  The CI asks that all conditions be considered.  Her 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 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 20020910	VA* - (~7 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Brief Psychotic Disorder, in Remission with Continuous Medication	9299-9210	0%	Psychotic Disorder, Not Otherwise Specified	9210	10%	20020906	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0	
RATING:  0%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20030414 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Brief Psychotic Disorder in Remission with Continuous Medication.  The narrative summary (NARSUM) exam was conducted while the CI was on the psychiatric inpatient unit.  The record reflects that the CI was hospitalized from 15 July 2002 to 29 July 2002 secondary to an altered mental status related to ingesting an unknown amount of her antipsychotic medication.  The CI initially presented to the emergency room (ER) on 11 July 2002 with the report of feeling anxious and depressed, and was having some struggles with caring for her 3-month old infant.  Her husband was in Germany on assignment and she did not have a support system.  The CI was discharged from the ER with outpatient follow-up.   The record is not clear, however, it appears she was started on an antipsychotic medication sometime within 48 hours of post-ER discharge.  The NARSUM indicated the CI returned to the ER on 13 July, with an altered mental status due to over-medicating herself; this was initially assessed as a possible suicidal attempt.  It was determined that she had not overdosed; however, due to the altered mental status she was hospitalized at the local state hospital before being transferred to the Army inpatient psychiatry ward.  The NARSUM examiner noted that the commander reported the CI was under significant stress being a single parent to the baby.  Shortly before her hospitalization she was noted to be disorganized in thinking and her judgment appeared impaired.  For example,   she reportedly tried to trade her car for a cell phone.  Her behavior also deteriorated.  At the time of admission to inpatient psychiatry 15 July 2002, she was noted to have disorganized thoughts and occasionally made statements with religious themes that seemed out of context.  She denied being depressed.  The psychiatric examination for the NARSUM was accomplished on 16 July.  The mental status examination (MSE) on that date demonstrated blunted affect, psychomotor slowing and disturbance of thought process (loose association).  Thought content was notable for prominent sexual and religious themes and she reportedly appeared paranoid at times.  She denied psychotic symptoms.  While on the inpatient unit, the CI participated in the treatment program and was compliant with her antipsychotic medication (Olanzapine).  Her mother visited her and took the baby back to the mid-west.  At the time of discharge from the hospital, the CI had no evidence of acute psychosis and denied suicidal ideation and depressive symptoms.  The psychiatrist diagnosed her with a brief psychotic disorder and stated, “Due to the severity of her psychotic episode, she has been maintained on antipsychotic medication to prevent a clinical relapse…it is recommended that she continue taking medication for several months and be followed in outpatient treatment upon her discharge from the Army.”  The examiner recorded paranoid personality traits on Axis II.  The VA Compensation and Pension mental exam was accomplished in September 2002, 7 months before separation.  The MSE was unremarkable and the CI had continued her medication.  The examiner documented the absence of signs or symptoms of psychosis or mood disorder, and her global assessment of functioning (GAF) score was recorded as “about 90 or above.”  It was opined that her psychotic symptoms were well controlled with medication and that she may have to take medication for a long period of time.  On 7 November 2002, 2 months after the PEB decision, a MEB addendum was submitted at the request of the PEB for a current MSE, diagnosis and medication profile.  The psychiatrist noted that the CI was promoted “earlier this month” and that her child remained in the mid-west with her parents.  The examiner noted the CI had been examined twice since the NARSUM and that she felt she no longer needs medication, but has continued her antipsychotic medication “to lessen the possibility of recurrent psychosis.”  Brief MSE was unremarkable.  The psychiatrist continued the diagnosis of brief psychotic disorder and recommended no changes to the profile or the MEB report (NARSUM).  The profile noted under the assessment of limitations that the CI could not have any assignments where definitive psychiatric care is unavailable. 

The Board directed attention to the rating recommendation based on the evidence just described.  The PEB rated the condition at 0%, coded analogously 9299-9210, citing “In remission with continuous medication.”  The VA also used the 9210 code and granted a 10% rating based on the need for continuous medication for control of symptoms.  A 0% disability rating under VASRD §4.130 (mental disorders) is granted when “a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.”  The record clearly demonstrates that both the MEB examiner and the C&P examiner documented the need for continuous medication beyond separation.  The commander’s statement noted that medication was required, and acknowledged that although she had improved she has not been working in her normal duty position. The record demonstrated that the CI was compliant with her antipsychotic medication, and was recommended by two physicians to continue it for several months.   All Board members agreed the 0% evaluation was exceeded at the time of separation.  The 10% disability rating is for “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” better reflects the CI’s condition at separation.  Thereupon, after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the brief psychotic disorder condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the paranoid personality trait 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.  This condition was recorded as an Axis II condition, not arising to the level of a personality disorder, and therefore, not considered a compensable condition.  In general, personality disorder is not a physical disability and is not ratable IAW DoDI 1332.38.  Any mental health (MH) symptoms associated with the above noted paranoid personality trait and contributing to the unfitting MH condition were accounted for in the rating of the psychotic condition, and cannot be rated separately IAW VASRD §4.14 (avoidance of pyramiding).  There was no performance-based evidence from the record that the contended condition significantly interfered with satisfactory duty performance.  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 and so no additional disability rating is recommended.

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 brief Psychotic Disorder, the Board unanimously recommends a disability rating of 10%, coded 9210 IAW VASRD §4.130.  In the matter of the contended paranoid personality traits, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  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	
Brief Psychotic Disorder, in Remission With Continuous Medication	9210	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140729, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXX, AR20160004322 (PD201403673)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 10% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA