RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03805
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20011031

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E7, Personnel Administration Specialist, medically separated for “delusional disorder,” with a disability rating of 10%.  

CI CONTENTION:  His condition continues to worsen and negatively impact his daily activities.  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 - Dated 20010703	VARD - 20020213	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Delusional Disorder	9208	10%	Delusional Disorder	9208	50%	20020213	
COMBINED RATING:  10%	COMBINED RATING:  50%	

ANALYSIS SUMMARY:  

Delusional Disorder.  The narrative summary (NARSUM) documented the CI was in his normal state of health prior to his arrival on Johnston Island, Hawaii, in late October 2000.  Prior to arriving in Hawaii, he was stationed in New Jersey on a 90-day compassionate reassignment to be near his father who was recovering from a heart attack.  Prior to his reassignment, he was stationed at Walter Reed Army Medical Center (WRAMC) for 4 years working in an administrative position.  His supervisor described him as “outstanding,” his relationships with peers, subordinates and superiors were good.  There had been no evidence of any conflict and he maintained his professionalism at all times.  The CI maintained a professional decorum in the first few days of his arrival to Hawaii.  He was noted to socialize appropriately; however, his behavior quickly became increasingly erratic and hostile, including acts of aggression.  One incident of aggression occurred at the BX when he became angry after the store clerk closed the door during closing and would not allow him entrance.  He reportedly shook the door, yelled and cursed at the employees inside.  He also had occasions in which he demonstrated a sense of entitlement, and grandiosity.  He started showing up late to work after 1-2 days of duty, telling his subordinates that he did not have to follow the orders of his supervisor.  He reportedly made threats to discredit his supervisor’s work as well as physical threats towards his family.    His behaviors were at times loud and argumentative.  He demonstrated hyper religiosity, frequently referred to his own suffering in religious terms and would compare his suffering to that of Christ.  The CI also became hostile with his father and girlfriend, and accused them of not caring about his perceived situation of being in danger.  He started barricading himself in his room at night, staying awake out of fear, and keeping a baseball bat nearby.  He got into arguments with people on the basketball court and complained that people were being paid to push his buttons.  At this point, the CI begin threatening to harm individuals that he did not like, including threats to harm his command.  

On 8 November, he underwent a command-directed mental evaluation.  The examiner noted that the CI appeared somewhat suspicious and guarded.  The CI denied symptoms of depression or psychosis, and his thought processes were recorded as normal.  After the evaluation (not among records) the CI was instructed to remain in his room in lodging.  However, he disobeyed this order and attempted to sign into the replacement unit at another installation.  He was apprehended and charged with communicating a threat and disobeying a lawful order.  He did not trust military legal representation and he hired his own civilian lawyer.  His lawyer hired a psychologist who described him as being paranoid, hyper-religious, and grandiose.  The CI participated in the Sanity Board process that lasted from late January through mid-March 2001.  The Board found him competent to undergo Court-Martial; however, noted that the CI suffered from delusional disorder and that this condition significantly affected his judgment.  

At the NARSUM dated 13 May 2001, approximately 5 months before separation, the CI was noted to have had a normal neurological and physical exam except for mildly elevated blood pressure.  Mental status examination recorded his report of a good mood and he was well dressed and well groomed.  His speech was soft; insight was impaired “in that he was unable to accept that his fear of his command was delusional.”  His judgment was assessed as fair, “being adequate for outpatient follow-up and for limited duty.”  He denied homicidal or suicidal thoughts or experiencing hallucinations.  The physician also noted that the potential for relapse was significant.  The diagnosis of delusional disorder-persecutory type (manifested by non-bizarre delusions of persecution that he was going to be killed or harmed) was noted to cause marked impairment for military duty and definite impairment for social and industrial adaptability.  A Global Assessment of Functioning (GAF) score of 60 (borderline moderate to mild impairment/symptoms) was assessed.  It was noted that the CI was not in any form of mental health treatment, and that although medication and therapy might not be helpful in general terms; it could have a role at times of stress.  However, it was opined that while he is capable of functioning in low stress jobs, he continues to demonstrate signs of mental disturbance and “have a high risk of exacerbations of his paranoia if re-exposed to a stressful military environment.”  The physician also noted that his functional limitations in a civilian setting would be similar, impairing his ability to supervise or work in stressful environments.  The commander’s statement noted the CI spent only 2 weeks on the island before being confined in pre-trial status at another location.  He was confined from 10 November until his release on 4 April 2001.  

The VA Compensation and Pension (C&P) exam was accomplished 3 months after separation.  The examiner noted the CI was not working, and that he had been “a very good soldier” prior to his transfer to Hawaii.  The CI reported he had several conflicts with co-workers and supervisors, and was jailed for several months for making threats.  He is having difficulty sleeping, believes that he was abused and persecuted in his last military assignment, and attributes this to racial discrimination.  He does not believe that there is anything wrong with him.  He denies making any threats, and stated that he had attempted to address his problems in the proper way, but was rebuffed.  The mental status exam documented absence of hallucinations, but noted that he verbalizes ideas of reference and persecutions because of his race.  His affect was moderately depressed and insight and judgment are “marginal.”  A GAF of 45 (serious impairment/symptoms) was recorded.

The Board directed attention to the rating recommendation based on the evidence just described.  The PEB and VA both used the same code, 9208 (delusional disorder), but arrived at different ratings.  The PEB rated the condition at 10% and the VA granted a 50% rating.  First, the Board noted there was no specific, highly stressful service related event to invoke §4.129 for a mental disorder due to traumatic stress.  All Board members agreed the provisions of §4.129 were not applicable.  The NARSUM examiner documented a moderate GAF score and noted that although the CI demonstrated some improvement at the NARSUM, his prognosis was generally not good.  His insight was impaired and his judgment was noted to be fair and adequate for outpatient follow-up and for limited duty.  The Board opined that this was not a strong endorsement for intact judgment.  Three months after separation, at the VA exam, the CI was not working and continued to demonstrate persecutory symptoms. His judgment was assessed as “marginal,” and he had some difficulty with sleep and depression.   At the time of separation the Board agreed that the §4.130 threshold for a 70% rating (occupational and social impairment in most areas due to suicidal or psychotic symptoms and demonstration of impairment in judgment, thinking) was not approached.  A 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  or impaired judgment; impaired abstract thinking).  

The Board considered the NARSUM’s examiner statement that the CI would likely decompensate when exposed to significant interpersonal conflict and re-exhibit paranoid thoughts and behavior that would seriously impact the function and morale of his unit and pose a potential danger to others.  The Board also considered the NARSUM opinion that while the CI “is capable of functioning in a low stress position, he still shows signs of continued mental disturbance…”  Additionally, the Board discussed the findings that suggested some impairment in judgment, as well as the recorded impaired insight in both examinations.  The NARSUM noted his ability to work in stressful environments within the civilian and military was impaired.  Both exams documented difficulty in establishing and maintaining effective relationships due to his symptoms.  All Board members agreed the CI’s condition was most closely reflected in the 50% disability criteria (impaired judgment, difficulty in establishing and maintaining effective relationships, continued paranoia, sleep disturbance, and disturbance in mood).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a disability rating of 50% for the delusional disorder condition.  

BOARD FINDINGS:  In the matter of the delusional disorder condition, the Board unanimously recommends a disability rating of 50%, coded 9208 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	
Delusional Disorder	9208	50%	
RATING	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140730, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160009356, 

Dear 

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to recharacterize your separation as a disability retirement with the combined disability rating of 50% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board's recommendation and record of proceedings for your information.

The re,characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.

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 your pay and allowances.  These agencies will provide you with official notification by mall as soon as the directed corrections have been made and will provide information on your retirement benefits.  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-00), 

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

Sincerely,

Deputy Assistant Secretary of the Arrnv

.Enclosure