RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04050
BRANCH OF SERVICE: NAVY	BOARD DATE:  20150619
DATE OF PLACEMENT ONTO TDRL:  20021213
DATE OF REMOVAL FROM TDRL:  20080125

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty GM3/E-4 (MK-41 Vertical Launching Sytems Maintenance Technician) medically separated for schizophrenia.  The schizophrenia could not be adequately rehabilitated to meet the requirements of his Rating.  He was placed on light duty and referred for a Medical Evaluation Board (MEB).  The “schizophrenia, undifferentiated type,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The Informal PEB adjudicated “schizophrenia, differentiated type” as unfitting, rated 30%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD), placing the CI on the Temporary Disability Retired List (TDRL) in December 2002.  Following TDRL evaluations in July 2004, January 2006, and November 2007, a PEB decreased the rating to 10% and removed the CI from the TDRL.  The CI made no appeals and was medically separated.

CI CONTENTION: The CI writes: “My initial VA Rating Decision granted 30% for Schizophrenia but the Navy provided severance pay at a lower percentage upon discharge.  The PEB misinterpreted my medical conditions and improperly rated me.  The DoD should have used VASRD which would have resulted in higher ratings and a sufficient disability rating for retirement.  I respectfully request consideration for medical retirement and all benefits associated with it, if it's in my best.”

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: 

Final PEB – 20071205	VA Rating Decision1 - 20030305	
TDRL Placement – 20021017	Code	Rating	Condition	Code	Rating
Proximate	
Condition		TDRL
Placement	TDRL Removal			TDRL2
Placement	TDRL3 Removal	
SCHIZOPHRENIA	9204	30%	10%	SCHIZOPHRENIA	9204	30%	30%	
Other x # (Not in Scope)	Other x 0	
RATING: 30% → 10%	RATING:  30%	
1. Most proximate to TDRL Placement
2. Rating derived from C&P exam dated 20030115, 1 mos. post-TDRL placement
      3. Rating derived from C&P exam dated 20030115, 1 mos. post-TDRL placement

ANALYSIS SUMMARY:

Schizophrenia.  The CI was medically evacuated from the Puerto Rico Navy Hospital to the Naval Medical Center in Portsmouth, Virginia on 21 April 2002.  He presented with disorganized speech, bizarre behavior, paranoia and delusions.  The Leading Petty Officer (LPO) reported the CI had always been “odd” and had not “bonded” with anyone socially on ship.  The CI’s speech was often disorganized, and rambling.  He often dissembled small electronics.  His command reported that 2 days prior to the transfer to the Portsmouth Hospital, the CI was asking irrelevant questions, engaging in meaningless behavior, and making unusual demands.  The LPO reported when he awoke 2 days previously, the CI was standing by his bed watching him.  A similar incident occurred the following day to the Chief.  The same day the CI began to rant things like, “I’m ready to die for this country,” prompting the medical evacuation.  The CI reported that on 20 April 2002, “everybody started changing their behavior.  He had trouble with sleep for three days prior to hospitalization because he could not trust anyone.”  “Sometimes he felt like someone was watching him from behind.  Mental status examination (MSE) on admission revealed a mildly blunted affect, mildly tangential thought process, loose associations, and delusional thinking.  He denied past and present suicidal or homicidal thinking.

Psychological testing while on the inpatient unit suggested the presence of a psychotic process.  The examiner noted MMPI-2 test reflected a “marked effort, by the patient, in denying and suppressing any psychological problems.”  The Projective Imagery Assessment showed symptoms of a psychotic thought process.  The CI was treated with various therapies and psychotropic medication, symptoms decreased and he was discharged a week after admission.  A diagnosis of schizophrenia, undifferentiated and a Global Assessment of Function (GAF) score of 55 (moderate impairment, symptoms.)  He was referred for a MEB.   

The narrative summary, dated 31 May 2002, noted the history of present illness and recounted the inpatient admission.  He had a year and 10 months of continuous active military service.  There was no previous history of psychiatric illness, and no history of alcoholism.  He denied difficulties since joining the navy and liked his duties “okay.”  He was not married.  The Board opined that his condition did not exist prior to service and that his impairment for military service was severe and for social and industrial adaptability was moderate.

The non-medical assessment noted the CI had not been in a full duty status since 28 April 2002.  He was not working in his specialty because of his medical condition (schizophrenia.)  He was above average prior to the onset of his medical condition and his current status made him ineligible to maintain his current rating assignment.

At the VA Compensation and Pension examination, dated 17 January 2003, (performed a month after TDRL removal), the CI reported he has felt depressed off and on since his initial presentation of psychosis but symptoms did not last more than several days at a time.  He had some trouble with energy, concentration, interest and motivation.  He endorsed symptoms of mania.  He did not participate in sports and spent most of his time watching television or reading.  He was living with his mother, grandfather and younger sister.  He planned to return to school part-time and begin vocational rehabilitation and attend computer classes.  MSE was essentially normal.  A diagnosis of paranoid schizophrenia and a GAF of 60 (the cusp of moderate to mild impairment, symptoms) was rendered.  The examiner noted he was generally functioning well and had meaningful relationships with family but had few friends and was more of a loner.

The first TDRL review examination, dated July 2004, noted he had three hospitalizations post-MEB despite ongoing outpatient psychotherapy and medication.  All occurred in the second half of 2002 and involved concern over psychotic symptoms.  Generally he improved by the final release from active duty.  Medication was changed and he had virtually no psychotic symptoms in the past year.  However, he reported a lack of “drive” (enthusiasm and spontaneous inspiration).  He lost interest in writing, video games, and sex.  He exercised and attended vocational school since February 2004.  Grades were good.  He went out with friends but had no girlfriend.  He continued to live with family members and remained unemployed.  MSE was essentially normal.  His diagnosis remained schizophrenia with a GAF score of 55 (moderate impairment).  The examiner noted his condition was the same since his last evaluation, although there was some early deterioration.

The second TDRL review examination, dated January 2006, noted he had not required hospitalization, remained compliant with follow-up and was still taking his medication.  Medical records revealed no delusions but frequent discussion of his religious beliefs during sessions.  The examiner noted he required redirection to stay on topic since he often tended to discuss his religious beliefs and concern about the state of the world.  He discussed a book he had written and talked about the human mind “in control of time travel.”  Grandiosity was evident as he discussed that “others look up to me” and compared himself to “early visionaries of the Bible.”  He expressed concerns about the world as “Revelation times,” referring to recent news stories of “wars, hurricanes, and fire.”  He had begun seeing a girlfriend and was employed at the post office (“ten to eight hours” per day) as a letter carrier while pursuing a degree in computer engineering.  The CI was talkative with an increased rate of speech, a mood that was “up and down,” an affect that was constricted to blunted, a thought process that was tangential and requiring direction at times, and thought content that showed preoccupation with religion and grandiose themes.  A diagnosis of schizophrenia, undifferentiated in partial remission was rendered with a GAF score of 55 (moderate.)  The examiner noted his condition was the same since the last evaluation and that he would require indefinite mental health treatment since he had a chronic condition.

The third TDRL review examination, dated November 2007, (performed 2 months prior to TDRL removal) noted he had not required hospitalization but he endorsed magical thinking (making relationships between actions and events that are not logical), grandiosity and ideas of reference (believing that occurrences illogically refer to oneself).  He reported he gets a “strange feeling” every 2 to 3 days that “God is telling me what to do.”  He does not make plans but waits for God to tell him what to do.  He was involved in multiple activities; working as a mail carrier, remaining in school studying business administration working as a “CEO of a company that is just getting off the ground,” mentoring young boys at a program he started at his church, joining the ministry, and working on his fourth book.  The new book was about his schizophrenia while the other books were religiously based.  He reported his only troubling symptom was “mood swings” and that in the morning he sometimes felt “evil.”  His mood would change when the feeling from God came over him.  He denied mania symptoms.  He reported he bought a house for his mother and lived there with her and his grandfather.  He wanted to complete his degree, “just to have it.”  He denied making plans and just “goes with the flow” and “waits for God to tell me what to do.”  He denied friendships or romantic relationships because he was too busy.  MSE was notable for a thought process that was not always logical, circumstantial thoughts, and preoccupation with religious and grandiose themes.  He denied hallucinations, paranoia, delusions, and suicidal ideation.  A diagnosis of schizophrenia, chronic and moderate and in partial remission was rendered with a GAF score of 55 (moderate impairment, symptoms).  The examiner opined that social and industrial impairment was considerable and his condition was the same since his last evaluation.

The Board directed attention to its rating recommendation based on the above evidence.  At TDRL placement, both the PEB and the VA rated the schizophrenia condition at 30%, coded at 9204.  The Board next considered whether the provisions of VASRD §4.129 were applicable for the unfitting MH condition.  Regardless of final PEB diagnosis, §4.129 does not specify a diagnosis of PTSD, rather it states “mental disorder due to a highly stressful event,” and its application is not restricted to PTSD.  Members agreed that the requisite §4.129 link that the condition occurred “as a result of” in-service stressors was not adequately satisfied; and therefore concluded that application of §4.129 was not appropriate in this case.

Regarding the rating at the time of placement on TDRL, Board members considered if there was evidence to support a rating higher than the 30% assigned by the PEB.  The §4.130 criteria for the 30% rating are “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.”  The next higher rating (50%) requires “occupational and social impairment with reduced reliability and productivity.”  A 50% rating requires occupational and social impairment, with deficiencies in most areas.  The Board considered that since the initial hospitalization, the CI had not been able to resume his duties, noting he had been above average prior to the onset of his illness but could no longer maintain his assignment.  In addition there had been three more inpatient psychiatric hospitalizations in the second half of 2002, all involving psychotic symptoms.  The Board agreed there was evidence of chronic mental instability affecting all areas of function, with multiple hospitalizations in 2002 and were consistent with a 50% rating.

As regards to the permanent rating recommendation, the Board considered if a rating higher than the PEB’s 10% was warranted.  The 10% rating specifies “occupational and social impairment due to mild or transient symptoms which decrease work efficiency … only during periods of significant stress, or; symptoms controlled by continuous medication.”  The second and third TDRL re-evaluations noted the CI retained symptoms of psychosis with abnormal MSEs, and the schizophrenia was only in partial remission.  Despite unverified work and school activities, the CI remained isolated and only associated with family members.  The MMPI-2 test, conducted during his first hospitalization, noted the CI worked hard to deny and suppress psychological problems.  The CI showed obvious signs of psychosis and mania (magical thinking, ideas of reference, auditory hallucinations, grandiosity) during the second and third TDRL evaluations, rendering the accuracy of his reported activities (works full time at post office, CEO of a company, mentoring young boys at a program) unreliable.  MSE also showed significant impairments in thinking and an impaired MSE.  The Board agreed that his symptoms were neither mild nor transient but were chronic and were not well controlled by continuous medication.  All three GAF scores were never more than 55 on TDRL re-exams, connoting continued moderate impairment and symptoms.  There had been no further hospitalizations since the first year of his illness and he had remained in treatment with regular psychiatric follow-up.  He was employed otherwise.  He remained in a chronic state of psychosis despite ongoing treatment.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a TDRL placement rating of 50% and permanent disability rating after TDRL removal of 30% for the schizophrenia condition, coded 9204.  (The Board majority voted 30% at TDRL removal.)

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.  In the matter of the schizophrenia condition, the Board unanimously recommends a TDRL placement rating of 50%, and §4.130; and by a majority vote, a 30% permanent rating at TDRL removal.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Schizophrenia	9204	50%	30%	
COMBINED	50%	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140927, w/aches
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 2 Dec 15 ICO XXXXXXXXXXXXXXXXXXXX
      (c) PDBR ltr dtd 23 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 19 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX.
	(e) PDBR ltr dtd 19 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 30 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 20 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 20 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 18 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (i) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability retired pay with a 40 percent disability rating (increased from 10 percent) with placement on the Permanent Disability Retired List effective date of discharge.

     b. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability retired pay with a 30 percent disability rating (increased from 10 percent) with placement on the Permanent Disability Retired List effective date of discharge.

     c. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability retired pay with a 40 percent disability rating (increased from 20 percent) with placement on the Permanent Disability Retired List effective date of discharge.

     d. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability retired pay with a 40 percent disability rating (increased from 20 percent) with placement on the Permanent Disability Retired List effective date of discharge.

     e. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXXXXXXX, former USN: Placement on the Temporary Disability Retired List for six months beginning the date of separation with a 50 percent disability followed by placement on the Permanent Disability 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Retired List at the conclusion of six months with a final rating of 30 percent and entitlement to disability retired pay.

     g. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability retired pay with a 30 percent disability rating (increased from 10 percent) with placement on the Permanent Disability Retired List effective date of discharge.

     h. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability retired pay with a 40 percent disability rating (increased from 10 percent) with placement on the Permanent Disability Retired List effective date of discharge.
     
3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.

	XXXXXXXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)