RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  pd-2015-00996
BRANCH OF SERVICE:  air force 	SEPARATION DATE:  20050930

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Communications Computer Systems Operations Journeyman, medically separated for “obsessive compulsive disorder” and “panic disorder,” rated 10% and 10%, respectively; however, given a combined disability rating of 0% citing aggravating and contributory factors.

CI CONTENTION:  “Generalized anxiety disorder and panic attacks began while I was TDY stationed at Keesler AFB (Jan-Mar 2004) as a result (triggered) by separation from my son who was 11 months old at the time.  Prior to this TDY I had never experienced anxiety or panic.  The anxiety and medications taken since (Lexapro, Zoloft, Klonapin, and Xanax) continue to this day.  I have medical records from the last 10 years to support this.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20050817	VARD – NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Obsessive Compulsive Disorder	9404	10%	No VA Examination in Evidence	
Panic Disorder		10%		
Generalized Anxiety Disorder	9400	CAT II 		
COMBINED RATING: 0% (20% deduction for Aggravating/Contributory Factors)	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Obsessive Compulsive Disorder, Panic Disorder, and General Anxiety Disorder.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s panic attacks began in approximately March 2004, although she had been prescribed Zoloft (sertraline, an antidepressant) and a trial of Celexa (citalopram, antidepressant) and Klonopin (clonazepam to treat a panic disorder) shortly before treatment by a social   worker.  Thereafter, she reported taking Serzone (nefazodone, an antidepressant) and Klonopin and receiving psychiatric care.  In January 2005 she was seen for by a psychologist for a panic disorder without agoraphobia (anxiety in certain places or situations), GAD, and OCD and had a GAF (Global Assessment of Functioning) of 55 (moderate symptoms).  The 9 June 2005 psychiatric clinic appointment revealed no manifest suicidal thoughts in recent weeks, but did note hopelessness, despair, problems sleeping, anxiety symptoms, marital problems, and a sense of lower self-worth.  Coping skills were not working.  Protective factors included no past suicide attempts, no self-hate or excessive agitation.    

The 13 July 2005 MEB NARSUM examination, 3 months prior to separation, noted complaints of depressive and anxiety symptoms prior to military service at age 19.  The CI dropped out of college due to fear of being alone and increased sadness and was placed on antidepressant medication in college, but continued to have bouts of depressed mood despite medication.  She enlisted in 2000 (but did not disclose her condition on DD Form 2807-2 according to a note dated 17 August 2005) and began to experience panic attacks when separated from her son to attend technical school.  She was seen several times in the Emergency Room (ER) and was treated with Atarax (hydroxyzine, an antihistamine), Ativan (lorazepam for anxiety), and Wellbutrin (bupropion, an antidepressant).  Serzone was changed to Lexapro (escitalopram, an antidepressant).  Despite intensive, psychological and psychiatric treatment and multiple medications, she continued to experience significant anxiety symptoms.  The mental status examination revealed the CI was well groomed and was slightly agitated.  Speech was normal to slightly pressured.  Her mood was anxious and her affect was appropriate, but tearful.  Thought process was normal as was thought content with ruminative worry.  Insight, judgment, and impulse control were fair and intelligence was average.  Cognitive function was within normal limits with no memory problems.  The examiner noted the CI’s mood symptoms began prior to military service when she attended college.  Anxiety symptoms dramatically increased when she was separated from her son and continued to increase in severity.  She displayed ruminative anxiety with a pessimistic outlook to improving her cognitive coping skills, which tended to serve to perpetuate or worsen her anxiety symptoms; and when anxiety spiraled up, she experienced severe panic attacks.  She also displayed significant obsessive compulsive behaviors, primarily focusing on checking behaviors.  The examiner noted the CI appeared to meet three separate simultaneous anxiety disorders, based on symptoms and service.  The examiner opined that the catalyst for her current severity was traceable to the separation from her son during military service and her symptoms worsened since entering into military service.  Despite multidisciplinary treatment, she continued to experience significant anxiety symptoms, including severe panic attacks, ruminative worry and obsessive compulsive behaviors. The examiner’s Axis I diagnoses were GAD, EPTS, not in remission, panic disorder without agoraphobia with moderate external precipitating stress and OCD.  There was definite impairment for civilian social and industrial adaptability.  Impairment for further military duty was considerable for GAD and definite for panic disorder and OCD.  The GAF range was 50-55 (moderate symptoms).  The commander’s statement dated 27 July 2005 indicated the CI worked in her Air Force Specialty, had no duty profile restrictions, missed work for a 1 hour appointment once a week, and was recommended for retention in the Air Force.  There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned separate ratings for an obsessive compulsive disorder (OCD) and a panic disorder and determined general anxiety disorder (GAD) to be a Category II condition.  However, IAW VASRD §4.130 General Rating Formula for Mental Disorders, although various diagnoses may be different and/or overlap, emphasis is based on overall occupational and social impairment; nevertheless multiple diagnoses will receive a single rating, and as such, the aforementioned diagnoses will be addressed together below.

The PEB rated the OCD condition 10%, coded 9404 (obsessive compulsive disorder), citing social and industrial adaptability impairment mild.  The PEB rated the panic disorder condition 10%, without a code, which presumably should have been 9412 (panic disorder and/or agoraphobia), citing social and industrial adaptability impairment mild.  The PEB then subtracted 20% for aggravating/contributory factors.  The PEB rated the Category II condition (conditions that can be unfitting but are not currently compensable or ratable) GAD condition 30%, but N/A (not applicable) coded 9400 (generalized anxiety disorder), citing the condition existed prior to service without permanent service aggravation with definite social and industrial adaptability.  Therefore, the net PEB rating was 0% for the aforementioned conditions.  The PEB went on to note that the EPTS GAD greatly affected the severity of the OCD and panic disorder.  The PEB then opined that if it were not for the EPTS condition, the social and industrial adaptability impairment rating would best be described as none IAW the DOD/VASRD guidelines, based on the fact that the CI was a “distinguished graduate of ALS and required no hospitalization.”  Panel members noted that the multiple conditions, while rated separately by the PEB, are not separately ratable since such rating would be based on the same occupational and social impairment and are prohibited by VASRD §4.14 (avoidance of pyramiding) and rating under VASRD §4.130 is based on overall occupational and social impairment due to mental health symptoms and not based on any specific mental health diagnosis.  

The panel noted that there was no traumatic event causing the unfitting mental health condition and concluded that application of VASRD §4.129 was not appropriate in this case.  Panel members then addressed an appropriate rating for the unfitting mental health conditions.  A 30% rating requires “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).”  The CI did have a depressed mood, anxiety, panic attacks, and obsessive compulsive behavior; however, the NARSUM did not address whether the impairment for civilian social and industrial adaptability was mild, but instead noted it was definite for each of the conditions.  However, a 10% rating that requires “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” is more likely to encompass the three diagnoses which were interrelated and she was on continuous medication and based on the commander’s statement, her work was not impaired.  Furthermore, although the PEB characterized the GAD as EPTS, the NARSUM examiner felt “the catalyst for her current severity was traceable to the separation from her son during military service and her symptoms worsened since entering into military service.”  Therefore, service aggravation was evident, albeit it was clear and unmistakable that the GAD condition did exist prior to service based on the CI’s input about dropping out of college and taking prescribed medication.  Because of the CI’s overall performance and recommendation to remain in the Air Force from the commander’s statement, members felt the overall condition did not rise to a 30% level, but rather to a 10% level without any subtraction for any aggravating or contributory factors since the EPTS condition seemingly was service aggravated and worsened while in the service.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the obsessive compulsive, panic, and general anxiety disorders, coded 9499-9400.  
BOARD FINDINGS:  In the matter of the obsessive compulsive, panic, and general anxiety disorder conditions, the panel unanimously recommends a disability rating of 10%, coded 9499-9400  IAW VASRD §4.130.  There were no other conditions within the panel’s scope of review for consideration.  The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Obsessive Compulsive, Panic, and General Anxiety Disorders	9499-9400	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150605, w/atchs
Exhibit B.  Service Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00996.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  The Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.  This will not result in any change to your separation documents or the amount of severance pay you are entitled to.  Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.
Sincerely,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR