RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2016-00604
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20040427

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Security Forces Apprentice, medically separated for “posttraumatic stress disorder associated with social phobia” with a disability rating of 10%.   

CI CONTENTION:  “Condition misdiagnosed as social phobia, should have been MST and PTSD.”  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040225	VARD - 20041202	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posttraumatic Stress Disorder Associated with Social Phobia	9411-9403	10%	Social Phobia	9403	10%	20040823	
			Post-Traumatic Stress Disorder	9411	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Posttraumatic Stress Disorder associated with Social Phobia.  According to the service treatment record (STR) and the MEB narrative summary (NARSUM), the CI was diagnosed with social phobia and PTSD after a reported sexual assault.  According to the CI, the assault occurred in April or May 2003, after she had fell asleep from drinking alcohol.  The record demonstrated that the CI was first diagnosed with social phobia in June 2003 and began treatment for that condition.  On 14 August 2003, at a follow-up primary care appointment for an un-related condition, the CI disclosed that she had been sexually assaulted by a service member, and felt guilt and shame.  The next day, she presented to her therapist where she disclosed the assault for the first time.  She stated that she blamed herself because she was drinking alcohol and did not report because of her guilt.  The CI noted that she was having difficulty sleeping at night and was very anxious about any situations or her future.  The therapist recorded the diagnosis of PTSD for the first time.  PTSD symptoms were not elaborated.  The record demonstrated absence of treatment in the emergency room (ER) and absence of inpatient treatment, and although PTSD was diagnosed, evidence of prominent PTSD symptoms was absent.

During the 10 September 2003 MEB NARSUM examination, 7 months prior to separation, the CI reported difficulty initiating sleep but felt her sleep was sufficient.  She was irritable at times and her energy level varied.  She was receiving therapy for anxiety, and noted that she was feeling better since the change of job and the move off of base.  The CI was also treated with an antidepressant medication.  The CI noted childhood history of physical and sexual abuse, and denied current concerns with domestic violence or abuse.  She had been married for only a few weeks.  The mental status examination (MSE) was unremarkable with the exception of flat affect.  Suicidal ideation or homicidal ideation was absent, and judgment was not impaired.  The examiner noted the Chain of Command had indicated the CI had been dedicated, hard-working and pleasant to work with, and should be considered for retention in another career field.  Her prognosis was assessed as “favorable” with continued treatment of her social anxiety.  The examiner noted support for the recommendation of re-training and retention.

Going forward, the STR noted the CI’s condition was stable and the single treatment goal was to decrease social anxiety.  In January 2004, the CI was prescribed medication for treatment of attention deficit hyperactivity disorder (ADHD), and the anti-depressant medication was discontinued.  Last treatment entry dated 9 March 2004, 6 weeks before separation, recorded diagnoses of social anxiety and ADHD.

There were 2 VA Compensation and Pension (C&P) mental evaluations of record.  During the 11 August 2004 examination, the CI reported a history of childhood traumas, and noted that while drinking at a party on the base, she was sexually assault by another service member.  She reported that the incident was investigated by the Office of Special Investigations (OSI) but OSI claimed there was no proof of any type of sexual abuse.  The CI was working full-time.  She reported she had dreams and nightmares of the assault, and avoided clubs and people, especially men.  She reported that she had problems with her memory at times and was being treated for ADHD.  She reported other symptoms of anxiety.  The MSE was unremarkable.  The examiner assessed social phobia and PTSD and indicated mild psychosocial stressors on Axis IV.  At the 23 August 2004 C&P evaluation, 4 months after separation, the CI reportedly stated, “The most stressful thing that ever happened occurred in April or May 2003” at the Air Force base.  She described the alleged assault, and noted the case was investigated and closed.  The CI reported she had occasional nightmares and anger outbursts, and avoided bars or nightclubs.  The CI was working full-time and reported she had a good marriage.  The MSE was unremarkable with the exception of affect “somewhat flat.”  The examiner did not record a mental health diagnosis, but noted a rule out diagnosis of “complex PTSD.”

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition of PTSD associated with social phobia at 10%, coded 9411-9403.  The VA rated the condition of social phobia at 10% coded 9403, and denied the PTSD claim, based on absence of evidence of a verifiable stressor.  

The panel, IAW DoDI 6040.44 and DoD guidance (which applies current VASRD §4.129 to all panel cases as appropriate), must consider if the definition of §4.129 is met for any psychiatric condition resulting in medical separation; i.e., “a mental disorder that develops in service as a result of a highly stressful event”.  If the panel judges that application of §4.129 is appropriate, it will recommend a minimum 50% rating for a retroactive 6-month period on the Temporary Disability Retired List (TDRL).  The panel must then determine the most appropriate fit with VASRD 4.130 criteria at 6 months for its permanent rating recommendation, based on the facts in evidence which are most probative for that interval.  

The panel next proceeded with its rating recommendation under VARSD§ 4.130 based on the evidence at constructive TDRL placement.  Regardless of the diagnosis, 4.130 rating is based on symptoms independent of diagnosis, therefore, all mental health symptoms (social phobia, PTSD) are considered in the rating, and reflected in the panel’s recommendation.  The panel considered the NARSUM and the commander’s statement dated 6 months prior to separation.  The panel also considered the absence of a history of psychiatric hospitalization, visits to the emergency room for MH symptoms; and the absence of clinical evidence of impaired judgment, problems with thinking, and suicidal or homicidal ideations, and absence of prominent PTSD or social phobia symptoms.  The commander's statement documented symptoms most consistent with her ADHD diagnosis, such as, short attention span, easily distracted, difficulty comprehending simple concepts, and difficulty interacting with others.  The commander stated her performance had been sub-standard and she was unable to work independently.  This report was likely the cause of treatment for ADHD, although the diagnosis had been recognized long before treatment initiation in January 2004.  It should also be noted that the NARSUM documented that the Chain of Command reported a very different assessment of the CI, and reportedly stated that “She [CI] has a good chance for success in an administrative job in the Air Force.”  The STR and the NARSUM demonstrated a clinical focus on ADHD symptoms and social anxiety.  The NARSUM’s treatment recommendations were solely related to the social phobia condition.  The panel considered the record in evidence did not support a higher than 50% rating for TDRL placement.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 50% for the PTSD condition at TDRL placement.

The panel next considered whether the evidence at the time of removal from TDRL and permanent disability disposition supported a rating higher than the 10% rating adjudicated by the PEB.  The C&P examinations were the sole documents in evidence during the TDRL period.  Both examinations recorded “occasional nightmares, sleep disturbance and avoidance of bars or clubs.  The CI was working full-time and reported a good marriage.  There was no mention of any occupational impairment attributable to her MH conditions.  There was an indication of minimal impairment that was transient in nature, in social functioning (avoided crowds and bars).

The panel considered the record in totality and noted that the CI had no history of hospitalization, no recorded ER visits, and no evidence of impairment in judgment as a result of his mental illness.  panel members concluded the evidence demonstrated the CI’s condition was stable during and post constructive TDRL period, and that her disability was most reflective of the 10% level for “Occupational or 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.”  After due deliberation, considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a retroactive 6-month period of TDRL with a rating of 50% (in accordance with §4.129), and a permanent rating of 10% for PTSD associated with social phobia. 

BOARD FINDINGS:  In the matter of the PTSD associated with social phobia condition, the panel recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129 as DOD directed; and a 10% permanent rating at 6 months IAW VASRD §4.130.  There are 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	RATING	
		TDRL	PERMANENT	
PTSD associated with social phobia	9411-9403	50%	10%	

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

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Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-00604.

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.  Accordingly, the Board recommended modification of your records to reflect placement on the Temporary Disability Retired List without change to your assigned disability rating and separation with severance pay, upon final disposition.

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.