RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00628
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20040612

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E4, Automated Logistics Specialist, medically separated for “generalized anxiety disorder, with associated depression” with a disability rating of 10%.  

CI CONTENTION:  “Depressive disorder to major depressive disorder.  No board was given for vasovagal syncope diagnosed as temporal lobe seizures.”  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 at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  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 - 20040423	VARD - 20050204	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Generalized Anxiety Disorder, with Associated Depression	9400	10%	Major Depressive Disorder, Generalized Anxiety Disorder	9400-9434	70%	20041216	
Vasovagal Syncope	Not unfitting	Vasovagal Syncope	8999-8914	20%	20050803	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Generalized Anxiety Disorder, with Associated Depression.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s mental health condition began in 2002.  He reported to Family Practice clinic in October 2003 that he had four episodes of loss of consciousness in the past year, beginning in October 2002.  A neurology consult resulted in a diagnosis of syncope and the CI was treated with an anti-convulsion medication, Keppra.  The CI reported multiple side effects to include decreased memory, depression, dizziness, anxiety, agitation and two episodes of suicidal ideation.  The last suicidal ideation occurred 2 weeks previously.  He had no history of anxiety and depression and was taking no other medications.  Due to the presence of a right hand tremor, the CI was referred to Neurology, who referred him to Psychiatry in December 2003 for further evaluation.  At initial screening, the CI endorsed symptoms of severe anxiety and depression, noting that his tremor was worsened by anxiety.  He reported his major stressors were divorcing his wife of 18 years and activation to duty in a high-stress environment.  

During the 18 February 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported hand shaking with rhythmic movement, which did not occur during sleep but starts within 10 minutes of awakening.  He denied pain or paresthesias.  The examiner noted right hand rhythmic tapping non-stop until distracted.  There would be a few seconds of non-tremor.  The tremor slowed with intentional movement.  A diagnosis of conversion disorder was suggested.  

The 4 March 2004 MEB NARSUM examination, 3 months prior to separation, the CI reported prominent anxiety symptoms of restlessness and feeling “keyed up,” easy fatigue, difficulty concentrating, irritability, muscle tension and sleep problems more days than not for the past 2 months.  He was depressed most day than not and had guilt feelings, low energy, loss of appetite and hopelessness but no suicidal or homicidal ideation.  Treatment with anti-depression and anti-anxiety medications has not resulted in any real improvement.  He appeared to have only a mild response to medication and therapy.  He reported a right hand tremor, exacerbated by his anxiety.  Mental status examination (MSE) showed a “very down” mood, blunted, restricted affect, anxiety, poor insight and fair judgment.  Diagnoses included major depressive disorder (MDD) and generalized anxiety disorder (GAD) with a Global Assessment of Function (GAF) score of 55 (moderate symptoms, impairment.)  The examiner noted the recurrent nature of his illness would likely require lifelong medication and treatment.  

At the 16 December 2004 VA Compensation and Pension (C&P) evaluation, 6 months after separation, the CI reported “a lot of depression, a lot of nervousness, which is really bad.  My hand shakes all the time, and sometimes my whole body shakes.”  He was in outpatient treatment at the Mental Health VA Clinic and took two anti-depression medications.  They provided some help but gave sexual side effects and made him feel tired.  He had been out of the work force since early 2004, however, not because of his mental health condition.  He was divorced and lived with a girlfriend.  MSE showed the CI had poor concentration and was disheveled with several days’ growth of beard.  He had a pronounced stutter and his right upper extremity was seen to tremble.  He reported inappropriate behavior of confining himself to his room and admitted to past suicidal thoughts but none current.  Personal hygiene was limited and recent memory was diminished.  He appeared preoccupied with his tremor and stuttering.  He reported irritability, poor sleep, depressed mood, and at times his mind went blank.  He went to the wrong building for his appointment.  Diagnoses of MDD and GAD were rendered with a GAF score of 40 (borderline impairment in reality and in major areas bordering on severe, and severe impairment.)

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the mental health condition 10%, coded 9400 (generalized anxiety disorder), citing Army regulation 635-40, Appendix B-107e, stating that the Soldier’s impairment for social and industrial adaptability was more accurately described as mild, not definite.  The VA rated the mental health condition 70%, coded 9400-9434, (generalized anxiety disorder and major depressive disorder), citing depressed mood, poor concentration, diminished recent memory, irritability, and poor sleep.  

Application of VASRD §4.129 is considered by the panel for all cases of service connected psychiatric conditions resulting in separation; but, all members agreed that the ‘highly stressful event’ requisite for §4.129 was not satisfied in this case.  The panel then considered if there was evidence for a §4.130 rating higher than the10% assigned by the PEB.  The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication,” for a 30% rating is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks,” while criteria for a 50% rating requires “occupational and social impairment with reduced reliability and productivity.”

The NARSUM examination noted symptoms of depression and anxiety with signs of impairment during the MSE.  He appeared depressed and reported that his anxiety exacerbated his right hand tremor.  Treatment with medication and therapy had brought limited improvement.  Panel members noted his GAF score declined from 55 (NARSUM) to 40 (C&P) from March to December, despite treatment with medications.  The panel by majority agreed the CI’s condition resulted from his divorce and work assignment, and that his symptoms proximate to separation were considered mild and transient, and controlled with medication.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the mental health condition.  

Contended PEB Condition:  Vasovagal Syncope.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement nor judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the mental health condition and IAW VASRD §4.130, the panel by majority recommends no change in the PEB adjudication.  In the matter of the contended syncope condition, the panel unanimously agrees that it cannot recommend it for additional disability rating.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160917, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170016326, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
						      					
Enclosure