RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01227
BRANCH OF SERVICE:  navy	SEPARATION DATE:  20040513

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E3, Store Keeper, medically separated for “schizophrenia, paranoid type” with a disability rating of 10%.

CI CONTENTION:  “Please review for possibility of uncompensated retirement status.”  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 - 20040323	VARD - 20051103	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Paranoid Schizophrenia 	9203	10%	Paranoid Schizophrenia	9203	70%	20040917	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:

Paranoid Schizophrenia.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s schizophrenia condition began on 13  June 2001 after experiencing auditory hallucinations, bizarre thoughts, and paranoia while serving at sea during a period of active duty. Treatment consisted of haloperidol (an antipsychotic medication) and lorazepam (a sedative).  She was transferred to the hospital psychiatric unit where there was a rapid decrease in psychotic symptoms and was she discharged on 15 June 2001 on clonazepam (a sedative).  On 20 June 2001, a hospital psychiatrist documented that she had no psychotic symptoms “at present” but she was “not medically suitable for sea duty/continued service in Naval Reserves.”  

The CI reported symptoms on 10 July 2001 and was placed on Zyprexa (olanzapine, an antipsychotic medication).  On 14 December 2001, the CI reported symptoms of loss of concentration, fatigue, thoughts of death, and fear of losing her job, but no psychotic symptoms.   Zyprexa was continued and Neurontin (gabapentin for nerve pain), Tagamet (cimetidine, an H2 blocker) and Wellbutrin (bupropion, an antidepressant) were added to the treatment regimen.  At a mental health examination on 14 January 2002 the CI reported the “sense someone is watching me.”  Zyprexa and Tagamet were discontinued.  Her Global Assessment of Functioning (GAF) score was 70 (some mild symptoms).  On 8 April 2002 she reported “people talking about me and watching me.”  Risperdal (risperidone, an antipsychotic medication) was added to the treatment protocol.  

On 13 August 2002, the CI had ideas of reference, paranoia, and restricted movement.  Seroquel (quetiapine-an atypical antipsychotic drug) was added to the treatment protocol on 1 October 2002.  On 7 January 2003, the CI indicated she believed “people reading my thoughts.”  On 8 April 2003, the CI reported she was “doing much better.”  On 5 February 2004, the CI reported increased symptoms of paranoia were associated with increased civilian job responsibilities.  Treatment consisted of Geodon (ziprasidone, an antipsychotic medication), Ambien (zolpidem, a sedative), Neurontin and Wellbutrin.  Her GAF score was 60 (moderate symptoms).  

During the 16 November 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported a sudden onset of a psychotic break. Physical examination revealed emotional lability.  The 4 February 2004 MEB NARSUM examination, 3 months prior to separation, noted the complaint of a psychotic breakdown and mental health treatment.  Mental status examination (MSE) revealed the CI to be alert and attentive; however, she remained paranoid and had ideas of reference that others were talking about her.  She heard auditory murmurs of people talking when no one was there and experienced anxiety daily, which restricted her from leaving home due to worsening symptoms when she was around people she did not know.  She was not suicidal or homicidal and her insight was not well-developed.  Her cognition and judgment were intact.

The 3 March 2004 MEB NARSUM examination, 2 months prior to separation, noted complaint of psychotic thoughts. An MSE showed the CI was appropriately dressed and groomed.  There was no psychomotor abnormality.  She described her mood as “afraid,” and her display of affect was frequently tearful.  Speech was linear and logical.  There was no evidence of psychosis, although she reported breakthrough psychotic symptoms when she was under normal stress encountered in everyday life.  She was not suicidal or homicidal.  Cognitive functions, including memory were intact and judgment was considered socially appropriate.  At the beginning of her illness she was a department store manager; however, when she was no longer capable of those responsibilities, she moved to a part-time position in the same store.  On 1 June 2004, the CI the still had anxiety, paranoia, and obsessive thoughts, remained on prescribed medications, and had a GAF score of 70+ (some mild symptoms).  

At the 17 September 2004 VA Compensation and Pension (C&P) Mental Disorder examination, 4 months after separation, the CI reported that in June 2001 while on a period of active duty she was transferred from her usual supply duties to an office with seven other personnel where after a week of rap music, of which two songs were derogatory, she became emotionally labile and suffered a psychotic break.  At the time of the C&P examination she noted that she was extremely anxious about going out into the public for fear that others could read her thoughts and would judge her.  An MSE showed the CI was dressed in casual attire and was clean and groomed.   She was fairly anxious and at times tearful, but was able to compose herself.  She was well-oriented in all spheres.  Her responses were fairly straight-forward and complete and she demonstrated an adequate fund of knowledge.  Her speech was noted at times for dysarthria (slurred or slow speech that can be difficult to understand) secondary to emotional lability related to paranoid ideation.  She felt others were reading her thoughts and judging her in a negative way.  Her affect was fairly guarded and restricted, and her dominant mood was dysphoric (uneasiness and dissatisfaction) and anxious. The examiner noted “the overall impact of [the CI’s] present psychologic distress would be expected to pose significant difficulties for [her] in occupational endeavors.  She reports overall ability to carry on employment . . . secondary to cutting back on her hours, as well as her responsibilities.”  The examiner’s Axis I diagnosis was “schizophrenic reaction paranoid type with ongoing auditory hallucinations, resolved with medications, ongoing delusions, paranoid ideations moderate control.”  Her GAF score was 45 (serious symptoms).  On 10 November 2004, Abilify (aripiprazole, an antipsychotic medication) was prescribed to replace the Geodon.  On 1 February 2005 the CI reported she was “better.” 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the schizophrenia condition 10%, coded 9203 (schizophrenia, paranoid type).  The VA rated the schizophrenia condition 70%, also coded 9203, based on the C&P Mental Disorder examination, citing 70% VASRD criteria.  The panel first considered whether the provisions of VASRD §4.129 (mental disorders due to traumatic stress) were applicable.  Panel members agreed that the evidence of record did not support a traumatic stressor as the cause of the mental condition for which application of VASRD §4.129 would be appropriate.   The panel next considered the §4.130 rating at the time of separation and considered whether the evidence at the time of separation supported a rating higher than the 10% rating adjudicated by the PEB.

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).” A 50% rating 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 (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.”  

Panel members agreed the CI was unable to function when at sea.  Once returned to her Reserve unit she was found physically unqualified, and in her civilian work she was unable to handle her managerial duties and transitioned to part-time employment.  Throughout that time she was under psychiatric care, which she regularly attended, and was treated with several different antipsychotic medications.  She still had anxiety, especially about leaving the house, and paranoia with disturbances of motivation and mood, but her condition did not rise to occupational and social impairment with deficiencies in most areas since she did work, albeit in a position with reduced responsibility and fewer hours, and she had a satisfactory relationship with her husband.  Her judgment remained intact throughout the course of treatment.  While her symptoms were difficult to control and required polypharmacy, nevertheless, they were generally sufficiently responsive such that she had no hospitalizations proximate to separation.   Therefore, panel members favored a 30% rating over a 50% rating.  

While the VA rated her schizophrenia condition 70%, panel members did not find supportive evidence proximate to separation in the STR or VA examinations to support that rating which requires “occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood.”  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the schizophrenia condition, coded 9203.

BOARD FINDINGS:  In the matter of the paranoid schizophrenia condition, the panel recommends a disability rating of 30%, coded 9203 IAW VASRD §4.130. There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Schizophrenia, Paranoid	9203	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160915, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:       (a) DoDI 6040.44
	(b) PDBR ltr dtd 12 Jun 18 ICO XXXXXXXXXXXXXXXXXX	
             (c) PDBR ltr dtd 05 Jul 18 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 11 Jun 18 ICO XXXXXXXXXXXXXXXXXX 
	(e) PDBR ltr dtd 05 Jul 18 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 05 Jul 18 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 05 Jul 18 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (g) are approved.  The official records of the following individuals are to be corrected as follows:

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

     b. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 40 percent rating (increased from 20 percent) effective date of discharge.  

     c. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.  

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

     e. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.   

     f. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
 
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.