RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01026
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20050826

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantryman, medically separated from the Temporary Disability Retired List (TDRL) for “panic disorder with agoraphobia” with a disability rating of 0%.  

CI CONTENTION:  He was rated 100% by the VA for post-traumatic stress disorder (PTSD) with panic disorder, agoraphobia, and depressive symptoms and also receives Social Security disability for this condition.  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 - 20050720	VARD - 20050615	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Panic Disorder with Agoraphobia	9412	0%	Post-Traumatic Stress Disorder with Panic Disorder, Agoraphobia, and Depressive Symptoms	9411	50%	20041009	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Panic Disorder with Agoraphobia.  According to the service treatment record (STR), the CI was placed on the TDRL on 26 February 2004 with a diagnosis of “panic disorder with agoraphobia and associated depression” rated at 30%.  Service entry examinations did not record or render a mental health condition.  

The 22 January 2004 VA mental health evaluation, 1 month before TDRL placement, revealed CI complaints of depression, anxiety, panic attacks, mood swings and suicidal ideation, which began in April 2003.  He also related that he had expressed some vague homicidal ideations towards other unit members during a deployment because they “picked on him” for taking “psychiatric medications.”  He reported several traumatic combat-related experiences, being treated with Zoloft (anti-depressant/anxiety medication), and eventually hospitalized in Iraq and Kuwait.  He was medically evacuated in June 2003 to Germany for outpatient treatment and was then hospitalized again upon returning to the US before arriving at his home station.  He reported panic attacks that lasted from 15-30 minutes, 3 times per day, due to stress concerning his wife who was pregnant with their third child.  He had problems with sleep, nightmares of Iraq, being fearful of crowds and leaving the house, and had not been able to work since he was medically evacuated and found he could no longer serve.  The examiner noted the CI had demonstrated an exaggerated startle response and difficulty being in the waiting room, and diagnosed PTSD in addition to panic disorder with agoraphobia and major depression with a Global Assessment of Functioning (GAF) score of 60 (moderate symptoms, impairment).  

At the 9 October 2004 VA Compensation and Pension (C&P) PTSD evaluation, 10 months before TDRL removal, the CI reported exposure to terrifying and disturbing experiences in Iraq, and treatment for depression, anxiety and panic attacks beginning in June 2003.  He suffered from nightmares about “kids scarred up” 2-3 times per week, avoided news about Iraq, felt irritable and anxious all the time, and stayed at home to avoid crowds.  He also experienced impaired concentration, paranoia and vigilance if someone walked behind him, and stated he had 7-8 panic attacks per month.  He was briefly hospitalized in September 2004 for 2 days due to marital stress and unemployment.   His marriage was still rocky and he had worked for several months after discharge, but was fired for missing a shift, and had not found another job.  He planned to enroll in a community college but preferred to stay home and care for his young sons while looking online for a job.  Current medications included an anti-depressant and sleep aid.  The mental status examination showed an anxious and somewhat depressed mood with subdued affect, and the provider noted that the CI’s legs shook throughout the interview.  A diagnosis of PTSD related to combat stressors in Iraq (pending verification of reported stressors) was rendered with co-existing panic disorder and depressive symptoms with a GAF score of 60. 

During the 18 May 2005 TDRL NARSUM evaluation, 3 months before TDRL removal, the CI reported he “always had a problem with anxiety and depression” and had a history of attention deficit hyperactivity disorder.  He stated that a year prior to joining the Army, he saw a psychiatrist for depressed mood, anxiousness, paranoia, and feeling uncomfortable around people.  The psychiatrist diagnosed agoraphobia and depression and treated him with Zoloft.  The CI began having problems in the first month of basic training and “started breaking down” feeling he was slower at learning than the other recruits.  He went to mental health but found treatment unhelpful, and then threatened to kill himself and went absent without leave.  With support from his commander, he completed basic training and graduated, doing well the first 2 years due to “having freedom.”   However, his depression persisted, and his supervisors noted he had some moodiness and other difficulties.  He reported immediately having problems after deploying to Iraq because he was “locked down with no freedom.” He felt very depressed and began having panic attacks.  When other soldiers “picked on him ruthlessly,” he retaliated by accusing them of robbing civilians and of committing “many war crimes.”  He made an equal opportunity and criminal investigational division complaint while in Iraq and was sent to another unit.  After being medically evacuated, he was placed in rear detachment, worked in the gym and began drinking heavily for 2 months.  He wanted to stay in the military but his psychiatrist told him he had too many problems.  

The CI was employed as a car detailer and stated he enjoyed the job and was able to talk to the people there.  His marriage was still strained, but he helped with dinner and getting the kids bathed and to bed in the evenings.  He enjoyed playing video games on the weekends, however, he remained depressed and uncomfortable with crowds.  He reported having no friends and living a socially isolated life; he had been taking medications to treat depression and nightmares since February 2005 when he sought mental health care at the VA.  Upon examination, the CI was normally groomed with a bland, anxious affect and depressed, angry mood.  He ruminated over his anger about the deployment in Iraq, which he found stressful.  The examiner diagnosed depressive disorder, not otherwise specified (NOS), and manifested by a history of depress mood, panic attacks and agoraphobia.  The examiner also noted the condition caused mild impairment for military service and social/vocational adaptability, existed prior to service (EPTS), and was not permanently aggravated by service.  Partner relational problems (manifested by conflict with spouse) were annotated, and Axis II classifications included personality disorder NOS and learning disorder NOS, with a GAF score of 65 (mild symptoms, impairment).  The CI’s condition was characterized by “a long history of maladaptive behavior and difficulty with interpersonal relationships” and the examiner noted the MEB had omitted “his significant past psychiatric history, which would have presented a different clinical picture to the PEB.”  The examiner opined that he met retention standards and made no clinical recommendations.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the panic disorder with agoraphobia 0%, coded 9412 (panic disorder and/or agoraphobia), citing minimal industrial impairment.  The PEB noted the Axis II personality disorder NOS was not ratable since it was not listed on the original MEB as not unfitting and appeared to be a new condition.  The VA initially rated the panic disorder with agoraphobia 30%, based on the STR, as related directly to military service in Iraq.  A 15 June 2005 Decision Review Officer Decision (DROD) then rated PTSD 50%, coded 9411 (PTSD), based on the C&P evaluation, noting a more accurate diagnosis of PTSD with co-existing panic disorder with depressive symptoms, a GAF score of 60,  and service onset with verifiable stressors (it was a combat zone and he was an infantryman).  

Members first considered application of VASRD §4.129, which is required for all cases of service- connected psychiatric conditions resulting in separation, and agreed that despite deployment to a combat zone, CI reports of combat trauma were not verified by command.  Thus, the panel concluded that a “highly stressful event” requisite for §4.129 application was not satisfied in this case.  Additionally, according to PDBR guidance, a new condition that develops while on TDRL is not eligible for review unless the condition meets the scope of review guidance (listed by the PEB and contended by the CI).  The CI contended PTSD, but it was not listed by the PEB, and therefore was not in the scope for review.  Finally, PDBR guidance states that if the PEB did not find a condition existed prior to service, that determination cannot be reversed even if the evidence indicates an EPTS condition should have been adjudicated.  

The final TDRL NARSUM recorded a diagnosis of agoraphobia and depression prior to service entry and reported recurring symptoms almost immediately during basic training as well as upon arrival in Iraq.  The CI returned to treatment in February 2005 for depression and received medication, and while the examiner noted his impairment was mild and he met retention standards, he had regular VA MH visits and reported feeling easily panicked when confronted with stress (often related to marital discord) and interpersonal difficulties.  He continued to take anti-depression medication, though erratically, stating it was helpful and reduced his anxiety and depression.  The panel agreed the CI’s condition was transient and mild with symptoms occurring only during periods of significant stress.  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 panic disorder with agoraphobia, coded 9412.  

BOARD FINDINGS:  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 panic disorder with agoraphobia, coded 9412.  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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Panic Disorder With Agoraphobia	9412	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170221, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180006634, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs. 

Sincerely,					      
Enclosure