RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXX	CASE: PD-2017-03554
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20080810

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Power Generator Equipment Repairer, medically separated for “anxiety disorder not otherwise specified [NOS]” with a disability rating of 10%.

CI CONTENTION:  “Review all conditions.”  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 – 20080407	VARD - 20081117	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Anxiety Disorder NOS	9413	10%	PTSD	9434-9411	70%	20080819	
Left Knee Pain	Not Unfitting	Left Knee Tendinopathy	5299-5024	10%	20080731	
Left Shoulder Pain (Dominant)	Not Unfitting	Left Shoulder Tendinopathy	5299-5024	10%	20080731	
Hypercholesterolemia	Not Unfitting	No VA Placement	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 80%	

ANALYSIS SUMMARY:

Anxiety Disorder NOS. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s mental health (MH) disorder began during basic training. He felt depressed and feelings increased during his deployment to Iraq from October 2005 to December 2006. During that time, at least four family members died and he reported he had a hard time dealing with that. He reported several combat stressors, including witnessing his best friend killed by a sniper, for which he saw the combat stress team. The CI reported that after the death

of his friend he began to have difficulty with sleep. He recalled taking no medications. His condition worsened when his tour was extended. He reported he was seen by Behavior Health in Alaska for depression and anger issues. In March 2007 he presented with complaints of combat stress (from his previous deployment), depression and anger management problems. Initial diagnoses were anxiety disorder, NOS, and PTSD. He began regular psychiatric care (therapy and medication). Multiple STR notes cited ongoing marital issues and subsequent marital counseling.

The CI recalled having depression at age 12 after his grandmother died. He had anxiety and occasional suicide ideations at some point but was never evaluated or treated by MH. The MEPS enlistment examination in September 2004 revealed no significant abnormalities or active problems, and he did not require any waivers to enlist. On the Post-Deployment Health Assessment (PDHA), dated 29 November 2006, the CI denied combat exposures or MH symptoms. He received a temporary S3 profile for anxiety disorder in June 2007. On 27 July 2007, his psychiatrist referred him to an MEB due to the chronicity and severity of his symptoms. The commander’s note, dated August 2007, referenced PTSD as a condition which affected his duty performance significantly.

The 29 August 2007 MEB psychiatry addendum, noted initial symptoms of irritability, anger, hypervigilance, avoidance of talking about Iraq, recurring nightmares of Iraq, indistinguishable “whispers at night” and difficulty with sleep. Mental status examination (MSE) showed anxious affect, worried and tearful and the CI stated his mood was depressed. He endorsed paranoid ideation but denied suicidal and homicidal ideation, but wanted to drop atomic bombs on Iraq. A diagnosis of PTSD was rendered with a Global Assessment of Functioning (GAF) score of 51 (moderate symptoms, impairment).

The 30 August 2007 MEB NARSUM examination, 11 months prior to separation and conducted by a family practice physician, noted no improvement although the CI was taking several medications, including celexa (for anti-depression), risperidone (for anti-psychosis), prazosin (for nightmares) and ambien (a sleep aide). The CI reported not working in his MOS since December 2006 because his condition made it difficult to focus and he had anger control problems. The CI reported he attempted to kill himself with his gun and smashed walls in his home in November 2007. He also reported getting a DUI in December 2007 but denied that alcohol use interfered with his work performance or with relationships. A letter submitted by another soldier who was deployed with the CI stated the CI had been on 5-10 missions outside of the wire and had received direct hits from IEDs. However, the CI was not awarded a combat action badge and on his post- deployment health assessment denied seeing anyone wounded or killed, denied being engaged in direct combat and did not feel he was in great danger of being killed. The commander’s statement (deployed commander) noted concerns with reduced duty performance and the CI not wanting to deploy again because of family and marital problems, but made no reference to the combat incidents reported by the CI. Diagnoses of PTSD and cognitive disorder, NOS, were rendered with a GAF score of 55 (moderate symptoms, impairment.) The diagnosis of PTSD was crossed out and a hand written note stated “psychiatry changed diagnosis to anxiety disorder.”

Neuropsychological evaluation in January 2008 noted the CI reported an IED blast that occurred to the right of the CI’s vehicle, reportedly slamming his head against the hatch. The CI reported he was severely dazed and was not sure of loss of consciousness. The CI also reported one of his good friends and fellow soldier was killed shortly after the explosion. After the explosion, the CI reported having increased sadness and anger, irritability, panic attacks and restlessness. The psychologist noted, “generally intact neuropsychological functioning with specific deficits” consistent with post-concussive syndrome. Self-report confirmed a diagnosis of PTSD. The 18 January 2008 psychiatry addendum resulted in a diagnosis of anxiety disorder, NOS, a GAF of 51 (moderate symptoms, impairment) and a recommendation for a permanent S3 profile.

At the 28 March 2008 MEB psychiatry consultation, the psychiatrist was unable to substantiate whether or not the traumatic incidents described by the CI occurred. The CI reported continued insomnia, nightmares (with agitation at night) and one incident in which he struck his wife. He was angry, irritable and minimally compliant with medications. He had been married for 3 years and had a 2-year-old daughter. He only slept with medication and reported decreased appetite over the past month with a weight loss of 15 pounds. He scored 29 on a Depression Inventory. The MSE showed mood and affect which appeared differently. Initially he appeared angry and irritable but affect was broad ranging and he was generally appropriate. When asked about Iraq, he became tearful but did not cry. He appeared depressed. Diagnoses of PTSD and cognitive disorder, NOS, and post-concussive syndrome were rendered with a GAF score of 55 (moderate symptoms, impairment).  Medications included prazosin, celexa, trazodone and ambien.

The 6 March 2008 commander’s statement (WTU commander) indicated the CI worked about 15 hours per week in the Cafe, cooperated well with others, worked independently, was an outstanding Soldier in the WTU, with exemplary performance, and presented no problems to the command. The CI reported to case management on 1 May 2008 that his marriage was getting better and the CI and his wife were not filing for divorce as previously planned. The CI requested a Continuance on Active Duty (COAD) on 29 May 2008 but the request was denied.

At the 19 August 2008 VA Compensation and Pension (C&P) examination, 9 days after separation, the CI reported ongoing symptoms of PTSD and depression. He reported low motivation, nightmares of family members in Iraq and episodic suicidal ideation. He had acquaintances but rarely socialized and reported trust issues. He reported hearing whispers of someone speaking Arabic. He was married and spent his days reading and teaching his kids academics. He enjoyed playing video games and playing with his children. He worked on developing his franchise in commercial cleaning. He reported he was receiving psychiatric treatment and was prescribed celexa, mini-press (anti-hypertensive), trazodone and ambien. He reported his medication were “good, working fine.” He was not currently in psychotherapy. He reported episodes of domestic violence and the last violence call to police was February 2008. The MSE showed a slightly flat affect with irritable and tearful mood when discussing the loss of his friend. Diagnoses of major depressive disorder and PTSD were rendered with a GAF score of 38 (some impairment in reality testing or communication or major impairment in several areas).

During the March 2009 C&P examination, 7 months post-separation, the CI reported sustaining a TBI after an IED. He was prescribed citalopram, prazosin, trazodone and zolpidem, which helped. He reported nightmares 2-3 times per week, flashbacks monthly, sleep difficulties, anxiety and other symptoms of PTSD. He reported weekly panic attacks, had punched a wall 2 weeks before this examination and lost control of his anger about twice a week. He was no longer working and had last worked in July 2008. That job had only lasted about 2 months because of anger issues. He had previously worked at a prison for a week or two but left due to irritability and anger. He was attending college full time online due to issues with a teacher, and had a 3.6 grade point average. He had to drop classes twice due to inability to keep up with his coursework. The MSE showed a mini mental status of 21 out of 30 and a depressed mood. Diagnoses of cognitive disorder, NOS, PTSD and depressive disorder, NOS, were rendered with a GAF score of 44 (serious symptoms, impairment).

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the MH disorder 10%, coded 9413 (anxiety disorder, NOS), citing symptoms that decreased work efficiency and ability to perform occupational tasks only during times of significant stress. The VA rated the MH disorder 70%, dual coded 9434-9411 (major depressive disorder-PTSD), based on the C&P examination, citing deficiencies in most areas.

The panel considered whether VASRD §4.129 applied to this case, but members agreed the requisite ‘highly stressful event’ was not satisfied.  The CI reported on the PDHA he had not been

exposed to any combat trauma and the buddy letter was not an eyewitness account of events. Record verification indicated the friend was not killed at the hands of a sniper as reportedly witnessed by the CI. The commander noted the CI was outstanding in the WTU and performance was exemplary. There was no evidence of PTSD at the time of separation as reflected by an absence of Criteria C symptoms of distancing in relationships, numbing or detached feelings (regular church attendance, cooperated well with others, worked independently, no problems with his command, played with his children and taught them academics) or sense of a foreshortened future. There was also no evidence of Criteria F clinically significant distress in occupational or social areas of functioning (marriage was getting better, requested a COAD and was developing his franchise).

The panel considered if there was evidence for a §4.130 rating higher than the 10% adjudicated by the PEB. The §4.130 criteria for a 10% rating is, “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.” The 30% criteria is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.” There were multiple MH notes in evidence before and after discharge, many of which addressed issues involving his wife rather than stressors of deployment. As noted above, the commander noted outstanding performance in the WTU prior to separation, a divorce had been avoided and his marriage was improving. The C&P examination noted he continued to take anti-depression medication and sleep aides, which he said was helping. He reported low motivation and isolation with episodic suicidal ideation. The 2009 C&P examination noted he was not able to keep his job in July 2008 due to anger issues and was attending school online due to issues with a teacher. The CI was admitted to inpatient psychiatry in April 2009 due to suicidal and homicidal ideation due to spousal conflict. After much discussion and review of the STR, panel members agreed there was some transient improvement prior to separation but the CI continued to show symptoms of depression, anger, irritability and sleep problems that met the criteria for a 30% rating. 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 MH disorder, coded 9413.

Contended PEB Conditions: Left Knee Pain, Left Shoulder Pain and Hypercholesterolemia. The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting. None of the conditions were profiled, implicated in the commander’s statement or judged to fail retention standards. There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS: In the matter of the MH disorder, the panel recommends a disability rating of 30%, coded 9413 IAW VASRD §4.130. In the matter of the contended left knee, left shoulder and hypercholesterolemia, the panel recommends no change from the PEB determinations as not unfitting.  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	
Anxiety Disorder Not Otherwise Specified	9413	30%	

AR20190007841, XXXXXXXXXXXXXXXXXX 

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Dear XXXXXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiries concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

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