RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:XXXXXXXXXXXXXXXXXXXXXXXXX	CASE: PD-2017-03978
BRANCH OF SERVICE:  NAVY	SEPARATION DATE: 20051007

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Dermatology Technician, medically separated for the overall effect of “social phobias,” “Tourette's disorder,” and “obsessive compulsive disorder [OCD],” with a disability rating of 0%.

CI CONTENTION: “Respectfully request reevaluation of rating...” 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 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 - 20050718	VARD - 20051014	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Social Phobias	
Overall Effect (0%)	
Neuropsychological Disorder with Residuals	
8599-9327	
100%	
20050810	
Tourette's Disorder						
OCD						
Asperger’s Disease	Cat IV					
Hyperlipidemia	Cat IV	No VA Placement	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 100%	

ANALYSIS SUMMARY:

Social Phobias, Tourette's Disorder and OCD. The PEB combined the social phobias, Tourette’s disorder, and OCD under a single disability rating for “overall effect” as permitted by DoDI 1332.38 (E3.P3.4.4). The combination of multiple conditions as a single disability reflects the PEB’s determination that each condition was not separately unfit, but the functional impairment resulting from the conditions when considered together was unfitting. The panel’s initial charge in this case was therefore directed at determining if the PEB’s single overall effect rating was justified in lieu of separate unfit determinations and ratings. If the panel judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was unfitting in and of itself as shown by a preponderance of evidence. The panel’s recommendations may not produce a lower combined rating than that of the PEB.

The evidence for the social phobias, Tourette’s disorder, and OCD is presented together, but with a separate fitness determination and rating recommendation for each condition, if indicated.

According to the service treatment record and MEB narrative summary (NARSUM), the CI was first seen for complaints of anxiety symptoms associated with claustrophobia, decreased social contact, and a depressed mood in October 2004, and Paxil (antidepressant) was prescribed. At a mental health (MH) clinic interview, it was clear that he was feeling anxious around others, had significant fear of large groups, avoided close communication or contact with others, and had difficulty understanding sarcasm or symbolic speech, which was reflective of significant psychiatric distress. He described chronic intrusive thoughts with themes of aggression, religion, and sexuality that were accompanied by rituals of checking so significant that he had been late to work and had worn out locks in base housing. He also endorsed obsessive concerns about safety, cleanliness, and counting behaviors, and had vocal tics with hissing sounds and motor tics manifested by muscle spasms of his hands, neck, and face. He also experienced mild auditory hallucinations like the sound of being in a room with many people talking. He reported being more even tempered since his Paxil dosage was increased. He regularly attended psychology treatment sessions which addressed work related stress and feelings of anger and frustration and techniques to provide relief. In May 2005, he took risperidone (atypical antipsychotic medication), but within several weeks he experienced more intrusive thoughts in the context of increased stress at work and at home related to a daughter’s medical condition; however, he stated his tics had resolved for the first time in his life and the intrusive thoughts occurred far less. Citalopram (antidepressant medication) was prescribed to replace the Paxil, but caused fatigue and memory impairment. At a psychiatry visit on 16 June 2005, he reported no tics and less intense intrusive thoughts, which were not bothersome.

The 15 June 2005 MEB NARSUM examination, 4 months prior to separation, noted CI complaints of declining occupational performance from previously being very conscientious and doing well in his military specialty. Increased patient contact, supervisory responsibilities, and competition for promotion exacerbated his symptoms. The MSE revealed good grooming and hygiene. He was cooperative and pleasant at all times, although his dysphoric mood (sadness or irritability) often contributed to brief responses and poor eye contact. No psychomotor abnormalities were noted, and speech was normal in rate, rhythm, and volume, but with a flattened tone. Mood was typically neutral with constricted affect, and thought content was focused on the interview process, with no obvious indications of a thought disorder or psychosis. Thought processes were logical, linear, and goal directed, and he denied current suicidal or homicidal ideation, plan, or intent. Intelligence was clinically estimated as at least average, and memory was intact for short and long term recall. Insight and judgment appeared good and impulse control was intact. The examiner’s Axis I diagnoses included: social phobias, which existed prior to service (EPTS) and were service aggravated; and OCD, Tourette’s disorder, and Asperger’s which all were EPTS conditions. Each condition was felt to be moderately impairing for social/civilian adaptability. The General Assessment of Functioning (GAF) score was 60-61 (mild to moderate symptoms or dysfunction). During the MEB examination (recorded on DD Forms 2807-1 and 2808), 5 days later, the CI reported a history of panic attacks that resulted in shortness of breath, anxiety, social phobias, OCD disorder, Asperger’s, and Tourette’s. Physical examination revealed a blunted affect and decreased eye contact with normal thought and speech.

The 5 July 2005 non-medical assessment noted the CI had increasing difficulty functioning in his role as leading petty officer, as exhibited in his inability to develop appropriate relationships with coworkers or peers, which led to a stressful and inefficient work environment. Although he did well with “routine” duties, he could not adapt to new or evolving tasks and this made each day an emotional struggle. His verbal and non-verbal mannerisms were perceived as odd and unsettling to many patients, and he was frequently absent from work because of medical appointments and therapy. Each day presented difficulties for him as his job required interaction

with dozens of patients and coworkers. Despite maximal treatment, improvement was not noticed in his ability to perform the duties expected of his rank.

At the 10 August 2005 VA Compensation and Pension (C&P) MH examination, 2 months before separation, the CI reported shoulder jerking and some vocalizations, which were diagnosed as Tourette's disorder. The MSE revealed he was casually dressed and cooperative with an anxious and blunted affect. Speech was of a normal rate and rhythm with no latency or pressure. He denied any suicidal ideation or hearing sounds during the interview, and concentration, comprehension, memory, and orientation were intact. The Axis I diagnoses were social phobia, OCD, and Tourette’s disorder with a GAF score of 70 (moderate symptoms).

The panel directed attention to its rating recommendation based on the above evidence. As noted above, the PEB determined that the social phobias, Tourette’s disorder, and OCD, taken together, were deemed to be unfitting based on the overall effect. The VA rated the neuropsychological condition 100%, analogously coded 8599-9237 (organic mental disorder, other), based on the C&P examination, citing evidence of an occupational and social impairment with associated complaints/findings of vocal/facial/upper extremity muscle tics, sudden disengagement from occupational duties, social isolation (both in group and interpersonal settings), anxiety intrusive thoughts with themes and aggression, inability to process parables (reports show that you presented with concrete answers), "checking" rituals, which were found to be significantly interfering with work, flattened affect, depressed mood, poor coping mechanisms, and mild auditory hallucinations. The VA determined the Tourette's, Asperger's, and social phobia syndromes existed prior to active duty military service; however, none of the conditions were mentioned at the enlistment examination nor was there evidence of psychological or neurological dysfunction. Therefore, they were felt to be service aggravated and were service connected.

Panel members concluded that there was not a preponderance of evidence showing that the Tourette’s disorder and OCD each standing alone would have caused the CI to be referred into the disability evaluation system or to be found unfit since he was able to function with both conditions during his many years of service and his tics had resolved with treatment. The panel then discussed the social phobias in depth. Because of the CI’s desire to avoid patients and/or people in general, he had difficulty at work, and panel members concluded the preponderance of evidence of the service records showed that the condition standing alone was separately unfitting for continued military service. Furthermore, the panel noted that although it may have existed prior to service, it was service aggravated and the EPTS designation is also overcome by the fact that he served more than 8 years of active duty IAW 10 USC 1207a. The panel then considered a rating using code 9403 (specific (simple) phobia; social phobia), and the panel majority agreed that although his condition met some criteria for a 50% rating, for “occupational and social impairment with reduced reliability and productivity,” the majority of social phobia symptoms persisted unabated resulting in significantly declined performance and an intermittent inability to perform tasks thereby favoring a 30% rating. The minority voter considered a 10% rating to be appropriate noting the CI had a specific plan for working after separation, was better on medication (tics resolved and intrusive thoughts were less intense and bothersome), was able to interact and train his replacement, had a GAF of 60-61 for “mild to moderate symptoms or dysfunction; only during periods of stress,” and had been married for 12 years. Additionally, although his symptoms were exacerbated symptoms due to his promotion and position and the requirement for increased patient contact and supervisory responsibilities, he did well when not in that situation. 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 social phobia condition, coded 9403.

Contended Category IV Conditions: Hyperlipidemia and Asperger’s Disorder. The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not

unfitting. In accordance with DoDI 1332.38, E4.13.1.4 and E5, none of the contended conditions constitute a physical disability, and are therefore not compensable.

BOARD FINDINGS: In the matter of the social phobia condition, the panel majority recommends a disability rating of 30%, coded 9403 IAW VASRD §4.130. The single voter for dissent recommends modification to 10% and did not elect to submit a minority opinion. In the matter of the Tourette’s disorder and OCD and IAW VASRD §4.130, the panel recommends that neither condition is separately unfitting. In the matter of the contended hyperlipidemia and Asperger’s conditions, 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	
Social Phobias	9403	30%	

The following documentary evidence was considered:

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN REPLY REFER TO
6040
CORB:003 14 May 21

From: Director, Secretary of the Navy Council of Review Boards To:	XXXXXXXXXXXXXXXXXXX

Subj:	Physical Disability Board of Review Determination Ref:	(a) 6040.44(Series)
1.	The Physical Disability Board of Review (PBDR) reviewed your case in accordance with reference
(a) and forwarded their recommendation for action.

2.	On 23 April 2021 the Assistant Secretary of the Navy (Manpower and Reserve Affairs) accepted the PDBR’s recommendation of an increase in disability rating to 30% and placement on the Permanent Disability Retired List. This decision was then sent to Navy Personnel Command for appropriate action.

3.	The PDBR determination is final and not subject to appeal or review.