RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXX	CASE: PD-2017-04553
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20061013

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Cannon Crewmember, medically separated for “anxiety disorder” with a disability rating of 10%.

CI CONTENTION: “Increase in depression and anxiety. Possible PTSD.” 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 – 20061002	VARD - 20070606	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Anxiety Disorder	9413	10%	Recurrent Depression with Anxiety Disorder	9412-9434	30%	20070110	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

Anxiety Disorder. According to the service treatment record and mental health (MH) MEB narrative summary (NARSUM), the CI first sought MH treatment in March 2006 after returning from a deployment to Iraq. While in the Reserves in 1999, he was treated for depression with antidepressant medication for 1-2 years, but was relatively symptom free before seeking active duty re-enlistment in 2003. He reported that he served in Korea without problems, and while in Iraq he performed “appropriately and reasonably,” while serving in a training capacity, and also during patrols once a week. His base was regularly hit with mortars and rockets, and he witnessed a good friend being hit and killed by a rocket. The CI sought MH treatment after his

return from deployment for increasing anxiety attacks. He was diagnosed with major depression and anxiety disorder, not otherwise specified (NOS), and was treated with antidepressant (Paxil) and sleep (Ambien) medications.

At the 11 August 2006 MH MEB NARSUM, 2 months prior to separation, the CI reported irritability, hypervigilance, difficulty sleeping, feeling emotionally numb and distant, and avoiding thoughts of stressful military experiences. He denied feeling suicidal or homicidal. During the mental status examination (MSE), he was neatly groomed with good eye contact, and described his mood as “okay.” The psychiatrist noted he was “intermittently slightly tearful when talking about some of the stressors in Iraq and at NTC,” but the examination was otherwise unremarkable. The Axis I diagnoses were anxiety disorder, NOS (incurred in the line of duty, but did not exist prior to service (EPTS)), and recurrent major depression (EPTS and service aggravated). A Global Assessment of Functioning (GAF) score of 58 (moderate symptoms, impairment) was rendered, and the examiner stated that although the CI’s depression had been in remission, since redeployment he had developed “increasing anxiety disorder symptoms in the PTSD spectrum.”

The 5 September 2006 commander’s statement noted that during his rear detachment assignment, the CI had not shown any visible signs of an MH condition, and was trusted to accomplish all tasks. The commander recommended the CI be given the opportunity to remain in the Army if he chose to do so.

The 15 September 2006 MEB NARSUM examination, 1 month prior to separation, noted complaints of anxiety in crowds, suicidal thoughts, and being easily angered with junior enlisted Soldiers. The examination summarized the same information recorded in the MEB psychiatric consultation above, and noted that the CI was restricted from access to firearms and assignments remote from definitive psychiatric care.

At a 15 December 2006 VA outpatient MH visit, 2 months after separation, the CI reported that he struggled with depression, hypervigilance and paranoia, and had anxiety attacks with nervous tics. The CI related that when he sought help from the chaplain in Iraq, he “knew the symptoms from before…[and] knew he was soon for breakdown.” He had difficulty falling asleep, awoke 4- 5 times a night, and made safety checks at night in response to noises. Within the past couple weeks, he reported an anxiety attack in the middle of a grocery store and subsequent tics that lasted all day. He was unemployed but was starting truck driving school in January 2007. The provider documented that he was nervous and jumpy in response to the sound of a motorcycle during the examination, and the MSE revealed an angry mood and speech with an anxious rate/rhythm, as well as loosening of associations and depersonalization in thought content. The Axis I diagnoses were recurrent major depression and PTSD, with a GAF assignment of 45 (serious symptoms, impairment).

At a 3 January 2007 VA outpatient MH visit for individual therapy, the CI endorsed an increase in flashbacks, intrusive thoughts, anxious shaking episodes and overwhelming grief after learning that a young Soldier he had trained had just been killed in Iraq and that his child was born just hours after his death. His insight and judgment were good with awareness of the impact of his frustrated and angry outbursts on his family. He denied suicidal/homicidal thoughts. At a visit with the VA psychiatrist on the same day, he reported depression and anxiety, with panic attacks that caused nervous tics and occurred 2-3 times a month despite medications. The MSE revealed a “mildly anxious” mood, normal speech, and loosening of associations and depersonalization. The Axis I diagnoses remained the same, with a GAF score of 55. Antidepressant and sleep medication dosages were increased.

At the 10 January 2007 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported difficulties while assigned to the NTC because he felt the training was

unrealistic and unhelpful. He was still grieving the loss of his friend in Iraq, as well his trainee, and reported 2-3 anxiety attacks per month. He had one ER visit in March 2006 when he had shortness of breath and “thought he was going to die.” He denied any problems with alcohol or use of illicit drugs, and was successfully attending truck driving school with good concentration, had secured his commercial driver’s license, and was looking forward to starting a new career. He and his fiancée and were planning to get married soon and he maintained good relationships with friends and family. He had a normal daily routine of waking, eating breakfast, going to truck driving school, doing homework after school and having supper with his fiancée and her daughter. He went to sleep at 9 PM but had difficulty with disrupted sleep (for which medication was being adjusted). He denied suicidal thoughts, irritability, helplessness, and hopelessness.  He did worry about money and had a panic attack on Christmas that lasted about 4 hours. However, he got through the holidays “pretty well” with all his social obligations. The MSE was normal, and psychiatrist opined that the CI’s current symptoms did not meet the full diagnostic criteria for PTSD as diagnosed by another MH provider. There had been no psychiatric hospitalizations and the CI’s anxiety and depression symptoms seemed under “pretty good” control on Paxil, trazadone (sleep aid) and Klonopin (anti-anxiety). The Axis I diagnoses were major depressive disorder and panic disorder with a GAF score of 66 (mild symptoms, impairment). The psychiatrist further noted the CI’s symptoms were intermittent and nearly in remission, with no impairment in social functioning or employment.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the MH disorder 10%, coded 9413 (anxiety disorder), citing “mild industrial impairment based upon functional capacity.” The VA rated the MH disorder 30%, dual coded 9412-9434 (panic disorder-major depressive disorder), based on the C&P examination, citing occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to panic attacks and chronic sleep impairment.

Panel members first considered whether the provisions of VASRD §4.129 (mental disorders due to traumatic stress) were applicable. During deployment, the CI experienced the highly stressful event of seeing his friend killed by a rocket. Thus, the panel agreed that the stipulations of §4.129 were met in this case and therefore recommends a minimum 50% rating for a retroactive 6- month period on the Temporary Disability Retired List (TDRL). However, there was no evidence to support a rating higher than 50% at the time of TDRL placement.

The panel then turned to its permanent rating recommendation at the time of TDRL removal. Panel members noted that at the time of the MEB MH NARSUM, the CI reported anxiety and some PTSD symptoms of emotional numbing and wanting to avoid military memories. However, the commander’s statement, written 3 weeks later, indicated he was performing his duties well and recommended retention in the Army. At the January 2007 VA MH visit, he had increased symptoms following news of the death of a young Soldier he had trained. At the C&P examination one week later, he reported continued difficulty sleeping and anxiety/panic attacks 2-3 times a month, but that he was performing well in a new job and had good relationships with family and friends. The VA psychiatrist indicated there was no impairment of the CI’s occupational or social functioning at the time of the examination and that symptoms were well-controlled on medications. The panel agreed that despite ongoing symptoms, the CI was functioning well, and that a 10% rating was supported for “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” based on the C&P examination, which was most proximate to TDRL removal. There was no evidence of occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks required for the next higher 30% rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a retroactive 6-month period on the TDRL with the mandatory minimum 50% rating (IAW §4.129) for the anxiety disorder and a permanent (at TDRL removal) disability rating of 10% for the anxiety disorder, coded 9413.

BOARD FINDINGS: In the matter of the anxiety disorder, the panel recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129 and a 10% permanent disability rating at 6 months IAW VASRD §4.130. There were no other conditions within the panel’s scope of review for consideration.

The panel recommends that the CI’s prior separation be modified as follows: TDRL at 50% for a period of six months following the CI’s prior medical separation (minimum of 50% IAW 4.129) and then permanently separate with severance pay with a final 10% rating as indicated below:

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Anxiety Disorder	9413	50%	10%	

The following documentary evidence was considered:

AR20190012735

Dear: XXXXXXXXXXXXXX

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to constructively place you on the Temporary Disability Retired List (TDRL) at 50% disability for six months effective the date of your original medical separation for disability with severance pay and then following this six month period no re-characterization of your separation or modification of the permanent disability rating of 10%.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The constructive TDRL period will result in an adjustment to your pay providing you 50% retired pay for six months from the date of your original medical separation and then no re-characterization of your separation or modification of the permanent disability rating of 10% following the constructive six month TDRL period	

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. 

	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.  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.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX.

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