RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04787
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050517

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, M1 Armor Crewmember, medically separated for “anxiety disorder, not otherwise specified [NOS]” with a disability rating of 0%.

CI CONTENTION:  In addition to the mental health disorder, the CI requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20050324	VARD - 20051102	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Anxiety Disorder, NOS	9413	0%	Post-Traumatic Stress Disorder (PTSD)	9411	30%	20050928	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Anxiety Disorder, NOS.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s first mental health (MH) presentation was on 21 September 2004 after returning from a 12-month deployment.  At the initial presentation he described “some dreams” but no acute MH issues and no intervention was required.  He returned 2 months later complaining of sleep disturbance, dreams of “dying in Iraq,” “carrying bodies” and depression associated with decreased energy and concentration.  He was experiencing financial and interpersonal stressors.  He denied flashbacks; and, no hypervigilance, avoidance, or other symptoms meeting PTSD diagnostic criteria were in evidence.  He was treated with three psychoactive medications:  Lexapro (mood stabilizer), Depakote (“for impulsivity and anger”) and later doxepin for sleep.  At follow-up a month later he endorsed “continued fatigue, decreased concentration, impulses, anger, irritability and nightmares.”  The psychiatric diagnosis and other details from these encounters were not in evidence.  There was no STR evidence for suicidal ideation or attempts, psychotic or other acute symptoms or any psychiatric crisis or hospitalization.  

At the 21 January 2005 MEB psychiatric NARSUM examination, 4 months prior to separation, the CI endorsed sleep disturbance, nightmares, irritability and depression with unspecified neurovegetative symptoms (possibly the fatigue and decreased concentration previously referenced).  No other PTSD criterion symptoms were documented.  PTSD criterion A stressors could be reasonably conceded, but none were elaborated in the NARSUM or available in the STR evidence.  No personal psychosocial stressors were documented at the time of the NARSUM.  Medications were unchanged from above.  The examiner noted a prior history of suicide attempt and “conduct disorder” at age 15-16, and a history of substance abuse, but stated that the CI currently denied drug use and only drank “about 6 beers a week.”  

The mental status examination (MSE) was normal, with an “okay” mood and “euthymic and congruent” affect.  There was no suicidal or homicidal ideation, no thought disturbance or delusions, no hallucinations or psychosis, “fair to good” insight and normal cognitive testing.  The Axis I diagnosis was “anxiety disorder, NOS,” the psychiatrist specifically opined that PTSD diagnostic criteria were not met, and there was no Axis II diagnosis.  The Global Assessment of Functioning (GAF) assignment was 75 (no more than slight impairment), and the DoDI 1332.39-derived assessment of social and industrial impairment was “mild.”  The examiner stated that the CI was having “mild to moderate difficulty continuing in his MOS” and noted that he was in a relationship without further elaboration of social functioning.  Of probative value import, the MEB psychiatrist opined, “Patient's reliability is somewhat questionable with his symptoms escalating without clear identification on exam and matching his presentation.”  The commander’s performance statement indicated that the CI was a “quality soldier” who could not meet his MOS demands because of S3 profile restrictions (non-deployable, no weapons access, no driving heavy machinery).  There was no STR evidence for any performance limitations outside those restrictions.

At the 12 July 2007 VA Compensation and Pension (C&P) PTSD examination, 5 months after separation, the CI endorsed “insomnia, combat-related nightmares and intrusive thoughts, exaggerated startle response, hypervigilance, irritability, depressed mood, and poor concentration [later adding] intrusive thoughts as well as feelings of detachment from others.”  This full complement of PTSD diagnostic criterion symptoms was stated to have been “continuous since his return from Iraq;” and, the CI provided a “detailed stressor letter” that described “numerous” criterion A stressors from his tour in Iraq.  This included accounts of multiple IED exposures and rocket strikes causing concussions and other injuries, for which there was no mention in the STR or listing on the MEB’s DD Form 2807 report of medical history.

At the time of the C&P, the CI was in MH treatment at the VA and still prescribed Lexapro and Depakote.  The examiner documented recent legal difficulties with current probation and incarceration at the time of military separation, although exact details and degree of overlap with military service could not be ascertained.  This included a recent offense associated with heavy alcohol use, although the CI denied any current alcohol or drug use.  He was unemployed and looking for work, but had held two jobs since discharge that he had lost for reasons unrelated to performance.  The CI contended that he was “not unemployed due to the effects of a mental disorder.”  The VA psychiatrist described some social isolation and stress with interpersonal interactions, but opined that the CI was “able to meet family responsibilities as well as work demands and responsibilities.”

The MSE recorded the CI was “somewhat agitated but overall friendly and cooperative” with no suicidal or homicidal ideation, normal thought process and content, no panic attacks or impaired impulse control, no delusions or hallucinations and no other abnormality except reported memory and concentration deficits for which no objective cognitive testing was documented.  The Axis I diagnoses were PTSD and “polysubstance dependence, in remission” with no Axis II entry.  The assigned GAF was 55 (range of moderate impairment) and the examiner opined that the PTSD symptoms had a “moderately severe impact” on social and occupational functioning (conflicting with the earlier statement that he was able to meet those demands and responsibilities).   A 24 March 2006 VA outpatient entry after the C&P documented an overall favorable course, 10 months after separation, documented the CI doing well, had gotten married and was attempting to enter the Navy reserve.  The VA psychologist opined that he “does appear fit for duty at this time” and assigned a GAF of 75.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the MH disorder 0%, coded 9413 (anxiety disorder, NOS), citing “minimal impairment” (likely equating this to the 0% “remission” criterion under DoDI 1332.39, E2.A1.5).  The VA, referencing the above C&P evidence, rated the MH disorder at 30%, coded 9411 (PTSD), quoting the VASRD §4.130 criteria for a 30% rating; i.e., “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily)” referencing such symptoms as depression, anxiety, suspiciousness, panic attacks, sleep disturbance, and mild memory loss.

With regard to the disparate psychiatric diagnoses between the service and VA, the panel notes that it does not have the authority to recommend a change in the service diagnosis; and, this notwithstanding, there was no service evidence for the requisite diagnostic criteria for PTSD in this case.  Especially considering the preceding, members agreed there was no evidence for a “highly stressful event” related to military service that would justify application of the provisions of VASRD §4.129.  As noted above, no specific stressor related to the Iraq deployment was identified in the available service evidence, although personal stressors unrelated to military service were documented.  It was also noted that the VA did not apply the provisions of §4.129.  

Having so concluded, the panel turned to deliberation of a fair rating recommendation based on criteria of §4.130 applied to the severity of disability in evidence at permanent separation.  Members first agreed that the PEB’s 0% rating was not compliant with the VASRD §4.130 criteria for a 0% rating which specifies that there be no requirement for continuous medication.  Members next agreed that the evidence temporally probative to separation would not support the §4.130 criteria for a 50% rating, “occupational and social impairment with reduced reliability and productivity” referencing such symptoms as flat affect, stereotyped speech, frequent panic attacks, deficits in comprehension and memory, impaired judgment, mood disturbance, and difficulty with establishing relationships.  The CI’s occupational impairment appeared to be mild at most with regard to routine duty, and there were no acute symptoms comparable to the referenced ones.  Deliberations thus settled on a recommendation for a 30% rating (see above §4.130 criteria) versus a 10% rating, with occupational and social impairment due to mild or transient symptoms which decrease work efficiency only during periods of significant stress, or; symptoms controlled by continuous medication.

Members ultimately agreed that the psychiatric impairment at separation was more closely aligned with the §4.130 criteria for a 10% rating than with those for 30%.  The psychiatric acuity, by both the STR and temporally probative post-separation VA evidence, appeared to worsen with personal stressors (finances, relationships, job stability) and to improve significantly as stress resolved.  The low acuity during relatively stress free periods at the time of the NARSUM and at the 10-month post-separation VA psychology note were good examples, as was the more acute presentation in the setting of significant personal stressors at the time of the C&P.  The normal MSE, high GAF assignment, and assessment of mild civilian occupational impairment documented in the NARSUM, along with the relationship to “periods of significant stress” as just elaborated, are well aligned with the 10% criteria.  With regards to the 30% criteria, an “occasional decrease in work efficiency” might be fairly conceded even in the absence of specific documentation to that effect; but, the STR and the post-deployment employment history did not identify any of the requisite “intermittent periods of inability to perform occupational tasks.”  Additionally, some probative value mitigation of the reported psychiatric severity is reasonably justified by the relevant MEB psychiatric opinion and the disparity between the STR evidence and VA accounts regarding the nature of the symptoms and severity of combat stressors.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a 10% rating for the anxiety disorder under code 9413.

BOARD FINDINGS:  In the matter of the anxiety disorder, the panel recommends a disability rating of 10%, coded 9434 IAW VASRD §4.130.  There are no other conditions within the panel’s scope of review for consideration.

The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Anxiety Disorder, Not Otherwise Specified	9413	10% 	

The following documentary evidence was considered:

[AR NUMBER], 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.

Enclosure