IN THE CASE OF: BOARD DATE: 11 February 2016 DOCKET NUMBER: 20150018375 THE BOARD CONSIDERED THE FOLLOWING EVIDENCE: 1. Application for correction of military records (with supporting documents provided, if any). 2. Military Personnel Records and advisory opinions (if any). THE APPLICANT'S REQUEST, STATEMENT, AND EVIDENCE: 1. The applicant requests a review of the military disability evaluation pertaining to a mental health (MH) condition. 2. The applicant states, in effect, the case file should be reviewed in accordance with the Secretary of Defense directive for a comprehensive review of members who were referred for a disability evaluation between 11 September 2001 and 30 April 2012 and whose MH diagnosis was changed during that process. 3. The applicant also states the Department of Veterans Affairs rated him permanently and totally disabled. 4. The applicant submitted an application through the Department of Defense (DOD) Physical Disability Board of Review (PDBR) MH Special Review Panel (SRP). CONSIDERATION OF EVIDENCE: 1. The PDBR SRP conducted a comprehensive review of the applicant’s submissions and records for evidence of inappropriate changes in the diagnosis of an MH condition during processing through the military disability system. 2. The DOD memorandum, dated 27 February 2013, directed the Service Secretaries to conduct a review of MH diagnoses for service members completing a disability evaluation process between 11 September 2001 and 30 April 2012 in order to determine if service members were disadvantaged by a changed diagnosis over the course of their physical disability process. 3. In the processing of this case, an advisory opinion was obtained from the PDBR SRP and the applicant was provided a copy. 4. The applicant did not respond to the advisory opinion. DISCUSSION AND CONCLUSIONS: 1. After a comprehensive review of the applicant's case, the SRP determined by majority vote that the applicant be permanently retired with a final disability rating of 50 percent. 2. The SRP reviewed the records for evidence of inappropriate changes in diagnosis of the mental health condition during processing through the military Disability Evaluation System (DES) program. The evidence of the available records recorded no inappropriate changes in diagnoses to the applicant’s possible disadvantaged during the DES process. Therefore, the applicant did not meet the inclusion criteria in the Terms of Reference (TOR) of the MH Diagnosis Review Project. 3. The SRP agreed that Physical Evaluation Board (PEB) adjudication of unfitting Post-Traumatic Stress Disorder (PTSD) was supported by the evidence and application of the provisions of VA Schedule for Rating Disabilities (VASRD) section 4.129 were appropriately applied. The SRP considered if there was evidence for a VASRD section 4.130 rating higher than 50 percent at time of placement on the Temporary Disability Retired List (TDRL). The higher 70 percent rating is for “Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 4. The SRP noted, the Medical Evaluation Board (MEB) Psychiatric Addendum recorded no history of suicidal ideation, no history of violent behaviors, no MH hospitalization, no visits to the emergency room for MH concerns and no evidence of impairment in judgment or thinking. The applicant reported good family relationships but became anxious around vehicles and only drove when necessary. The mental status examination (MSE) documented the covered individual (CI) as restless and agitated. He required medication for his anxiety and sleep disturbance. The SRP agreed the record in evidence based on VASRD section 4.3, did not support a rating higher than the 50 percent rating rendered by the PEB at TDRL placement. 5. The SRP then considered the rating at TDRL removal or permanent retirement. As noted above, the TDRL examination (3 months pre-TDRL removal) documented no change since TDRL placement exam. The applicant had not worked or gone to college since placement. However, treatment entry noted he was the primary caretaker of 6 children ages 1-9, while his wife worked. He was not participating in MH treatment but was taking medication for anxiety which had not controlled his anger outbursts or panic attacks. 6. After considerable deliberation, the SRP majority found the applicant’s MH condition was worse at TDRL removal. The applicant stated symptoms remained relatively unchanged from 2008 (6 years ago); however, the SRP majority also found the evidence in the TDRL exam more impairing than 6 years earlier. 7. The CI noted having panic attacks when he was driven on the highway around semi- trucks or passed a motor vehicle accident. When the CI drove, he compensated by driving on side streets or during off peak traffic hours. He was now divorced and living with a friend. The applicant stated he used to enjoy going to the park with his children but now he mostly watched television. His only noted activities were the occasional trip to the grocery store and some yard and garden work. The examiner opined the applicant continued to have PTSD symptoms and his condition was unstable, and unlikely to improve to permit return to duty. 8. The SRP majority found these symptoms reflect a difficulty in establishing and maintaining effective work; difficulty maintaining effective social relationships; inaction and disturbances of motivation and mood; and isolation. Based on these aforementioned MH symptoms and impairments, the SRP majority finds it reasonable to conclude the CI had occupational and social impairments with reduced reliability and productivity to recommend a 50 percent rating at TDRL removal. The SRP agreed the VA compensation & pension mental examination, dated 09 June 2012, rendered a PTSD diagnosis and 50 percent rating; however, the exam was performed more than 2 years prior to the TDRL removal and found the exam to have low probative value. After due deliberation, and in consideration of all the evidence and VASRD Section 4.3, the SRP majority recommended a permanent 50 percent rating at TDRL removal. 9. The available evidence shows the SRP's assessment should be accepted. BOARD VOTE: ____x___ ___x____ ____x___ GRANT FULL RELIEF ________ ________ ________ GRANT PARTIAL RELIEF ________ ________ ________ GRANT FORMAL HEARING ________ ________ ________ DENY APPLICATION BOARD DETERMINATION/RECOMMENDATION: The Board determined that the evidence presented was sufficient to warrant a recommendation for relief. As a result, the Board recommends that all Department of the Army records of the individual concerned be corrected by modifying the applicant’s record to reflect the applicant be permanently retired with a final disability rating of 50 percent for PTSD (VASRD Code 9411). . _______ _ _x______ ___ CHAIRPERSON I certify that herein is recorded the true and complete record of the proceedings of the Army Board for Correction of Military Records in this case. ABCMR Record of Proceedings (cont) AR20040003532 3 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS 1 ABCMR Record of Proceedings (cont) AR20150018375 4 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS 1