IN THE CASE OF: BOARD DATE: 8 March 2016 DOCKET NUMBER: AR20160003268 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 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 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 unanimous vote that the applicant’s record should be modified to reflect his unfitting and his condition diagnosis and changed to Post-Traumatic Stress Disorder (PTSD), and that his prior separation be modified to reflect that the applicant was placed on the Temporary Disability Retired List (TDRL) at 70 percent for a period of 6 months and then a permanent combined 70 percent disability retirement. 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). The evidence of the available records show a diagnosis of anxiety disorder not otherwise specified (NOS) was rendered and a rule-out of PTSD. The SRP determined that a MH diagnosis was likely changed to the applicant’s possible disadvantage in the disability evaluation. The rule-out PTSD diagnosis remained and therefore, should have either been confirmed or ruled-out prior to medical retirement. Therefore, the applicant met the inclusion criteria in the Terms of Reference (TOR) of the MH Diagnosis Review Project. 3. The SRP agreed the Physical Evaluation Board PEB adjudication of unfitting anxiety disorder NOS was not supported by the evidence since the preponderance of evidence strongly supported the diagnosis of PTSD. The SRP reviewed the Statement of Medical Examination Duty Status (LOD) document dated 14 June 2005 that noted the covered individual was injured in an attack on his High Mobility Multipurpose Wheeled Vehicle, and was diagnosed with depression and PTSD. The commander’s statement dated 28 December 2007 noted the applicant had a PTSD diagnosis. It was noted on two different psychiatric evaluations with different providers that the applicant met Diagnostic and Statistical Manual of Mental Disorders-IV diagnostic criteria for PTSD and both provided strong clinical documentation supporting the diagnosis. The applicant’s profile listed PTSD as the only MH health diagnosis. The applicant attended PTSD groups, took medication, and both his therapist and psychiatrist continued to treat him from 2005 for the diagnosis of PTSD. 4. The SRP in compliance with the provisions of Department of Veterans Affairs Schedule for Rating Disabilities (VASRD) section 4.129 (mental disorders due to traumatic stress) noted the provision was applicable in this case and therefore, must recommend placement a period of constructive TDRL with a minimum rating of 50 percent with reassessment after 6 months. The higher 70 percent rating criteria requires evidence of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The psychiatric addendum was the only record in evidence prior to constructive TDRL period and that exam did not record a history of psychiatric hospitalizations, visit to the emergency room (ER) for mental health issues, or evidence of impairment in judgment or thinking. His MSE during the addendum was normal and he had a Global Assessment of Functioning score of 60. He was having some interpersonal struggles at work but was able to maintain employment. 5. The SRP determined the record in evidence did not support a higher than 50 percent rating for TDRL placement, and therefore concluded there was insufficient evidence for recommending a rating higher than 50 percent at TDRL placement. The SRP next determined an appropriate rating using VASRD section 4.130 criteria at the end of TDRL for its permanent rating recommendation. The SRP deliberated the evidence for the 50 percent, 30 percent and 10 percent disability rating. The 30 percent disability rating requires evidence of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to symptoms such as depressed mood, anxiety, panic attacks, chronic sleep impairment, and mild memory loss. The VA compensation & pension exam was the sole examination in evidence at the time of permanent separation. 6. The SRP further observed, the examiner noted that the applicant continued with disturbance of sleep, concentration, and flashbacks with dissociative episodes. His reported difficulty with employment was the result of problems with focusing and concentration, as well as interpersonal conflicts. However, he was capable of full-time employment and retired after 35 years of service, which he indicated he had planned retirement. The psychiatrist opined that he was at risk for rage behaviors, and major mood shifts, but evidence reflecting mood symptoms or rage behaviors was absent. There was no evidence of impairment in judgment or thinking. 7. The SRP agreed that the 50 percent disability level was not supported by the evidence. After careful deliberation, the SRP agreed that the totality of evidence best reflected the 30 percent level of disability. The SRP recommends that the applicant’s unfitting condition diagnosis be changed to PTSD, and that his prior separation be modified to reflect that the applicant was placed on the TDRL at 70 percent for a period of 6 months and then a permanent combined 70 percent disability retirement. 8. 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’s unfitting condition diagnosis be changed to PTSD, and that his prior separation be modified to reflect that the applicant was placed on the TDRL at 70 percent for a period of 6 months and then a permanent combined 70 percent disability retirement. UNFITTING CONDITION VASRD CODE TDRL RATING PERMANENT RATING Post Traumatic Stress Disorder 9411 50 percent 30 percent Right Shoulder Pain 5299-5201 20 percent 20 percent Right Hip Pain 5099-5003 10 percent 10 percent Non-radicular Cervical Pain 5099-5003 10 percent 10 percent COMBINED 70 percent 70 percent ____________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) AR20160003268 4 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS 1