RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-00276
BRANCH OF SERVICE:  Army	BOARD DATE:  20140819
SEPARATION DATE:  20050805

SUMMARY OF CASE:  The available evidence of record reflects that this covered individual (CI) was an activated Reserve SGT/E-5 (21J, General Construction Equipment Operator) medically separated for posttraumatic stress disorder (PTSD).  The condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty.  He was issued a permanent S3 profile and referred for a Medical Evaluation Board (MEB).  Major depressive disorder (MDD) and PTSD were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded four other conditions for PEB adjudication. The Informal PEB adjudicated PTSD as unfitting, rated 10% and the remaining conditions were determined to be not unfitting. The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in his application.

SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  In addition, the CI was notified by the Service that his case qualifies for review of his mental health (MH) condition in accordance with the Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012 and whose MH diagnoses were unfavorably changed or eliminated during that process.  In response to said notification, it is presumed the CI has elected review by this Board for the MH condition.  Accordingly, the case file was reviewed regarding unfavorable diagnosis change, fitness determination, applicability of the VA Schedule for Rating Disabilities (VASRD) §4.129 and rating of the MH condition Service adjudicated as not unfitting.  The rating for the unfitting PTSD condition is addressed below and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20050620	VA - (12 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posttraumatic Stress Disorder	9434-9411	10%	Posttraumatic Stress Disorder	9411	50%	20060808	
Other x 4 (Not in Scope)	Other x 9	20060808	
Combined:  10%	Combined:  60%	
Derived from VA Rating Decision (VARD) dated 20060821.

ANALYSIS SUMMARY:

Posttraumatic Stress Disorder Condition.  The psychiatric narrative summary (NARSUM) noted the CI was air-evacuated from Operation Iraqi Freedom in February 2005 secondary to MH symptoms.  The CI, in his eighth month of deployment, began to demonstrate “bizarre and unusual” behavior.  He was described as isolative and withdrawn, showed signs of paranoia (people conspiring against him, watching his every move).  He was observed mumbling and laughing to himself.  His behavior became increasingly bizarre over time and his family (also in theater) noticed changes in the CI’s personality and thinking.  He was referred to area support medical company and evaluated by MH.  No Axis I diagnosis was made; however, a rule out diagnosis of delusional disorder, persecutory type versus depressive disorder, not otherwise specified (NOS) was considered.  He was also prescribed antipsychotic and anxiolytic medications; however, the physician recommended evacuation from theater.  Records indicated the CI was admitted to the psychiatry inpatient unit in Landsthul on 10 February 2005 with the diagnosis of psychosis, NOS.  On 15 February 2005, his condition improved; he was discharged and air evacuated to back to CONUS.  Treatment records were scarce; however, the NARSUM noted the CI spent 4 days on an inpatient psychiatry unit after arriving stateside.  He was then followed in the outpatient MH clinic.  His psychotic symptoms had decreased; however, he had occasional symptoms that included paranoia and disorganized thinking.  Depressive symptoms emerged and an antidepressant medication was added to his treatment regimen.  The CI also participated in a weekly PTSD group and had multiple Axis I differential diagnoses, to include PTSD.  At the psychiatric NARSUM dated 11 April 2005, the CI reported he had kept a log where he recorded anything he regarded as suspicious or improper, such as safety violations, insulting comments.  He eventually was able to “decode” what others said by “reading between the lines.”  Later he experienced auditory hallucinations, problems with memory, organizing tasks and concentration.  The command found him to be lacking in sound judgment and removed his weapons.  The CI stated he initially had only a vague awareness of his worsening condition.  He became depressed and stressed out, physically exhausted by the increasing work load and lacked sleep.  The CI reported his unit was frequently under attack by enemy fire.  He recalled a specific incident in May 2004, when his convoy came under heavy grenade attack; several Soldiers were wounded and were evacuated.  Five soldiers (to include the CI) remained on-site to continue the mission.  Due to extensive equipment damage, limited manpower and continued enemy attack the mission was aborted. The CI noted he was haunted by the image of an Iraqi civilian holding the body of a small child, a child that appeared to have been close in age to his own son.  The CI noted other stressful events, including another grenade attack on his convoy.  The examiner noted the MH evaluation in February 2005 revealed a possible history of paranoia from several years prior to the current presentation.  The mental status examination (MSE) recorded the CI was fully oriented, appropriately dressed, in no apparent distress, normal attention, concentration and memory, and no evidence of psychosis or suicidal/homicidal ideation.  Insight was partial and judgment was good.  Affect was blunted and mood was stated as “good.”  The psychiatrist noted the CI had continued to use antipsychotic medication for management of his symptoms.  The diagnoses of major depressive disorder (MDD) (severe), with mood-incongruent psychotic features and PTSD (chronic) were assessed and a Global Assessment of Functioning (GAF) score of 65 (mild) was recorded.  The physician noted the CI’s antipsychotic dose had been decreased significantly (from 2mg at bedtime to 0.5mg) overtime and because the CI denied all symptoms of psychosis.  His condition was recorded as stable; however, his risk for relapse if re-exposed to combat environment was opined to be significant.  The VA Compensation and Pension (C&P) mental examination, a year after separation in August 2006, noted the CI’s PTSD symptoms had continued to diminish; he no longer had nightmares and intrusive thoughts.  He was working as a mechanic; he denied any problems with anger or intrusive thoughts on the job and his wife had a baby girl.  The examiner noted the brief hospitalization in 2004 (incorrect year, it was 2005) and did not provide evidence for additional hospitalizations or visits to the emergency room (ER) for MH concerns.  PTSD was the only diagnosis rendered; GAF was 60 (borderline moderate-mild).
The Board directs its attention to the evidence presented.  The Board first reviewed the records for evidence of inappropriate changes in diagnosis of the MH condition during processing through the military Disability Evaluation System.  The evidence of the available records showed the diagnoses of MDD and PTSD were the only diagnoses rendered.  The Board determined that no MH diagnosis was changed in the disability evaluation process.  This applicant therefore did not appear to meet the inclusion criteria in the Terms of Reference of the MH Review Project.  

The Board next considered the rating recommendation.  The PEB rated the condition of PTSD, coded analogously 9434-9411, at 10%.  The VA, a year later, rated the condition of PTSD, coded 9411, at 50%.  The PEB noted that 10 AC (§4.129) applied in this case; however, failed to apply the associated provision.  The Board in compliance with the provisions of VASRD §4.129 (mental disorders due to traumatic stress) noted the provision was applicable.  All members agreed that the §4.130 criteria for a rating higher than 50% were not met at the time of separation and therefore the minimum Temporary Disability Retired List (TDRL) rating is applicable and thus recommends a minimum 50% PTSD rating for a retroactive 6-month period on the TDRL.  The Board must then determine the most appropriate fit with VASRD §4.130 criteria at the end of TDRL for its permanent rating recommendation.  The Board placed high probative value to the NARSUM and the VA C&P evaluation in deliberating the permanent disability rating.  The NARSUM recorded no evidence of psychosis, a stable mood, no suicidal or homicidal thoughts and no impairment in judgment or thinking.  A GAF of 65 was recorded.  There was no evidence in the record of recurrent suicidal behaviors and no impairment in thinking or judgment in the 6 months prior to separation.  The MSE from the C&P was not in evidence; however, the Board noted the CI was working full-time, he reported his symptoms had not interfered with his job and the examiner recorded a GAF of 60.  The examiner indicated his psychosis was in remission (psychosis by history).  The CI had been off of his medication for many months prior to the examination.  There were no reported issues with memory or depressed mood and no evidence of panic attacks.  He had remained with a few PTSD symptoms that had not interfered with overall functioning.  The Board also considered the absence of hospitalizations, ER visits and other psychiatric care notes were indicative of mild or transient decrease in work efficiency and inability to perform occupational tasks only during periods of significant stress.  After due deliberation, and in consideration of all the evidence and VASRD §4.3 (reasonable doubt), the Board recommends a 10% permanent disability rating.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the PTSD condition, the Board unanimously recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129 as DOD directed; and a 10% permanent rating IAW VASRD §4.130.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that no change in the applicant’s unfitting condition diagnosis, and that his prior separation be modified to reflect that the applicant was placed on the TDRL at 50% for a period of 6 months (at minimum 50% IAW §4.129 and DoD direction) and then permanently separated with severance pay by reason of physical disability with a final 10% rating as indicated below.

UNFITTING CONDITION	VASRD CODE	TDRL RATING	PERMANENT
RATING	
Post Traumatic Stress Disorder	9434-9411	50%	10%	
	COMBINED	50%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130507, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXX, AR20140018668 (PD201300276)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to  constructively place the individual on the Temporary Disability Retired List (TDRL) at 
50% disability for six months effective the date of the individual’s original medical separation for disability with severance pay and then following this six month period no recharacterization of the individual’s separation or modification of the permanent disability rating of 10%.

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum as follows:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of temporary disability effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was separated with a permanent combined rating of 10% effective the day following the six month TDRL period with no recharacterization of the individual’s separation.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will provide 50% retired pay for the constructive temporary disability retired six month period effective the date of the individual’s original medical separation [and adjusting severance pay as necessary to account for the additional TDRL time in service.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     

CF: 
(  ) DoD PDBR
(  ) DVA