RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	    CASE: pd-2014-00080  
BRANCH OF SERVICE:  MARINE CORPS 	SEPARATION DATE: 20071031 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Infantryman, medically separated for posttraumatic stress disorder; with a disability rating of 10%.  

CI CONTENTION:  The CI believes his rating for his PTSD is unfair and that the VA rated it higher.  He also believes he has other conditions, among them TBI, which have worsened.  His complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited 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 PEB, but determined to be not unfitting.  Any conditions outside the Board’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.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20070907	VARD - 20071130	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post Traumatic Stress Disorder	9411	10%	Post Traumatic Stress Disorder	9411	50%	20070330	
Bipolar Disorder not Otherwise Specified	Category II	No VA Placement	
Blast Injury with Headaches	Category III	Residuals, Traumatic Brain Injury with Headaches	9304-8045	10%	20070405	
Disturbed Sleep	Category III	No VA Placement	
Alcohol Dependence in Early Remission	Category IV	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Posttraumatic Stress Disorder.  Service treatment records (STR) indicate the CI deployed twice to Iraq (January through August 2005 and March through October 2006).  There were combat experiences during both deployments and he received a Combat Action Ribbon after the first deployment and a Purple Heart after the second deployment.  The first Post-Deployment Health Assessment (PDHA), dated in August 2005, documented combat exposures and nightmares, avoidance, hypervigilance, and emotional numbness.  On the PDHA, dated in January 2007, the CI endorsed the above symptoms as well as frequent depression and an excessive use of alcohol in the past month.  He was interested in mental health consultation.  He also had shrapnel injuries that caused pain in his face, back, left ankle and right shoulder.  

At the VA Compensation and Pension (C&P) examination, dated in April 2007, the CI reported nightly sleep problems since Iraq, combat related nightmares twice per week, daily anxiety, panic attacks two to three times a month, and other PTSD and depression symptoms.  He reported he had just begun psychiatric treatment 2 weeks previously but had not taken the medications prescribed to treat anxiety and depression.  He reported he had gone to substance abuse rehabilitation after his deployment in November 2005 and February 2007.  He planned to return to his home state and become an emergency medical technician and was engaged.  He lived in the barracks, liked to fish, go hiking, go to the beach and go kayaking.  He watched television, read, and listened to music, got on the internet, worked out, played video games, and wrote in his journal, and went out with his friends to eat or to see movies.  He got along with his family.  Mental status exam (MSE) showed he was depressed, anxious, irritable, and had psychomotor retardation.  He admitted to panic attacks.  Diagnoses of PTSD and alcohol abuse due to PTSD were rendered with a Global Assessment of Functioning (GAF) score of 50 (serious symptoms bordering on moderate, impairment.)  The psychiatrist examiner noted work impairment, problems dealing with the public, coworkers and supervisors, and work stress.  He was socially impaired, demonstrated by his irritability when in public.  The examiner noted occupational and social impairment with decrease in work efficiency and occupational tasks only during periods of significant stress.  The examiner noted there was no cognitive disorder and memory problems and forgetfulness were due to PTSD.  

The non-medical assessment noted the CI had not been in full duty status since May 2007 and required time away from duties for treatment/evaluation/recuperation and noted he had numerous health problems, both physical and psychological.  

The narrative summary (NARSUM), dated in July 2007, noted the CI decompensated due to his psychiatric illness and insomnia and began to use alcohol to self-medicate.  He had withdrawal symptoms if he did not drink and also had blackouts.  He had received a driving under the influence of alcohol charge.  He had evidence of mania as well as depression.  He was receiving medication daily to target depression and bipolar disorder and medicines as needed to target anxiety and sleep.  He was also treated in the intensive outpatient PTSD group.  He showed depressed mood, blunted affect, and a report of intermittent combat flashbacks that included visual and auditory hallucinations.  Diagnoses of PTSD, bipolar disorder and alcohol dependence with a GAF score of 45-50 (serious impairment, symptoms.)  

The NARSUM Addendum, dated 30 July 2007, noted the CI had daily, throbbing headaches with some photosensitivity, disturbed sleep, some difficulty with recent memory, and shrapnel in the left jaw.  Diagnoses included blast injury with headaches and disturbed sleep.  

The C&P examination dated 4 June 2008, noted the CI was married, lived with a roommate, was unemployed, and was not receiving any mental health care, saying “I won’t touch medication.”  He reported nightmares of war related events a few times/week, intrusive thoughts of war, daily dissociative flashbacks, avoidance, diminished interest in activities, emotional numbing, a foreshortened sense of future and distress related to reminders of the war.  He was highly irritable, had severe sleep disturbance and limited attention span.  He reported symptoms of depression that included significant survivor guilt.  He reported episodes of self-mutilation prior to discharge consisting of cuts to his wrist and leg with a knife without suicidal intent.  Since his discharge, he denied drinking behavior and rarely had a drink.  He felt he could not work due to difficulties with concentration, forgetfulness, and interpersonal difficulties.  He had never lived with his wife though married for a year.  He had just recently begun speaking to her after a three month period of silence.  He had some veteran friends with whom he played Frisbee and made paper.  He used the paper to write about the war and his combat experiences.  He was not interested in seeking treatment but would be interested in acupuncture.  He denied psychiatric hospitalizations.  MSE showed a CI wearing a bandana around his head and hair, with an unkempt beard, a pierced lip with a ring, multiple tattoos, and beaded necklaces and bracelets on his arms.   He was irritable, defensive and challenging with some improvement as the interview progressed.  He denied suicidal/homicidal ideation and there was no evidence of a thought disorder.  He attributed problems with memory and concentration to a TBI.  Diagnoses of PTSD, MDD, and alcohol dependence were rendered with a GAF score of 44 (serious impairment, symptoms.)  

A C&P psychiatric examination conducted 17 June 2008, noted the CI stopped all treatment, including medications, after discharge.  He attributed his unemployment to both psychiatric and medical problems that included pain in multiple locations as well as headaches.  Despite a 6-month separation from his wife at one point, he had a good relationship with his stepson.  He enjoyed listening to music and hiking.  He reported he attempted suicide the previous year by cutting his wrist and ankle.  MSE showed minimal personal hygiene, frequent swearing, endorsed panic symptoms, and other PTSD and depression related symptoms.  A diagnosis of PTSD was rendered with a GAF score of 40 (severe impairment, symptoms.)  The psychiatrist examiner noted deficiencies in most areas.

The Board directed its attention to its rating recommendation based on the above evidence.  Both the PEB and the VA coded the PTSD condition 9411 but the PEB rated the condition at 10%, and the VA rated the condition at 50% after the initial C&P examination.  The PEB adjudicated the “bipolar disorder NOS” as Category II, a condition that contributes to the unfitting condition.  The Board, IAW DoDI 6040.44 and DoD guidance (which applies current VASRD 4.129 to all Board cases as appropriate), agrees that the stipulations of §4.129 are met in this case; and, will thus recommend a minimum 50% rating for a retroactive 6-month period on the Temporary Disability Retired List (TDRL).  The Board next considered if a rating higher than 50% was warranted at the time of placement on the constructional TDRL period.  The next higher 70% rating requires “occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood.”  Board members agreed however that these criteria were not approached, and therefore a rating higher than 50% was not supported.  The Board must then determine the most appropriate fit with VASRD 4.130 criteria at 6 months for its permanent rating recommendation.

The most proximate source of comprehensive evidence on which to base the permanent rating recommendation in this case are the C&P examinations for PTSD, dated in June 2008.  These assessments document continued symptoms of PTSD and depression with partial remission of his alcohol abuse and a GAF score in the serious impairment range.  He was unemployed due to both physical and psychiatric impairment.  He had terminated all treatment after discharge and was only interested in acupuncture as a future therapeutic intervention.  The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication,” for a 30% rating is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks,” criteria for a 50% rating requires “occupational and social impairment with reduced reliability and productivity,” and 70% rating as noted above.  He did have some leisure activities, interacted with some family members and friends with whom he made handmade paper, which he was using to write about his experiences.  He denied suicidal ideation and there was no evidence of impaired thinking.  Therefore, the PEB’s conclusion that the CI’s condition met the criterion for the 10% rating, “symptoms controlled by continuous medications,” does not appear accurate.  He appears to meet criteria for the 50% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a retroactive 6 month constructive TDRL rating of 50% and a permanent rating of 50% thereafter for the permanent separation rating.

Contended conditions.

Blast Injury With Headaches.  At the C&P General medical examination in March 2007, the CI reported he had received a shrapnel wound to the right side of his face in August 2006 and the next day a blast rocked his Humvee and he struck his head against the glass.  He had a brief loss of consciousness and developed memory problems and recurrent headaches on the right side of his head.  They occurred four times a week and lasted for 45 minutes at a time.  He reported dizziness a couple of times a day.  He was able to work and there was no functional impairment.  The examiner noted a diagnosis of headaches, more likely than not tension.  Magnetic resonance imaging (MRI) was normal.  The first C&P examiner noted no cognitive disorder and reported symptoms of memory loss and forgetfulness was due to PTSD.  The neuropsychological report dated in June 2007, noted were minor deficits of very questionable validity and were likely related to his testing attitude and effort, no pattern of deficits to suggest underlying neurological cause for isolated areas of decline in cognition, and no reason for any neurocognitive measures at that point.  A TBI evaluation in September 2008 noted findings were consistent with diagnosis of TBI, but that post-concussive symptoms after TBI and PTSD had many similar features.  

Disturbed Sleep.  There was little or no evidence of disturbed sleep separate from the sleep issues related to PTSD and/or depression.  

Alcohol Dependence in Early Remission.  Alcohol dependence is a substance use disorder and IAW DoDI 1332.38, enclosure 5 is a condition not constituting a physical disability and is not eligible for a disability rating.

The blast injury with headaches and disturbed sleep, and alcohol dependence in early remission conditions was not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.   There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the blast injury with headaches and disturbed sleep, alcohol dependence in early remission contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the PTSD disorder, the Board unanimously recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129, as DOD directed, and §4.130; and a 50% permanent rating at 6 months IAW VASRD §4.130.  In the matter of the bipolar NOS contended condition and IAW VASRD §4.130, the Board recommends no change in the PEB adjudication.  In the matter of the contended blast injury with headaches and disturbed sleep, alcohol dependence in early remission conditions, the Board recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation::  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
PTSD Disorder	9411	50%	50%	
RATING	50%	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131216, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 11 Mar 16 ICO XXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 2 Mar 16 ICO XXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 14 Mar 16 ICO XXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 14 Mar 16 ICO XXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 14 Mar 16 ICO XXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 14 Mar 16 ICO XXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (g) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.  

     c. XXXXXXXXXXXXXXX, former USMC: Assignment to the Temporary Disability Retired List for six months effective date of discharge with a 50 percent disability rating followed by transfer to the Permanent Disability Retired List with a final disability rating of 30 percent.

     d. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent disability rating effective date of discharge.

     f. XXXXXXXXXXXXXXX, former USMC: Assignment to the Temporary Disability Retired List for six months effective date of discharge with a 50 percent disability rating followed by transfer to the Permanent Disability Retired List with a final disability rating of 50 percent. 

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.