RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00172
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20040228

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Infantry, medically separated for “cognitive disorder with adjustment disorder status post (s/p) traumatic brain injury (TBI)” with a disability rating of 10%.

CI CONTENTION:  The assigned PEB percentage did not accurately reflect his mental health severity.  The VA awarded her mental health condition 50%.  The CI’s 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 - 20030910	VARD - 20041201	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cognitive Disorder with an Adjustment Disorder s/p TBI	8045-9304	10%	Adjustment Disorder w/Mixed Anxiety and Depressed Mood	9304-9440	50%	20040719	
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:

Cognitive Disorder with an Adjustment Disorder s/p TBI.  In August 2002 the NARSUM documented the CI was involved in a motor vehicle accident, found unconscious and hospitalized for a month.  He lost his memory about one month before and after the event.  While hospitalized, he underwent consultation with psychiatry, speech pathology, vocational rehabilitation, rehabilitative therapy, and neuropsychology.  The CI was discharged with the diagnosis of status post TBI.  A brain CT scan dated 7 August 2002 documented small tiny bleeds in the brain consistent with contusions.  A brain MRI dated 22 November 2002 read “essentially normal.”

In October 2002, the CI was seen in the primary care clinic with the report of right-sided weakness.  A mini-mental status examination was administered and the CI scored 30/30.  His speech was recorded as slightly slurred.  He later developed behavioral problems and was referred to the neurology clinic in November 2002. Neurology referred him to psychiatry.  The CI reportedly had anger management issues, was easily frustrated, intermittently depressed, and had difficulty focusing and concentrating.  On 30 March 2003, neuropsychological (NP) testing assessed cognitive disorder not otherwise specified (NOS), adjustment disorder with mixed emotional features status-post TBI.  He tested at average intellectual ability with a decline in short-term memory, attention, concentration, and social and emotional functioning.  The psychologist opined his deficits were compounded by ongoing anxiety, depression, and emotional lability.

During the Medical Evaluation Board (MEB) psychiatric addendum to the narrative summary (NARSUM), in April 2003, the CI reported depression, decrease mood coupled with irritability and frustration, up to three times daily typically lasting an hour then he felt better.  His symptoms were thought to be related to his disabilities which frustrated him.  The examiner diagnosed cognitive disorder NOS and adjustment disorder with mixed emotional features which might benefit from antidepressant medication.  The NARSUM dated in June 2003, 9 months prior to separation was conducted by neurology.  The examination recorded clear and fluent speech without cranial nerve (eye movement, balance and speech) abnormalities.  Strength was 5/5 throughout with normal muscle tone and bulk.  There was no evidence of disturbance in sensory function, reflexes, or coordination.  Gait was normal and the CI could heel and toe walk.  The examiner noted the CI was easily angered and frustrated, had difficulty concentrating, because of the decline in cognitive functioning the CI was “unable to perform those duties expected of a soldier.”

At the VA Compensation and Pension (C&P) examination dated July 2004, 5 months after separation, the CI reported being employed stocking a warehouse where he was irritated toward his disrespectful coworkers.  He had not missed any time off work since his discharge.  He was not receiving mental health treatment but continued antidepressant medication prescribed prior to discharge.  The psychologist opined the CI had residual cognitive symptoms and demonstrated mild memory, attention and concentration impairments.  He was diagnosed with adjustment disorder with mixed anxiety and depressed mood, chronic; and cognitive disorder NOS.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the condition of cognitive disorder with an adjustment disorder at 10% coded 8045-9304 (analogous for brain disease due to trauma - dementia due to trauma).  The VA rated adjustment disorder with mixed anxiety and depressed mood, residuals of motor vehicle accident, coded 9304-9440 (analogous for dementia due to trauma - chronic adjustment disorder) rated 50% IAW VARSD §4.130.  The C&P examiner opined that the CI had some residual cognitive symptoms with some mild impairment in memory largely related to his impairment in attention and concentration.  The cognitive impairment residuals were subsumed under the primary adjustment disorder diagnosis.  The Board first acknowledged that an adjustment disorder is not a physical disability and is not a ratable condition IAW DoDI 1332.38, and therefore, is not a compensable condition.  However, the CI was separated for the primary condition of cognitive disorder secondary to a TBI.  Cognitive disorders in such situation are rated under VARSD §4.124a.  The VARSD in effect at the time of separation captured brain injuries under the generic category of brain disease due to trauma (8045).  There are two different scenarios for rating under this code; analogously with purely neurological deficits, or purely subjective symptoms.  In the absence of associated neurological disabilities (seizures, nerve paralysis, etc.), rating of this condition under 8045-9304 is limited to 10%, and cannot be combined with any other rating for a disability due to brain trauma.  The Board found absence of evidence that would support any neurological disability, and therefore, only 10% was supported.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the cognitive disorder with adjustment disorder condition.

BOARD FINDINGS.  In the matter of the cognitive disorder with adjustment disorder, status post TBI condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140102, 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 XXXXXXXXXXXXXXXXXX, AR20160006624 (PD201400172)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA