RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00961
BRANCH OF SERVICE:  ARMY                                                          DATE PLACED ON TDRL:  20030621	
	DATE REMOVED FROM TDRL:  20060821

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Integrated Family of Test Equipment Operator, medically separated from the Temporary Disability Retired List (TDRL) for “cognitive disorder,” with a disability rating of 10%.

CI CONTENTION:  The CI attached a two page statement to her application which was reviewed and considered by the Board.   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 – 20030416/20060809	VARD - 20040203	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL Removal	
Cognitive Disorder	9327	30%	10%	Cognitive Disorder with Associated Mixed Symptoms, Status Post Craniotomy	9327	30%	50%	
Chronic Headaches	5399-5323	10%	NA	Headaches, Status Post Cranial Surgery	8045-9304	10%	10%	
Micro adenoma of the Pituitary	Not Unfitting	No VA Placement	
Non-Union of Cranium	Not Unfitting	Status Post Craniotomy Residual Scar and Bone Tenderness	5299-5296	10%	10%	
COMBINED RATING:  40% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Cognitive Disorder.  According to the Medical Evaluation Board (MEB) narrative summary (NARSUM) the CI’s symptoms began in August 2001 with the onset of migraine type headaches.  Attempts to treat them with medications were unsuccessful.  She underwent brain magnetic resonance imaging (MRI) studies and was found to have two tumors; one of which was located in the pituitary gland and the other was found in the 4th ventricle.  The CI underwent resection surgery in January 2002 for removal of the 4th ventricle tumor.  After the surgery, the headaches progressed and she developed cognitive and mood symptoms.  The CI underwent evaluations with psychiatry and neurology and had neuropsychological testing.  

The psychiatric addendum to the MEB was accomplished on 2 January 2003.  It was noted that the CI had continued problems with headaches, noise sensitivity, photophobia, and sensitivity to vibration.  She had daily headaches, and problems with concentration, memory, anxiety and mood.  She felt depressed and her commander reportedly indicated she was unable to perform effective duty.  It was noted that she had participated in psychotherapy since April 2002 with little progress.  The CI reported a depressed mood, sadness, loss of interest and pleasure, sleep disturbance, fatigue and decreased energy.  She noted diminished ability to think or concentrate and decreased libido.  She also reported symptoms of anxiety.  There was no indication that she had taken or was taking psychotropic medication.  The mental status examination (MSE) documented absence of psychotic symptoms, suicidal or homicidal ideation.  Cognitive screening noted deficiencies in attention and concentration.  The psychiatrist diagnosed mood disorder due to surgical intervention into cranial cavity with major depression-like features; anxiety disorder due to brain surgery with generalized anxiety disorder features, and cognitive disorder not otherwise specified.  A Global Assessment of Functioning (GAF) score of 45 (serious impairment in occupational functioning) was assessed.  The psychiatrist recommended complete neurological evaluation and neuropsychological testing and endocrinology evaluation.  

At the neuropsychological evaluation on 24 January 2003 (5 months prior to separation), the CI was diagnosed with cognitive disorder, not otherwise specified (NOS), mild, persistent; adjustment disorder with depressed mood; and with a GAF of 65 (mild).

On 14 March 2003, the MEB psychiatrist submitted a second MEB addendum in response to the nueropsychiatric (NP) testing.  The addendum referenced letters from the unit commander that reportedly noted the CI had problems with concentration that negatively impacted duty performance, and that she was unable to be a supervisor as her rank and position demanded.  She was an ineffective leader, was withdrawn, and in addition to concentration difficulties she had problems with short-term memory.  The psychiatrist opined that the CI had chronic problems with thinking and mood, and that her symptoms reflected greater pathology than an adjustment disorder; however, fell short of meeting full DSM-IV diagnostic criteria for major depression.  The psychiatrist diagnosed mood disorder due to brain surgery with major depressive-like features, noted the condition was severe and had “markedly” interfered with occupational functioning as evidenced by the commander’s letter.

At the 19 November 2003 VA Compensation and Pension (C&P) mental evaluation, performed 7 months after separation, reportedly documented intact short and long-term memory, and absence of psychotic symptoms.  It was noted that the CI reported she became more socially avoidant, had reduced confidence and self-esteem, and had difficulty initiating and sustaining gainful activity, post-surgery.  However, her symptoms had somewhat improved.  A GAF score of 68 (mild) was recorded, and the diagnosis of cognitive disorder, NOS with associated mixed symptoms was assessed.

The Board directed attention to the rating recommendation based on the evidence just described.  Both the PEB and VA rated the condition at 30%, coded 9327 (organic mental disorder) under VARSD 4.130 (schedule of ratings-mental disorders). The PEB combined the conditions of mood disorder due to brain surgery and cognitive disorder, persistent, under the category of organic brain disease and placed the CI on the TDRL.  The Board noted the PEB’s combining of conditions is not uncommon, and had no impact on rating since mental health disability ratings are based on symptoms and not diagnoses.  

The Board first addressed whether this condition met the §4.129 definition of “a mental disorder that develops in service as a result of a highly stressful event [that] is severe enough to bring about the veteran’s release from active military service.”   All Board members agreed that the provisions of §4.129 were not applicable in this case.  

The Board next proceeded to the rating recommendation based on §4.130 criteria.  The higher 50% rating criteria requires demonstration of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.  The Board noted at the time of the psychiatry MEB, the CI’s symptoms and level of impairment did not reflect the 50% level of disability.  The Board concluded there was insufficient evidence to support a rating higher than 30% at TDRL placement.  The Board next deliberated a permanent rating.  

The Board reviewed the VA C&P mental examination, performed on 12 April 2006, 4 months before removal from the TDRL.  The CI reported moderate impairment in sleep.  She indicated that she was socially withdrawn due to feeling embarrassed that her husband had left her. She was not working at the time, but indicated she had been dismissed from a job due to inability to work at an acceptable pace.  She denied a history of psychiatric hospitalizations, suicidal or homicidal ideation, or panic attacks.  Current mental health treatment was not documented. The examiner noted that she was frustrated and had uncertain thoughts about her future progress and outcomes. The MSE recorded impairment in memory, an anxious, depressed, agitated mood and constricted affect.  It was noted that she was preoccupied with her cognitive and emotional status, “which causes her significant stress and dysfunction.” Although, the examiner documented impairment in memory, there was no evidence of formal cognitive testing or that a simple cognitive screen had been conducted.  The Board considered the absence of psychiatric hospitalization, absent of visits to the emergency room, absence of evidence that her condition required her to use a PDA device to assist with her memory, absent of evidence of disorientation or evidence to support that her memory problems resulted in the inability to maintain employment.  The Board also considered the presence of employment at TDRL removal, and the ability to maintain stability in the absence of treatment.  

The TDRL mental examination was conducted on 23 June 2006, 2 months before TDRL removal.  It was noted that the CI married shortly after her discharge and had worked a few jobs since TDRL placement.  She was working at the time of the examination as an administrative assistant and was participating in psychotherapy.  It was noted that at the time of TDRL placement, the CI was taking antidepressant medication that she later discontinued.  She reportedly felt the medication had not been helpful and had caused her to feel numb.  Since then, she was offered a different antidepressant but declined.  The CI had marital problems and had separated from her husband.  She and her two children relocated to be near her parents.  In regards to her symptoms, the CI reported continued depressive symptoms, including anhedonia described as inability to laugh and absence of joy in previously enjoyable activities.  She reported limited ability to focus and concentrate, poor energy level, feelings of hopelessness, and problems with cognitive functioning, especially her memory.  She noted she was unable to work in noisy environments, or overstimulated environments, and due to her memory issues she often forgot to pay bills or she paid bills twice.  She reported easily getting lost in her town, and a general decline in pre-morbid cognitive functioning.  She did not like her current job but noted that she appreciated the quiet atmosphere and the singleness of task focus which afforded her the ability to function adequately.  The MSE was unremarkable with the exception of depressed mood and affect.  The psychiatrist noted that her attention and concentration were limited “per patient report;” however, evidence of objective cognitive testing was absent.  The diagnoses of mood disorder due to brain surgery and cognitive disorder-persistent were recorded along with a GAF score of 65 (mild).  After considerable deliberation, all Board members agreed her condition at the time of permanent separation was best reflected in the description for a 10% rating for occupational and social impairment due to mild or transient symptoms which decrease work efficiency … only during periods of significant stress.  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 condition.

Chronic Headaches. The CI underwent a neurology evaluation in April 2002, 3 months after surgery, and was diagnosed with chronic daily headaches.  The NARSUM was accomplished on 26 November 2002, 4 months prior to TDRL placement.  At the examination, the CI reported constant headaches with fatigue, concentration difficulties and memory problems.  The CI noted she had tried medications to abort her headaches, and after she had brain surgery, her headaches worsened.  She was prescribed abortive and preventive medication; however, continued to have headaches.  The CI indicated she was not able to perform her daily duties due to her inability to concentrate and she could not run because of the headaches she got when she ran.  Treatment records demonstrated her headache condition was managed by an internist.  The NARSUM noted the report of daily headaches; however, intensity of headaches was not documented anywhere in the treatment record.  The examiner opined that the CI would continue to need medication for her headaches and that biofeedback recommended by psychology could play a role in managing her headaches and her frustration.  The diagnoses of chronic headaches and micro adenoma of the pituitary were recorded, along with the recommendation for separation.  As noted above, the CI was placed on the TDRL with a 10% rating for chronic headaches.  

At the 27 October 2003 VA C&P evaluation, performed 6 months after TDRL placement, the examination documented the CI’s report of daily headaches that began upon waking and subsided as the day progressed.  By mid-morning her headache was at an intensity of 1/10, and was about 5/10 at initiation.  She noted she had missed 2 days from work out of 4 months of employment, due to headaches.  She reported she had surgery and a piece of bone had not healed.  Both physical and neurological examinations were unremarkable with the exception of tenderness to palpation at the surgical scar site.  Mild to moderate chronic headaches was assessed.

The Board directed attention to the rating recommendation based on the evidence.  At TDRL placement, the PEB adjudicated the CI’s headache condition at 10% coded analogously 5399-5323 (muscle group torso and neck, moderate).  The PEB documented that the CI had “rare migraine headaches, last occurrence March 2002, aggravated by strenuous physical activities and environmental agitations (vibration, noise, etc…).”    The VA rated the headache condition 10% analogous coding 8045-9304 (brain disease due to trauma).  

The higher rating of 20% (moderately severe) under the 5323 code was not supported by the evidence.   Although the commander’s statement noted that her headaches were chronic and limited her ability to perform the duties required of her, there were no indication that her headaches were severe enough to cause work stoppage.  The Board concluded there was insufficient evidence to support a rating higher than 10% at TDRL placement under any applicable code.  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 chronic headache condition at TDRL placement.  
At the conclusion of TDRL, the PEB, on 9 August 2006, adjudicated one single condition, cognitive disorder, and assigned a 10% disability rating.  The PEB was silent on the headache condition, and made no indication that the headache condition was no longer unfitting, except by eliminating it for consideration.  However, PEB DA Form 199 recorded, “The medical evidence in your recent evaluation indicates that your disease, cognitive disorder, is no longer unfitting and thus was not rated by this Board.”  It is reasonable to speculate that the PEB erroneously stated cognitive disorder, but meant headaches.  The Board therefore, reviewed the available evidence regarding the CI’s condition at the time of permanent separation. 

The CI underwent three comprehensive evaluations during the TDRL period.  At the 14 November 2005 VA C&P neurology evaluation, performed 9 months before separation, the CI continued having headaches that lasted for several hours.  Her headaches were alleviated by rest most of the time, and she was not taking any medications due to side effects.  It was noted that she had recently started a part-time job and she reported that the headaches had interfered with her ability to work.  Her headaches were severe and occurred almost every week.  The neurologist noted that her headaches “are not prostrating in nature, only incapacitating in nature.” The examiner noted that the CI was unable to perform her job duties secondary to her inability to focus, and that the headaches had moderate effect on her usual daily activities.

At the 12 April 2006 VA C&P mental evaluation, performed 4 months prior to TDRL removal, the examiner documented that the CI was dismissed from the job she had at the time of the November 2005 neurology examination.  It was noted that she was unable to complete tasks at an acceptable pace.  The CI indicated that she continued to suffer from headaches that often interfered with her sleep.  She was not working at the time of this examination.
 
At the 23 June 2006 psychiatry TDRL evaluation, performed 2 months prior to TDRL removal, the CI recorded that she continued to affirm headaches and problems with balance and episodic dizziness; however, no reference was made to frequency, quality, or an associated disability.  Although the examiner recorded the diagnosis of chronic headaches, occupational impairment was not assessed.  The CI had just begun to work again, and noted that she had adequate ability to function on the job; however, still suffered from chronic headaches.

The Board noted the CI was working at the time of the 27 October 2003 VA C&P evaluation where she reported that she had lost 2 days from work out of 4 months of employment due to headaches.  The TDRL examination demonstrated the CI had attempted employment with several different jobs, but would either quit or was dismissed due to poor job performance, although the association to headaches was not clear.  The Board considered the continued report of chronic daily headaches reported in the VA C&P evaluation in April 2006 and in the June 2006 TDRL examination, and the CI’s inability to maintain employment.  All Board members agreed, the preponderance of evidence demonstrated that the condition had not significantly improved since TDRL placement.  Therefore, after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the chronic headache condition, coded analogously 5399-5323 at permanent separation.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that micro adenoma and non-union of cranium were not unfitting.  The micro adenoma condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  Although the condition of non-healing bone fracture of skull (non-union cranium) was profiled, it was not implicated in the commander’s statement or judged to fail retention standards.  There was no performance based evidence from the record that either condition 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 contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the cognitive disorder associated with a depressed mood condition, the Board unanimously recommends no change in the PEB adjudication at TDRL placement and at permanent separation.  In the matter of the chronic headache condition, the Board unanimously recommends a disability rating of 10%  rating, coded 5399-5323 IAW VASRD §4.75, at TDRL placement, and 10% disability rating coded 5399-5323 at permanent separation. In the matter of the contended micro adenoma, and non-union of cranium conditions, the Board unanimously 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, effective as of the date of her prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Cognitive Disorder	9327	30%	10%	
Chronic Headaches	5399-5323	10%	10%	
COMBINED	40%	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, 20131219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXX, AR20160009922 (PD201400961)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

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.   

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:

CF: 
(  ) DoD PDBR
(  ) DVA