RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-01498
BRANCH OF SERVICE:  Army
DATE OF PLACEMENT ONTO TDRL:  20071221
DATE OF REMOVAL FROM TDRL:  20090604

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Cavalry Scout, medically separated from the Temporary Disability Retired List (TDRL) for “Posttraumatic Stress Disorder (PTSD)” with a disability rating of 10%.

CI CONTENTION:  The condition continues to worsen and negatively impact daily activities.  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 - – 20090522	VARD1 - 20080303	
TDRL Placement – 20071221	Code	Rating	Condition	Code	Rating
Proximate	
Condition		TDRL
Placement	TDRL Removal			TDRL2
Placement	TDRL3 Removal	
PTSD	9411	50%	10%	Posttraumatic Stress Disorder (PTSD)	9411	30%	70%	
Prediabetes	Not Unfitting	No VA Placement	
Chronic Right Knee Pain		Degenerative Changes of Right Knee, Status Post
Arthroscopic Repair	5003	10%	10%	
Other x 0	Other x 6	
COMBINED RATING:  50% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	
1. Most proximate to TDRL Placement
2. Rating derived from C&P examination dated 20071105, ~1 mos. pre-TDRL placement
3. Rating derived from service treatment record, ~13 mos. Post-TDRL removal
ANALYSIS SUMMARY: 

Posttraumatic Stress Disorder (PTSD).  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) mental health (MH) narrative summary (NARSUM) the CI had two consecutive deployments to Iraq and was involved in direct combat.  The NARSUM noted that he had witnessed multiple traumatic events during both deployments, and he provided descriptions of specific traumatic exposure.  The CI was initially evaluated in the psychology clinic on 13 March 2007, approximately 4 months post-redeployment.  At the time he stated he was depressed and was “drinking too much”.  He noted that he would stop drinking if he was given an antidepressant medication.  The CI reported symptoms of restlessness, high irritability, quick temper, sleep disturbance and other symptoms suggestive of a depressive illness.  He indicated that he had suffered symptoms for 4 months.  The CI also noted that he presented for help primarily because his wife forced him.  The diagnoses of alcohol abuse and depression was recorded and he was referred for a psychiatric evaluation.  

The CI was prescribed medication to address mood symptoms and sleep disturbance, and initially had a robust response to the medication.  However, on 24 May 2007 he was admitted to the inpatient program on a suicide/homicide watch.  The CI was jailed for 4 days prior to the admission due to a domestic disturbance with his wife.  When the police arrived, the CI reportedly asked the police to shoot him.  He denied suicidal or homicidal thoughts on admission, and was stable at the time of discharge.  The discharge diagnoses recorded PTSD, mood disorder NOS and alcohol abuse.  A Global Assessment of Functioning (GAF) score of 48 (serious symptoms/impairment) was assessed.

The MEB NARSUM was conducted on 6 June 2007 and recorded trauma exposure history of multiple events, but notably recorded an event that occurred involving an exploded IED that had invoked significant fear of death.  The CI noted that he had vivid dreams, insomnia, night sweats, and intrusive memories of his experiences in Iraq.  Other symptoms of PTSD were documented.  The examiner noted that on 22 May 2007, the CI was arrested after being barricaded in his house and for domestic violence.  He had also been arrested on 5 May for failure to disperse and incitement.  Both incidents involved alcohol.  The 22 May incident led to the admission noted above.

The mental status examination (MSE) was unremarkable.  The diagnoses of chronic PTSD and alcohol abuse were documented with a GAF score of 55 (moderate symptom/impairment).  

The CI was admitted overnight to the mental health unit in July 2007 secondary to an accidental overdose of his prescription medication (psychotropic).  He noted that he had been “worked-up” and took several pills to “calm down”.  He denied suicidal intent.  

An addendum to the MH NARSUM dated 13 November 2007, noted the CI had completed alcohol treatment program but had continued to abuse alcohol.  His PTSD symptoms continued and he was less engaged socially with others.  It was noted that he had not fully engaged in treatment, although he continued to receive once monthly medication treatment with the psychiatrist.  The examiner opined that the alcohol use had no longer contributed to the CI’s clinical picture and that the PTSD was the sole source of his clinical issues.  The diagnoses of PTSD and alcohol dependence, in early partial remission were recorded with a GAF of 55.

The VA Compensation and Pension (C&P) mental examination was accomplished approximately 2 months before TDRL placement.  That examination noted that the CI was not in treatment with the exception of seeing his psychiatrist for medication management.  There had been no additional hospitalizations or legal issues.  He was still on active duty, reporting in to work but not attending any work schedule.  He had remained married, and there were no recorded marital issues.  He reported significant sleep difficulties, high anxiety and irritability, and panic symptoms.  He continued to experience PTSD symptoms.  MSE noted that he was depressed and guarded.  A GAF score of 55 (moderate) was assessed.

The TDRL MH removal examination dated 29 April 2009, 16 months after placement onto TDRL, noted the CI was an ‘A’ student enrolled full-time in an Associate’s degree program in environmental technology, and was not employed.  He was expected to graduate in a few months and then planned to seek full-time employment and attend college part-time to earn his Bachelor’s degree.  At the time of the examination, the CI reported 10 months of sobriety.  He was not receiving any talk therapy treatment but had continued his medication prescribed by the psychiatrist every 2 months.  He reported the medications were helpful.  He noted he was socially active, and was less avoidant of crowds or situations that had provoked extreme anxiety.  He also noted that his PTSD symptoms were less intense, and less frequent.  His sleep had improved with medication.  The MSE was unremarkable, and his GAF score represented mild symptoms and or impairment.
 
The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition of PTSD coded 9411, at 50%, noted 10 A/C was awarded, and placed the CI on the TDRL.  The VA rated the condition of PTSD coded 9411, at 30%.  All Board members agreed the provisions of VASRD §4.129 (mental disorders due to traumatic stress) was appropriately applied, and proceeded with the rating recommendations.  The criteria for the higher rating of 70% was reviewed.  At the time of the NARSUM, the CI demonstrated a pattern of mood instability with impairment in sleep and concentration: however, his MSE noted no evidence of impaired thought process, or any evidence of psychosis or impaired judgment.  He had one hospital admission several months before TDRL placement.  All Board members agreed that examination did not justify the 70% level of disability at TDRL placement, and could only support the 50% rating.  The Board next determined the most appropriate fit with VASRD §4.130 criteria at the end of TDRL for its permanent rating recommendation.  

The TDRL removal mental examination documented a history consistent with mild and transient symptoms or impairment.  The CI was a full-time student with an ‘A’ average.  He noted symptoms that were responsive to medication.  He had no additional hospitalizations, or domestic violence incidents.  He had been sober for several months and was more socially engaged.  The Board reviewed the 2010 C&P examination; however, the examination was too remote for Board’s consideration.  After considerable deliberation, Board members agreed that the best description of his condition was reflected in the 10% disability rating criteria (based on TDRL removal examination).  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 PTSD condition at TDRL placement and at permanent separation.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that pre-diabetes and chronic right knee pain conditions were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The Board noted the L2 profile for the right knee that limited the CI’s running activity; however, there were no limitations on walking, biking or swimming.  The pre-diabetes condition was not profile.  Neither conditions were 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 the pre-diabetes or the chronic right knee pain 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 any of the contended conditions and so no additional disability ratings are recommended.
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 no change in the PEB adjudication.  In the matter of the contended pre-diabetes and chronic right knee pain 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, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140218, with attachments
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 XXXXXXXXXXXXXXXXXXXXX AR20160010974 (PD201401498)

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