RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02182
BRANCH OF SERVICE:  Army  	
DATE OF PLACEMENT ONTO TDRL:  19991122
DATE OF REMOVAL FROM TDRL:  20030127 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve O-2, Quartermaster Officer, medically separated from the Temporary Disability Retired List (TDRL) for “cognitive, mood, and anxiety disorders status post traumatic brain injury” with 10% disability rating.   

CI CONTENTION:  The applicant makes no specific contention in her application.  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 – 19991019/20021205	VARD - 20060831	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Cognitive Disorder, Personality Change, secondary to Traumatic Brain Injury	9304	50%	10%	Post-Traumatic Brain Injury, Dementia, Cognitive Disorder, Post-Traumatic Headache, Increased Sensitivity to Sounds, Loss of Smell	8045-9304	NSC	NSC	
	Not Unfitting /Cat II, III, IV					
COMBINED RATING:  50% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Cognitive Disorder, Personality Change, secondary to Traumatic Brain Injury Condition    According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI first experienced cognitive disorder symptoms after an unwitnessed event that occurred 12 September 1998.  She was found crawling on the road just outside post, confused, disoriented, and combative and agitated with her pants partially down.  Contrast tomography (CT) scan showed a closed head injury: bi frontal subarachnoid hemorrhage (bleeding).  She was in a coma and developed a Medical Amnestic Syndrome (memory loss).  She developed periods of panic, anxiety, depression, paranoia, delusions, hallucinations and decrease in cognitive function.  Neuropsychological testing noted lower average intelligence, and mild to moderate cognitive deficits affecting nearly every psychological domain. 

The August 1999 updated MEB noted the CI had been followed by mental health (MH) since February 1999 for mood and cognitive disorders due to the TBI.  Energy and concentration were poor but sleep was adequate.  She was taking a high dose of an anti-depression medication.  The examination noted depression and anxiety, severe loss of competence in occupation, new dependence on family and financial stress.  MSE noted mildly depressed mood and dysphoric affect.  She denied suicidal and homicidal ideation, showed normal recall, attention and concentration. There was no evidence of psychosis.  Diagnoses of mood disorder due to head trauma, cognitive disorder NOS and anxiety disorder NOS were rendered with a Global Assessment of Functioning (GAF) score of 55 (moderate symptoms, impairment.) Impairment for military service was marked and social and industrial adaptability were rated as severe.  

Neuropsychological testing September 2002 revealed motor and mental slowing, subtle deficits in memory and higher level reasoning ability and possible residual deficit in visuospatial skills.  She reported residual symptoms of depression and fatigue which likely interfered with functioning. Depression was present but had improved. Testing showed a full scale intelligence quotient (IQ) of 94 and Performance IQ of 87, lower than expected of someone who had a Master’s Degree and had worked as a congressional legislative assistant.  Diagnostic impressions included cognitive disorder due to TBI, mild and Personality change due to TBI.  

The second TDRL evaluation, dated September 2002, noted the CI was taking no psychotropic medication and receiving no MH services.  She was employed for 4 months as a seasonal employee and then in January 2002 full time as a customer service representative.  Her work was mentally and physically exhausting and she reported “”I sleep a lot.” She was interested in jazz, attended church, and much less dependent upon her family and able to live independently.  Mental status examination (MSE) showed sleep was good, energy was reduced and suicide ideation was absent.  She had good recall though she still had to make notes to herself as reminders.  A diagnosis of cognitive disorder, mild was rendered.  Impairment for social and industrial adaptability was rated as slight. 

Psychiatry evaluation December 2002 noted the CI worked at Sears as a telephone operator and found the job demeaning given her educational background.  She noted she still suffered from depression and anxiety.  A diagnosis of PTSD with major depression and an estimated 20% loss of cognitive functions was rendered.  The psychiatrist prescribed an anti-depression medication and a sleep aid. MRI of the brain 2 weeks prior to TDRL removal showed post-traumatic/postoperative changes of the bilateral frontal lobes and bilateral anterior temporal lobes.  

At the VA Compensation and Pension (C&P) examination performed over 12 years after separation, the CI reported sort and long term memory loss.  She had problems with concentration and multitasking.  She had not been able to return to work in her field due to cognitive problems and mood/personality changes.  She worked as a travel consultant for the past year.  She could drive but had to maintain the same route or else get lost.  She managed her own finances and could perform basic tasks.  She recently returned to counseling but was not taking any psychoactive medications.  She slept 8-10 hours nightly and had some anxiety.  A diagnosis of neurocognitive disorder due to TBI was rendered.  

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 50% rating under the 9304 code (dementia due to head trauma) at TDRL placement, citing TBI with bi frontal contusions progressing to encephalomalacia (brain damage) rated as considerable and a 10% rating at TDRL removal, citing mild social and industrial impairment.  The VA assigned a 100% rating effective February 2005 using the analogous 8045-9304 code (post traumatic encephalopathy) based on the VA C&P examination 12 years after separation, citing a list of residuals of TBI with examples of total impairment.    

The cognitive disorder was due to physical trauma and not psychological trauma.  Disability associated with any psychiatric condition, regardless of the diagnosis or multiple diagnoses, is subsumed under a single rating using the same criteria IAW VASRD §4.130 general rating formula for MH conditions.  The Board then considered if there was evidence for a §4.130 rating higher than the 50% assigned at time of TDRL placement.  

The §4.130   criteria for a 50% rating requires “occupational and social impairment with reduced reliability and productivity,” and criteria for a 70% rating required disability in most areas.  The STRs and NARSUM examination noted the CI had severe social and occupational impairment and had impairments that were financial, work, family and mood related.  Yet the MSE examination suggested a moderate level of impairment.  Board members agreed that the 50% rating most accurately depicted the clinical condition at the time of TDRL placement.  

The Board next considered if a rating higher than the 10% adjudicated by the PEB at the time of permanent separation was justified.  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.” Neuroimaging showed continued damage to brain tissues and she continued to endorse cognitive residuals of a TBI but was working full time, enjoy leisure activities and could live independently.  She was not receiving any treatment.  The Board agreed she did not meet criteria for a higher rating. 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.  

BOARD FINDINGS:  

In the matter of the cognitive disorder condition and IAW VASRD §4.130, 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 re-characterization of the CI’s disability and separation determination.    

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140512, 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 XXXXXXXXXXXXXXXXXXXXX AR20160013536 (PD201402182)

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