RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02375
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080623

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E4, Military Police, medically separated for “mood disorder due to mild closed head injury” with a disability rating of 10%.

CI CONTENTION:  “Please consider all conditions.”  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 based on 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 - 20080307	VARD - 20150622	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mood Disorder due to Mild Closed Head Injury	8045-9304	10%	Unspecified Bipolar Disorder and Unspecified Trauma and Stress Related Disorder	9432	50%	20150428	
Anxiety Disorder NOS	Not Unfitting					
Migraine Headaches		Migraine Headaches	8100	50%	20150501	
Left Shoulder Pain		Impingement Syndrome with Rotator Cuff Tendinitis…	5203-5201	20%	20150417	
Bilateral Knee Pain		Patellofemoral Pain Syndrome, Left Knee	5257	0%		
		Right Knee Condition	5257	NSC		
Left Ankle Pain		No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:

Mood Disorder due to Mild Closed Head Injury.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s mood disorder condition began in June or July 2004 while deployed to Iraq after being hit in the chest plate with an AK47 round.  In July 2004 a piece of asphalt struck his helmet and he was reportedly “out for 10 minutes.”  He later developed hypervigilance, violent dreams and symptoms of hypomania.  He received a Combat Action Badge in April 2004.  The CI reported symptoms resembled bipolar disorder were present after his first deployment to Afghanistan (August 2002-March 2003) but he did not seek help until after the Iraq tour.  He reported he developed irritable bowel syndrome after deployment to Afghanistan.  During this first deployment he saw dead children, performed body part retrieval and had other traumatic exposures.  

In January 2005, the CI was evaluated at the VA Hospital and diagnoses of PTSD and rule out bipolar disorder were rendered.  He was treated with several psychotropic medications.  He was hospitalized from 8 February 2006 to 17 February 2006 for homicidal ideation directed at his mother-in-law and a diagnoses of mood disorder, not otherwise specified (NOS) and depression NOS were rendered.  He was discharged with referrals for partial hospitalization program, individual psychotherapy and with a mood stabilizing and anti-psychosis medication.  He was re-admitted in September 2006 for 6 days due to homicidal and suicidal ideation.  Discharge diagnoses of bipolar I disorder and PTSD were rendered. He worked as a contractor for a security firm in Iraq from December 2006-April 2007.  An evaluation for suitability for deployment to Iraq resulted in a recommendation for non-deployment, citing diagnoses of PTSD, complex, chronic due to combat experiences in Afghanistan and Iraq, bipolar disorder, and adult survivor of child physical abuse with a Global Assessment of Functioning (GAF) score of 50.  He denied any difficulties in his role as a contractor when he returned to Iraq.  The MEB forwarded mood disorder due to closed head injury for PEB adjudication.  

The MEB NARSUM examination, dated 24 September 2007, noted complaints of mild hypomanic symptoms, including racing thoughts, intermittent periods of decreased sleep, and increased goal-directed activities.  He had mild attentional difficulties and risk for worsening mood symptoms. He was taking a mood stabilizing medication. The psychiatrist requested neuropsychological testing to rule out traumatic brain injury (TBI.)  Neuroimaging was negative.  The NARSUM examination noted he intended to return to his job as a contractor in Iraq.  Psychiatric evaluation 21 September 2007, resulted in provisional diagnosis of cyclothymic disorder and anxiety disorder NOS.  PTSD symptoms were present but the examiner did not feel he met full criteria for PTSD.  The mental status exam noted rapid speech though not pressured, tangential and overly inclusive thought process, mildly elevated affect and no suicidal or homicidal ideation.  Diagnoses of mood disorder due to mild closed head injury and anxiety disorder medically acceptable were rendered by the NARSUM examiner.  

Neuropsychological testing, dated October 2007, noted it was not clear if memory problems identified through formal testing were due to affective interference or instability or the results of exposure to an IED blast injury.  At the MEB examination on 2 October 2007, 8 months prior to separation, the CI reported PTSD problems since Iraq and Afghanistan and the examiner listed diagnoses of anxiety disorder and cyclothymic disorder.

The MEB Psychiatric NARSUM addendum on 16 October 2007, 8 months prior to separation, noted the hypomanic symptoms would likely cause mild occupational impairment.  Symptoms were severe enough to decrease work efficiency and impair ability to perform occupational tasks only during times of stress.  He appeared able to function in a low stress environment based on the commander’s letter and was able to function fairly well as a civilian in Iraq.  The first completed VARD was performed on 22 June 2015 with respective 2015 C&P examinations.

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating under 8045-9304 code (dementia due to brain trauma), citing mild closed head trauma.  The VA also assigned a 50% rating using 9432 code (bipolar disorder) based on the service treatment records 8 years after separation.  The Board noted the PEB diagnosis of mood disorder, due to mild closed head injury, but noted that the service treatment records indicate diagnoses of PTSD, anxiety disorder, depressive disorder and mood disorder without reference to brain trauma throughout the record.  The presence of psychiatric symptoms, and specifically hypomania symptoms, was documented as developing after traumatic emotional exposures during both deployments and prior to any record of head trauma.  Neuropsychological testing did not result in a diagnosis of TBI and could not confirm the source of affective disability (mood disorder.)  

The Board first considered if application of VASRD §4.129 with a 6 month (50% minimum) period on the TDRL was indicated in this case.  Board members agreed that the provisions of VASRD §4.129 were applicable in this case due to the traumatic combat exposures.  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 §4.129 minimum mandated 50% at time of TDRL placement.  The Board agreed that the §4.130 criteria for a rating higher than 50% were not met near the time of separation, and therefore the minimum 50% initial TDRL rating is applicable.

The most proximate source of comprehensive evidence on which to base the permanent rating is the MEB NARSUM examination and its associated psychiatric addendum.  This examination noted the CI continued to take mood stabilizing medication for ongoing hypomanic symptoms.  He wished to return to his contractual job.  He appeared to function well in low stress environments, condition was stable and symptoms would improve with medication compliance.  The Board concluded the 10% rating most accurately depicted the condition at the time of removal from TDRL.   After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a TDRL placement rating of 50% and permanent disability rating after removal from TDRL of 10% for the mood disorder.

Contended PEB Conditions. Migraine headaches, Left shoulder pain, Bilateral knee pain, and Left ankle pain.  The CI reported he had migraines for years and they did not cause him disability or loss of work time.  He treated them with over the counter medication.  These conditions were 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 at separation.  After due deliberation, and 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:  In the matter of the mood disorder, the Board unanimously recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129 and §4.130; and a 10% permanent rating at 6 months IAW VASRD §4.130.  In the matter of the contended migraine headaches, left shoulder pain, bilateral knee pain, and left ankle pain 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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Mood Disorder 	9432 	50%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140520, 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 AR20160016865 (PD201402375)

Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to  constructively place the individual on the Temporary Disability Retired List (TDRL) at 50% disability for six months effective the date of the individual’s original medical separation for disability with severance pay and then following this six month period no recharacterization of the individual’s separation or modification of the permanent disability rating of 10%.

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 as follows:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of temporary disability effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was separated with a permanent combined rating of 10% effective the day following the six month TDRL period with no recharacterization of the individual’s separation.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will provide 50% retired pay for the constructive temporary disability retired six month period effective the date of the individual’s original medical separation and adjusting severance pay as necessary to account for the additional TDRL time in service.

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