RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02622
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20080531

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Rifleman, medically separated for traumatic brain injury (TBI) rated at 10%.  Posttraumatic stress disorder (PTSD) was determined as "Existed Prior to Service (EPTS)" without permanent service aggravation and not rated.

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 upon a 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 - 20080721	VARD - 20080709	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Traumatic Brain Injury	8045-9304	10%	Migraine Headaches status Post Traumatic Brain Injury …	8045-9304	10%	20071211	
PTSD	9411	EPTS	Posttraumatic Stress Disorder	9411	70%	20071212	
Right Ankle Pain	Cat  III	Chronic Tendonitis of the R Ankle…	5271-5024	0%	20071212	
Bilateral Knee Pain	Cat  III	Degenerative Joint Disease, L Knee	5010	10%	20071212	
		Degenerative Joint Disease, R Knee	5010	10%	20071212	
Groin Pain	Cat  III	No VA Placement	
Tinnitus	Cat  III	Tinnitus	6260	NSC	20071212	
Bilateral Shoulder Pain	Cat  III	Chronic Rotator Cuff Insufficiency, Right Shoulder	5201-5024	10%	20071212	
Rhinitis S/P Septoplasty	Cat  III	Status Post Deviated Septum Repair	6502	NSC	20071212	
Wilson’s Disease	Cat  III	No VA Placement	
Internal Hemorrhoid	Cat  III	Internal Hemorrhoid…	7336	0%	20071212	
Alcohol Abuse	Cat  IV	No VA Placement	
Cluster B Traits	Cat  IV	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	
ANALYSIS SUMMARY:  

Traumatic Brain Injury (TBI).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a history of multiple head injuries and was assessed with mild TBI while in Germany.  Later screening showed a more severe TBI.  The CI was referred for neuropsychological testing and the recommendation for cognitive remediation on an outpatient basis was made.

The neuropsychological evaluation dated 16 November 2007, 6 months before separation, recorded the CI’s report that he had struck his head several times, accompanied by loss of consciousness.  It was not clear if the incidents (hitting of his head) occurred prior to service.  He reported daily headaches, but no disturbance in vision, and had problems with word finding and short term memory.  The examiner documented cognitive deficits; however, a diagnosis of cognitive disorder was not recorded.  The examiner opined that the CI’s “confusion and difficulty concentrating” were most likely related to his TBI and “its cognitive sequelae.”  On 29 February 2008, 3 months before separation, the psychologist indicated that the CI’s cognitive deficits surpassed the mild range.  

The VA Compensation and Pension (C&P) neurological evaluation dated 11 December 2007 documented the CI’s report of having had progressive memory loss over time, due to many head injuries, none of which were evaluated medically.  The examiner did not document a headache condition.  The VARD noted that there were no service-related head trauma.

The Board directed attention to its rating recommendation based on the above evidence.  The disability was determined under the Disability Evaluation System (DES) Pilot Program.  The PEB accepted the VA proposed rating of 10% coded analogously 8045-9304 (dementia due to head trauma).  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 TBI condition.  

Posttraumatic Stress Disorder.  The MH NARSUM documented the CI was evacuated from Iraq due to suicidal and homicidal thoughts towards a specific member of his chain of command.  He was becoming more irritable to the point of wanting to harm the Sergeant he worked with.  The CI described tension with members in his command and difficulty dealing with his wife leaving him as the reason why he was having such a difficult time.  Two days before the CI deployed, he reportedly caught his wife with someone else, and was now ambivalent about a divorce.  The CI also reported that he felt one Sergeant in particular would single him out and even threaten him.  He stated the Sergeant spoke to him in a way that reminded him of his abusive stepfather and he had a very difficult time controlling his anger to the point that he told the Sergeant that he would kill him.  There were other incidents with the Sergeant which led to having his weapon taken away.  Subsequently when permitted, the CI refused his weapon stating he could not guarantee he would not attempt to harm the Sergeant.  The non-medical assessment (NMA) noted the CI was unable to perform his duties because he was not allowed to carry a weapon; MH symptoms were not implicated.  It was noted that the CI had four suicide attempts with a gun pointed in his mouth each time, and each time the gun jammed.  These incidents occurred in his adolescent years.  He reported that he began cutting when he was 12 years old as a way to release his anger.  He got into fights frequently in childhood and he used to shoot cats because they were a nuisance.  The CI reported his first drink was at age 2.  

The CI reported nightmares related to “the casualties he saw in Iraq while he was waiting to undergo nasal surgery in an Iraq hospital and he could hear their screams.”  The NARSUM examiner wrote the CI “suffers from a condition that did not exist prior to entry into the service”; however, it was not noted which condition was being referenced.  The examiner documented PTSD, cluster B traits and TBI.

The PEB determined the PTSD condition existed prior to service (EPTS) and was not permanently service aggravated, therefore not compensable.  The VA assigned a 70% rating coded 9411 for PTSD.  The Board carefully considered the evidence and found no evidence to indicate that the PEB’s assessment was not correct.  The Board acknowledged the CI had prior and severe childhood exposure to traumatic events; however, there were no service-related stressors documented to support that the PTSD condition was the result of a service-connected stressor.

The PEB, in a point paper dated 20 June 2008, documented that the STR had extensive documentation of prior to service psychiatric history that included four suicide attempts between the ages of 12 and 16, alcohol abuse secondary to parental abuse, and self- cutting from age 12.

The medical record repeatedly documented that the CI’s symptoms and behaviors were longstanding and not related to any combat experienced or exposures.  The initial psychiatric evaluation in Landstuhl, and upon return to CONUS repeatedly documented longstanding symptoms and behaviors associated with his stepfather as well as the lack of any association of symptoms or behaviors with combat experiences.

The Board next considered whether or not there was evidence of service aggravation.  A presumption of service aggravation may only be overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of military service.  As noted above, the CI reported his symptoms occurred in the context of conflict with service members, and seeing and hearing the injured screams, while awaiting a surgical procedure.  There was no specific stressor identified.  He had no combat exposure.   However, he was the victim of childhood abuse that was significant enough to have caused him to attempt suicide four times and to chronically engage in self-mutilation cutting behaviors to relieve stress and anger.  In this case, the natural progression of his PTSD symptoms was unaltered by military service.  The CI’s responses to the events were natural given prior exposure to what the CI perceived as trauma childhood experiences, and would have likely occurred in any situation where the CI felt disrespected, and unvalued.   The Board considered the evidence in its totality and was unable to find any justification to support a change in the PEB’s decision in this matter.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded the EPTS PTSD condition was not permanently aggravated by service beyond the natural progression of the condition and therefore recommends no change in the PEB’s adjudication.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the right ankle pain, bilateral knee pain, groin pain, tinnitus, bilateral shoulder pain, rhinitis status-post septoplasty, Wilson’s disease and internal hemorrhoids conditions were not unfitting, and the conditions of alcohol abuse and cluster B traits are not physical disabilities and therefore, not ratable or compensable.  None of the contended conditions were not profiled or implicated in the commander’s statement and none were not judged to fail retention standards.  These conditions were not listed on MEB.  These conditions were claimed by the CI while undergoing the PILOT program at the VA.  The conditions of alcohol abuse and cluster B personality traits IAW DoDI 1332.38, do not constitute physical disability, and are therefore, not compensable or ratable.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS: In the matter of the TBI condition and IAW VASRD §4.124a, the Board recommends no change in the PEB adjudication.  In the matter of the PTSD condition and IAW VASRD §4.130, the Board recommends no change in the PEB adjudication.  In the matter of the contended right ankle pain, bilateral knee pain, groin pain, tinnitus, bilateral shoulder pain, rhinitis status-post septoplasty, Wilson’s disease and internal hemorrhoids, alcohol abuse and cluster B traits conditions, the Board recommends no change from the PEB determinations.  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 20140520, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 21 Oct 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC

						  XXXXXXXXXXXXXXXXXXXX
	     				  Assistant General Counsel
						  (Manpower & Reserve Affairs)