RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02679
BRANCH OF SERVICE:  Army 	
DATE PLACED ON TDRL:  20060201	
DATE REMOVED FROM TDRL:  20070419

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E6, Signal Support Systems Specialist, medically separated from the Temporary Disability Retired List (TDRL) for posttraumatic stress disorder (PTSD), with a disability rating of 10%.  

CI CONTENTION:  The CI requested consideration of 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 – 20051216/20070409	VARD - 20060203	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
PTSD…	9411	50%	10%	PTSD	9411	50%	50%	
Bilateral Knee Pain	Not Unfitting	Medical Collateral Ligament Laxity, Left Knee	5257	10%	10%	
		Chondromalacia Patellae, Left Knee	5299-5260	10%	10%	
		Chondromalacia Patellae, Right Knee	5299-5260	10%	10%	
Right Elbow Pain	Not Unfitting	Olecranon Bursitis, Right Elbow	5299-5206	0%	0%	
COMBINED RATING:  50% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	
ANALYSIS SUMMARY:  

PTSD.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) mental health (MH) narrative summary (NARSUM), the CI developed symptoms of PTSD and was treated with antidepressant after returning from Iraq in April 2005.  His symptoms consisted of irritability, nightmares, increased startle responses, and intrusive recollection.  The CI was part of a security detail for his brigade commander and one of the members of the detail was killed in action.  He was also exposed to IED attacks.  The CI participated in outpatient MH treatment, the Army Substance Abuse Treatment Program and had three inpatient psychiatric admissions.  His condition did not improve sufficient enough to allow for continued service, and he was therefore, referred to the MEB.

At the MH NARSUM examination dated 28 November 2005, approximately 3 weeks prior to TDRL placement, the examiner noted that the CI’s met the diagnostic criteria for PTSD.  It was noted that he had been exposed to many traumatic incidents during combat experiences in Iraq, and he had used alcohol to treat his PTSD symptoms.  His first 2 hospitalizations were in July 2005, the first was an overnight stay due to the CI’s report that the television had told him to go to the emergency room (ER).  It was noted that he was brought into the ER after negative interaction with the local police.  The second hospitalization was for suicidal ideation.  The CI had a recent history of aggressive behaviors towards police and medical personnel, and was thought to have had severe PTSD with dissociative symptoms.  At the time of the second admission he reported a history of having used crack cocaine and cannabis.  The third psychiatric admission occurred in November 2006; he was hospitalized for 2 weeks because of depressed mood, uncontrollable anxiety, and other symptoms suggestive of depression.  However, he was not suicidal.  However, the NARSUM examiner noted that the hospitalization was an attempt to help him avoid punitive action against him related to his aggressive behaviors towards senior officers and noncommissioned officers.

At the NARSUM, the CI reported he had vivid recollection of all the traumatic events he experienced and was unable to go out into the public.  He also stated that he “crawls into the corner at home like a dog.”  He had panic attacks in certain circumstances during patrols and he continued to have them when exposed to reminders of his combat trauma.  He was still in the ASAP program for alcohol dependence.  He tended to binge drink.

The mental status examination (MSE) recorded that the CI appeared gaunt (he had lost 35 pounds over past 6 months), very anxious and irritable.  He had poor eye contact, his posture was stooped, and his speech varied from a paucity of speech to angry outbursts.  His insight and judgment were poor, and the CI described his mood as “I am ashamed that I have embarrassed the Army.”  There was no evidence of psychosis and he denied suicidal or homicidal ideation (SI/HI).  It was noted that he and wife had been married for about 21 months and that there was significant problems in the marriage because of his restricted range of affect related to PTSD.  The diagnosis of PTSD, chronic, severe was recorded with a Global Assessment of Functioning (GAF) score of 40 (serious impairment or some impairment in reality testing or communication).  It was noted that the alcohol dependence condition was in early full remission.

The 3 February 2006 VARD documented that the CI underwent a VA pre-discharge examination on 10 January 2006, 2 weeks prior to TDRL placement.  It was not clear if he had a MH C&P examination; however, the MSE recorded in the VARD was identical to the MH NARSUM’s MSE.

The TDRL removal examination was conducted on 20 March 2007, 1 month prior to separation.  At the examination, the CI reported he continued to have a few PTSD symptoms, such as poor sleep, anxiety in crowds, and daily ruminations about his experiences in Iraq.  He had weekly talk therapy at the VA but was not taking any medication.  He reported that he had “tried to commit suicide last October but went to the VA where he was not admitted.”  No details were documented about this reported event, and evidence of post TDRL placement inpatient admission was absent.  

The CI was working as a line supervisor at the job he held since August 2006 (7 months).  He stopped drinking alcohol in 2006.  MSE was unremarkable with the exception of an anxious and sad affect.  The CI reported that he was “still getting better.”  The examiner noted that he had made significant improvement and was able to enjoy himself, was much less angry and was able to hold a job.  It was also noted that the CI had poor sleep and was somewhat socially isolated, had anxiety, but “is able to function on the job and have relaxing time with his girlfriend.”  The examiner opined that the CI needed to continue in psychotherapy and have appropriate medication treatment for his PTSD symptoms.  The examiner recorded his diagnosis as PTSD, chronic, treated in partial remission.

The CI underwent neuropsychological evaluation in June 2007 (2 months after separation).  His MSE was unremarkable and he reported that he worked 70 hours a week, and that he planned to return to school to seek retraining.  The results of psychological testing demonstrated no impairment in attention, memory or executive functioning from a neuropsychological perspective; however, the examiner opined that his memory and attention complaint was likely secondary to poor sleep.  There was no indication that the CI lost time from work due to poor sleep or his PTSD symptoms.

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.  Likewise, the VA used the same code and granted a 50% evaluation for the PTSD condition.

The NARSUM documented a history of three inpatient admissions and a MSE that reflected poor judgment.  There was evidence of deficiencies in most areas.  The commander’s statement (CS) documented severe impairment in his ability to perform his duties.  It was noted that he required nearly continuous supervision.  He had irrational, often unpredictable behavior that made him a threat to self and possibly others.  He had significant marital problems.  All Board members agreed that his condition at the time of TDRL placement was more reflective of the 70% disability level of impairment.  Therefore, the Board recommends a disability rating of 70% at TDRL placement.

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 employed full-time and the NP evaluation documented 10 months of employment as a line supervisor working 70 hours a week.  The CI was living with his girlfriend and had divorced his wife in January 2007.  His MSE was unremarkable and he was not taking any psychotropic medications but was attending weekly talk therapy which he noted was beneficial.  There had been no additional hospitalization, although he reported he had tried to commit suicide in the year prior to the TDRL removal examination.  At the time of the TDRL examination, his symptoms were stable and although he reported daily memories of the events of Iraq, there was insufficient evidence that his PTSD symptoms had interfered significantly with his occupational functioning.  However, there was some indication that his condition had mildly impacted his social functioning. 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, and in consideration of all the evidence and VASRD §4.3 (reasonable doubt), the Board recommends a 70% disability rating at TDRL placement and a permanent 10% disability for the condition of PTSD.

Contended PEB Conditions: Bilateral Knee Pain and Right Elbow Pain.  The Board’s main charge is to assess the fairness of the PEB’s determination that his bilateral knee and right elbow 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.  While the contended conditions were profiled as U2L2, neither was 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.  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:  In the matter of the PTSD condition, the Board recommends a disability rating of 70%, coded 9411 for the TDRL interval and a permanent disability rating of 10%, coded 9411 IAW VASRD §4.130.  In the matter of the contended Bilateral Knee Pain, and Right Elbow 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 to medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Post-Traumatic Stress Disorder with Depression	9411	70%	10%	
RATING	70%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140521, 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 AR20160016964 (PD201402679)

1.  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 
70% disability rather than 50% for the period February 1, 2006 to April 18, 2007 and then following this 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 TDRL period with no recharacterization of the individual’s separation.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will provide 70% retired pay for the temporary disability retired period effective the date of the individual’s original medical separation and adjusting severance pay as necessary.

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:

Enclosures

CF: 
(  ) DoD PDBR
(  ) DVA