RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03384
BRANCH OF SERVICE:  Army	BOARD DATE:  20150609
SEPARATION DATE:  20080105

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Tracked Vehicle Mechanic) medically separated for a mental health (MH) condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) but was authorized to perform an alternate physical fitness test (per PROFILE).  He was issued a permanent S3 profile and referred for a Medical Evaluation Board (MEB).  The “delusional disorder” and “post-traumatic stress disorder (PTSD),” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “delusional disorder associated with posttraumatic stress disorder” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please Consider All Conditions”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the 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/Naval 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 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:

IPEB – Dated 20071106	VA* - (~2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Delusional Disorder associated with Posttraumatic Stress Disorder	9208	10%	Post-Traumatic Stress Disorder	9411	100%	20080229	
Other x 0 (Not In Scope)	Other x 2 	
RATING:  10%	RATING:  100%	
*Derived from VA Rating Decision (VARD) dated 20080425 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Delusional Disorder associated with Posttraumatic Stress Disorder Condition.  Service treatment records noted the CI was deployed to Iraq twice: September 2003–January 2004 and February 2005-March 2006.  He reported the first deployment was “not bad,” but the second deployment marked the beginning of his difficulties.  He took small arms fire four times weekly as he performed the duties of his MOS as mechanic.  Over the course of the one year deployment, he went from anxiety to denial to anger.  About 3/4 of the way through the deployment, he developed sleep difficulties due to anxiety, constant ruminations, recurrent nightmares, and “sweats.”  He began to not trust others, especially unit members.  He became irritable and had rage reactions to small things.  After he chased an officer with a screwdriver and had other physical altercations with other soldiers, he was sent to Combat Stress.  After re-deployment, he began to drink in excess to handle his sleep issues and nightmares and was referred for substance abuse treatment.  His primary problem was determined to be PTSD and he was treated with therapy and psychotropic medication.  The distrust of others spread to people in general and he threatened someone with a gun and a knife.  He worried for his safety, leading him to be away without leave (AWOL).  He lived in the woods for 3 months to “get his head right,” and returned to duty, receiving an Article 15 and referral to MH.  He was followed at the Restoration and Resilience Center (R&R) and was diagnosed with PTSD and delusional disorder because of extreme paranoid beliefs.  He was treated with therapy and medications but symptoms remained.  An emergent command directed mental status examination (MSE) resulted in a Global Assessment of Function (GAF) score of 6.  His treating psychiatrist initiated a MEB.  The CI received a S3 profile.  A commander’s statement, dated 10 May 2007, noted the CI required constant supervision to perform any tasks and some prescribed medications prevented him from working with heavy equipment.

The narrative summary, date unknown, noted the CI remained in treatment at the R&R Center, and continued to endorse mild paranoid ideations and PTSD/anxiety symptoms, while still taking three psychotropic medications.  The examiner noted his condition was “stable” but that he continued to periodically show moderate PTSD symptoms and mild to moderate paranoid ideation. The MSE noted episodic anger/irritability and periods of cautiousness/distrust.  Diagnoses of delusional disorder, PTSD, Cannabis abuse, and alcohol abuse-episodic were rendered with a GAF of 55 (moderate impairment, symptoms).  Combat operations were noted to be severe stressors associated with the first two diagnoses.

Treatment notes, dated July 2007, noted the CI appeared to the clinic because of increased agitation and anxiety in the workplace.  He felt like he “might go off (on his co-workers)…under a lot of stress.”  His primary psychiatrist had recently left.  He reported intrusive, deployment related thoughts, nightmares, sleep issues and persistent anxiety, despite taking psychotropic medications.  He related that medication had never completely relieved his symptoms.  He was agitated, wringing his hands, and unable to sit still in the chair.  He reported paranoid delusions.  Medications were changed with some improvement in symptoms.  A second commander’s statement, dated 23 October 2007, noted the CI was performing indoor duties that included a Security Desk position.  He performed these duties “to standard,” without supervision, and with respectful behavior towards supervisors and co-workers.

At the VA Compensation and Pension (C&P) exam performed 2 months after separation, the CI reported anhedonia, panic attacks, difficulty concentrating, irritability, suspiciousness of others, a delusional episode that has not recurred, and ongoing PTSD symptoms that have been “stable” since their onset in 2005-2006.  He lived with his father and cousin and they were his only social contacts.  He did not leave the house unless necessary and had no friends in the area, though he kept in touch with a few friends in another state by phone.  He had not worked though he has been offered several jobs; he “does not see how he will be able to tolerate the social contact.”  He returned to his home in December 2007, had not received further treatment, was taking no medications, but was interested in resuming treatment at the VA.  MSE was notable for a “good” mood, constricted affect, anxiety reflected by “shaking of his hands throughout the interview and picking his hands nervously.”  He had some memory impairment and “obvious trouble concentrating.”  A diagnosis of PTSD and alcohol abuse was rendered with a GAF of 45 (severe impairment, symptoms).  The examiner opined that his social and occupational function was significantly and severely impaired: no social contacts other than two relatives, extreme aggression with others and loses temper easily, flashbacks that endanger him, lost relationships with friends, and isolation with serious impairments in work, school, family, judgment, thinking and mood.  The VARD assigned a disability rating of 100%.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB characterized the CI’s condition as delusional disorder associated with PTSD and assigned a disability rating of 10%.  The delusional disorder and PTSD are not separately ratable since such ratings would be based on the same social and occupational impairment and is prohibited by VASRD §4.14 (avoidance of pyramiding; the granting of more than one rating for the same impairment).  The Board, IAW DoDI 6040.44 and DoD guidance (which applies current VASRD 4.129 to all Board cases as appropriate), agrees that the stipulations of §4.129 are met in this case, noting the association with combat experiences.  The Board then considered if there was evidence for a §4.130 rating higher than the 4.129 minimum mandated 50% at time of Temporary Disability Retired List (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 recommendation in this case is the VA C&P examination performed 2 months after separation.  There was no relevant VA outpatient or civilian provider evidence providing psychiatric details during the 6-month interval.  Since the C&P examination 6 months after separation also reflects the stress of transition to civilian life, which is a core intent of §4.129, it carries the highest probative value in the Board’s assessment of a fair permanent rating recommendation at the 6 month rating timeframe.  The MEB evaluation nevertheless serves as a useful reference point and retains relevant probative value.  The MEB described the CI’s condition as “stable” while acknowledging that he continued to show moderate PTSD symptoms and mild to moderate paranoid ideation.  The C&P examination, known to be within 2 months of separation, documented a GAF of 45, representing severe symptoms and impairment across a global spectrum.  In accordance with VASRD §4.126, the Board considered all of the evidence of record that bears on occupational and social impairment.  MH treatment records consistently described chronic, debilitating and at times endangering MH symptoms and repeatedly abnormal MSEs.  The Board agreed the CI’s condition exceeded the assigned disability rating of 10%, denoting mild or transient symptoms only during periods of significant stress, and were more consonant with a disability rating of 70%, denoting social and occupational impairment, with deficiencies in most areas.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 50% for 6-months of constructive TDRL and a 70% permanent rating thereafter for the PTSD condition.

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.  In the matter of the delusional disorder with PTSD condition, the Board unanimously recommends a disability rating of 50%, coded 9411 IAW VASRD §4.129 for 6 months from the time of discharge consistent with a constructive period of TDRL and then a permanent separation rating of 70% IAW VASRD §4.130.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Delusional Disorder with PTSD	9208-9411	50%	70%	
RATING	50%	70%	

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20140616, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AH RC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX, AR20160003510 (PD201403384)

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 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 recharacterize the individual's separation as a permanent disability retirement with the combined disability rating of 70%.

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: 

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 retired with permanent disability effective the day following the six month TDRL period.

c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will account for recoupment of severance pay, provide 50% retired pay for the constructive temporary disability retired six month period effective the date of the individual's original medical separation and then payment of permanent disability retired pay at 70% effective the day following the constructive six month TDRL period.

d. Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:

Enclosure

CF:

( ) DoD PDBR
( ) DVA