RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03658
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060516

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E-5, Mortar Carrier Driver/Gunner, medically separated by the Informal Physical Evaluation Board (PEB) for “posttraumatic stress disorder (PTSD)” and “dyshidrotic eczematous dermatitis,” rated at 10% and 10% respectively, with a combined disability rating of 20%.

CI CONTENTION:  The applicant requests consideration of all of his conditions.  The applicants 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 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 – 20060427	VARD - 20070124	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD	9411	10%	PTSD	9411	70%*	20080625	
Dyshidrotic Eczematous Dermatitis	7806	10%	Left Hand Eczema	7806	0%	20061122	
			Right Hand Eczema	7806	0%	20061122	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

PTSD.  Service treatment records noted the CI was deployed to Iraq from August 2003 to September 2004.  He described traumatic combat exposures and eventually developed nightmares, anxiety, increased irritability and startle response, hypervigilance and depressed mood.  After return from Iraq he began having flashbacks, intrusive memories of combat, insomnia, marital conflict, excessive alcohol intake, and symptoms of panic attacks e.g. palpitations, shortness of breath, sweating.  At his wife’s urging, he presented to Life Skills clinic and was referred to the emergency room (ER) and treated with a medication for anxiety.  No other mental health (MH) treatment records were in evidence.  He received the Combat Infantryman badge.  There was no prior history of psychiatric diagnosis or treatment.  The psychiatric narrative summary (NARSUM), undated, noted he was treated with medications for depression, anxiety, sleep, and nightmares for 2 and one-half months and received individual therapy with some relief.   The nightmares, flashbacks, insomnia and irritability were improving but still present. He was taking two psychotropic medications.  Mental status exam (MSE) was normal.  A diagnosis of PTSD was rendered with a Global Assessment of Functioning (GAF) score of 60 (moderate symptoms, impairment bordering on mild).  Impairment for military service was considerable and for social and industrial adaptability moderate.   

On the MEB history and physical DD Form 2807, Report of Medical History, dated 15 March 2006, the CI indicated he had anxiety/panic attacks, difficulty with sleep, depression, and counseling.  He indicated he was treated in the ER for an anxiety attack, and was being treated for PTSD by a psychiatrist.  The profiling section of the DD Form 2808, Report of Medical Examination, listed a diagnosis of PTSD, and assigned a S4 profile.  The commander’s statement attributed the CI’s duty limitations to the blisters on his hands as well as PTSD, which eliminated his ability to perform his responsibilities.  The CI did not report for the VA initial PTSD exam that was scheduled for December 2006.  At the VA Compensation and Pension (C&P) General Medical exam, dated November 2006, the CI reported he was taking a medication for depression but had run out of it.  He was unemployed by choice and receiving unemployment benefits.  He was getting a divorce and denied the use of illicit drugs.  Hobbies included listening to music and watching movies.  

At a VA C&P exam performed 25 months after separation, the CI reported significant psychiatric symptoms that included anxiety, nightmares, depression and insomnia.  He reported he was working and had worked in a number of jobs since his discharge.  He quit several of them because they evoked memories of Iraq.  He had one friend and enjoyed watching martial arts and was active with his children’s sporting events.  MSE revealed daily panic attacks, suicidal and homicidal ideation under some circumstances but no plan or intent, visual hallucinations once per month, severe depression and marked anxiety.  A diagnosis of PTSD and major depressive disorder were rendered with a GAF of 40 (Some impairment in reality testing or communication.) 

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA applied the clinically appropriate code 9411 (PTSD) and arrived at different ratings (10% and 70% respectively) under the VASRD §4.130.  The service cited combat events as the reason for the symptoms and partial control by periodic psychotherapy and medications as the reason for the 10% rating.  The VA cited symptoms from a C&P exam conducted over 2 years after separation and assigned a 70% rating but awarded the rating the day after separation.  

The Board first deliberated whether the DoD mandate for application of VASRD §4.129 were relevant to its recommendations in this case.  The clinical record provides enough evidence the CI’s condition arose as a result of a highly stressful event that the Board agrees §4.129 is applicable.  The Board is therefore obligated to recommend a minimum 50% rating for a retroactive 6 month period on the Temporary Disability Retired List (TDRL).  The Board must then determine the most appropriate fit with VASRD §4.130 criteria at the end of the constructional TDRL interval for its permanent rating recommendation. The Board next considered if a rating higher than 50% was warranted at the time of entry on the constructional TDRL period.  The next higher 70% rating requires “occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood”.  Board members agreed however that these criteria were not approached, and therefore a rating higher than 50% was not supported.

The most proximate source of comprehensive evidence on which to base the permanent rating recommendation 6 months after placement on TDRL in this case was the MEB exam.  The VA C&P PTSD Examination was not performed until June 2008, over 2 years after separation.  There was no relevant VA outpatient or civilian provider evidence providing psychiatric details during the 6-month interval but VA General Medical exam did provide some relevant social and occupational information.  The Board considered if there was evidence for a §4.130 rating higher than 10% at time of TDRL removal.  The next higher 30% rating requires “Occupational and social impairment, with occasional decrease in work efficiency and intermittent ability to perform occupational tasks.  The MEB examiner reported a GAF suggesting moderate symptoms or impairment and noted since treatment began, symptoms were improving though still present.  The General Medical exam revealed the CI was living alone, not working by choice, had run out of his medicine but planned to enroll at the VA to continue his treatments and had hobbies he could enjoy.  The later VA exam (over 2 years after separation) provided additional data regarding employment for the 6 month constructive TDRL period.  The CI worked in a variety of jobs after discharge from the service but would quit jobs because of reminders of Iraq and conflict with a supervisor.  He was having trouble sleeping and missed time from work because of MH appointments.  The Board agreed there was evidence of chronic symptoms during the six month constructive TDRL period that interfered with his ability to work. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a TDRL placement rating of 50% and permanent disability rating after removal from TDRL of 30% for the PTSD disorder.

Dyshidrotic eczematous dermatitis.  The CI reported his skin problems began in fall of 2004 after he returned from Iraq.  It began with a rash of both hands and palms that was unresponsive to over the counter and steroid treatment.  He was referred to dermatology and two biopsies were performed and showed spongiotic dermatitis.  The cause of his condition could not be determined.  He was reportedly told the condition most likely related to eczema.  Various medications, including steroids did not result in improvement.  The CI received a P3 profile that described functional limitations as: “must wear gloves when temperature is below 32 degrees, must keep hands clean, no pushups, no sit ups, no weight lifting when blisters present, no lifting more than 20lbs., no training hand to hand combat, no chemical cleaners without barrier gloves, no weapons ammunition or explosives.”  The commander’s statement attributed the CI’s duty limitations to “the blisters on his hands are vulnerable to infections and cannot come into contact with anything involved with his PMOS.”

At the NARSUM, dated April 2006, the CI reported activity modification and conservative care with emollients.  The exam of both hands showed redness and excoriation, consistent with eczema.  He was in the care of a dermatologist.  He received ultra-violet light (UVA) therapy until January 2006 without improvement. At the C&P exam performed 5 months after separation, the CI reported he was taking a steroid cream for the eczema but had run out.  He reported monthly flare-ups of lower intensity but still with some scaly redness and dry areas in the web spaces between the fingers of both hands.  He reported he was right hand dominant but the left hand was more affected than the right.  He was not using any treatment but reported discomfort and disfigurement of both hands.  He denied any loss of function but reported his hands were slightly swollen. He reported he would have difficulty performing any job that required the use of his left arm and left shoulder.  Exam of the hands showed no deformity or abnormal nodes.  There was increased redness, dryness, and scaling over the web spaces of the fourth and fifth fingers of the left hand.  There was relatively decreased dryness, redness, and scaling over the right hand between the web spaces.  The total area affected was 5% of the total exposed skin surface.  He was able to form a fist.  The VARD assigned a disability rating of 0% for left hand eczema and 0% for right hand eczema, noting that the Rating schedule criteria was for evaluation of each extremity, not both extremities in combination thereof.

The Board directed attention to its rating recommendation based on the above evidence.  Based on the PTSD disorder and §4.129 constructional TDRL requirements outlined above, the Board must determine a rating recommendation for the “dyshidrotic eczematous dermatitis” condition at TDRL placement and removal.  The PEB combined the two hand conditions into a single unfitting condition characterized as: “dyshidrotic eczematous dermatitis,” rated at 10 %, coded 7806.  The PEB noted the dermatitis involved the palmar surface of both hands, involving 17.8 percent of exposed area.  The VA rated the hands separately.  The Board noted the skin condition was not subject to unbundling since the rating consideration is for the total body area affected.  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 dyshidrotic eczematous dermatitis condition at TDRL placement.  

The Board then determined the rating recommendation for the condition at TDRL removal assigned at the 6-month TDRL interval.  The Board determined the most proximate source of comprehensive evidence, to evaluate the CI at TDRL removal, was the VA C&P examination performed 5 months after separation.  The CI reported monthly flare ups of less intensity.  As noted above, the VA examiner determined there was evidence of redness, dryness, and scaling of both hands but the left hand was more affected than the right.  There were no VA treatment notes or other examinations for Board consideration. The Board noted the total area affected was 5% of the total exposed skin surface.  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 dyshidrotic dermatitis condition. 

BOARD FINDINGS:  In the matter of the PTSD disorder, the Board unanimously recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129, as DoD directed and §4.130; and a 30% permanent rating at 6 months IAW VASRD §4.130.  In the matter of the dyshidrotic eczematous dermatitis condition and IAW VASRD §4.118, the Board unanimously recommends an initial TDRL rating of 10% and no change in the PEB adjudication at 6 months. 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 his prior medical separation:  

UNFITTING CONDITION	VASRD CODE	TDRL RATING	PERMANENT
RATING	
Posttraumatic Stress Disorder	9411	50%	  30%	
Dyshidrotic Eczematous Dermatitis	7806	10%	  10%	
	COMBINED	60%	  40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140805, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160005139, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to constructively place you on the Temporary Disability Retired List (TOAL) at 60% disability for six months effective the date of your original medical separation for disability with severance pay and then following this six month period recharacterize your separation as a disability retirement with the combined disability rating of 40%.  Enclosed is a copy of the Board's recommendation and record of proceedings for your information.

The constructive TDRL period and the recharacterization of your separation as a disability retirement will result in an adjustment to your pay providing you 60% retired pay for six months from the date of your original medical separation and then 40% disability retired pay effective the date following the constructive six month TDRL period, minus the amount of severance pay you were previously paid at separation.

The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances. These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits. Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted. Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-00), XXXXXXXXXXXXXXXXXXX.

A copy of this decision has also been provided to the Department of Veterans Affairs and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,

Enclosure