RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04108
BRANCH OF SERVICE:  Army 	
DATE OF PLACEMENT ONTO TDRL:  19990411
DATE OF REMOVAL FROM TDRL:  20020811

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Personnel Journeyman) medically separated for Posttraumatic Stress Disorder (PTSD), rated at 10%.

CI CONTENTION:  She was the victim of assault by another service member.  The applicant’s complete submission, with attachments, 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 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.  In addition, the Secretary of Defense Mental Health Review Terms of Reference directed a comprehensive review of Service members with certain mental health (MH) conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The MH condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.

RATING COMPARISON:  

Final FPEB – 20020501	VA Rating Decision1 - 20000516	
TDRL Placement – 19990410	Code	Rating	Condition	Code	Rating
Proximate	
Condition		TDRL
Placement	TDRL Removal			TDRL2
Placement	TDRL3 Removal	
PTSD…	9411	50%	10%	PTSD…	9411	50%	50%	
Other x 0	Other x 5	
RATING:  50% → 10%	RATING:  %	
1. Most proximate to TDRL Placement
2. Rating derived from C&P exam dated 19990923, ~5 mos. post-TDRL placement
3. Rating derived from C&P exam dated 19990923, ~3 yrs. pre-TDRL removal, as well as VA Outpatient treatment reports

ANALYSIS SUMMARY:  

PTSD Condition.  The psychiatric narrative summary (NARSUM) noted the CI had self-referred to the mental health (MH) clinic in September 1998 for symptoms of obsessive compulsive personality disorder (OCPD) and depression.  The initial NARSUM dated 9 November 1998 documented the diagnosis of major depressive disorder, recurrent, severe and assigned a Global Assessment of Functioning (GAF) score of 50 (borderline serious to moderate symptoms/impairment).  At the second NARSUM dated 1 December 1998, the CI reported difficulties with sleep, depressed mood, decreased energy, decreased concentration, and lack of interest in previously enjoyed activities.  She also reported feelings of guilt and significant anxiety.  She also reported history of sexual abuse and rape at the age of 15, and a history of multiple suicide attempts resulting in psychiatric hospitalization and extensive outpatient MH treatment.  In addition to her pre-military trauma history, the CI noted that while on active duty and engaged to a service member, she suffered physical abuse and a rape by her fiancé, which resulted in multiple police reports and a court order of protection.  Since that time she has experienced a gradual decline in her mental health.  Her OCD symptoms increased, and her past trauma history symptoms resurfaced, both have contributed to a decline in her occupational and social functioning.  The CI was admitted to the psychiatry inpatient unit on 22 October 1998 following thoughts of self-harm with plan to overdose on her medication and alcohol.  She remained inpatient for 4 weeks and demonstrated some improvement after 2 weeks; however, after returning to the unit from a 3-hour home visit pass, she made superficial cuts to her wrists.  The following week she attempted to hang herself from the rafters of her hospital room, but the beam supporting her did not hold.  Once stabilized, she was released to outpatient care on 18 November 1998.  The mental status examination (MSE) was unremarkable except for the CI’s report of suicidal ideation without a plan.  The diagnosis of PTSD, acute, with delayed onset was recorded with a GAF score of 50.  The PTSD and MDD, recurrent conditions were forwarded to the PEB and the applicant was placed on TDRL on 10 April 1999, for PTSD associated with depression recurrent rated 50% without documented evidence of applying VASRD §4.129 (noted the condition was not caused by an instrumentality of war).  

The VA C&P evaluation was accomplished approximately 5 months after placement onto TDRL, and recorded the CI’s report of physical abuse by her ex-boyfriend in 1995 that led to a suicide attempt that resulted in hospitalization.  She noted that she is married and has two children, and she continues to have PTSD symptoms.  The MSE noted absence of suicidal ideation, hallucinations, obsessions, delusions, and cognitive deficits; however, documented that she continues to struggle with daily thoughts of suicide.  The CI described symptoms opined to be consistent with panic attacks, and the examiner noted although there was depressive symptoms it is difficult to assign an additional diagnosis of MDD due to overlap in symptoms with PTSD.  These symptoms are depressed mood, sleep impairment, decreased interest in activities and difficulty concentrating.  The diagnoses of PTSD and panic disorder were assessed with a GAF of 45 (serious symptoms).  The examiner noted the CI had diminished social support network and lacked meaningful vocational or avocational activities.  The VA rated this exam at 50% based on VASRD 4.130 criteria “Occupational and social impairment with reduced reliability and productivity”.  At the TDRL removal NARSUM, 32 months after being placed on the TDRL, it was noted the CI was still living on the base in Florida with her active duty spouse and two children, but the couple are divorcing.  She receives emotional support from her mother who lived in Florida and her sister living in Australia.  The CI is seen monthly at the local VA clinic and is taking two antidepressant medications and Ativan for anxiety.  The examiner noted there had been no psychiatric hospitalizations since TDRL placement, and also documented that she had been retained on the TDRL after the June 2000 initial TDRL examination.  That exam noted the CI had occasional suicidal ideation, but none since November 1999.  The CI had been offered a job but thought it might be too stressful, therefore, was not working.  The TDRL removal exam noted the CI recently registered at the community college and is going through the VA rehabilitation program.  She also reportedly stated she feels that she is doing better now than when she was placed on the TDRL.  MSE noted she was anxious, her body shook, and she held herself with her arms crossed during the interview.  No other abnormality was recorded.  The CI reported depressive symptoms of decreased libido, increased guilt, decreased appetite with loss of 50 pounds since November 2000, and decreased concentration and memory.  She reported that her sleep was “all right” and suicidal ideation was absent.  The examiner opined, “There is a slight improvement in the patient’s condition from previous TDRL examination,” and indicated that her condition was stabilized.  A GAF of 70 (mild symptoms) was recorded, and the examiner recommended maintenance of the TDRL status with re-examination in 18 months.  The PEB adjudicated PTSD as unfitting rated 10% for mild social and industrial adaptability impairment, citing the condition has improved since being placed on the TDRL and had stabilized.  The CI did not concur, and the Formal PEB upheld the Informal PEB finding of unfit at 10%. 

The Board directed its attention to the evidence presented.  The Board first reviewed the records for evidence of inappropriate changes in diagnosis of the mental health condition during processing through the military DES.  The evidence of the available records showed the diagnoses of MDD and PTSD were the only diagnoses rendered.  The Board determined that no mental health diagnosis was changed in the disability evaluation process.  This applicant therefore did not appear to meet the inclusion criteria in the Terms of Reference (TOR) of the Mental Health Diagnosis Review Project. 

The Board next considered the rating recommendation.  The PEB rated the condition of PTSD associated with depression recurrent coded 9411, at 50% and placed the CI on the TDRL.  The VA, 5 months later, rated the condition of PTSD with depression and panic attacks, coded 9411, at 50%.  The majority of Board members agreed the provisions of VASRD §4.129 (mental disorders due to traumatic stress) was appropriately not applied in this case, and proceeded with the rating recommendations.  The higher rating of 70% is for “Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to such symptoms as …” At the time of the NARSUM, the CI demonstrated a pattern of mood instability with impairment in sleep and concentration, and chronic suicidal thinking; however, her MSE noted no evidence of impaired thought process, or any evidence of psychosis.  She participated in self-harm behaviors while on the inpatient unit.  All Board members agreed that exam supported a 50% level of disability.  Although the VA documented panic attacks, the CI never presented to the emergency room for mental health care, and it was noted there were no additional self-harm behaviors or psychiatric hospitalization.   All Board members agreed the record reflects the condition did not exceed the 50% level of disability at TDRL placement.  The Board concluded there was insufficient reasonable doubt (IAW VASRD §4.3) for recommending a 70% TDRL placement rating.  The Board next determined the most appropriate fit with VASRD §4.130 criteria at the end of TDRL for its permanent rating recommendation.  The Board deliberated the evidence for the 50%, 30% and 10% disability rating.  The 50% disability rating requires evidence of “Occupational and social impairment with reduced reliability and productivity due to symptoms such as: flat affect, panic attacks more than once a week, difficulty in understanding complex commands, impaired short and long-term memory and impairment in judgment and thinking…”  The TDRL removal examination documented the CI was not working, but had just begun attending the local community college.  She was in the process of divorcing, and noted that she received emotional support from her mother who also assisted her in the care of her children.  The CI continued in treatment which she received once a month and she noted that she felt her condition had improved since separation.  Although the psychiatrist did not continue the diagnosis of depression, she continued with depressive symptoms and noted a 50-pound weight loss over a 14-month period due to poor appetite related to feeling overwhelmed.  During the MSE she reportedly was “shaking all over” due to anxiety, and suicidal ideation had not been recorded since the VA exam.  All Board members agreed the 50% threshold was not approached.  The psychiatrist recommended a continuation of the TDRL and noted a “slight” improvement from the previous TDRL exam.  That exam documented that the CI reported her relationship with her husband was “very good” and that she acknowledged some paranoid preoccupations.  That exam did not record A GAF score.  Later it was noted that she and husband are divorcing.  The Board also considered the disparity in the CI’s GAF score of 70 (removal exam) and the recommendation for continuing the TDRL status as well as the ‘guarded’ prognosis, and the examiner’s assessment of “slight” improvement, all seems to imply that the condition was not transient.  After considerable deliberation, Board members agreed that her condition was not transient or controlled by continuous medication as described in the 10% criteria, and therefore, the best description of her condition was reflected in the 30% disability rating criteria.  After due deliberation, and in consideration of all the evidence and VASRD §4.3 (reasonable doubt), the Board recommends a 30% permanent disability rating. 

BOARD FINDINGS:  In the matter of the PTSD condition, the Board unanimously recommends no change to the TDRL rating and a 30% permanent rating IAW VASRD §4.130.

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 her prior medical separation:  

CONDITION	VASRD CODE	RATING	
		PERMANENT	
Posttraumatic Stress Disorder	9411	30%	
RATING	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141006, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-04108.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

Attachments:
1. Record of Proceedings 
2. Directive

cc:
SAF/MRBR 
DFAS-IN