RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04282
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051021

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantryman, medically separated for “posttraumatic stress disorder” and “psychotic disorder, not otherwise specified,” with a combined disability rating of 10%. The psychotic disorder, not otherwise specified was determined to have existed prior to service (EPTS) and was not rated. 

CI CONTENTION:  The CI was given a higher rating for posttraumatic stress disorder (PTSD) by the VA.  The 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 on 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 - 20050906	VARD - 20060429	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD	9411	10%	PTSD and Psychotic Disorder, NOS	9411	100%	20060322	
Psychotic Disorder, Not Otherwise Specified (NOS)	9210	EPTS					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:  

PTSD.  According to the service treatment record (STR) and the psychiatric Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI sought mental health (MH) care in 2004 (after re-enlisting), and was subsequently diagnosed with PTSD.  The CI completed a PTSD questionnaire in November 2005 that recorded his report of involvement in a combat assault during his deployment to Iraq in April 2003 while in the Marine Corps.  He suffered shrapnel injuries to his left hand and left leg, and engaged in multiple incidents where he killed several enemies as well as women and children.  He re-entered the military as active duty Army in April 2004, and in December 2004, he self-referred to MH for symptoms of nightmares and irritability.  The CI noted a history of anxiety symptoms shortly after re-deployment after serving 6 months in theater.  He had problems being in crowds and with emotional distancing.  He believed he could deal with his symptoms; however, his condition worsened, and due to homicidal threats towards others, he was given a profile for no access to weapons.

The 27 June 2005 NARSUM documented that the CI was evacuated from Korea in May 2005 and referred for an MEB.  While in Korea, he began to experience interpersonal difficulties with co-workers, was unable to concentrate due to the “voices,” he isolated himself and was having fantasies of buying a gun to kill himself or shoot other people. The CI reported he had auditory hallucinations that affected his concentration and his memory.  He reported other symptoms suggestive of psychosis but did not have command hallucinations.  He had depressed mood, sleep disturbance, disturbance of appetite and temperament issues.  He noted he felt anxious all the time, had occasional intrusive thoughts about his participation in combat and fleeing thoughts of harming himself and others.  He noted all of his symptoms improved and that the medications helped with his hallucinations which had been present prior to joining the service in 1999.

His mental status examination (MSE) was remarkable for constricted and flat affect, decreased concentration, and occasional suicidal ideation; however, suicidal ideation was not present during the examination.  Although reference was made to psychotic content, the examiner indicated his thought processes were coherent and logical. Judgement and cognitive functioning were intact.

The recorded diagnoses were PTSD and psychotic disorder NOS, deemed EPTS and not aggravated by military service.  A Global Assessment of Functioning (GAF) score was not assessed.

The March 2006 VA Compensation and Pension (C&P) examination, 5 months after separation,  noted that the CI was hospitalized for a psychotic episode and received a (2005) diagnosis of PTSD.  Since then, he had no additional hospitalizations.  At the time of the examination, the CI was unemployed and had two MH follow-up visits since discharge.  The CI reportedly indicated that he began hearing voices 6 months before he entered the Marines and that his symptoms escalated after leaving Iraq.  The CI had continued taking psychotropic medications, and reported he continued to have nightmares, daily problems with sleep, concentration, difficulty controlling his temper, recurrent and intrusive thoughts, and flashbacks.  He had these symptoms for months.  The MSE noted that the CI was having difficulty concentrating and gathering his thoughts.  Evidence of psychosis, suicidal or homicidal ideation was absent.  The examiner documented problems with both short- and long-term memory, and that he reported he felt sad most of the time.  The psychiatrist assessed a GAF of 40 and noted this was based on his psychotic symptoms and avoidance behaviors.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the PTSD condition 10%, coded 9411 (PTSD), and noted the condition of psychotic disorder, NOS and EPTS not permanently service aggravated.  The VA rated the condition of PTSD and psychotic disorder NOS, coded 9411 at 100%.

The PEB rating, as described above, was derived from DoDI 1332.39 and preceded the promulgation of the National Defense Authorization Act (NDAA) 2008 mandate for DoD adherence to Veterans’ Administration Schedule for Rating Disabilities (VASRD) §4.129. The Board, IAW DoDI 6040.44 and DoD guidance (which applies current VASRD §4.129 criteria to all Board cases as appropriate), must consider if the definition of §4.129 is met for any psychiatric condition resulting in medical separation; i.e., “a mental disorder that develops in service as a result of a highly stressful event.”  If the Board judges that application of §4.129 is appropriate, it will 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 6 months for its permanent rating recommendation, based on the facts in evidence which are most probative for that interval.  The Board noted that the PEB documented that the CI’s condition was combat-related, and the PTSD was related to the conflict in Iraq. Therefore, all Board members agreed the provisions of §4.129 were applicable in this case.  

The Board first considered the evidence for the PEB’s determination that the condition of psychotic disorder NOS was EPTS.  Both the MH addendum and NARSUM indicated that the condition was EPTS. The C&P also documented the condition was EPTS and opined that his condition was due to the natural progress of his psychosis.  Board members concluded, there was insufficient evidence to determine that the PEB’s determination was not correct.

The Board next proceeded with its rating recommendation under VARSD §4.130 based on the evidence at constructive TDRL placement.  Regardless of the diagnosis, 4.130 rating is based on symptoms independent of diagnosis, therefore, all MH symptoms were considered in the rating.  

The higher 70% rating criteria requires evidence of “occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood.”  Available treatment records prior to the constructive TDRL period demonstrated some impairment in occupational and social functioning; however, there was no documented evidence to support impairment in judgment or thinking, or deficiencies in most areas.  The CI had a history of one psychiatric hospitalization 3 months before separation.  He had no recorded visit to the emergency room (ER) for MH issues and no reports of suicidal or homicidal ideation in the 6 months before separation.  Although he reported psychotic symptoms, grossly psychotic symptoms were not recorded during any of the MSEs.

The record did not reflect that his psychotic symptoms or symptoms of PTSD led to violence or legal issues.  No behaviors or symptoms of his illness were recorded in the commander’s performance statement.  The Board considered the record in evidence did not support a higher than 50% rating for TDRL placement.  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 the PTSD condition at TDRL placement.

The Board next considered whether the evidence at the time of removal from TDRL and permanent disability disposition supported a rating higher than the 10% adjudicated by the PEB.  

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 C&P MH examination, 5 months after separation, documented that the CI was not working and was not socially engaged.  He had chronic sleep issues, difficulty with concentration, depressed mood and problems with memory; however, he had no hospitalizations, no recorded visits to the ER, and his judgment was not assessed as impaired.  Although he reported continued problems with his temper, reports of violence or legal issues were not documented.

The Board considered the record in totality and noted that the CI had not been hospitalized since prior to separation, had no recorded ER visits, no acute psychotic episodes, no history of suicidal or homicidal attempts, and no evidence of impairment in judgment during the TDRL period.

Board members agreed, the 50% level of disability was not supported.  He did however, have chronic sleep impairment, depressed mood, anxiety symptoms and memory issues.

Board members concluded the evidence demonstrated the CI’s condition was stable at the time of separation; however, his disability was most reflective of the 30% level for “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks” due to his symptoms.

After due deliberation, considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a retroactive 6-month period of TDRL with a rating of 50% (in accordance with §4.129), and a permanent rating of 30% for PTSD. 

BOARD FINDINGS: In the matter of the PTSD condition, the Board recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129 as DOD directed; and a 30% permanent rating at 6 months IAW VASRD §4.130.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
PTSD	9411	50%	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141115, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB														

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

06 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170002714 (PD201404282)

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 re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30%.

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 30% 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:

CF: 
(  ) DoD PDBR
(  ) DVA