RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04306
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071127

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantry, medically separated for “anxiety disorder” and “brain disease due to trauma,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  A nine page brief in support of the CI’s application was reviewed and considered by the Board in its recommendations.  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 - 20070925	VARD - 20080506	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Anxiety Disorder	9413	10%	PTSD with Depressive Disorder and cognitive Disorder NOS (claimed as anxiety disorder and memory loss) 	9434-9411	50%	20080324	
Brain Disease due to Trauma	8045-9304	10%	Migraine Type Headaches Status Post Traumatic Brain Injury	8045-8100	30%	20080324	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Anxiety Disorder.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s anxiety disorder condition began in January 2007 after deployment to Iraq from December 2005-November 2006.  He had been diagnosed with attention deficit hyperactivity disorder (ADHD) when he was 8 years old and had been treated for the next 8 years with stimulant medication.  The medication was resumed when he attended college.  He was first seen by mental health (MH) in February 2005 in association with past history of ADHD and mild depressive symptoms.  He was treated with anti-depression medications and was cleared to deploy.  He felt the deployment went well, stating “Iraq was fine” and he had the “normal” amount of being scared and feeling slightly depressed regarding being away from family and the US albeit it there were traumatic exposures.  He felt he did a good job and depression and ADHD symptoms were stable during deployment.  After his return in November 2006, he began to experience increasing levels of anxiety by January 2007 and was seen in the emergency room (ER) and treated with anxiolytic medication which was changed to another anxiolytic medication by the clinic doctor. His commander noted he was a solid Soldier up until gunnery exercises in March 2007.  He was no longer capable of performing duties as a gunner but was utilized as a staff duty runner, performing only administrative tasks.  The MEB forwarded anxiety disorder for PEB adjudication.  

The MEB psychiatric NARSUM examination in May 2007, 7 months prior to separation, noted complaints of periods of intense anxiety fearing the worst would happen, feeling dizzy and lightheaded, having a pounding heart, unsteady gait, feeling terrified, difficulty breathing, and indigestion.  He was taking a stimulant, an anxiolytic, and an anti-depression medication and a sleep aid.  He continued with ongoing periods of intense anxiety.  The CI had two admissions to the hospital for stomach bleeding and was diagnosed with Mallory-Weiss syndrome (tears in upper stomach/lower esophagus).  He married in late January 2007 and described the relationship as chaotic.  His wife reported he appeared to be having nightmares with thrashing at night, emotional numbness, periods of irritability and physical reactions when reminded of stressful military experiences.  He had no hospitalizations for MH reasons.  Mental status examination (MSE) noted tension and anxiety when discussing his Iraqi experiences and marital difficulties.  Diagnoses of anxiety disorder and ADHD were rendered with Global Assessment of Functioning (GAF) score of 58 (moderate symptoms, impairment.)  The psychiatric NARSUM examiner, who was his treating psychiatrist, noted he had been reporting and treated for persistent increased anxiety since his redeployment, during which there were no significant psychiatric problems.  His impairment for social and industrial adaptability was definite.  At the MEB examination dated May 18, 2007, 6 months prior to separation, the CI reported depression and anxiety that felt like a heart attack and a problems with sleep due to thinking too much.  A diagnosis of anxiety NOS was rendered.  

At the 24 March 2008 VA Compensation and Pension (C&P) evaluation, performed 5 months after separation, the CI reported he was taking an anxiolytic medication twice daily and as needed.  He had domestic violence charges, which he believed were related to drinking and having a flashback and blacking out.  Nightmares had not occurred in recent weeks.  His wife said he yelled in his sleep and frequently tossed and turned.  He reported rage attacks sometimes when he had problems with strangers or loved ones.  He often felt overwhelmed by a sense of worry and impending doom.  He did not avoid reminders of the military but generally avoided crowds.  He was working at a restaurant as a server and had some difficulty dealing with customers.  At times he worked double shifts.  He enjoyed snowboarding.  He did not recall the domestic violence incident for which he was charged.  He reported ongoing panic attacks which responded to anxiolytic medication if he took it.  However, he was recently seen in the ER with severe symptoms after he had run out of his anxiolytic medication and was treated with a new anxiolytic medication with good results.  He reported he felt depressed, “all of the time” and his last severe episode of depression was a month ago, lasting one and a half weeks.  He had intermittent thoughts of self-harm but no plan or attempts.  Energy, interests and motivation levels were good and at times he wished he was back in Iraq where he was busy and needed.  He enjoyed being busy and working.  He went to a gym daily and worked out with a friend.  MSE noted he had difficulty with staying focused during the interview and needed frequent redirection.  He often interrupted the interviewer.  Mood was generally irritable with restricted and guarded affect.  Diagnoses of PTSD, depressive disorder NOS, cognitive disorder and ADHD, diagnosed in childhood with a GAF score of 50 (serious bordering on moderate symptoms, impairment.)  The examiner noted he was employable from a psychiatric standpoint.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the anxiety condition 10%, coded 9413 (anxiety disorder), citing continued medication required to control symptoms.  The VA rated PTSD with depressive disorder 50%, coded 9434-9411 (major depressive disorder-PTSD), based on the VA C&P examination 5 months after separation, citing reduced reliability and productivity. 

The Board first considered if application of VASRD §4.129 with a 6 month (50% minimum) period on the TDRL was indicated in this case.  Board members agreed that the provisions of VASRD §4.129 were applicable in this case due to the combat experiences.  Disability associated with any psychiatric condition, regardless of the diagnosis or multiple diagnoses, is subsumed under a single rating using the same criteria IAW VASRD §4.130 general rating formula for MH conditions.  The Board then considered if there was evidence for a §4.130 rating higher than the §4.129 minimum mandated 50% at time of TDRL placement.  The Board agreed that the §4.130 criteria for a rating higher than 50% were not met at 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 was the C&P examination conducted 5 months after separation.  The CI had developed a drinking problem and received a domestic violence charge, requiring treatment for anger management.  He was taking one stimulant medication and one anxiolytic medication.  He reported panic attacks and depression “all the time.”  The CI had been working at a restaurant and had some difficulty dealing with customers but had no negative feedback.  Sometimes he worked a double shift.  The last week he worked 43 hours.  He arose daily at 8 am and worked out at the gym with a friend and was married.  He enjoyed staying busy, working out and snowboarding.  He looked forward to the birth of his daughter.  He had friends he remained in touch with.  The CI reported if he took his medications regularly he did not experience panic attacks.  His energy, interest and motivation were good.  Board members concluded that the 10% rating most accurately depicted the condition at the time of removal from TDRL.  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 10% permanent rating thereafter for the anxiety condition.

Brain Disease due to Trauma.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s brain disease due to trauma condition began in January 2007 after a parachute grenade hit his vehicle while deployed to Iraq.  He reported that the event was “just loud” and he was momentarily dazed but did not lose consciousness.  He reported memory problems and had neuropsychological testing that showed marginal to mild cognitive disorder that met retention standards.   Neuroimaging of the brain was normal.  He had a history of migraine headaches that occurred occasionally since age 16 or 17, but since exposure to blasts, the headaches were “a little worse.”  The MEB forwarded post concussive syndrome with headaches, dizziness and nausea for PEB adjudication.   

A neurological examination in June 2007 noted symptoms of memory loss, irritability, poor balance, dizziness and occasional headaches.  Neurological examination was unremarkable.  The neurologist noted it is difficult to separate symptoms of a traumatic brain injury from those of PTSD and that CI had a number of physical findings suggestive of anxiety or panic.  He rendered a diagnosis of post-concussion syndrome.  

The MEB NARSUM examination on 10 August 2007, 3 months prior to separation, noted complaints of regular migraine headaches twice a month with a pain level 9 to 10 and lasting “a couple hours.”  He was able to function but moved slowly and preferred to lie down.  He took over the counter pain medication which was somewhat helpful.  He also had some sharp headaches 2-3 times per week that came in waves and lasted about 2 hours.  Sometimes he felt dizzy and this occurred, “every once in a while.” He denied emergency room visits or hospitalization for symptoms.  

At the 24 March 2008 VA Compensation and Pension (C&P) evaluation, performed 5 months after separation, the CI reported he was taking a daily anxiolytic, a sleep aid, and a stimulant medication.  He was exposed to mortar attacks, car bombs and a grenade explosion.  But since Iraq, he had severe intense headaches 2-3 times per month, lasting from hours to a day and associated with sweating, nausea, light sensitivity and occasional vomiting.  He felt irritable prior to and post headache.  He took no chronic medications for these but used a narcotic medication prescribed for his knees.  He also had problems with short and long term memory loss and concentration.  He lost balance twice weekly.  Neurological exam was unremarkable.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated brain disease due to trauma 10%, coded 8045-9304 (dementia due to trauma), citing daily non-prostrating headaches.  The VA rated migraine-type headaches post-TBI 30%, coded 8045-8100 (headaches due to TBI).  Code 8045, per the VA Schedule for Rating Disabilities (VASRD) in effect at that time, stipulates, “Purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, will be rated 10 percent and no more under diagnostic code 9304.”  

The evidence in the record supports that the CI had mild memory problems possibly due to medications, decreased concentration, mild behavioral symptoms of irritability, some worsening of previously diagnosed migraine headaches following exposure to blasts.  Under the VA rating guidelines in effect at the time of separation noted above the Board unanimously agreed the CI met the 10% rating coded 8045-9304 for the cognitive and behavioral symptoms.  The Board reviewed to see if a separate or higher rating for the headache disorder (as a neurological disability) was supported by the evidence.  The CI reported “regular migraine headaches” twice a month and sharp headaches twice a week at the MEB examination, lasting two hours, requiring no work stoppage.   He took non-steroidal medication or a narcotic medication prescribed his knee condition.  He denied ER visits or hospitalizations and there was no evidence of frequent medical visits to treat headaches.  The Board noted that headache condition did not meet a compensable evaluation coded 8199-8100 (analogous to migraine) IAW §4.124a (neurological conditions), which specifies “characteristic prostrating attacks averaging one in two months over the last several months.”  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the brain disease due to trauma condition.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a TDRL placement rating of 10% and permanent disability rating after removal from TDRL of 10% for the brain disease due to trauma condition.

BOARD FINDINGS:  In the matter of the anxiety disorder, the Board unanimously recommends a disability rating of 50%, coded 9413 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 10% IAW VASRD §4.130. In the matter of the brain disease due to trauma, the Board unanimously recommends an initial TDRL rating of 10% and a 10% permanent rating 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 the prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Anxiety Disorder NOS	9413	50%	10%	
Brain Disease Due To Trauma	8045-9304	10%	10%	
COMBINED	60%	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141119, 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 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20160018399 (PD201404306)

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 
60% 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 no recharacterization of the individual’s separation or modification of the permanent disability rating of 20%.

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 20%  effective the day following the six month TDRL period with no re-characterization of the individual’s separation.

c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will provide 60% retired pay for the constructive temporary disability retired six month period effective the date of the individual’s original medical separation and adjusting severance pay as necessary to account for the additional TDRL time in service.

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