RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00095
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080428

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Infantryman, medically separated for “posttraumatic stress disorder with elements of cognitive disorder” with a disability rating of 10%.

CI CONTENTION:  The CI contends that his PTSD, migraines, and poor memory retention pose challenges to his professional and personal life.  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 - 20080409	VARD - 20080827	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posttraumatic Stress Disorder with Elements of Cognitive Disorder…	9411	10%	Anxiety Disorder with PTSD Symptomology	9499-9413	50%	20080701	
Postconcussive Headaches	Not Unfitting	Migraine Headaches Due to Post Concussion Syndrome	8045-8100	10%	20080723	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Post-Traumatic Stress Disorder (PTSD).  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed symptoms suggestive of PTSD after deploying to Iraq during 2004-2005.  He was diagnosed with PTSD in November 2007, and referred for MEB.

The CI underwent neuropsychological testing (NP) in December 2007.  He reported he had several weeks of increased irritability, sadness, mood swings, emotional lability and high anxiety in the weeks after returning from theater.  He also suffered insomnia and had daily pain which limited his sleep.  He had occasional nightmares, avoided social situation and was irritable when in groups of people or crowds.

The CI reported a history of head injuries from boxing, both before and after entering the service.  He was taking medication for his PTSD symptoms and first saw the psychiatrist in August 2007.  He had approximately 7 counseling sessions prior to the NP evaluation.  At the time of the evaluation, the CI was taking an antidepressant medication.  In regards to his cognitive complaints, the CI reported he had problems with his memory.  He noted that he had problems with concentration, slow thinking, starring spells, and listlessness, confusion in complex situations, memory lapses, slurred speech, and poor coordination. He had multiple episodes of being knocked unconscious and at the age of 17 he had a computed tomography (CT) head scan, but was never told to stop boxing.  Testing revealed above average intelligence, and working memory and processing speed was in the average range.  Mental status examination (MSE) demonstrated blunted affect, but otherwise unremarkable.  He was assessed with cognitive disorder NOS and PTSD.

At the MEB NARSUM dated 23 January 2008, approximately 3 months prior to separation, the CI reported that he was participating in individual therapy, and that he stopped his antidepressant medication, because it was not helping.  He noted that his symptoms were slightly improved, he has decreased irritability, but continued to have insomnia, social withdrawal and startled response to loud noises.  The examiner recorded data from the NP evaluation, specifically, that the CI had engaged in boxing since age 12 and had several episodes of being knocked unconscious.  The CI had also complained of frequent headaches which occurred in the context of increased stress or lack of sleep.  He reported that he had about 2 headaches a week that varied in intensity and were not incapacitating.  MSE was not performed.  The physician recorded the diagnosis of cognitive disorder NOS as existing prior to service (EPTS) and exacerbated by service.  The PTSD diagnosis was also recorded.

The VA Compensation and Pension (C&P) mental examination was accomplished approximately 2 months after separation.  The CI reported ongoing problems with memory.  He was working full-time and reported good relationship with wife, children, and his parents with whom he lived with.  He was not in treatment, but noted that he continued to have problems with sleep, and concentration.  He denied panic attacks, suicidal or homicidal ideations, and history of inpatient treatment.  He noted that he worried about finances but managed things fairly well.  MSE was unremarkable with the exception of restricted range of affect.  Active PTSD symptoms were not recorded.  The psychologist diagnosed anxiety disorder NOS and opined that the CI’s condition did not qualify for a full diagnosis of PTSD since Criterion B&C (intrusion symptoms and avoidance, respectively) were not fully met.

The STR in the year after separation reflected the CI was employed and enjoyed his jobs.  He had a history of 2 jobs in the 12 months after separation and enjoyed both.  He attended talk therapy and in the last documented visit with the psychologist, it was noted that he was stable and could be treated on as needed basis.  Evidence of significant impairment in social and occupational functioning was absent.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the PTSD condition with elements of cognitive disorder at 10%, coded 9411, with the notation that the condition required psychotropic medication.  The VA granted a 50% disability rating coded analogously 9499-9413 (anxiety disorder).  The Board noted the PEB determined that the cognitive disorder NOS was EPTS and acknowledged that the condition was exacerbated by service.  The Board noted that the condition of cognitive disorder NOS could not be recommended for additional rating IAW VASRD 4.14 (avoidance of pyramiding).  Regardless of diagnosis, VARSD §4.130 rates conditions based on symptoms, and therefore, all symptoms related to mental health are considered in the rating scheme.  

In accordance with VASRD §4.129, when a mental disorder that develops in service as a result of a highly stressful event is severe enough to bring about the CI’s release from active military service, the rating agency should assign an evaluation of not less than 50% and schedule an examination within the 6-month period following the Veteran’s discharge to determine whether a change in evaluation is warranted.  

The Board next considered the §4.130 rating at the time of constructive TDRL placement (date of separation).  Available treatment records demonstrated some impairment in occupational and social functioning; however, there was no documented evidence to support impairment in judgment or thinking.  The NP consult recorded an unremarkable MSE with the exception of blunted affect, and although the CI reported problems with memory and concentration, the commander’s statement noted that he worked 40 hours a week in an administrative capacity and was very capable of working independently.  He had appropriate relationships with his peers and superiors.  The CI was not taking medication at the time of the NARSUM and noted that he had improved.  He was never treated inpatient and had no history of treatment in the emergency room (ER) for MH issues.  There was no evidence of suicidal or homicidal ideation, or a legal history at the time of constructive TDRL.  The Board considered the record in evidence did not support a higher than 50% rating for TDRL placement. 

The Board next determined the most appropriate fit with VASRD §4.130 criteria at the end of TDRL for its permanent rating recommendation.  The C&P MH examination and the STR reflected the CI was employed, living with his family in his mother’s home, and had minimal MH treatment.  He continued to report problems with sleep and concentration; however, he worked full-time and enjoyed his jobs.  He remained stable in the year after separation.  Board members concluded the CI’s condition was stable at the time of separation, and his disability was most reflective of the 10% level for “Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress.

After due deliberation, and in consideration of all the evidence and VASRD §4.3 (reasonable doubt), the Board recommends a 50% disability rating at TDRL placement and a permanent 10% disability for the condition of PTSD.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the post-concussive headaches condition was not unfitting.  The headache condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the PTSD condition, the Board unanimously recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129 as DOD directed; and a 10% permanent rating IAW VASRD §4.130.  In the matter of the contended post-concussive headache condition, the Board recommends no change from the PEB determination as not unfitting.  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:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
PTSD	9411	50%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150121, 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

08 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXXX, AR20170001010 (PD201500095)

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 no recharacterization of the individual’s separation or modification of the permanent disability rating of 10%.

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 10% effective the day following the six month TDRL period with no recharacterization of the individual’s separation.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will provide 50% 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