RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02475
BRANCH OF SERVICE:  army	SEPARATION DATE:  20070723

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 “post-traumatic stress disorder” with a disability rating of 10%.

CI CONTENTION:  Additional unfitting conditions were not considered.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20070702	VARD - 20080808	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post-Traumatic Stress Disorder	9411	10%	Post-Traumatic Stress Disorder with Memory Loss, Insomnia and Post-Concussive Headaches	9411	50%	20080428	
Post-Concussive Headaches	Not Unfitting					
Low HDL Cholesterol	Not Unfitting	No VA Placement	
Alcohol Dependence	Not Compensable	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70% 	

ANALYSIS SUMMARY:  

Posttraumatic Stress Disorder.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had two combat deployments as an infantryman.  After the first deployment (April 2003 to March 2004) he developed nightmares and insomnia which were treated with medication.  After returning from the second deployment (November 2006) his mental health symptoms included irritability, insomnia, nightmares, intrusive thoughts, flashbacks, intolerance of crowds and difficulty with concentration.  He was treated and diagnosed with post-traumatic stress disorder (PTSD).

The 30 March 2007 MEB Mental Health NARSUM examination, 4 months prior to separation, noted complaints of nightmares from his deployments, intrusive thoughts, irritability, flashbacks, insomnia, hypervigilance, anxiety, emotional withdrawal, and mood symptoms.  The CI noted that he witnessed a child’s head explode which left him with intrusive images.  He reported incidents of being ambushed and having to killed several enemy combatants.  He also reported being in a basement filled with dozens of bodies shot in the back of the head which also gave him intrusive images.  The CI was taking psychotropic medication which resulted in a moderate response to his symptoms.  The mental status examination was unremarkable with the exception of an “anxious, irritable and dysphoric” mood and affect.  PTSD was diagnosed and a Global Assessment of Functioning (GAF) score of 55 (moderate symptoms and or impairment) was rendered.  The psychiatrist also assessed alcohol dependence in remission.

At the 31 May 2007 MEB NARSUM examination, 2 months prior to separation, the CI reported taking psychotropic medication.  His PTSD symptoms included difficulty sleeping, spotty short-term memory, dislike for crowded rooms, easily startled response, and difficulty with concentration.  He noted that his medication controlled the nightmares to the extent that “if he has them he is not aware of it.”

At the 28 April 2008 VA Compensation and Pension (C&P) evaluation, 9 months after separation, the CI reported medications helped him sleep and reduced his depression and nightmares.  The CI reported panic attacks about once a week and dissociative events not recorded by the MEB NARSUM examinations.  He had no history of psychiatric inpatient treatment or visits to the emergency room due to mental health symptoms.  The CI worked for an insurance company for about 4 months and missed 2-4 days of work every 2-weeks due to PTSD.  The mental status examination was unremarkable.  The psychologist noted that the CI’s PTSD, mood disorder and panic disorder all require continuous medication.  There was no GAF score provided.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the PTSD condition 10%, coded 9411 (post-traumatic stress disorder).  The VA rated the condition of PTSD, coded 9411 at 50%, based on evidence showing occupational and social impairment with reduced reliability.

The panel determined IAW DoD guidance, VASRD section §4.129 (mental disorders due to traumatic stress) will be applied when PTSD is an unfitting condition.  Therefore, as a matter of policy, the PDBR must recommend placement of the CI on a period of constructive TDRL with a minimum rating of 50% IAW §4.129 with reassessment after six months.

The panel next considered the §4.130 rating at TDLR placement.  The §4.130 criteria for a 70% rating is “Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood,” for a 50% rating, “Occupational and social impairment with reduced reliability and productivity”.  Available treatment records prior to constructive TDRL period demonstrated some impairment in occupational and social functioning; however, there was no documented evidence to support impairment in judgment or thinking.  The CI was taking psychotropic medications and was noted to have had moderate response to treatment.  The CI did not have a history of psychiatric hospitalization, nor was he evaluated in the emergency room for mental health symptoms.  The commander’s performance statement implicated the CI’s mental health condition.  The panel 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 panel recommends a disability rating of 50% for the PTSD condition at TDRL placement.

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

The C&P mental health examination, 9 months after separation, documented that the CI was working full-time, but reported he frequently missed work due to his PTSD symptoms.  Although the C&P examination recorded the report of symptoms that were not recorded at separation, there was no report that the CI sought treatment in the emergency room for his panic attacks, and the CI was not hospitalized psychiatrically.  The mental status examination was essentially normal.  He reported that his insomnia, depression and nightmares had responded to medication, and clinical evidence of worsening symptoms was absent.

The panel considered the record and concluded the evidence demonstrated the CI’s condition was stable at TDRL removal, and that his disability was most reflective of the 10% level for “Occupational or social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication mild or transient” 

After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a retroactive 6-month period of TDRL with a rating of 50% (in accordance with §4.129), and a permanent rating of 10% for PTSD. 

Contended PEB Conditions:  Post-Concussive Headaches, Low HDL Cholesterol, Alcohol Dependence.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended headache and cholesterol conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.

The alcohol dependence is a condition not constituting a physical disability, IAW DoDI 1332.38; therefore, the panel has no basis for recommending it as unfitting.  After due deliberation in consideration of the preponderance of the evidence, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination the contended condition and so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the PTSD condition, the panel recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129 as DOD directed; and a 10% permanent rating at 6 months IAW VASRD §4.130.  In the matter of the contended post-concussive headaches, low HDL and alcohol dependency conditions, the panel recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.  The panel 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	
Post-Traumatic Stress Disorder	9411	50%	10%	

The following documentary evidence was considered:

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

AR20170013247, XXXXXXXXXXXXXXXXXXX

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 (TDRL) at 50% disability for six months effective the date of your original medical separation for disability with severance pay and then following this six month period no re-characterization of your separation or modification of the permanent disability rating of 10%.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The constructive TDRL period will result in an adjustment to your pay providing you 50% retired pay for six months from the date of your original medical separation and then no re-characterization of your separation or modification of the permanent disability rating of 10% following the constructive six month TDRL period. 

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

	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.  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-DO), XXXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,

Enclosure