RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00597
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041118

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Food Service Specialist, medically separated for “posttraumatic stress disorder [PTSD]” with a disability rating of 10%. 

CI CONTENTION:  “Conditions were totally disabling.”  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 - 20040727	VARD - 20050928	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD	9411	10%	PTSD and Major Depressive Disorder	9434-9411	50%	20050617	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

PTSD.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s mental health (MH) condition began while deployed in June 2003, with complaints of anxiety, insomnia, depressed and irritable mood and poor appetite.  She was initially diagnosed with depressive disorder versus adjustment disorder and was treated with medication, which helped reduce the symptoms.  At a 31 July 2003 outpatient MH follow-up appointment, the CI reported she felt guilty about the people killed in Iraq even though she had not killed anyone.  She had other MH symptoms that resulted in changes in her medication.  In December 2003, she noted an improvement in her mood and sleep, her depression and suicidal ideation resolved, and her interest in activities returned.

In January 2004, the CI reported concerns regarding her upcoming deployment.  She did not do well at her deployed location and began experiencing increased panic attacks and nightmares which required psychiatrist support.  An anti-anxiety medication was added to her treatment and she was assessed with panic disorder in addition to PTSD.  The CI requested an MEB.

The 16 March 2004 MEB NARSUM examination, 7 months prior to separation, noted complaints of anxiety and panic symptoms since June 2003.  The CI had not been hospitalized or treated in the emergency room (ER), and had not expressed suicidal ideation since October 2003.  The CI had a son and had been married for 2 years.  She enjoyed cooking and stated she wanted to have her own bakery after she left the Army.  The mental status examination (MSE) was unremarkable with the exception of an anxious and slightly depressed affect.  Her judgment was noted as good.  The diagnosis of chronic PTSD was assessed.  The examiner noted her symptoms were improved with mild impairment for social and industrial adaptability, but marked impairment for military duty.

At the 17 June 2005 VA Compensation and Pension (C&P) initial evaluation, 7 months after separation, the CI reported she was still married and had worked briefly but was fired from her job the week before the evaluation due to absences.  The CI stated her PTSD symptoms had caused her to miss about 3 days of work per month and with additional time from work lost due to being sent home.  The CI had not received any MH treatment with the exception of an antidepressant prescription written by a private practitioner. She had good response to the medication.  She reported difficulty falling and staying asleep but indicated she obtained about 6 hours per night.  Although she reported visual and auditory hallucinations, and passive suicidal ideations, she had no history of psychiatric hospitalizations or visits to the ER for panic attacks or other MH symptoms.  The MSE was unremarkable with the exception of her being described as nervous and tense.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the PTSD 10%, coded 9411 (PTSD), citing the condition required psychotropic medication and outpatient therapy.  The PEB awarded “10A/C” because the PTSD was directly related to armed conflict in Iraq.  The VA rated the PTSD with major depressive disorder 50%, coded 9434-9411, based on the C&P examination 7 months after separation, citing “occupational and social impairment with reduced reliability and productivity due to such observed and reported signs and symptoms as: occasional suicidal ideation, panic attacks, nightmares, intrusive thoughts, guilt, insomnia, a flat affect, poor appetite, hyper-startle, irritability, depression, forgetfulness, psychomotor agitation, difficulty getting along with others, avoidance of crowds, decreased motivation, hyper-vigilance, decreased concentration, anxiety, flashbacks, occasional agitation and anhedonia.” 

The panel, IAW DoDI 6040.44 and DoD guidance must apply current VASRD §4.129 to all cases as appropriate and recommend a minimum 50% rating for a retroactive 6-month period on the Temporary Disability Retired List (TDRL).  The panel 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.  Regardless of the diagnosis, the 4.130 rating is based on symptoms independent of diagnosis, therefore, all MH symptoms are considered in the rating, and reflected in the panel’s recommendation.  

The panel next proceeded with its rating recommendation under VARSD§ 4.130 based on the evidence at constructive TDRL placement.  The panel considered the NARSUM and commander’s statement, both dated 7 months prior to separation.  The panel also considered the absence of psychiatric hospitalization, the one visit to the ER for MH symptoms; and the absence of clinical evidence of impaired judgment, problems with thinking, and suicidal or homicidal attempts.  The commander wrote, “She performs her duties as a food service specialist as adequately as any other SPC in the DFAC.”  MH issues were not mentioned.  In fact, the commander stated that future assignments may include becoming a supervisor, “if she would apply herself to improve and become an NCO.”  The panel agreed the record in evidence did not support a rating higher than 50% 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 PTSD at constructive TDRL placement.

The panel next considered whether the evidence at the time of constructive TDRL removal supported a rating higher than the 10% rating adjudicated by the PEB.  The C&P mental examination occurred 1 month after the end of constructive TDRL re-evaluation.  It noted the CI was no longer in therapy, had not seen a psychiatrist for medication management nor required hospitalization or treatment in the ER.  Although the CI reported auditory and visual hallucinations, there was no evidence of impairment in judgment or that she experienced frank psychosis.  Her panic attacks did not require treatment in the ER.  The CI had no history of psychiatric hospitalization and no visits to the ER since prior to TDRL placement.  Chronic insomnia or memory issues were not recorded during the post-TDRL placement period, but the CI reported one panic attack 1 month into the post-TDRL placement period that required no medical intervention.  The CI reported her medication had continued to be effective in reducing her symptoms.  

The STR documented two MH encounters 12 and 13 months after separation, which showed the CI had a stable 5-year marriage, only required one psychotropic medication and had no suicidal or homicidal ideations.  However, the CI reported problems with depression, anxiety and avoidance of activities.  There was no mention of difficulty with work or lost time from work secondary to her PTSD symptoms.    

The panel considered the record in totality and concluded the CI’s disability at constructive 6-month post-TDRL placement 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.”  After due deliberation, considering the totality of 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. 

BOARD FINDINGS:  In the matter of the PTSD condition, the panel unanimously 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.  There are no other conditions within the panel’s scope of review for consideration.  
The panel recommends 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	
Posttraumatic Stress Disorder	9411	50%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160912, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180000712, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	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. 

	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), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

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

Sincerely,					      
						      					
Enclosure