RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00917
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040416

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

CI CONTENTION:  “I was rated at 100% disability upon my discharge of the military service, until 2015 of January.  I am now rated by the VA at 70%.”  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 progression or complications of service-connected conditions after separation.  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 - 20040318	VARD - 20040420	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posttraumatic Stress Disorder	9411	10%	Post-Traumatic Stress Disorder	9411	100%	20040419	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  100% 	

ANALYSIS SUMMARY:  

Posttraumatic Stress Disorder (PTSD).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s mental health condition began in January 2003 after being sexually assaulted.  She reported she was raped by a male soldier in her unit and reported the rape to authorities.  On 9 January 2003, she reported to emergency room (ER) staff that she was assaulted while sleeping.  She provided them with physical evidence and was interviewed by the investigation unit.  Her assailant persisted in stalking her and she reported specific incidents to command.  After the assault the CI deployed to Iraq but her alleged assailant stayed behind.  She reported that her unit was ambushed in Iraq.  Afterwards, her supervisor allegedly began to harass her by making degrading remarks and striking her physically.  She said there was a witness to one incident and she reported the incidents to her chain of command and they were investigating.  She had difficulty with focus due to the stress and was sent on rest and recuperation (R&R) leave in November 2003.  She did not reveal the rape to her family and was afraid to access mental health in Iraq.  She eventually told her mother and reported she was feeling lost and hopeless.  At this time her mother helped her find psychiatric care, resulting in her psychiatric hospitalization for 9 days.  The military investigative and legal units interviewed her during the hospitalization.  The CI found these interviews very difficult which led to flashbacks of the rape.  

During the 5 February 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported weight loss of 15 pounds from October 2003-December 2003, memory problems and occasional heart pounding.  She also reported anxiety attacks, trouble sleeping and depression.  She reported participation in rape counseling and attending psychiatric appointments beginning in December 2003.  Examination rendered diagnoses of PTSD, anxiety and depression.  The 5 February 2004 Commander’s statement noted the CI had a workday limited to 10 hours.  During the 9 February 2004 MEB examination (recorded on DD Forms 2697), the CI reported she took an anti-depression medication, an anti-anxiety medication and two sleep medications.  The 3 March 2004 MEB NARSUM psychiatry examination, 2 months prior to separation, noted complaints of pervasive anxiety, difficulty sleeping, nightmares and episodes of sadness and tearfulness in response to the traumatic events.  She reported a pervasive feeling of fear that caused her to stay alone in her room as much as possible.  She had difficulty tolerating even mild stressors, was easily startled and upset by noises or other reminders of the rape or her time in Iraq.  The examiner noted she had a tenuous stability after multiple episodes of trauma.  Mental status examination (MSE) showed a blank countenance, soft speech, and mildly depressed mood.  She denied current suicidal ideation though had been depressed at the time of hospitalization.  She felt unsafe at Fort Hood where her alleged assailant remained on duty.  A diagnosis of PTSD was rendered without a scoring of functional level.  

The 11 April 2004 psychiatry inpatient admission history and physical examination noted the CI was admitted after her mother called the police due to fear the CI would harm herself.  The CI had an argument with her mother who put her out of the house.  The CI had recently attempted to jump out of a moving car and had been writing good-bye letters.  She denied these were suicide attempts.  She was also experiencing increased flashbacks to both Iraq and to the sexual assault.  She was taking an increased amount of her anti-anxiety medication to sleep and to deal with her PTSD.  MSE showed a depressed mood and flat affect.  A diagnosis of PTSD and adjustment disorder with depressed mood was rendered with a GAF score of 40 (impaired reality testing or communication, major impairment in several areas.)  

At the 19 April 2004 VA Mental Health and Medical evaluation, 3 days after separation, the CI reported she was still taking the maximum dose of the anti-depression medication as described above.  She reported she was taking an anti-psychosis/mood stabilizing medication twice daily.  She reported she felt on edge all the time, stayed up most of the night and checked outside to make sure everything was ok.  She frequently called the police to check the neighborhood.  She was extremely hypervigilant since the assault and Iraq combat, where she felt her life was in danger constantly.  She reported nightmares about an Iraq civilian who died in front of her.  The nightmares were about both the sexual assault and combat.  She reported flashbacks and specific triggers.  She blacked out and couldn’t recall time periods with the flashbacks, which occurred every 10 days.  She had intrusive thoughts daily and anxiety was constant.  She was not eating well due to her nerves.  The CI denied depression and felt happy she was out of the army but felt like she had nothing to do.  She was considering going to Boston with a boyfriend to “sight see.”  She wanted outpatient therapy to “get rid” of these feelings.  She admitted to lying during a visit 3 days previously to avoid hospitalization but the therapist noted they again discussed outpatient vs. inpatient treatment.  She was receptive to various therapies as well as to medication management sessions and PTSD therapy.  MSE showed a constricted affect and fine hand tremors.  A diagnosis of PTSD was rendered with a Global Assessment of Functioning (GAF) score of 47 (serious symptoms, impairment.)

At the 5 May 2005 VA Compensation and Pension (C&P) examination, 13 months after separation, the CI reported she was admitted to inpatient psychiatry July 2004 for almost 2 months due to flashbacks and panic attacks and not feeling safe at home.  Records show she was hospitalized initially after taking more than the prescribed amount of medication because she wanted to end her life.  She was subsequently transferred after 2 days to the above referenced inpatient psychiatry unit.  She reported she would stay in bed for days due to depression and her last episode was October 2004.  She was hospitalized again from 10 October-1 December 2004 after another suicide attempt by overdose.  Records showed she had begun to abuse alcohol and was not taking her medication regularly.  She was admitted after a flashback that resulted from riding down an unsafe street that reminded her of Baghdad.  She attended substance abuse treatment groups and medications were restarted during this hospitalization.  She was discharged against medical advice after she left the hospital December 1 without authorization.  She was hospitalized again 12 February 2005 after drinking and taking her medications.  She denied that this was a suicide attempt.  She reported she had the most help from inpatient groups; it was hard for her to speak one to one with someone.  She reported ongoing panic attacks every 2 months.  She reported daily anxiety, hypervigilance about safety leading her to check windows and doors.  She watched her Muslim neighbors and had flashbacks of tracers if dark outside.  Her last flashback was April 30.  She slept with the light on and did not like being alone; her sister stayed with her.  Records showed she became intoxicated on weekends and was not taking her medications regularly and was missing appointments.  Her current stressor was not working.  She did not feel confident to leave home alone.  MSE showed an anxious mood.  She had problems remembering appointments and words and keeping a schedule.  A diagnosis of PTSD was rendered with a GAF of 45 (serious symptoms, impairment.)  She reported she was unable to hold a job since leaving the military due to PTSD.  

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), citing hospitalized December 2003, required psychotropic medication and outpatient psychiatric care.
The VA rated the PTSD condition 100%, coded 9411, citing the PTSD condition was not stabilized, was severe disability, with gainful employment not being feasible or advisable.  IAW DoD guidance, VASRD section §4.129 (mental disorders due to traumatic stress) will be applied when PTSD is an unfitting condition.  Therefore, 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 6 months. 

The panel next considered the §4.130 rating at TDRL 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.”  The commander’s statement specified the CI was limited to a 10-hour workday.  The March 2004 NARSUM reported the CI was isolating, staying alone in her room as much as possible.  The STR noted the CI had an inpatient psychiatric admission 5 days prior to separation.  She had recently tried to jump from a moving car and was writing good-bye letters.  Her mother had put her out of the house.  The C&P examination 3 days after separation and 8 days after hospitalization, noted continued, prominent symptoms of PTSD.  Symptoms were escalating despite significant doses of anti-depression and anti-anxiety medications.  The hospital admission just prior to discharge, and the mental health evaluation 3 days after separation noted a level of function in the serious range.  The panel agreed the CI showed impairment in most areas (work, judgment, thinking, and mood) at the time of separation.  Evidence prior to separation shows impairment in most areas, and therefore supports a rating greater than 50%.  A rating of 70% is assigned for placement into the TDRL period IAW with VASRD §4.129 and §4.130
At TRDL removal, the PEB rated the PTSD condition 10%, coded 9411, citing occasional decrease in work efficiency.  The VA rated the PTSD condition 100%, coded 9411, citing total occupational and social impairment.  The most proximate source of comprehensive evidence on which to base the permanent rating is the VA C&P examination.  The May 2005 C&P examination provides more comprehensive information that includes the complete TDRL period.  The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication,” for a 30% rating is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.”  
	
The C&P examination documented pervasive symptoms and recurrent suicidal ideation and lengthy hospitalizations.  She was hospitalized for nearly 2 months in both July 2004 and in October 2004.  On both occasions she had attempted suicide by overdose.  She began drinking heavily and attended substance abuse treatment groups.  She left the hospital against medical advice (AMA) in December 2004.  She was admitted again to inpatient psychiatry in February 2005 after drinking with her medications.  She denied this was a suicide attempt.  She continued to drink on weekends, did not take her medications regularly and missed appointments.  She had not been able to work since separation and said this was her biggest stressor.  Members concluded that the 70% 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 panel by majority vote recommends a disability rating of 70% for 6 months of constructive TDRL and a 70% permanent rating.

BOARD FINDINGS:  In the matter of the PTSD condition, the panel by majority recommends a disability rating of 70%, coded 9411 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 70% IAW VASRD §4.130.  The single voter for dissent elected not to submit a minority opinion.  There are 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; 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	
Posttraumatic Stress Disorder	9411	70%	70%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160916, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170018461, 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 70% disability for six months effective the date of your original medical separation for disability with severance pay and then following this six month period re-characterize your separation as a disability retirement with the combined disability rating of 70%.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The constructive TDRL period and the re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing you 70% retired pay for six months from the date of your original medical separation and then 70% disability retired pay effective the date following the constructive six month TDRL period, [minus the amount of severance pay you were previously paid at separation].
 
	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 and will provide information on your retirement benefits.  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, XXXXXXXXXXXXXXXXXXX.

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

Sincerely,

	
Enclosure