RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01070
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20041216

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

CI CONTENTION:  “Reference VA documentation.”  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 - 20041104	VARD - 20051103	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posttraumatic Stress Disorder	9411	10%	Post-Traumatic Stress Disorder; Major Depressive Disorder	9411	50%	20050913	
Low Back Pain	Not Unfitting	Thoracolumbar Strain	5237	10%	20050928	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

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 PTSD began during his deployment to Iraq in 2003.  He self-referred to Community Mental Health (MH) in July 2003 due to inability to control his anger.  The disorder was causing problems in his marriage and with his children.  He reported nightmares and intrusive recollections of traumatic events he experienced in Iraq.  He also reported reduced concentration, fatigue, discomfort in crowds, social withdrawal, irritability and non-specific violent ideation.  He would occasionally hit his wife during a nightmare.  His wife would not allow him to be alone with his children due to his low frustration tolerance.  He had olfactory (smell) flashbacks.  The CI took an 8-week anger management course and felt somewhat better overall.  However, he did not seek further treatment and returned to MH on 15 June 2004.  Presenting problems had worsened and his wife had left him, refusing to return until he sought treatment.  He reported that he slept 3 hours per night, had episodic crying spells, loss of appetite, loss of motivation to stay in military, lack of interest in sexual relations with his wife and constant anger and irritation.  He began to drink heavily to reduce his anxiety, improve his sleep and blunt his anger/irritability.  He enrolled in individual therapy and started taking an antidepressant medication and an antipsychotic, anxiolytic medication at bedtime.  He enrolled in a PTSD group and attended regularly.  His wife returned and the dosing of his medications was increased.  Sleep and anxiety medications were added.  He eventually began to respond to a new anti-depression agent but developed passive suicidal ideation.  

The 22 October 2004 MEB NARSUM examination, 2 months prior to separation, noted his marital relationship improved but he remained estranged from his children.  Medications included an antidepressant, an anxiolytic and a sleep aid.  At the mental status examination (MSE) the CI presented in disheveled military attire with poor eye contact and a dysphoric demeanor with moderately severe psychomotor agitation.  Speech was increased in rate and amount with an interrupted rhythm.  Mood was “down” and affect was depressive, irritable, restricted.  He was episodically tearful.  He expressed fears but denied suicidal ideation.  Impulse control was questionable with intense emotion.  Diagnoses of PTSD and major depressive disorder (MDD) were rendered with a Global Assessment of Functioning (GAF) score of 55 (moderate symptoms, impairment.)

During the 29 October 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported panic attacks, trouble sleeping and depression due to PTSD.  The psychiatric evaluation was marked normal.  The 1 November 2004 commander’s statement noted that the CI was physically unable to perform his duties due to his symptoms of PTSD.  

At the 13 September 2005 VA Compensation and Pension (C&P) evaluation, 10 months after separation, the CI reported bouts of depression that lasted 1-2 weeks at a time, with irritability and argumentativeness as key aspects of the depression.  Energy level was adequate for work and then he “crashed” at home.  Appetite was diminished but had stabilized after losing 20 pounds.  Self-esteem was low and he was irritable and “ornery.”  He had no hobbies but often worked 15 hours a day.  He was anxious all the time and worried about money and bills.  He was compulsive about keeping things “aligned” and neatly organized.  He had anxiety, shown by excessive sweating and tremors.  He had anxiety and panic attacks that lasted 2-3 hours with trouble breathing.  He had a moderate fear of heights.  He had a couple of good friends and remained married to his second wife.  He worked a full time job for the past 6 weeks and worked part time as a bartender for the past 2 months.  He reported he had never been written up for poor quality work and his work was well regarded.  He might throw something when mad at work.  He was interested in returning to the Service but had to wait 2 years.  He drank 2 beers on nights he worked as a bartender.  He met the criteria for PTSD clinically and scored above the cutoff on a PTSD scale.  Personality testing noted he responded to questions in a highly over inclusive fashion and nearly all of the Content scales were elevated.  Both findings suggested an exaggerated response style.  During the MSE he showed poor eye contact, reduced range of affect, but denied feelings of hopelessness.  He had passing thoughts of suicide the previous week after an episode of marital conflict.  Diagnoses of PTSD and depressive disorder were rendered with a GAF score of 55 (moderate symptoms, impairment.)  

The panel directed attention to its rating recommendation based on the above evidence.  The panel determined IAW DoD guidance, that 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 if the rating at constructive TDRL placement (separation) should have been greater than the minimum 50%.  The next higher rating is 70% and the §4.130 criteria at this rating level requires the CI to have “occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood.”  The NARSUM examination noted the CI was engaged in several therapeutic interventions, was beginning to respond to the new anti-depression medication, Effexor, and nightmares had declined with the introduction of Prazosin.  He was still estranged from his children but his marital relationship was improving.  Evidence at separation did not support a rating of 70%, therefore a rating of 50% is assigned for entry into the constructive TDRL period IAW with VASRD §4.129.

The panel next considered the permanent rating.  The PEB rated the PTSD 10%, coded 9411, (post-traumatic stress disorder), citing that it required psychotropic medication and outpatient therapy.  The VA rated the PTSD 50%, coded 9411, based on the C&P examination 10 months after separation, citing reduced affect, panic attacks, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships.  The most proximate source of comprehensive evidence on which to base the permanent rating is the C&P examination conducted 10 months post-removal.  The CI reported he stopped taking his medications after 6 weeks.  He reported no legal problems or psychiatric hospitalizations.  He had ongoing symptoms of anxiety and depression, but was able to work a full-time and a part-time job.  He said his work was well regarded and was a haven and a distraction.  He often worked 15 hour days, had two good friends and remained married.  He was living with his wife and children and was interested in returning to the Service.  His primary stressors were financial, dissatisfaction with employment and domestic strain.  Members concluded that the 10% rating (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, or; symptoms controlled by continuous medication) most accurately depicted the condition at the time of removal from the constructive TDRL period.  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 6 months of constructive TDRL and a 10% permanent rating thereafter for the PTSD condition.

Contended PEB Condition:  Low Back Pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.    The Commander’s statement non-specifically suggests the involvement of a medical condition that affected performance; he only identified PTSD.  The NARSUM describes daily mild pain with positional worsening.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  The contended condition was not profiled, or judged to fail retention standards.  After due deliberation, the panel 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 a disability rating of 50%, 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 10% IAW VASRD §4.130.  In the matter of the contended low back condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  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, 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 20160921, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170018528, 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 recharacterization 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 recharacterization 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 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, (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