RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXXX	CASE: PD-2017-00427
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20081001

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Field Medical Service Technician, medically separated for “mood disorder,” “headaches with mixed features,” “blast exposure,” “post traumatic stress disorder (PTSD),” “cognitive disorder not otherwise specified (NOS),” “major depressive disorder (MDD)” and “social phobia,” rated for overall effect, with a combined disability rating of 0%.

CI CONTENTION: Did not receive adequate review of his conditions. The CI also requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the MEB, but determined by the PEB 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. The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate. The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20080812	VARD - 20081206	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mood Disorder	

Overall Effect	

0%	Traumatic Brain Injury with Residual of Chronic Tic Disorder and Headaches.	
8045-8103	
10%	

20080709	
Headaches							
Blast Exposure							
PTSD			
PTSD	
9411	
30%		
Cognitive Disorder (NOS)							
MDD							
Social Phobia							
Dyspepsia	
Cat III	Hiatal Hernia, with GERD	7346	0%		
Tic Disorder		See TBI above				
Back Pain		Strain, Thoracic Spine	5299-5261	10%		
Histoplasmosis		Granulomatous Disease of the Lung	6699-6602	0%		
Sleep Disorder		No VA Placement	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:

Mood Disorder, Headaches, Blast Exposure, PTSD, Cognitive Disorder NOS, MDD, Moderate Social Phobia. The PEB determined that the CI was unfit due to the “overall effect” of multiple conditions. In an “overall effect” case, each condition has been determined by the PEB to be separately not unfit, but the “overall effect” considered together creates a condition of unfitness. Such cases are identified by the PEB explicitly stating the conditions were combined under the provisions of “Overall Effect,” citing SECNAVINST 1850.4E. The panel noted that this was also IAW DoDI 1332.38 E3.P3.4.4. In these cases, the panel evaluates each condition separately for fitness, but does not recommend a rating unless a preponderance of evidence demonstrates that a specific condition should have been separately unfitting at separation.

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s multiple conditions began in 2004 after deployment to Iraq. The CI deployed as a combat corpsman and experienced significant exposure to psychological trauma. At the January 2005 post deployment health assessment, the CI reported combat exposures but denied psychiatric symptoms and did not wish to receive help for emotional, alcohol or family problems. The CI also reported exposure to numerous blasts, resulting in loss of consciousness three or four different times. He did not seek medical help after the blast exposures. In addition, the CI reported he drank heavily for 6 months after returning. During the 25 August 2006 internal medicine visit, the CI again reported significant combat exposure and fully defined PTSD symptoms, including sleep disturbance, nightmares, anxiety with palpations, shortness of breath, irritability, hostility and labile mood. He was effectively treated with Celexa (depression), but nightmares, anxiety and sleep problems returned. The CI first reported to mental health (MH) on 20 August 2007 with complaints of increased anxiety, poor sleep and nightmares. However, the October 2007 LIMDU only included back pain; the 11 February 2008 LIMDU included tics, traumatic brain injury (TBI) and PTSD and cited a blast injury as the source of illness. The CI did not return to MH until April 2008 due to a fear of a perception of personal weakness. The CI received a combat action ribbon (CAB).

The 28 February 2008 NARSUM examination, 7 months prior to separation, noted complaints of several problems, but specifically daily headaches. The CI also reported problems with sleep, memory, mood manifested as anxiety, worry and a tremor. He also reported occasional obsessive compulsive disorder behavior and anxiety about his tic disorder. There was an occasional uncontrolled facial and upper extremity movement, including vocalization, which he could suppress. The examiner noted the CI had neuropsychological testing consistent with TBI and/or PTSD. Physical examination showed occasional jerking and twitching of the facial muscles, which he was able to suppress, when asked, for several seconds. Gait (including tiptoe), heel- walk and tandem walk were normal, as were motor strength and sensory. The CI had elevated strep titers above 600. The movement disorder specialist had previously suggested a trial treatment of penicillin but there was no change in his movement disorder. An MRI of the brain was normal and the CI appeared otherwise intact. The examiner noted there was no clear history of TBI. The examiner noted the problems with headaches, disturbed sleep and recent memory, changes in mood and features consistent with a tic disorder were debilitating and placed the CI and other soldiers at risk if deployed again.  He was referred to the PEB.

The 28 April 2008 MEB psychiatry addendum, 5 months prior to separation, noted complaints of moderate symptoms of depression while PTSD symptoms remained stable except for minor improvement in irritability, intrusive thoughts, emotional response of reminders and disturbing dreams. He denied panic attacks, but reported physiological reactivity to sudden loud noises and generalized to most public situations where he felt extreme levels of social anxiety and the need to remove himself. He reported he was increasingly isolative. He reported healthy interpersonal relationships and satisfaction with his marriage, and had decreased beer consumption to 3-5

beers per day. Mental status examination (MSE) showed an essentially normal examination with the exception of a somewhat blunted affect. Axis I diagnoses of PTSD, MDD and social phobia and Axis III diagnoses of histoplasmosis, back pain, TBI and headaches were rendered with a Global Assessment of Functioning (GAF) score of 65 (mild impairment). The examiner noted the diagnoses were somewhat interdependent and his reluctance to engage in MH treatment since initial intake was the greatest barrier to progress so far. The examiner noted a high degree of symptomatology related to physical injury, protracted recovery and post deployment stress; and symptoms had continued to worsen and generalize over time. The MEB noted the CI would not be mentally capable of full duty without a significant period of treatment. He was non- deployable and should not engage in field exercises or have access to a weapon, and should remain near a treatment facility with full psychiatric services. He should also be placed in a minimal stress job and be monitored by MH pending discharge.

At the 25 June 2008 VA Compensation and Pension (C&P) general examination, 3 months pre- separation, the CI reported tension headaches, which occurred all day every day, were worse with stress and increased muscle activity. The CI reported no medication or functional impairment for headaches or for tics. The back condition showed no evidence of limitation or painful motion and he could function with medication, although at times he needed complete bed rest. He hoped to return to Missouri, work on a farm and become a physician’s assistant. He continued to take Celexa and was able to perform activities of daily living as well as more complex tasks. Physical examination showed a normal gait without a need for assistive devices. There was no motor weakness.  Tics were not observed.

Although the 9 July 2008 VA C&P examination, 2 months before separation, was not in evidence, the 2008 VARD referenced findings from that examination. The CI reported difficulty with sleep, nightmares, anxiety and tension with startle and hypervigilance. The CI displayed mild depression and anxiety but no panic attacks. There was mild irritability and good concentration. Diagnoses of PTSD and mild cognitive disorder were rendered with a GAF score of 60 (moderate bordering on mild impairment).

The 4 August 2008 non-medical assessment (NMA) did not identify a specific condition, but noted the CI demonstrated a lack of concern and did not seem able to concentrate on the tasks at hand. He could not be trusted with direct patient care, but when he concentrated on a task, he could produce good results with little or no supervision.

The March 2009 Poly trauma/TBI consult, 5 months post-separation, noted the CI was unemployed and looking for work. He remained in treatment for TBI, had an AA degree with general education requirements and planned to continue his education to be a physician’s assitant. The April 2009 initial primary care visit to the VA noted the CI remained unemployed, had about six alcohol drinks per day and took Elavil (depression) and Zomig (headaches.)

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the multiple conditions, as described above, 0%, for overall effect. The VA rated the TBI with residual chronic tic disorder 10%, analogously coded 8045-8103 (tic, convulsive, moderate), citing tics that were moderate in severity. The VA rated the PTSD 30%, coded 9411 (PTSD) based on the C&P examination, citing occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.

PTSD, Mood Disorder, MDD and Social Phobia. The panel considered the evidence for fitness for PTSD. The condition was listed on the LIMDU and the NARSUM Psychiatry Addendum, neuropsychological testing, MEB and VA C&P examination noted PTSD as medically unacceptable. The psychiatric addendum noted a decrease in alcohol consumption but continued high level of daily use. The August 2008 NMA noted a lack of concern to be on time and frequent unexplained absences, a lack of concentration and a lack of trust he could perform

patient care. Panel members concluded there was a preponderance of evidence showing that the condition, standing alone, would have caused the CI to be referred into the DES or be found unfit due to traumatic exposures. The PEB noted the PTSD was the direct result of a combat exposure. The panel concluded the provisions of VASRD §4.129 (mental disorders due to traumatic stress) applied, and determined the PTSD was due to a “highly stressful event.” Therefore, a minimum 50% rating for a retroactive 6-month period on the Temporary Disability Retired List (TDRL) is recommended. Disability associated with any psychiatric condition, regardless of the diagnosis or multiple diagnoses (in this case, MDD, mood disorder and social phobia), is subsumed under a single MH rating IAW VASRD §4.130. Members agreed there was no evidence to support a rating higher than 50% at the time of TDRL placement.

The panel then considered the permanent rating recommendation at the time of TDRL removal. The most proximate source of comprehensive evidence on which to base the permanent rating recommendation in this case is the July 2008 C&P examination, performed 2 months prior to TDRL placement. The examination noted the CI continued to endorse symptoms of PTSD described as mild-to-moderate. According to the June 2008 general C&P examination, the CI continued to take anti-depression medication. Panel members agreed the CI’s MH symptoms most closely approximated the criteria for a 10% disability at TDRL removal. 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% (IAW §4.129), and a permanent rating of 10% for the PTSD, coded 9411.

Headaches, Blast Exposure w/possible TBI and Cognitive Disorder NOS). The panel considered the evidence for fitness for the headaches and cognitive disorder due to blast exposure with possible TBI. The TBI was cited on the 2008 LIMDU and the NARSUM examiner noted headaches and memory problems (part of cognitive disorder) did not meet retention standards. The August 2008 NMA noted problems with concentration (a symptom of cognitive disorder) that interfered with duty performance. However, the C&P examination, which was more proximate to separation than the NARSUM examination, noted there was no functional impairment from tics or headaches. Attention was normal and there was only a mild decrease in memory. The panel concluded there was not a preponderance of evidence that showed the headaches, TBI or cognitive disorder would have caused the CI to be found unfit.

Contended PEB Condition: Dyspepsia, Back Pain, Tic Disorder, Histoplasmosis and Sleep Disorder. The panel’s main charge is to assess the fairness of the PEB determinations that the contended conditions were not unfitting. Although the NARSUM examiner noted the tics interfered with duty performance and the LIMDU listed tics, the VA C&P noted no functional impairment due to the tics. Although both the April and October 2007 LIMDUs cited back pain, the CI could function with medication. Physical examination showed a normal gait without a need for assistive devices. There was no motor weakness or loss of range of motion and the CI was able to perform basic and instrumental activities of daily living. Dyspepsia, histoplasmosis and sleep disorder were not noted on LIMDU forms, implicated in the non-medical assessment or judged to fail retention standards. There was no performance-based evidence from the record that any of the contended conditions significantly interfered with satisfactory duty performance at separation. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS: In the matter of the PTSD, the panel recommends an initial TDRL rating of 50%, coded 9411 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 tic disorder, back pain, dyspepsia, histoplasmosis and sleep disorder, the panel recommends no change from

the PEB determinations as not unfitting. 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 the date of medical separation:

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

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD DC 20374-5023

IN REPLY REFER TO

1850
CORB:003
9 Jun 20

From: Director, Secretary of the Navy Council of Review Boards 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

Ref:   (a) DoDI 6040.44
(b) PDBR ltr of 14 May 19

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation to the Department of the Navy for appropriate action.

2.	On 4 June 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) took action in your case by accepting the recommendation of the PDBR. Accordingly, your records will be corrected to reflect your assignment to the Temporary Disability Retired List for six months with a 50 percent disability rating at the time of your discharge followed by assignment to the Permanent Disability Retired List with a final rating of 30 percent.

3.	For your information, since all disability ratings from 0% to 20% qualify for disability severance pay, the above stated increase will not result in your entitlement to additional compensation.

4.	The Assistant Secretary’s determination, which represents final action in your case by the Department of the Navy, has been forwarded to the office of the Navy Personnel Command for appropriate changes to your personnel records and notification to you upon completion.