RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01033
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20061113

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Fire Support Specialist, medically separated for “post-traumatic stress disorder” with a disability rating of 10%.

CI CONTENTION:  “Review for fairness.”  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 Medical Evaluation Board (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 - 20060901	VARD - 20070407	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post-Traumatic Stress Disorder	9411	10%	Post-Traumatic Stress Disorder	9411	50%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:

Post-Traumatic Stress Disorder (PTSD).  According to the service treatment record (STR) and the MEB narrative summary (NARSUM), the CI’s mental health condition began after returning from a deployment to Iraq from March 2003 to 2004.  He developed thoughts of suicide, and homicidal ideations towards his wife.  He began drinking as “self-medication.”  Symptoms worsened from December 2004 to January 2005.  The CI reported PTSD symptoms which included:  recurrent thoughts of Iraq, nightmares, detachment, and eventually becoming absent without leave from a training mission in Italy.  He developed specific suicidal ideation and an unsuccessfully attempted suicide.

The CI deployed to Afghanistan in February 2005 where his performance deteriorated.  He began using hashish to “calm” himself and used valium to relax.  He eventually self-reported to Combat Stress and was treated with an anti-depression medication.  He had a verbal altercation with a senior officer and was medically evacuated due to his worsening performance, behavior disturbance, and mood symptoms.  He was admitted to Walter Reed inpatient psychiatry from 18 August 2005 to 7 September 2005.  The mental status examination showed the CI poorly groomed with rapid-pressured speech, agitated psychomotor, calluses on his hands from repetitive rubbing motion, poor eye contact, a bad mood and anxious affect, thought content notable for suicidal and homicidal ideations without plan, poor judgment, and impaired impulse control.  The CI remained alcohol free with a good substance abuse prevention program, and was compliant with four psychotropic medications.  Axis I:  PTSD, alcohol abuse, and alcohol-induced mood disorder were diagnosed with a Global Assessment of Functioning (GAF) score of 65 (mild impairment symptoms).  The examiner opined the CI was incapable of full-time civilian employment but might be able to work part-time in a highly supportive environment with continued medical treatment.

The CI was readmitted to inpatient psychiatric care from 15 December 2005 to 29 December 2005 for a psychotic presentation, recent exacerbation of previous PTSD and major depressive disorder symptoms, and relapse in his alcohol dependence.  The CI had significant cigarette burns marks and cuts to both forearms.  The mental status report showed moderate distress and he appeared disheveled in civilian attire.  Psychomotor state was restless.  He had poor eye contact with the interviewer; alternating between pleasant and apologetic to paranoid.  Mood was “I don’t know.”  Affect was anxious, worried, and tearful.  He was not homicidal but was suicidal, endorsing command auditory hallucinations in his own voice to kill himself.  He had mild paranoid delusions in relation to his spouse, staff, and unit, and endorsed persecution by a higher power for acts in Iraq and Afghanistan.  The initial Axis I diagnoses were psychosis not otherwise specified; alcohol dependence, early partial remission; history of mood disorder (single episode); and history of PTSD, chronic.  GAF was 32 (some realty testing impairment).  The diagnoses at discharge were Axis I:  PTSD, chronic and alcohol abuse with GAF of 55 (moderate impairment symptoms).

During the 28 February 2006 MEB NARSUM examination, 9 months prior to separation, the CI reported he was unable to take two of the medications due to side effects.  He was taking one psychotropic medication to treat nightmares and insomnia at night, and was not drinking alcohol.  He endorsed nightmares several times per week and had insomnia some nights.  His relationship with his wife was better and he helped take care of their daughter.  He was working at the Chaplain’s office.  Axis I:  PTSD and alcohol abuse in early full remission diagnoses were rendered with a GAF of 65 (mild impairment symptoms).  No mental status report was recorded.

A 24 August 2006 email from the assistant platoon sergeant noted the CI remained under Ward 53 treatment and checked into the substance abuse program periodically.  He worked in the platoon office as needed, performing furniture detail, helping with change of command ceremonies, police calls, escorting soldiers to appointments, and attending platoon sergeant meetings.  The sergeant also stated “in a non-military environment it could become challenging for this CI to function under micromanagement of any kind.”

At the 28 February 2007 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported sleep was variably problematic, and he was nervous “a lot,” especially when around many people.  He enjoyed camping and said he got along with others but did not have any close friends.  Appetite was good but concentration and memory were “pretty bad.”  People would talk to him but he did not hear them.  He did dishes and went to the store.  He helped his father on the farm while looking for work.  He was living with his parents so they could help with childcare.  He had not worked since leaving the service but he had some job interviews.  He was not separated but his wife worked away.  He ran out of medication 3 weeks previously and had not received outpatient follow up since discharge because he lived 200 miles from the VA and had no money to get treatment.  The mental status examination showed a mildly disheveled quality, a mild fidgetiness congruent with his mildly anxious affect, and mild depression.  He was tearful when talking about his PTSD experiences and seemed to underemphasize problems.  He was confused about his past history as well as his present feelings.  The examiner opined the CI “probably tended to minimize pathology.”  Axis I:  PTSD and alcohol abuse in remission were diagnosed with a GAF score of 53 (moderate impairment symptoms).

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the PTSD condition 10%, coded 9411 (PTSD), citing psychological difficulties that have a mild impact on his industrial and social capabilities.  The VA rated the PTSD condition 50%, coded 9411, based on the C&P examination, citing sleep, anger, and concentration difficulties which caused clinically significant distress in social functioning.  

The panel determined that, 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 then considered if there was evidence for a §4.130 rating higher than the §4.129 minimum mandated 50% at time of 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,” and for a 50% rating is “Occupational and social impairment with reduced reliability and productivity”.  The August 2006 email noted the CI worked as needed, remained in treatment, and was able to work with peers.  The panel agreed that the §4.130 criteria for a rating higher than 50% were not met near the time of separation, and therefore the minimum 50% initial TDRL rating is applicable.

The most proximate source of comprehensive evidence on which to base the permanent rating (TDRL removal) is the VA examination 3 months after TDRL placement; there are no subsequent VA examinations in evidence.  The VA examiner opined that the CI had mild-to-moderate difficulty with social relationships and difficulty maintaining family role functions.  The CI was not working, other than to help his dad on the farm.  The mental status showed the CI to still be disheveled, fidgety, anxious, and depressed.  The CI had difficulty with concentration, memory, and sleep.  He was tearful when talking about his PTSD experiences.  The examiner opined that the CI underemphasized problems and his level of function remained in the moderate zone.  The panel agreed the CI met criteria of 30% disability at the time of TDRL removal.  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 30% permanent rating thereafter for the PTSD condition. 

BOARD FINDINGS:  In the matter of the PTSD condition, the panel recommends a disability rating of 50%, coded 9411 IAW VASRD §4.129, for 6 months, followed by a disability rating of 30%, coded 9411 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; and, that the discharge with severance pay be re-characterized to reflect placement on the TDRL for 6 months, effective the date of medical separation, followed by permanent disability retirement:

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
PTSD	9411	50%	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170217, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180006635 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 re-characterize your separation as a disability retirement with the combined disability rating of 30%.  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 50% retired pay for six months from the date of your original medical separation and then 30% 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, (AHRC-DO), XXXXXXXXXXXXXXXXXX.

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

Sincerely,					      
Enclosure