RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01298
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20050219

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Laundry Textile Specialist, medically separated for “anxiety disorder not otherwise specified [NOS]” with a disability rating of 10%.  

CI CONTENTION:  “Inaccurate diagnosis (i.e., hemotological disorders excluded) and unfair rating.”  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 - 20041130	VARD - 20050721	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Anxiety Disorder NOS	9413	10%	Post-Traumatic Stress Disorder (PTSD)	9411	50%	20050427	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50% 	

ANALYSIS SUMMARY:  

Anxiety Disorder NOS.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s mental health (MH) condition began in June 2004 after his one- year deployment to Iraq.  He did not report observing any killing but had nightmares of a person having his head cut off.  He self-referred to MH due to problems with insomnia, nightmares, occasional flashbacks, and decreased concentration, energy and appetite.  He reported his depression as feeling low and worried his life wasn’t going anywhere.  He occasionally cried.  A diagnosis of PTSD was rendered and he was treated with Wellbutrin (depression), Trazodone (sleep aide), weekly psychotherapy, and relaxation skills training.  He was placed on a temporary profile due to intense anxiety and flashbacks.  The MEB forwarded “PTSD” for PEB adjudication.

The 15 October 2004 MEB NARSUM examination, 8 months prior to separation, noted complaints of somewhat disturbed sleep with nightmares.  He awakened confused and believing himself to be in Iraq.  He stated that many routine activities brought up frightening memories.  He reported flashbacks that appeared to be descriptions of brief panic attacks; his heart rate increased and he felt anxious.  However, he reported he was generally calmer with an improvement in his mood. Medications included Wellbutrin and Seroquel (anti-psychosis).  A mental status examination on 30 June 2004 showed obsessive ruminations, ideas of reference and depressed mood but no suicidal/homicidal ideation.  A diagnosis of PTSD was rendered with a Global Assessment of Functioning (GAF) score of 60 (moderate bordering on mild symptoms, impairment).  The commander noted the CI had constantly shown erratic behavior since his return from Iraq, possibly caused by delusions probably caused by his combat experiences.  

At the 27 April 2005 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported exposure to bomb explosions and reports of civilians who were beheaded.  He reported flashbacks, hypervigilance, nightmares, panic attacks, depression easy startle, thoughts of death, and poor concentration.  He said he stopped taking medicines since they were not working and he was not getting any psychiatric treatment.  Symptoms were moderately severe and he had them most days.  He had not been able to find a job since his return in December 2004.  He lived with his parents and had contact with the family but tended to isolate and spent time alone.  Physical examination showed an anxious mood but appropriate affect.  He reported that he spent a lot of time worrying and watching television.  He had few friends and was looking for a job.  A diagnosis of PTSD was rendered with a GAF score of 45 (serious symptoms, impairment).  The examiner noted his symptoms did not prevent employment.  Using STR and a military website, the VA confirmed his service in Kuwait and Iraq at locations exposed to bombings and mortar attacks.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the MH condition 10%, coded 9413 (anxiety disorder), citing flashbacks, irritability, depression, nightmares, agitation and avoidance behaviors which improved with the use of psychotherapy and anti-depressant medications.  The VA rated the MH condition 50%, coded 9411 (PTSD), based on the C&P examination, citing nightmares, poor sleep, hypervigilance, and depression.  

The panel considered if application of VASRD §4.129 with a constructive 6-month (50% minimum) period on the Temporary Disability Retirement List (TDRL) was indicated in this case. Application of VASRD §4.129 is considered by the panel for all cases of service-connected psychiatric conditions resulting in separation.  The PEB did not apply §4.129, although noting the condition was “secondary to service in Iraq in 2003.”  The commander referenced “erratic behaviors…caused by combat experiences.”  Panel members agreed the provisions of VASRD §4.129 were applicable in this case, noting the association with combat experiences impacting his current symptoms.  The panel then considered if there was evidence for a §4.130 rating higher than the section 4.129 minimum mandated 50% at the time of retroactive TDRL placement.  The panel unanimously agreed 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 recommendation in this case is the April 2005 VA examination.  The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication,” and for a 30% rating is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.” The CI continued to report symptoms of PTSD and that he had not been able to find a job since his return although he was seeking employment.  He reported he was not taking medicines and not getting any psychiatric treatment.  The examiner noted his symptoms did not prevent employment.  The panel also considered the absence of psychiatric hospitalization or visits to the emergency room for MH symptoms; and the absence of clinical evidence of impaired judgment, problems with thinking, and suicidal or homicidal attempts.  The panel considered the record in totality, and concluded that at the time of separation, the CI’s disability 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.”  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 the anxiety condition. 

BOARD FINDINGS:  In the matter of the anxiety disorder, the panel recommends a disability rating of 50%, coded 9413 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 PTSD condition, the panel recommends no change from the PEB adjudication. 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 the medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Anxiety Disorder	9413	50%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170227, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record  

AR20180008619, 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