RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01817
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 E6, Infantryman, medically separated for “posttraumatic stress disorder (PTSD)” with a disability rating of 10%.   

CI CONTENTION:  “PTSD.”  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 - 20041116	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD	9411	10%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

PTSD.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s PTSD began while deployed in May 2004 after having to dispose of “dozens” of human remains after a car bomb exploded.  He reported he had never experienced anything like it and began having nightmares most nights.  He was medically evacuated in June 2004 due to an abdominal emergency.  His nightmares persisted and he felt extreme guilt about not being with peers.  This led to significant emotional detachment from his wife, which created marked marital strife.  He could not concentrate on his job because he was “too charged to sleep…worrying about dreams that [would] come.” 

At the 28 September 2004 psychiatric MEB NARSUM examination, 5 months prior to separation, the CI reported “thoughts haunt me” and he could not seem to move past the experience.  He reported depressed mood, poor sleep, lowered interest, poor concentration, diminished appetite and low energy.  He voiced multiple avoidance and hypervigilance symptoms.  He was taking anti-depression and anti-nightmare medications as well as individual therapy and attending a Combat Veteran’s group.  The mental status examination (MSE) showed moderate evidence of retardation, extreme distance emotionally but attentiveness through the interview with a dysphoric and anxious affect, which was slightly constricted, moderately mobile and poorly reactive, fitting a definition of alexithymia.  No psychosis or suicidal/homicidal ideation was noted.  A diagnosis of PTSD was rendered with a Global Assessment of Functioning (GAF) score of 60 (moderate symptoms).  The CI did not attend his scheduled VA examination.

He was seen in the VA’s mental health (MH) clinic on 7 October 2005 for a complaint of sleeping difficulty.  He reported medication had not helped and he really didn’t want to take medication.  He also reported that he had “some difficulty at home with his wife understanding his mood swings, his anxiety.”  The MSE noted the CI was of “normal to superior intelligence” and showed “no evidence of a primary thought disorder.”  The CI had “an active religious life and appear[ed] to be a very caring, warm individual.”  The CI reported that he was placed on Remeron and Seroquel, but those medications didn’t help very much with sleep, but the “Remeron helped with his anxiety.”  His Remeron was reduced and he was placed on Klonopin for anxiety.

On 13 October 2005, the CI was voluntarily admitted to the VA hospital.  A social work note indicated that he had “been experiencing severe anger outbursts.”  The CI reported “he was cut-off in traffic by a motorist.  That motorist followed behind him and drove to his house.  At that time, [the CI] went into his house loaded a gun and put it under his pillow.  Fortunately, the driver of the vehicle did not come to the door.  [The CI states], I was prepared to shoot the gun to protect my life and my family."  The social worker recorded that “it was reflective of his response to combat experiences.  In addition, last evening, he hit one of his children with a coat hanger.”  The CI reported “the incident that brought him into treatment [was] an ‘episode’ due to changes in his psychiatric medication.”  The CI admitted “suffering from anger management difficulties, anxiety, depression and ha[d] difficulties sleeping.”  He was taking anti-depression medication (mirtazapine) daily, anti-anxiety medication that was also used as a sleep aide (hydroxyzine) and two anti-anxiety medications (tenazepam and clonazepam) as needed under the care of a psychiatrist.  He received treatment from an individual therapist and was offered medication to treat his nightmares.  He was a full time student pursuing a degree as a registered nurse.  The initial behavioral assessment showed clear thought patterns, no hallucinations or delusions, sad affect, depressed mood and memory intact.  The initial admission MSE showed a flat affect and mood of underlying depression.  Diagnoses of PTSD and depression were rendered with a GAF score of 60 (moderate symptoms).  

At the 14 October 2005 “treatment team meeting” the CI had a somewhat blunted affect, but was cooperative, appropriately dressed, displayed normal speech, answered questions appropriately, appeared comfortable speaking with staff members and was cooperative and pleasant during the interview.  The CI reported that he was “ready to go home.”  On 17 October 2005, the CI expressed readiness to be released and reported that he understood the consequences of signing out against medical advice.  The social worker recorded that the CI was not hostile or threatening, but had a strong desire to return home and no longer felt the need to remain on inpatient status.  The CI signed out of the hospital against medical advice after 4 days of hospitalization.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the PTSD 10%, coded 9411 (PTSD), citing “requiring pharmacotherapy and outpatient psychotherapy, does not require hospitalization, able to perform duties in his unit but cannot perform his PMOS.”  In May 2008, 3 years after separation, the VA initially rated the PTSD, coded 9411, at 50% effective back to 20 February 2005 then increased the rating to 70% effective back to 19 July 2005 based on VA treatment records.  

IAW DoD guidance, the panel determined VASRD section §4.129 (mental disorders due to traumatic stress) applied because PTSD was an unfitting condition.  Therefore, as a matter of policy, the PDBR recommends 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 §4.130 rating at TDLR placement should be rated at higher than the minimum 50% rating.  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.”  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 is the October 2005 inpatient psychiatric admission examination 6 months after separation.  He remained depressed, angry, and anxious and had difficulty with sleep.  The MSE showed a flat affect and depression.  The CI was admitted to inpatient psychiatry after he struck his son with a coat hanger and hid a loaded gun after a confrontation with another driver.  These aggressive behaviors persisted despite being a full time student, being under the care of a psychiatrist and a therapist and taking anti-anxiety and anti-depression medication.  The panel majority agreed the CI showed signs of impairment in judgment, family relations, mood and thinking, thereby meeting criteria for a 70% disability rating.  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 the panel majority recommends a 70% permanent rating thereafter for the PTSD, coded 9411. 

BOARD FINDINGS:  In the matter of the PTSD, the panel 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 the panel majority recommends a permanent separation rating of 70% IAW VASRD §4.130.  The single voter for dissent recommends modification to 30% at the time of removal from TDRL and submitted the appended minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

The panel majority recommends 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	
PTSD 	9411	50%	70%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

Minority Opinion.  The majority asserts, based on the CI’s over-reaction to the motorist incident and the incident involving the striking of his son with a hanger, that the CI’s occupational and social impairment was consistent with deficiencies in most areas.  However, the minority voter notes that the two incidents occurred on the same day, were associated with a change in the CI’s medications and were not consistent with the CI’s normal behavior.  

The minority voter asserts that, at constructive TDRL removal, the CI’s occupational and social impairment was more consistent with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily) with routine behavior, self-care, and conversation normal, due to symptoms of depressed mood, anxiety, anger and sleep impairment.  The CI was attending school full-time pursuing a degree in nursing, was married with two children and owned his own home (almost paid off).  On admission to the hospital, the CI indicated the incident that prompted him to seek treatment was an “episode” resulting from a change in his medications and intimated that it was not consistent with his normal behavior.  During a treatment meeting on the second day of hospitalization, the CI was noted to be cooperative, comfortable speaking to the staff, appropriately dressed and pleasant.   

The evidence clearly shows that at the time of constructive TDRL removal, the CI had depression, anxiety, anger issues and sleep impairment, but these symptoms did not cause deficiencies in most areas.  Although the minority voter concedes the CI had two incidents of “impaired impulse control,” these were attributed to a change in his medications and not consistent with his normal behavior.  He did not have symptoms of suicidal or homicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting his ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or the inability to establish and maintain effective relationships.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the minority voter recommends a disability rating of 50% for 6 months of constructive TDRL and a 30% permanent rating thereafter. 

The panel minority recommends 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	
PTSD 	9411	50%	30%	

AR20180008180, 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 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 50% 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, (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