RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02725
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070611

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Human Resources Specialist, medically separated from the Temporary Disability Retired List (TDRL) for “posttraumatic stress disorder (PTSD), chronic, associated with a major depressive disorder, a cognitive disorder and alcohol dependence” with a disability rating of 10%.   

CI CONTENTION:  “Review all conditions.”  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 - 20070430	VARD - 20071031	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD with Major Depressive Disorder (MDD)	9411- 9434	10%	MDD with PTSD	9434-9411	70%	20040922	
Low Back Pain	Not unfitting	Degenerative Disc Disease, Lumbar and Thoracic Spine	5242	30%	20040917	
Wrist Pain (Right)	Not unfitting	Ulnar Neuropathy, Right	8599-8515 	10%	20040917	
		Scar on Dorsum, Right Wrist	7802	0%	20040917	
Deep Venous Thrombosis (DVT)	Not unfitting	DVT, Left Leg	7199-7120	0%	20040917	
		DVT, Right Leg	7199-7120	0%	20040917	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

PTSD with MDD, Cognitive Disorder and Alcohol Dependence.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s history of depression presented several years prior to diagnosis and treatment.  He experienced traumatic stressors while serving in the Persian Gulf War in 1991.  In 1995, he attended a 30-day alcohol rehabilitation program while serving in Korea.  He was a member of the casualty team that provided first line service following a SCUD missile attack on the US Army Barracks in Dhahran, Saudi Arabia, where 28 soldiers were killed and 100 soldiers were injured.  He reported that he did not receive any psychological or psychiatric treatment for his symptoms until approximately 2001.  In March of 2003, he spent 7 days in the psychiatric inpatient unit.  At that time, he was diagnosed with MDD and PTSD.  The CI was treated with antidepressant medication and talk therapy.  He had cognitive issues that were thought to have been possibly due to a previous head trauma (motorcycle accident 1975 and during service in Saudi Arabia around 2000) and chronic alcohol consumption.

At the 9 May 2003 NARSUM, 7 months prior to TDRL placement, the CI complained of fatigue, excessive worry, feeling overwhelmed, guilty, hopeless, worthless and helpless.  He reported other symptoms related to depression.  The CI also reported difficulty with sleep, forgetfulness, decreased concentration, and cognitive problems on the job such as problems with switching tasks, and performing multiple tasks at one time.  He also had PTSD-type symptoms.  The CI reported a history of one psychiatric hospitalization as noted above.  The mental status examination (MSE) was unremarkable with the exception of depressed mood and difficulty with recalling exact dates and related information, opined to be due to cognitive deficits.  His immediate recall and concentration were intact, and his judgment was not impaired.  The examiner diagnosed MDD and PTSD associated with traumatic experiences, and alcohol dependence, in full remission.  A Global Assessment of Functioning (GAF) score of 51-55 (connotes moderate symptoms and or impairment) was recorded.  Personality disorder was recorded as a past diagnosis.  He was placed on TDRL on 16 March 2004 with a 30% disability rating.  

At the 26 February 2007 TDRL removal examination, 3 months prior to separation, the CI reported no current mental health (MH) treatment and was not taking any psychotropic medication.  He had not been hospitalized for psychiatric reasons or treated in the emergency room for MH issues, but continued to drink heavily and experienced withdrawal symptoms.  The CI was rejected for admission to an alcohol treatment program due to his medical conditions.  The CI was not working due to his physical condition.  He was still married and lived with his wife and two teenage sons.  The CI had poor sleep, irritability, hyperarousal and social avoidance.  He also reportedly had depressed mood, and was unable to perform many routine household tasks such as paying bills.  Frequency of sleep difficulty was not documented.  The CI felt that his cognition was better than it was when he retired and noted that the antidepressant medication he took in the past was effective in managing his depression but he was reluctant to take the medication as long as he continued to drink alcohol.  The MSE was unremarkable with the exception of poor 5-minute recall skills.  The examiner noted the CI’s PTSD appeared stable compared to the 2003 NARSUM examination and the MDD was manifested by depressed mood, insomnia, anhedonia and passive suicidal ideation.  Evidence of impairment in thinking or judgment was not recorded.  The GAF score connotes moderate impairment in social or occupational functioning.  There was no evidence in the available records that documented or suggested that the CI was unable to work due to him MH disorders.  There was no VA examination proximate to TDRL removal in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the MH disorders 30%, coded 9411-9434 (PTSD-MDD) and noted that the CI was not sufficiently stable for final adjudication.  The VA rated the MH disorders at 70%, coded 9434-9411.  The panel acknowledged the three mental health diagnoses assigned to the CI; however, regardless of diagnosis, VASRD §4.130 rates symptoms based on overall MH condition independent of diagnosis or multiple diagnoses.  Recommending additional rating for PTSD, cognitive disorder or MDD is not permitted IAW VASRD 4.14 (avoidance of pyramiding).
The panel, IAW DoDI 6040.44 and DoD guidance (which applies current VASRD §4.129 to all Board cases as appropriate), agreed the provisions of §4.129 were applicable in this case, and therefore, a minimal of 50% was warranted at TDRL placement.  The panel next proceeded with its rating recommendation under VARSD §4.130 based on the evidence at TDRL placement.  Regardless of the diagnosis, §4.130 rating is based on symptoms independent of diagnosis; therefore, all MH symptoms are considered in the rating and are reflected in the panel’s recommendation.  

The panel considered the NARSUM and the STR, which indicated the CI had no additional hospitalizations prior to being placed on the TDRL.  The panel also considered the C&P examination, 6 months after TDRL placement that showed no deficits in thinking, family relations or judgment, and no hospitalizations or visits to the emergency room related to a MH condition.  Panel members agreed the record in evidence did not support a rating higher than 50% at TDRL placement. 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 the PTSD with MDD and cognitive disorder condition at TDRL placement.

The panel considered whether the evidence at TDRL removal supported a rating higher than the 10% rating adjudicated by the PEB.  The panel noted the alcohol dependence had been added as an associated condition as a result of the TDRL examination finding, but IAW DoDI 1332.38 E4.13.1.4, the condition does not constitute a physical disability, and is therefore, not compensable or ratable.  The panel noted the absence of documented hospitalizations, emergency room visits and employment during the TDRL period.  The panel also noted the CI continued to have mild memory problems and other mild cognitive problems that impacted his ability to pay bills by his report, but his depressive symptoms had decreased despite absence of antidepressant medication.  Documentation of chronic sleep impairment, panic attacks or other non-PTSD anxiety symptoms was absent.  Despite his continued symptoms, the record demonstrated a chronic, but stable, condition in the absence of treatment.  

The panel recommended a 10% rating for “occupational and social impairment due to mild or transient symptoms which decrease work efficiency…only during periods of significant stress” versus a 30% rating for “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.”  Panel members agreed the CI’s symptoms were mild or transient, therefore, the 10% disability level better reflected the level of disability at TDRL removal.  After due deliberation, considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a retroactive period of TDRL with a rating of 50% (in accordance with §4.129), and a permanent rating of 10% for the PTSD with comorbid MDD and cognitive disorder. 

Contended PEB Conditions:  Low Back Pain, Right Wrist Pain and DVT.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  The low back and right wrist conditions were profiled L2 and U2 respectively, but none of the conditions were implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the 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 with comorbid MDD and cognitive disorder, the panel recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129 as DOD directed effective 16 March 2004; and a 10% permanent rating after removal from the TDRL IAW VASRD §4.130.  In the matter of the contended low back, wrist and DVT conditions, 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	
Post- Traumatic Stress Disorder	9411-9434	50%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170423, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008718, 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), XXXXXXXXXXXXXXXXXX.

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

Sincerely,					      
Enclosure