RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX		CASE: PD-2017-03654 BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20080101

Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E7, Chief Equipment Operator, medically separated for “post-traumatic stress disorder [PTSD], chronic ” with a disability rating of 10%.

CI CONTENTION: “Traumatic Brain Injury, PTSD, hearing loss, sleep apnea, right inguinal hernia.” 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 - 20070626	VARD - 20060719	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD, Chronic	9411	10%	PTSD	“9434”	50%	20071215	
Headache Syndrome	Cat II	Post Concussion…	8045	10%	20050706	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 60%	

ANALYSIS SUMMARY:

Chronic PTSD. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s mental health (MH) condition began sometime after experiencing a significant blast injury while deployed to Iraq in August 2004. Due to cognitive issues related to the blast, the CI returned to the United States in November 2004. It is not clear when the CI was first diagnosed with PTSD; however, the STR showed the diagnosis in an outpatient clinic note dated June 2006. At the time of the 16 June 2006 MH evaluation, the CI denied any significant symptoms of sadness, or depressed mood, but did endorse fatigue, feelings of guilt about Iraq,

irritability, and concentration and memory problems. The 22 February 2007 psychiatry encounter, 10 months prior to separation, noted the CI reported sleeping through the night, improved mood and “attitude” since changes to his medication, and better relationship with his wife. The mental status examination (MSE) was unremarkable.

The 24 April 2007 MEB NARSUM examination, 8 months prior to separation, noted complaints of depressed mood, irritability, fatigue, decreased energy, difficulties in concentration, and memory issues. The CI also reported PTSD symptoms of avoidance behavior, nightmares, hypervigilance and startled responses. The CI’s symptoms had not required emergency room (ER) treatment or psychiatric hospitalization. There was no history of suicidal ideation. He was prescribed antidepressant/antianxiety medication that provided significant relief. The CI had continued to work full-time as a construction supervisor since 2006. The MSE showed normal mood with normal affect. Eye contact was direct and he had normal psychomotor activity and speech. There was no evidence of psychosis, mood instability or dangerousness to self or others. There was no evidence of significant cognitive impairment, or impairment in judgment. The examiner indicated that the CI had significant symptoms that interfered with his ability to work; however, he had been able to maintain full-time employment.

At the 15 December 2007 VA Compensation and Pension (C&P) examination, 17 days prior to separation, the CI reported PTSD symptoms to include sleep disturbance, irritability and anger outbursts. His relationship with his wife remained good, but he had difficulty getting along with some peers from work. The CI continued his construction employment, and there was no report of work-related disciplinary action or aggression. The CI did not report concentration, memory, or chronic insomnia problems. The MSE was unremarkable with the exception of mild psychomotor slowness, mild difficulty in articulation, and mildly reduced range of affect.

Treatment records were silent until a 29 June 2009 psychiatry encounter noted the CI was stable and happy with his medication. The MSE was unremarkable. The 24 September 2008 encounter, 15 months after separation, recorded no MH complaints. The CI reported he generally slept well and was still working full-time. He enjoyed riding his bike and hunting. The December 2009 psychiatry encounter, 18 months after separation, noted the CI was pleasant and cooperative, and in a good mood. The examiner stated the CI was stable on medication.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the PTSD condition 10%, coded 9411 (PTSD). The VA rated the PTSD condition 50%, coded “9434” [Sic] 9411 (PTSD), based on the C&P examination, citing the MH criteria for a 50% rating. The panel considered the provisions of VASRD §4.129 (mental disorders due to traumatic stress), and determined that application of §4.129 was appropriate in this case. Therefore, a minimum 50% rating for a retroactive 6-month period on the Temporary Disability Retired List (TDRL) is recommended.

The panel then turned to its rating recommendation at the time of TDRL placement. The MEB NARSUM, 8 months prior to separation, noted problems with memory, concentration, mood and irritability. However, MSE was normal, and showed good ability to concentrate and intact memory. The examiner noted the CI was able to maintain full-time employment but was considered disabled in that he was unable to perform the duties of his rating. The non-medical assessment (NMA) recorded the CI was assignable within the continental United States (INCONUS) and had potential for continued service in his “physical and mental condition.” The C&P examination noted that the CI was working full-time in construction, and had a supportive spouse. Although he reported difficulty with getting along with some co-workers, there was no report of aggression or violence in the workplace. There was no indication that he was disciplined for any behavioral issue, and he had no legal history of aggression. The MSE was unremarkable with the exception of mild psychomotor slowness, and mild difficulty with the pronunciation of

words. Cognition was intact and judgement was not impaired. Members agreed there was no evidence to support a rating higher than 50% at the time of TDRL placement.

The panel then turned to its permanent rating recommendation at the time of TDRL removal. The most proximate source of comprehensive evaluation to consider in the permanent rating recommendation in this case is the C&P MH examination, 17 days prior to TDRL placement and 6 months prior to TDRL removal. There are no STR entries more proximate to TDRL placement. The panel noted that the C&P assigned a GAF score which showed a serious impairment provided no point of reference to support that degree of impairment. There was no legal history, the CI worked full-time without any reported loss of time from work, and he had a good relationship with his wife. The CI did report sleep impairment related to dreams, and noted he had irritability and angry outburst. However, he was able to maintain full-time employment and his judgment was noted as fair. There was no problem with memory or panic attacks. Additionally, the three outpatient MH encounters, 11-18 months after TDRL removal were also considered by the panel. The 29 June 2009 psychiatry encounter noted that the CI was stable and happy with his medication. The CI stated he coped with his MH condition by staying busy. The MSE was unremarkable.

The 24 September 2008 encounter, 15 months after TDRL removal, recorded no MH complaints. The CI reported he generally slept well and was still working full-time. He enjoyed biking and hunting. The December 2009 psychiatry encounter, 18 months after separation, noted the CI was pleasant, cooperative, and in a good mood. The examiner stated the CI was stable on medication. The CI was seen at a frequency of once every 3 months during the post-TDRL period. The STR did not reflect a history of suicidal or homicidal ideation, emergency room visits, or inpatient psychiatric treatment. The CI was stable with medication, and had continued to maintain full-time employment for more than 3 years. Panel members concluded, at the time of TDRL removal or separation, the preponderance of evidence most reflects a 10% level for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 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% (in accordance with §4.129), and a permanent rating of 10% for PTSD condition, coded 9411.

Contended PEB Condition: Headache Syndrome. The PEB listed the headache syndrome as Category II condition (related and contributing to the primary unfitting condition). The panel’s first charge for this condition is to assess whether it can be reasonably justified as separately unfitting for rating consideration. The 12 September 2007 NMA, 4 months prior to TDRL placement, does not specifically implicate the CI’s headache condition, but states, “I believe the [CI] does have a medical condition that renders him a loss to this command.” However, the commander did not state the CI lost work time or was sent home or to medical treatment due to the headache condition. There was no limited duty form in evidence for the panel’s review. The NMA also stated that the CI’s current medical condition did allow for INCONUS assignment and potential for continued service in his “physical and mental condition.”

The 24 April 2007 MEB NARSUM examination, 8 months prior to TDRL placement, the CI reported continuous left-side headaches with daily stabbing exacerbations that could last 30 minutes to an hour. He took Midrin for relief. A physical examination was not conducted. The examiner opined that the CI was unsuitable for continued naval service due to his psychiatric condition.

The 25 April 2007 MEB NARSUM neurology addendum documented the CI’s blast injury. The CI reported continuous left-side headaches with daily stabbing exacerbations that could last 30 minutes to an hour. The examiner documented there are no associated autonomic (involuntary or unconscious nervous system symptoms) findings and there are no migranious features present

or behaviors typical for a cluster headache. The neurological and cranial nerve examinations were normal. However, the examiner opined that the CI’s headaches were severe and substantially disabling at that point. The Medical Board judged the headaches failed retention standards. There was no C&P examination or VA treatment records proximate to TDRL placement or removal.

The panel deliberated and determined there was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation. The panel also determined the STR did not show prostrating headaches occurring on average once every 2 months, or more frequently, over the last several months prior to TDRL placement or removal to support a rating higher than 0%. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.

BOARD FINDINGS: In the matter of the PTSD condition, 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 headache syndrome and IAW VASRD §4.124a, the panel recommends no change in 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 medical separation:

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Post Traumatic Stress Disorder, Chronic	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
10 Sep20

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

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) Ref:	(a) DoDI 6040.44
1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation to the Department of the Navy on 13 Aug 2020 for appropriate action.

2.	On 27 August 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR ofno change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.