RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-03811 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20080620

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

CI CONTENTION:  No specific contention was made.  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 - 20080327	VARD - 20080912	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD	9411	10%	PTSD	9411	70%	20080904	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 70%	

ANALYSIS SUMMARY:

PTSD. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s PTSD condition began in July 2007 after being medically evacuated from Iraq for report of depression, anxiety, and insomnia after witnessing a friend burned alive in a HUMVEE. He reported that he was having night terrors, daily flashbacks, suicidal ideation, and was not sleeping or eating. Since returning from Iraq, there were no visits to the emergency room (ER) or any psychiatric hospitalizations.

The 22 December 2007 MEB NARSUM mental health (MH) examination, 6 months prior to separation, noted complaints of flashbacks, nightmares, irritability, difficulty with concentrating,

and other PTSD-related symptoms. The CI participated in weekly MH treatment through September 2007. He was diagnosed with PTSD and prescribed psychotropic medication. Between August and October he had several domestic incidents which resulted in the military police escorting him to the barracks. Since September 2007, the CI was seen regularly for treatment but reported little improvement in his symptoms. The mental status examination (MSE) was unremarkable with the exception of dysthymic mood and restricted affect. Judgment was intact and suicidal or homicidal ideation was absent. The diagnosis of PTSD was recorded and a Global Assessment of Functioning (GAF) score of 55 for moderate symptoms/impairment was documented.

At the 4 September 2008 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported continued problems with insomnia, nightmares and irritability. He also reported memory problems. The CI was in treatment and noted he had not had suicidal ideation since Iraq. He denied history of panic attacks. The CI was working full-time as a trash truck driver and had missed less than a week from work for an unstated reason. The CI had remained married to his wife of more than 2 years and they were raising four children. There was no report of domestic violence, and the couple was in counseling with their pastor. The MSE was unremarkable with the exception that the CI reported his mood was “empty,” and his memory was somewhat impaired per his report. Affect was normal as was judgment. The examiner recorded a GAF score of 53, in the moderate symptoms/impairment range.

There were no MH treatment entries after the C&P MH examination; however, during the general C&P examination, 3 months after separation, the CI reported he had been laid off from his job. There were two MH entries by different providers on 22 July 2008, one month after separation. The nurse practitioner note indicated that the CI was still taking psychotropic medication and continued to have problems with sleep, and PTSD symptoms. The CI reported isolative behaviors and he was not employed at the time but noted he was looking for a job but hadn’t been able to find one. The MSE was unremarkable with the exception of depressed mood and affect. The CI stated he did not like the way his current medication regimen was working. The social work entry, 1.5 hours after the nurse practitioner visit, noted the CI reported that his symptoms “have been improving, as they were 100 times worse” while in the military environment. The CI noted that his relationship with his wife had improved with counseling. The CI reported that he had acquired full-time employment and would begin the first of the following week.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the PTSD condition 10%, coded 9411 (PTSD), citing symptoms controlled with continuous medication. The VA rated the PTSD condition 70%, also coded 9411, based on the C&P examination, citing §4.130 criteria.

Panel members agreed, the provisions of VASRD §4.129 were applicable in this case, and recommends 6-month period of constructive TDRL. The panel next proceeded with its rating recommendation under VARSD §4.130 based on the evidence at constructive TDRL placement. The panel considered the record in evidence did not support a higher than 50% rating for TDRL placement. There was no evidence of impaired judgment, and suicidal ideation was not present in the months prior to separation. 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 condition at TDRL placement.

The panel next considered whether the evidence at the time of TDRL removal and permanent disability disposition supported a rating higher than the 10% rating adjudicated by the PEB. There were two treatment records during the constructive TDRL period, along with the C&P examination. Treatment records indicated that the CI was still receiving MH care, and his symptoms were chronic but stable.  The social worker entry, one month after separation, noted

the CI’s condition was improving, and he had found employment. This was contrary to his report to the nurse practitioner during a medication visit 1.5 hours earlier that day. Both visits recorded depressed mood and abnormal affect. The social worker MSE noted good attention/concentration and intact memory. The MSE during the nurse practitioner visit was unremarkable except for mood and affect.

The C&P examination noted the CI was working full-time, had little to no social interest, was married, and complained of problems with sleep, memory and irritability. There was no mention of mood symptoms during work or problems with co-workers or a supervisor. There was no report of domestic violence or violence in the workplace or community. There was no history of psychiatric hospitalization or visits to the ER. The symptoms that were reported at the C&P examination and two outpatient visits were nightmares, sleep disturbance and irritability. The CI reported a problem with memory during the C&P examination that was not recorded in any other MH examination. The CI had no history of panic or anxiety attacks. There was no report of visits to the ER related to MH symptoms. There was no cognitive impairment found during the evaluation, and no evidence of impaired judgment. The CI was working full-time, and had not lost any time from work due to MH issues. However, the general C&P examination, 4 months into the TDRL period, noted the CI had been laid off from his job. There was no evidence of significant occupational impairment due to a MH condition, but there appeared to have been mild impairment in social functioning. The panel considered the record in totality and concluded the evidence demonstrated the CI’s condition was most reflective of the 10% level of disability. 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 PTSD condition.

BOARD FINDINGS: In the matter of the post-traumatic stress disorder, the panel recommends  an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129 as DOD directed; and a 10% permanent rating at 6 months 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, effective the date of medical separation:

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Post-Traumatic Stress Disorder	9411	50%	10%	

The following documentary evidence was considered:

PD-2017-03811 

AR20190011833, XXXXXXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXX

	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), XXXXXXXXXXXXXXXXXXXXXXXXX.

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

PD-2017-03811