RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXX		CASE: PD-2017-04006 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20080628

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Radio Operator/Maintainer, medically separated for “posttraumatic 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 - 20080318	VARD - 20081203	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD	9411	10%	PTSD	9411	70%	20080919	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 70%	

ANALYSIS SUMMARY:

PTSD. According to the service treatment record and MEB narrative summary (NARSUM), in December 2006 the CI self-referred for a mental health (MH) disorder that manifested during his first of two deployments. He had no prior psychiatric history. He was exposed to traumatic events during both deployments and was awarded the Combat Action Badge. Symptoms included anxiety, headaches, increased heartrate with chest pain, dizziness, muscle tension/jitters, stomach discomfort, hot and cold flashes, self-isolation, and sleep disturbances, which included constant dreams, frequent waking, difficulty falling asleep, recurring flashbacks/nightmares, and episodes of awakening and checking doors and locks.

The CI reported that during his second deployment he showed agitation, anxiety, and aggression with subordinates. He declined treatment while deployed. After redeployment, he could not stop his aggressiveness. He was easily agitated and raged at large crowds, traffic and at Arabic- speaking or -looking people. He avoided public places and purchased a number of weapons, including guns and knives. He would not go out without a knife. His irritability caused him to distance himself from his children and wife, who suggested he seek help at MH. He was evaluated and treated with medication and counseling. In October 2007 the CI assumed leadership of a new team but continued to display irritability and excess aggression with his soldiers. In February 2008, he was at a point of wanting to kill members of his command and was referred for admission to inpatient psychiatry to ensure safety.

The 5 February 2008 MEB NARSUM examination, 5 months prior to separation, noted the CI was discharged from the hospital with a recommendation for outpatient treatment. Medications included two anti-depressants, an anti-psychotic, and an anti-anxiety medication. Mental status examination (MSE) showed an agitated appearing male with impulse control that appeared fair to poor, a mood described as “angry” with congruent affect, and homicidal ideation, but no suicidal ideation. A diagnosis of PTSD was rendered with a Global Assessment of Functioning (GAF) score of 50 (moderate symptoms). At the 13 February 2008 follow-up visit, the CI reported feeling remarkably better since discharge. He denied mood problems and reported only one anger episode since discharge.  The MSE was unremarkable.

At the 19 September 2008 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported flashbacks of experiences in Iraq, sleep problems that included bad dreams, thrashing and kicking during sleep, mood swings with irritable, angry outbursts, and  extreme aggression over little things. He had severe problems with family and his relationship with his wife was somewhat impaired due to his temper, mood swings and avoidance of social situations. He had a good relationship with his daughters although he avoided contact with their school and activities. The CI also reported easy startle, hypervigilance and a constant aware of his immediate perimeter, exits and entrances. Since discharge he carried a knife for protection, and avoided people, road traffic and most social situations. The CI experienced short-term memory loss. He was working full time for the past month and a half. He was taking anti-anxiety and anti-depressant medication but declined talk therapy because it was too uncomfortable and upsetting. The CI reported memories of his Iraqi experiences were a primary source of stress. In addition he felt extremely out of place in civilian life and missed the military; he felt empty without purpose. The CI enjoyed gun repair and shooting on the range and worked on cars by himself. He denied legal problems and performed activities of daily living. The MSE showed a somewhat blunted and restricted affect, problems with memory and extreme problems with impulse control at home. He admitted homicidal ideation and the ability to become extremely aggressive and belligerent with feelings to kill a person. A diagnosis of PTSD, chronic and severe, was rendered with a GAF score of 46 (moderate symptoms). The examiner noted the prognosis for vocational ability was uncertain due to his brief period of employment.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the MH disorder 10%, coded 9411 (PTSD), citing “symptoms controlled with continuous medication.” The VA rated the MH disorder 70%, also coded 9411, based on the C&P examination, citing occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships.”

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 considered a rating higher than the minimum 50% rating, but agreed there was no evidence that would justify a higher rating.

Panel members next considered the permanent rating and agreed the most proximate source of comprehensive evidence on which to base the permanent rating in this case are the post- separation VA treatment notes and the VA C&P examination performed 3 months after TDRL placement. This VA examination noted flashbacks and nightmares and the CI remained aggressive, had short-term memory loss, carried a knife at all times and was isolated. His temper and mood led to homicidal ideation, but he was able to remove himself from situations. His symptoms negatively affected his relationship with his wife. However, a VA note in February 2009 showed he was working for the DoD in communications, and treatment notes in May 2009 indicated that despite his PTSD symptoms, he adapted to his job and was “successfully employed in logistics.” Panel members agreed the CI’s condition most closely approximated the criteria for a permanent 30% disability rating. 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% IAW §4.129, and a permanent rating of 30% for PTSD, coded 9411.

BOARD FINDINGS: In the matter of the post-traumatic stress disorder, the panel recommends  an initial TDRL rating of 50%, coded 9411 in retroactive compliance with VASRD §4.129 as DoD directed; and a 30% 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
PTSD	9411	50%	30%	

PD-2017-04006

AR20190012191, XXXXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXXXX

	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 30%.  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 30% 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), XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX.

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

PD-2017-04006