RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE: PD-2017-04294
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20060828

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Infantryman, medically separated for “post-traumatic stress disorder [PTSD]” 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 - 20060717	VARD - 20061220	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD	9411	10%	PTSD	9411	70%	20060801	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 80%	

ANALYSIS SUMMARY:

PTSD. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s mental health (MH) condition began in January 2006 after he returned from deployment to Iraq. He slept only 2-4 hours per night and had frequent nightmares that woke him in a panic. The CI reported combat-related behaviors during sleep and reported he awoke with lacerations on his hands and feet. He avoided crowds, driving off base, and overpasses due to fear of IEDs on the overpasses. He tried to stay busy at all times to distract himself from any opportunity to think or daydream, since his thoughts reflected his experiences in Iraq. The CI reported many combat exposures and was especially distraught over civilian casualties. Medical records showed the CI compulsively clicked, disassembled, and reassembled an ink pen during the appointment.

It seemed to be his strategy for fending off intrusive unpleasant thoughts. He did not see MH while deployed. The CI was treated with an anti-psychosis, anti-depression, anti-nightmare, anti- headache, and anti-anxiety medications and a sleep aide. The CI received a Combat Infantry Badge. The 20 April 2006 commander’s statement noted the CI had extreme outbursts of frustration and anger which were distracting for himself and others.

The 19 June 2006 MEB NARSUM examination, 2 months prior to separation, noted complaints of an inability to work around other people due to frequent agitation and anxiety/anger outbursts. He had displayed some potentially self-injurious behaviors when he appeared to be in a dissociative state. He could perform duties when he was solitary and could do his job on his own initiative. He showed extraordinary resistance at the outset but was voluntarily continuing treatment.

Mental status examination (MSE) showed the CI was extraordinarily anxious at all times. He would sit in an office only if he could view the door. He sat on the edge of the seat and turned his body away from the examiner. He was visibly startled and lost his train of thought with any unexpected sound, and he avoided eye contact except when directly asked a question. At every visit he presented as tense in posture, action and bearing. Speech was pressured and staccato. Although he described his mood as “okay,” his affect was not congruent but extremely vigilant, anxious, and apprehensive. He displayed grief and sadness at times but suppressed those emotions quickly. He minimized his distress and reported irrational thoughts. His thought content was markedly abnormal with frequent flashbacks, visual illusions, hallucinations, and pervasive paranoia. He denied suicidal/homicidal ideation. The CI was very defensive against admitting his own level of dysfunction. Judgment was fair; he admitted he came to treatment only because his wife insisted. A diagnosis of PTSD was rendered with a Global Assessment of Functioning (GAF) score of 60 (moderate bordering on mild). The examiner noted his civilian performance was likely to be adversely impacted by his high level of anxiety and inability to tolerate crowds. His denial and minimization of his symptoms was likely to interfere with his future recovery.

At the 1 August 2006 VA Compensation and Pension (C&P) examination, one month before separation, the CI reported problems similar to those reported above. He had an inability to sleep even with medication. Sleep varied from 2 to 4 hours per night with nightmares whenever he slept and he still displayed combat type behaviors. Going to a small restaurant made him nervous and he avoided crowds and overpasses. He could not drive off base. He knew his fear was irrational but he could not control it. He tried to stay busy and was still taking medications as described above. He could not concentrate on his work. He lived alone but planned to join  his wife in Germany.

MSE showed the CI was very distressed. He was so anxious he kept rotating a pen in his hand and fingers very fast. He avoided eye contact and shook with fear and anxiety. He admitted to ruminations about incidents in Iraq and nightmares almost daily. He had flashbacks, smells, noises, etc. that reminded him of Iraq. He was fearful and panicked in crowds and could not go to a grocery store. He had several incidents of disassociation. The examiner noted he seemed  to be disassociating in the office and appeared to be in extreme anxiety and agony. He did not want to believe anything was wrong with him. In addition to the nightmares and flashbacks there were signs of depression, anxiety, and rumination. He denied suicidal/homicidal ideation. The PTSD seemed marked and severe probably to the level of needing intensive treatment. A diagnosis of PTSD was rendered with a GAF score of 35 (impairment in reality testing or major impairment in several areas).

The 5 September 2007 MH discharge summary noted the CI was hospitalized from 22 August to 6 September 2007 due to worsening PTSD symptoms. He reported seeing a civilian psychologist for six to seven sessions and then saw a military provider for the MEB. He had seen a provider

for the past 7 or 8 months on a weekly basis and had tried group therapy which he did not like. He endorsed current symptoms of mania and reported episodes of psychosis. He reported he moved to Germany after discharge to live with his wife but he drank a great deal of vodka and trashed their house while staying with her for 3 months. She insisted he return home for treatment. He reported his symptoms had continued since his return in December 2006. He reported frequent night sweats with nightmares. He reported recent passive suicidal ideation and had considered drinking and driving his car off of a cliff. The CI reported he once put a .45 in his mouth and thought of killing himself. He arrived for admission intoxicated and reported drinking about 11 beers to cope with the anxiety of highway driving. He was not interested in medication. The CI reported he lived in a cabin on a mountain near his hometown and remained married to his wife. They talked every night and she visited him in May 2007. He wanted to return to Germany to live with her. He had returned to college after discharge but reported having “weird experiences” in the classroom and was classified as having a disability. Discharge medications included an anti-anxiety, anti-nightmare, and mood stabilizer medication with a sleep aide.  Suicide Risk Assessment at discharge showed low risk.

MSE showed increased psychomotor activity, agitation, distrust, and suspicion. Mood was anxious and affect was labile. He showed pressured speech, and endorsed visual hallucinations and delusions. Thought process was circumstantial. He denied suicidal/homicidal ideation but reported passive suicidal ideation. Judgement was fair. Physical examination showed a fine tremor of both upper extremities when extending his hands. Diagnoses included PTSD, bipolar disorder, psychosis not otherwise specified (NOS), and nicotine dependence. Alcohol abuse was not ruled out. The admission GAF score was 25 and the discharge GAF score of 37. He was discharged with improved stability and without psychotic symptoms

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the PTSD 10%, and the VA rated 70%, both coded 9411 (PTSD. The PEB cited mild social/industrial impairment. The VA based rating on the C&P examination, citing deficiencies in most areas. Application of §4.129 was appropriate in this case. Therefore, a retroactive 6-month period on the Temporary Disability Retired List (TDRL) is recommended. Both the NARSUM and the C&P examination noted the CI appeared to be extremely anxious, showed evidence of psychosis, and appeared to be disassociating. At these times, he engaged in self-injurious behaviors. He was unable to work with others and showed signs of severe PTSD. There was evidence of impaired reality and impairment in several areas to warrant a 70% disability rating at the time of TDRL placement.

The most proximate source of comprehensive evidence on which to base the permanent rating in this case is the September 2007 hospital discharge summary. The CI denied previous hospitalization but noted he was still in treatment from the medical outpatient clinic. The CI had not held a job since separation and displayed unusual behaviors in his attempt to return to the classroom. He began drinking, and at times, displayed violent behaviors. He was unable to stay with his wife in Germany and returned for treatment but refused medication. She eventually divorced him because she felt unsafe. At the time of hospitalization, the CI showed signs of excessive drinking, and symptoms of mania and psychosis. However, he accepted medication and agreed to outpatient follow-up visits. He expressed a desire to complete an Associate’s Degree and eventually become a teacher. There were signs of impairment in most areas at hospitalization and no documented follow-up post discharge. Panel members agreed criteria was met for 70% disability at the time of TDRL removal. 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 70% (in accordance with §4.129), and a permanent rating of 70% for the PTSD condition, coded 9411.

BOARD FINDINGS: In the matter of the post-traumatic stress disorder, the panel recommends a retroactive 6-month period of TDRL with a rating of 70%, coded 9411 (IAW §4.129), and a permanent rating of 70% for the PTSD condition, coded 9411. 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	
Post-Traumatic Stress Disorder	9411	70%	70%	

The following documentary evidence was considered:

	PD-2017-04294
AR20190012246, XXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXXXX

	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 70% 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 70% 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), XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX.

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