RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04951
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070315

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E4, Chemical Operations Specialist, medically separated for “mood disorder, not otherwise specialized [NOS]” with a disability rating of 10%.  

CI CONTENTION:  “Entitlement benefit amount letter.”  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 - 20070215	VARD - 20060814	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mood Disorder, NOS	9435	10%	Posttraumatic Stress Disorder (PTSD)	9411	NSC	20060710	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Mood Disorder, NOS.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s mental health (MH) condition began during deployment to Afghanistan from February 2005 to February 2006.  The CI had been enlisted in the Army from 1994 to 1997 and was discharged for misconduct.  He enlisted in the National Guard in 2000 and then re-enlisted in the Army Reserve in 2001.  In December 2005, while deployed, the CI reported anxiety, depressed mood, irritability, isolation, insomnia, nightmares, and hypervigilance.  He endorsed feeling threatened with harm by mortar attacks and IED explosions, and was treated with antidepressant medication (Paxil).  After return from deployment, he started drinking excessively.  Scores on two symptom assessments (Mississippi Scale for Combat related PTSD and PTSD Checklist-Military Version (PCL-M)) were consistent with verified PTSD, and the CI was diagnosed with chronic PTSD.  Positive responses on the PCL-M included distressing memories of military experiences, disturbing dreams, flashbacks, avoidance of reminders, panic attacks, irritability, hypervigilance, loss of interest in activities, and feeling detached from others.  The CI was referred for alcohol treatment and prescribed antidepressants for mood and sleep (citalopram and trazadone).  

At the 10 July 2006 VA Compensation and Pension (C&P) initial PTSD examination, 8 months prior to separation, the CI reported depressive symptoms with loss of interest and pleasure, psychomotor slowing, mild forgetfulness, increased irritability, sleeping during the day, and decreased energy.  He reported 9 hours of sleep at night with awakenings and nightmares, and denied suicidal ideation (SI).  He described panic attacks while in Afghanistan with lightheadedness, nausea and shaking hands that lasted for approximately 20 minutes.  He had one panic attack since redeployment, without worry about recurrent attacks, and could not identify precipitating factors.  He denied any abuse during childhood and believed his father had anxiety and depression, but was unsure of any treatment.  

During his deployment to Afghanistan, the CI reported that was in his tent when a rocket came within 30 yards of where he was sleeping.  There were no injuries from that attack, but he had distressing combat related nightmares every night and physiologic reactivity to memories or cues of the traumatic event.  He also experienced avoidance of thoughts, feelings, conversations, activities, and places or people that aroused recollections of the trauma; and isolation with a feeling of detachment from others.  He endorsed difficulty sleeping, concentrating, and hypervigilance with an exaggerated startle response.  He reported alcohol abuse that began after redeploying and current alcohol treatment with abstinence from alcohol for the past 6 weeks.  

Standardized testing (Minnesota Multiphasic Personality Inventory-2 [MMPI-2]) results suggested that the CI was over-reporting his symptoms.  Despite an elevated PTSD subscale score, the VA examiner noted it could not be interpreted as consistent with a diagnosis of PTSD given the over-reporting and was judged to be “probably invalid.”  The mental status examination (MSE) revealed an anxious and depressed mood and flat affect, but was otherwise unremarkable.  The Axis I diagnosis was alcohol abuse, in full remission, with a Global Assessment of Functioning (GAF) score of 55 (moderate impairment).  The VA psychiatrist commented that the CI was not diagnosed with PTSD because his avoidance symptoms could be attributed to personality issues that pre-dated his traumatic exposure.  

The 7 November 2006 MEB NARSUM examination, 4 months before separation, noted complaints of depression, anxiety, and irritability for over one year, but no past history of MH treatment prior to being activated in 2005.  He reported a family history of alcohol abuse, MH problems in his father purportedly related to Vietnam War service, and some physical abuse by his parents as a child.  The examination noted a personal history of three marriages, two divorces, and two children.  The MSE showed an anxious and depressed mood, constricted affect and no SI or homicidal ideation; the remainder of the examination unremarkable.  The Axis I diagnosis was chronic PTSD, and an S3 profile was recommended.  

In a memorandum for record dated 1 December 2006, the CI’s commander summarized  “military conditions of the deployment” and noted the following:

•	He “did travel outside the wire on multiple occasions to provide support for construction elements and would have been called upon to provide convoy and static security support.”  
•	He generally performed his duties in the motor pool, but “once or twice a week, he would be required to perform on-site maintenance” which would require him to “travel outside the wire, often in an unarmored vehicle.”  
•	He was not present at any of the three unit incidents of “direct contact either by IED, VBIED, or small arms fire with the enemy.”

The commander further noted that towards the end of the deployment, multiple rocket attacks occurred on the base, with one landing inside the base perimeter.  There were no combat related injuries or deaths within the unit, but higher headquarters did experience two soldiers killed in an IED attack, and their vehicle was returned to the motor pool and was likely seen by the CI.  

The commander’s statement written on 19 December 2006, 3 months prior to separation, indicated the CI was unable to perform his primary military specialty duties due to chronic PTSD, but that in his current tasking in maintenance, his performance had been “outstanding.”  In a note regarding a telephone conversation with the Personnel Management Officer, dated 23 January 2007, 2 months before separation, the battalion combat commander stated that the most stressful event that the CI witnessed was “air raid sirens in the middle of the night,” and that he “stayed behind the wire most of the time.”  When he did leave the base, “nothing of significance happened.”  

The PEB proceedings were discontinued on 26 January 2007 and the PEB questioned the diagnosis of PTSD because of apparent discrepancies in the commander’s letter and the CI’s description of his deployment experiences.  The MEB psychiatrist reviewed the two accounts and noted in a memorandum on 1 February 2007, that the CI claimed being fired upon in a convoy, whereas the commander said he was not; and that he described seeing vehicles destroyed by IEDs, while the commander noted only one instance of this occurring.  Other than these discrepancies, the psychiatrist observed that the CI’s statements were substantiated by the commander.   Regarding whether PTSD could be diagnosed in a patient whose life was not directly or immediately threatened, the psychiatrist indicated fear of death or injury was a subjective issue and that the CI obviously felt there was a threat of death or injury.  However, due to the “concerns of the PEB,” the MEB narrative was amended and “the diagnosis changed to Mood Disorder, NOS.”  

The 2 February 2007 MEB NARSUM examination, 1 month prior to separation, was amended and indicated an Axis I diagnosis of mood disorder, NOS and was otherwise identical in content to the earlier version of the MEB NARSUM summarized above.  The PEB had also requested clarification of the CI’s duty hours and the commander’s statement on 12 February 2007 was amended from the 19 December 2006 version by adding the CI’s uniform as Army combat uniform (ACU) and duty hours from 0900-1600 Monday through Friday.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated mood disorder, NOS 10%, coded 9435 (mood disorder, NOS).  The VA did not rate any MH condition and denied service-connection for PTSD based on the C&P examination, citing no diagnosis of PTSD.  An 18 February 2009 Decision Review Officer Decision (DROD) service-connected PTSD and rated it 30% (effective the day after separation from active duty), coded 9411 (PTSD), citing that although PTSD was diagnosed at a C&P general medical examination on 14 July 2006, the C&P PTSD examination days earlier had not diagnosed PTSD and so it was not service-connected; however, a review confirmed PTSD based on the 2006 MEB proceedings.  

The panel first considered whether the provisions of VASRD §4.129 (mental disorders due to traumatic stress) were applicable.  Although PTSD was diagnosed in the STR, but was not a MH diagnosis referred by the MEB or considered by the PEB, the application of §4.129 and rating under §4.130 are not based on a specific MH diagnosis.  The panel agreed that the stipulations of §4.129 were met in this case based on fear of threatened death or injury of self or others due to the combat exposures of mortar attacks and IED explosions (reported by the CI and corroborated) and therefore recommends a retroactive 6‐month period on the Temporary Disability Retired List (TDRL).  Members agreed that the §4.130 criteria for a rating higher than 50% at the time of placement on TDRL were not met; and, therefore the minimum 50% TDRL rating prescribed by §4.129 is applicable.

The panel then turned to its permanent rating recommendation at the time of TDRL removal.  The most proximate source of comprehensive evidence on which to base the permanent rating recommendation was limited to VA MH outpatient treatment notes from September 2007 to 15 May 2008, between 6 and 14 months after separation.   At a 27 September 2007 VA social work visit, 6 months after separation, the CI reported that he worked full time at FedEx and had “good days, bad days.”  He reported recurrence of bad dreams and that he got anxious and paced a lot.  He denied any alcohol problems but had a “few drinks” occasionally.  He was taking an antidepressant medication and denied any SI, legal problems or issues with physical violence.  

At a 26 October 2007 MH visit, 7 months after separation, the CI reported he was working full time as a mechanic and experienced insomnia, intrusive thoughts, bad dreams, avoidance, hypervigilance, social withdrawal, loss of interest and decreased concentration.  He denied drinking in the last 12 months, and had some symptom improvement on his antidepressant medication.  He was currently living with his girlfriend, and his two children were living with their mothers.  The MSE showed “sufficient” attention and concentration, as well as intact memory.  Mood was depressed with an appropriate affect, and the remainder of the examination was normal.  The Axis I diagnosis was PTSD with a GAF of 61 (mild symptoms, impairment).  

At a 22 February 2008 MH evaluation, 11 months after separation, the CI reported that depressive symptoms following deployment had significantly improved.  He had run out of his antidepressant medication in the past 2 months and noticed an increase in PTSD symptoms in the past 2-3 weeks.  He also had relapsed into having two drinks (liquor) 2-3 times per week.  He also reported PTSD symptoms triggered by helicopters overhead while working at an airfield as a mechanic, as well as dreams of danger (not combat specific) and rare flashbacks.  He endorsed irritability, increased startle response, hypervigilance, intermittent depressed mood with some decreased energy and concentration.  He denied decreased self-esteem or hopelessness, panic attacks, SI, hallucinations or symptoms of mania.  He reported being close to only his girlfriend and one friend and being less socially active than he used to be.  The examiner noted the CI was working everyday but was available for evening treatment.  The diagnosis remained the same, with a GAF of 55, and the CI was advised to stop drinking alcohol.  He was restarted on previous medications for mood and sleep (citalopram and trazadone), which had good response. 

At a follow-up MH visit on 15 May 2008, 14 months after separation, the CI reported some improvement in his PTSD symptoms on his medications and less irritability.  The addition of a third medication (Lamictal) to target PTSD symptoms was noted.  He was trying to get out more and said a friend had him golfing.  His was still employed full-time and his personal relationships remained the same.  

The panel noted that at the time of TDRL removal, the CI was working full time and living with his girlfriend.  While he reported less socializing than in the past, he did have a friend and participated in recreational activities with him.  In September 2007, he was doing well when taking his medications and not drinking alcohol regularly.  The CI reported increased MH symptoms at the May 2008 visits when he was off his medications for a few months and had returned to regular weekly alcohol use, which began to improve with the reinstitution of his medications and alcohol avoidance.  

The panel agreed the evidence supports a 10% rating for “occupational and social impairment due to mild or transient symptoms which decrease work efficiency … only during periods of significant stress, or; symptoms controlled by continuous medication.”  The higher 30 % rating requires evidence of “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks” due to  such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events.  In this case, although the CI continued to report waxing and waning MH symptoms at the time of TDRL removal, he was functioning well and there was no evidence of intermittent periods of inability to perform occupational tasks.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the mood disorder at the time of TDRL removal.

BOARD FINDINGS:  In the matter of the mood disorder, the panel recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129, and a 10% permanent rating at 6 months IAW VASRD §4.130.  There were no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior separation be modified as follows, effective the date of medical separation:

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Mood Disorder	9435	50%	10%	

XXXXXXXXXX 

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Dear XXXXXXXXXX:

	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] [Reserve retirement] 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), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs [and to the counsel you listed on your application; [name and address]].

	

Sincerely,					      
						      					
Enclosure