RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05356
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050608

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve O3, Tactical Intelligence Officer, medically separated for “major depressive disorder” and “post-traumatic stress disorder” with a disability rating of 10%.  

CI CONTENTION:  Review of 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 - 20050317	VARD - 20051012	
Condition	Code	Rating	Condition	Code	Rating	Exam	
MDD and PTSD	9434	10%	PTSD with Depression	9411	30%	20050810	
Bulimia, Purging Type	Not Unfitting  	Anorexia Nervosa, Binge Eating-Purging Type	9520	0%	20050810	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Major Depressive Disorder (MDD) and Post Traumatic Stress Disorder (PTSD).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s mental health (MH) disorders began after a sexual assault while deployed sometime during the period of February to May 2003.  She developed flashbacks, intrusive thoughts, hypervigilance and difficulty wearing a military uniform.  She returned to CONUS with symptoms of PTSD manifesting as nightmares, fear of all men in her unit, feelings of hopelessness and helplessness and multiple symptoms of depression.  She also reported a history of bulimia with inpatient treatment in 2003 for 30 days at the Rosewood Treatment Center for Eating Disorders, where she was noted to suffer from PTSD with periods of panic attacks.  She was hospitalized at Ft. Campbell for about three days due to suicidal ideation with a plan to kill herself by overdosing.  She left the hospital against medical advice.  She was placed on Medical Hold with home duty.  

The 12 July 2004 MEB NARSUM examination, 11 months prior to separation, noted complaints of purging about five times per day, stable weight and electrolyte imbalances.  She was stable on Zoloft (anti-depression) and Ambien (sleep aid).  She was undergoing weekly outpatient therapy.  She was seven months pregnant and having a difficult time due to her eating disorder.  Diagnoses of MDD, PTSD and bulimia, purging type, were rendered with a Global Assessment of Functioning (GAF) score of 55 (moderate impairment).  Mental status examination (MSE) showed an irritable and anxious mood and chronic suicidal ideation with no intent or plan.  

During the 20 July 2005 VA Compensation and Pension (C&P) examination, one month after separation, the CI complained of bi-frontal-temporal headaches, which she awoke with every morning.  She reported tension headaches on almost a daily basis since the sexual trauma in Iraq.  The examiner noted headaches of the type described were commonly associated with PTSD or depression.  

The 1 August 2005 psychosocial assessment noted the CI had anxiety and depression and had been taking medication for it.  She was currently taking Zoloft and a sleep aide.  She also had a private therapist as well as case manager.  She and her baby lived with her parents while her husband was deployed.  

At the 10 August 2005 VA C&P psychiatry examination, two months after separation, the CI reported engaging in self-induced vomiting 15-20 times in a given week, purges after consuming small amounts of food, exercising for long periods of time such as 4 hours and/or until she had burned off a specific number of calories.  She reported she weighed 110 pounds, (130 pounds normal and expected for height) with 9% body fat.  She took a synthetic hormone to re-start menses.  She reported cutting herself during a short time while pregnant.  She described an intense fear of weight gain and appeared to realize she was underweight but maintained current weight for her son’s health.  She reported amenorrhea and was working with a specialist regarding maintenance of menses.  She reported the bulimia began after the sexual assault in Iraq and after the sergeant major dispersed her diary to the unit.  She planned to start treatment in October.  She also reported increased anxiety around people and was no longer in touch with friends.  She felt okay being alone with her son.  She denied suicidal or homicidal ideation.  She was unemployed but had initially worked as a teacher for 9 months after discharge but left since the experience reminded her of the military.  She worked for one month as a personal trainer, but felt the work fed into the eating disorder.  No formal MSE was documented.  Physical examination showed height of 64 inches and weight of 130 pounds with BMI of 21 (normal).  Diagnoses of anorexia nervosa, binge-eating-purging type, PTSD with agoraphobia and MDD were rendered with a GAF of 45 (serious impairment).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the MH disorders 10%, coded 9434 (MDD), citing psychotropic medication and outpatient treatment.  The VA rated the MH disorders 30%, coded 9411 (PTSD), based on the C&P examination.  Although the PEB listed both MDD and PTSD as unfitting, disability associated with any psychiatric condition, regardless of the diagnosis or multiple diagnoses, is subsumed under a single rating using the same criteria IAW VASRD §4.130.  IAW DoD guidance, VASRD  §4.129 (mental disorders due to traumatic stress) will be applied when PTSD is an unfitting condition.  Therefore, as a matter of policy, the PDBR must recommend placement of the CI on a period of constructive TDRL with a minimum rating of 50% IAW §4.129 with reassessment after six months.  

Panel members considered if the §4.130 rating at constructive TDLR placement should be greater than the minimum 50% rating.  The §4.130 criteria for a 70% rating is “occupational and social impairment, with deficiencies in most areas.”  The panel agreed that the §4.130 criteria for a 70% rating at TDRL placement were not met, and therefore the minimum 50% initial TDRL rating was applicable for the 6 months of constructive TDRL.  

The most proximate source of comprehensive evidence on which to base the permanent rating was the C&P examination, two months after separation.  The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication” and for a 30% rating “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.”  The CI reported increased anxiety around friends and isolation from others.  She reported an intense fear of weight gain.  The panel noted purging was usually associated with depression.  She was unable to maintain employment due to her psychiatric symptoms.  She had one job for 9 months and the next for only one month.  She had been a high functioning West Point graduate and regarded as independent.  The psychosocial assessment, two weeks previously, noted the CI was taking anti-depression medication and a sleep aid, was living with her parents and unemployed.  Panel members agreed symptoms most closely met the criteria for a 30% disability rating.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 50% for 6 months of constructive TDRL and a 30% permanent rating thereafter for the MH disorders. 

Contended PEB Condition:  Bulimia, Purging Type.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  Although the contended condition was profiled, implicated in the commander’s statement and judged to fail retention standards, there was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  The NARSUM addendum noted she had not been hospitalized for bulimia nor had the bulimia interfered with her duty performance in the past year.  Her weight and electrolyte status were stable and her dental hygiene was not poor.  The STR documented one medical follow-up visit for bulimia between November 2004 and June 2005.  The C&P examination noted she was 130 pounds (normal) with BMI of 21.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition.

BOARD FINDINGS:  In the matter of the MH disorders, the panel recommends a disability rating of 50%, coded 9434-9411 IAW VASRD §4.129 for 6 months from the time of discharge consistent with a constructive period of TDRL and then a permanent separation rating of 30% IAW VASRD §4.130.  In the matter of the contended bulimia condition, the panel recommends no change from the PEB determination as not unfitting.  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	
Major Depressive Disorder and PTSD	9434-9411	50%	30%	

AR20190008630, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

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 recharacterize 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 recharacterization 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.  Inquiries 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.