RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXX	CASE: PD-2021-00065
BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20080615

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Assault Amphibious Vehicle (AAV) Crewman, medically separated for “posttraumatic stress disorder [PTSD]” and “migraine headaches,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION: “The PTSD and Migraines/TBI was directly related to Coma.” 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 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 - 20080414	VARD - 20080923	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD	9411	10%	PTSD	9411	50%	20080717	
Migraine Headaches	8100	10%	Migraine Headaches	8100	50%	20080717	
Occupational Problems	Cat II					
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 80%	

ANALYSIS SUMMARY:

PTSD. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s PTSD began about 6 months after he sustained a grade III concussion from an IED blast during his deployment to Iraq in November 2006. His condition did not require hospitalization or emergency room (ER) visits, and there was no history of suicidal or homicidal ideation.

The 5 March 2008 MEB NARSUM examination, 3 months prior to separation, noted complaints of some cognitive and PTSD symptoms. Specifically, he had problems with short-term memory, tracking and organizing tasks, emotional numbness, and avoidance. The symptoms had been present for at least 10 months and had caused him significant difficulty in his ability to function. He received an extensive neuropsychological assessment, which determined that cognitive

Controlled by: DAF Controlled by: SAF/MRBD
CUI Categories: SP-MIL/SP-PRVCY Limited Dissemination Control: N/A POC: SAF.MRBD.Workflow@us.af.mil

symptoms were more related to PTSD than TBI. The CI also endorsed depression, insomnia, loss of energy, and anxiety and panic (but no full-blown panic attacks). After being referred to a psychologist in November 2007, he was followed regularly until the middle of March 2008, which coincided with a move. Prescribed psychotropic medications provided mild improvement, but significant symptoms continued to impair his ability to function. The mental status examination was unremarkable with the exception of constricted affect. There was no evidence of a formal thought or perceptual disturbance and no suicidal or homicidal ideation. Immediate, short-term, and long-term memory, as well as insight and judgment, were intact. There was no VA Compensation and Pension (C&P) examination for the PTSD.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the PTSD 10%, coded 9411 (PTSD). The VA rated the PTSD 50%, also coded 9411, based on the STR, citing 38 CFR §4.129. The panel considered the provisions of VASRD §4.129 (mental disorders due to traumatic stress) and determined that the PTSD was due to a “highly stressful event,” and that 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. Panel members next turned to the rating recommendation at the time of TDRL placement and agreed that the §4.130 criteria for a rating higher than 50% were not met at the time, and therefore the minimum 50% initial TDRL rating is applicable.

The panel then turned to is permanent rating recommendation at TDRL removal. Although there was no comprehensive mental health (MH) examination during the constructive TDRL period, the 15 July 2008 VA psychological intake evaluation, one month after separation, noted the CI was not employed and was ‘just enjoying the summer.’ He anticipated going to work after a family trip in August. He lived in his grandparents’ home and had a good relationship with them. He was never married and had no children. He continued to consume alcohol but denied having any related problems. The CI said he had several friends and had no difficulty socializing but was uncomfortable around crowds. He enjoyed playing softball and card games with his friends, as well as watching movies. While he said he did not feel depressed, he endorsed depressive symptoms on the intake questionnaire. The CI continued to have sleep problems; he averaged 4 hours a night but could sleep 8 hours after drinking alcohol. He endorsed continued PTSD symptoms, although he made no complaint.

At the 17 July 2008 VA C&P neurological examination, the neurologist noted that the CI was “told he had PTSD,” however, there was no discussion of any PTSD symptoms. The CI described anxiety about finances, employment, and mentioned “depressed mood on occasion.” He was not taking any medication.

Treatment records further revealed frequent moves and no established MH care. The CI had stopped taking his medications due to weight gain, but also indicated no significant benefit from his prescriptions. He remained stable during the TDRL period and beyond and did not take any psychotropic medications during the 12 months after separation. There were no documented panic attacks, ER visits, or psychiatric hospitalizations. There was no report of anger outbursts or impulse control issues, and no record of domestic or workplace/community violence. There was no objective evidence of memory impairment interfering with daily functioning. While the CI continued to report chronic insomnia and depressive symptoms, there was no evidence these issues interfered with occupational or social functioning; nor was there evidence that the MH condition was solely responsible for the insomnia, since alcohol is a major disrupter of sleep.

Panel members concluded that at the time of TDRL removal, the CI’s symptoms was stable and his disability warranted a 10% rating for “occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.” 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% (in accordance with §4.129), and a permanent rating of 10% for PTSD, coded 9411.

Migraine Headaches. According to the STR and MEB NARSUM, the CI’s migraines began in November 2006 after he sustained a grade III concussion. On 22 August 2007, an ears, nose, and throat examiner recommended the CI be transferred to medical hold for post-TBI issues (dizziness, balance issues, headaches) that required “4 hours plus therapy,” 4-5 times per week. During medical hold, the CI’s treatment improved his TBI related issues and there was no record of any acute treatment for headaches. Although he continued to report daily headaches, there was no indication that they were severe enough to interfere with daily functioning.

The 18 December 2007 neurology visit, 7 months before separation, noted CI complaints of daily headaches accompanied by anxiety and mood changes. He had an initial trial of medication but experienced side effects. The neurologist prescribed a different medication at this visit and diagnosed headache syndrome as well as post-concussion syndrome. In January 2008, a brain MRI was negative and the CI was discharged from neurology. He continued to be seen by his primary care provider, who noted in February 2008 that his medication effectively treated “the bad headaches.” At this visit, the CI reported a mild headache with pain rated at 3/10 in severity.

The MEB NARSUM examination did not record any complaints of headaches. The CI reported he was taking migraine medication, and the examiner continued the prescription. Headache frequency and intensity was not documented. During the 24 March 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), the CI checked “yes” for frequent or severe headaches, but the examiner did not note frequency or intensity. Physical findings were unremarkable.

On 4 June 2008, at a VA primary care initial evaluation, the CI reported acceptable headache pain rated at 2/10. At the VA C&P neurological examination, he described chronic headaches triggered by bright light (required sunglasses), stress, or thinking about finances and the future. He had sharp stabbing bi-temporal and frontal pain, which responded to massage, and he experienced nausea, visual scintillations, and dizziness with headache exacerbations. When experiencing headaches, he had to sit down or sleep them off; severe headaches occurred 1-2 times per week. The physical examination was unremarkable.

As discussed above, the CI was placed on a retroactive TDRL period for 6 months. During this time, there was no record of treatment for headaches, and the few MH encounters did not note any complaint of migraines.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the migraine headaches 10%, coded 8100 (migraine headaches). The PEB also listed occupational problems as a related Category II condition (contributed to the primary unfitting condition but not separately ratable). The impairment from the occupational problems was properly subsumed under the overall rating for the migraines IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited). The VA rated the migraine headaches 50%, also coded 8100, based on the C&P examination, citing severe headaches occurring 1-2 times a week.

Rating guidance under diagnostic code 8100 is based on the frequency of “prostrating attacks” over the “last several months.” The VASRD does not further define prostrating attacks, however commonly accepted definitions include “utter physical exhaustion or helplessness” (Webster's New World Dictionary of American English), “complete physical or mental exhaustion” or “extreme exhaustion or powerlessness” (Dorland's Illustrated Medical Dictionary). The panel carefully considered the frequency and nature of the CI’s headaches including objective and corroborating subjective evidence.

The MEB NARSUM was silent regarding the severity of the headaches. Panel members agreed the C&P examination was most proximate to constructive TDRL placement and provided the most comprehensive evidence related to the headache condition. The examiner noted the CI’s headaches were both tension and migrainous in nature, and while they were reported as “severe” and occurring 1-2 times a week, “prostrating” headaches were not described in any detail. The examiner suggested the CI “follow through with MH evaluation and relaxation techniques as stress seems to be a significant headache trigger.” The panel noted the absence of any headache treatment records during the constructive TDRL period. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the migraine headaches condition.

BOARD FINDINGS: In the matter of the PTSD, the panel recommends an initial TDRL rating of 50%, coded 9411, in retroactive compliance with VASRD §4.129 as DOD directed; and a 10% permanent rating at 6 months IAW VASRD §4.130. In the matter of the migraine headaches and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication. 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:

UNFITTING CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Posttraumatic Stress Disorder	9411	50%	10%	
Migraine Headaches	8100	10%	10%	
	COMBINED	60%	20%	

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20210521, w/atchs Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Record

9/6/2022

THE ASSISTANT SECRETARY OF THE NAVY
(MANPOWER AND RESERVE AFFAIRS) I 000 NAVY PENTAGON
WASHINGTON, D. C. 20350-1000

6040
Memo 00/01

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER AND RESERVE AFFAIRS COMMANDER, NAVY PERSONNEL COMMAND
Subj:	 PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS Ref:	(a) DODI 6040.44
(b)	PDBR ltr dtd 6 Sep 22 ICO
(c)	PDBR ltr dtd 9 Sep 22 ICO 

1.	Pursuant to reference (b) and (c), the recommendation of the Physical Disability Board of Review set forth in references (b) and (c) are approved. The official record of the following individuals are to be corrected as follows

b. XXXXXXXXXXXXX former USMC: Placement on the Temporary Disability Retired List with a 50 percent disability rating for a period of six months, and upon final disposition no re-characterization of separation of modification of the disability rating previously assigned.

2.	Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.