RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  	CASE:  PD1201726
BRANCH OF SERVICE:  Army	BOARD DATE:  20130515
SEPARATION DATE:  20021121

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Army Reserve CW2/W-2 (152F/AH64 Attack Pilot) medically separated for posttraumatic stress disorder (PTSD).  While deployed to Bosnia in 2001 the CI experienced a dual engine failure during a maintenance test flight at night, reportedly executing a safe autorotation into a field with landmines in the vicinity.  Neither of the pilots was physically injured in the mishap and the aircraft suffered no damage.  The CI and the other pilot were extracted from the area after several hours waiting for a reaction force.  Following the mishap investigation the CI requested his commander give him several days off from the flight schedule to compose himself.  Following the hiatus the CI resumed flight duties and completed the deployment with no further reported incidents.  The CI and his unit returned to CONUS several months later.  Three months after returning to CONUS the CI again approached his commander and asked to be grounded due to his severe fear of flying.  The commander referred the CI to medical evaluation where a diagnosis of PTSD was made.  It was determined that the condition could not be rehabilitated to meet Military Occupational Specialty (MOS) requirements.  The CI was issued a permanent S3 profile and referred for a Medical Evaluation Board (MEB).  The MEB diagnosed PTSD and forwarded the case to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated “post traumatic stress disorder…” as unfitting and rated 10%.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I misunderstood the severity of the severity of the PTSD condition I was suffering from at the time of my separation.  I felt my conditions would improve once I was separated and away from the stimulus which aggravated my condition, as suggested by the Army Psychologist I was being treated by at the time of my diagnosis of PTSD.  Taking psychoactive medication to treat my condition was not something I wanted to do for fear of dependence on medication and was relieved to know that once I was separated from the military, my condition would most likely resolve itself.  Therefore, I declined medications and further therapy. I self medicated with alcohol.  Once I was separated from active duty and away from the stimulus, the condition did not resolve itself.  I continued to self medicate with alcohol.  I sought mental health therapy with the VA after realizing that my condition was actually getting worse to the point that I felt I was in dire need of help.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting PTSD condition is addressed below.  Any conditions or contention not requested in this application or otherwise outside the Board’s defined scope of review remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service PEB – Dated 20020718	VA - (1 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post Traumatic Stress Disorder…	9411	10%	Post-Traumatic Stress Disorder	9411	30%	20020830	
No Additional MEB/PEB Entries	Other x 8	20020814	
Combined:  10%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20021122.   

ANALYSIS SUMMARY:  

PTSD.  CI was a copilot of an Apache helicopter that experienced a dual engine failure in Bosnia in 2001.  They fell from 1000 feet to the ground in about 7 seconds with a glide distance of less than 200 meters.  They were flying without night vision goggles but CI could hear the first engine tearing itself up.  Lights flashed and two alarm horns blared.  He made a mayday call.  After landing he realized that the front seat pilot could have been decapitated in the rotating blades.  They landed in a suspected minefield.  The CI and the pilot, alone in the dark, were prepared to defend themselves because the recovery took about four hours.  After recovery, he quickly became apprehensive about flying again and only flew as copilot when required.  He became obsessively concerned with maintenance.  His anxiety became daily panic attacks.  He later told his flight commander he did not feel safe in the cockpit.  He told mental health he felt like he was “boxed in a death trap.”  He lost his sense of humor, had trouble sleeping and had nightmares.  The sound of an Apache aircraft caused him stress.  There was no previous history of trauma or psychiatric issues.  He was given a permanent profile for PTSD and referred for MEB.  Form 2807-1 noted psychiatry diagnosed CI with PTSD and prescribed Zoloft, but the CI did not continue to take the prescription.

The narrative summary (NARSUM) dictated 25 March 2002, 8 months prior to separation did not include a mental status exam (MSE) but reviewed CI’s medical and psychosocial history.  The psychiatrist examiner diagnosed PTSD manifested by persistent flashbacks and nightmares of the trauma, hypervigilance, hyperarousal, and interference with sleep.  Impairment for social and industrial adaptability was moderate, with Global Assessment of Functioning (GAF) of 55.  Prognosis was fair with ongoing treatment.  At the VA Compensation and Pension (C&P) exam performed 3 months prior to separation, the CI reported frequent nightmares related to the crash, flashbacks of the experiences, avoidance of aircraft and discussions of the crash, anxiety, insomnia, loss of interest in many activities, irritability and lack of concentration.  He denied psychiatric medications, treatment or hospitalization.  He indicated he drank 3-8 beers daily to improve mood and decrease anxiety.  He planned to “move to Colorado to finish his degree and then get a job”.  MSE revealed a cooperative, pleasant, well-dressed and groomed individual.  Mood was depressed and anxious, affect restricted.  Speech was normal.  Thoughts were organized and logical with no evidence of psychosis.  He denied suicidal and homicidal ideation.  There was no psychomotor agitation or retardation.  He was alert and oriented in all spheres.  He had a good fund of knowledge.  Judgment and insight were good.  Abstract thinking was intact.  Memory was fair.  GAF was 50.

There was no evidence of mental health follow up or visits to an emergency room until a year 
(3 November 2003) post separation when the CI sought treatment at the VA Colorado Springs clinic.  A clinical social worker conducted an intake and assessment exam.  CI described the same PTSD symptoms as described in the C&P exam 3 months prior to separation.  The CI stated he had been drinking 6-12 beers a night to “calm my heart” and get to sleep, but didn’t drink beer when he had class the next day.  The examiner indicated “he was unable to work and finally went to voc rehab, where he was accepted for higher education.”  MSE revealed a well-groomed individual, “with bloodshot eyes and trying to tell his story without crying.  Mood and affect were sad and depressed, crying frequently.”  Memory was intact and there were no suicidal or homicidal ideations.  The examiner indicated “flashbacks are multiple, daily and intrusive, creating a sleep disorder…” The examiner’s assessment was “traumatic accident has left him with multiple, daily panic attacks and hallucinations and unable to function without the help of alcohol to get to sleep…adjustment to civilian life has been difficult.  He will continue with psychotherapy and has been referred to a psychiatrist.”  Diagnoses were PTSD, chronic; anxiety disorder; depressive disorder; and alcohol abuse.  GAF was 45.

During a psychotherapy visit a week later, CI indicated he was doing well in his courses but angry and resentful of how Army has treated him, and that he “doesn’t want mind altering drugs”.  A consultation with a psychiatrist that same day revealed the CI “Cites good things as good husband/father/homeowner/ and student (all A’s).”  Thoughts were organized.  Mood was mildly dysphoric moderately anxious in interview and “many issues.”  The psychiatrist prescribed Cyproheptadine for sleep.  CI did not return for psychotherapy or psychiatric follow up.  Medication management notes indicated drinking to aid sleep 4-5 beers a night and “has regular panic and anxiety related to seeing helicopters, reminders of trauma, or hearing approach of copters this is exacerbated as lives on landing approach for flight for life.”

The next available evidence for Board consideration was the psychiatric C&P exam 10 December 2004, 2 years after separation.  At that time, CI indicated he had not sought mental health intervention since November, 2003.  He still drank beer to sleep and endorsed the presence of depression, nightmares, panic attacks, and avoidance, with visual and auditory flashbacks while denying frank psychotic symptoms, and no homicidal or suicidal ideation.  There had been no hospitalizations and he was not taking psychotropic medications.  He still was not working but was helping with childcare and house care and attending classes for electrical engineering twice a week.  He was still married and interacted with family and other students.  MSE was largely unremarkable but noted some sadness and anxiety “under the surface.”  He scored 29/30 on the mini MSE.  Diagnosis was PTSD, chronic moderate to severe; depressive disorder not otherwise specified (NOS); and alcohol dependence with GAF of 56.  At that time the VA increased his rating to 50% because of reduced reliability and productivity in occupational and social impairment.

The Board directs attention to its rating recommendation based on the above evidence.  Both PEB and VA coded CI’s condition 9411, but rated it differently.  The PEB rated it 10% because the CI had PTSD symptoms but was not receiving medications or regular psychiatric care at the time of separation.  The VA rated the CI’s condition 30% citing mental status and occupational and social impairment reflected criteria for a 30% rating.  The VA also cited a GAF of 50, which means serious symptoms or impairment.  The PEB rating, as described above, derived from DoDI 1332.39, preceded the promulgation of the National  Defense Authorization Act (NDAA) 2008 mandate for DoD adherence to Veterans Administration  Schedule for Rating Disabilities (VASRD) §4.129.  IAW DoDI 6040.44 and DoD guidance, which applies current VASRD 4.129 to all Board cases as appropriate, the Board is obligated to recommend a minimum 50% PTSD rating for a retroactive 6-month period on the Temporary Disability Retired List (TDRL).  The most proximate source of comprehensive evidence on which to base the constructive TDRL was the C&P psychiatric examination performed 3 months prior to separation.  After application of the TDRL rating, the Board must then determine the most appropriate fit with VASRD 4.130 criteria at 6 months for its permanent rating recommendation.

The Board directs its attention to its rating recommendations based on the evidence just described.  All members agreed that the §4.130 criteria for a TDRL 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 VA assigned a 30% rating for the PTSD condition based on §4.130 criteria without relying on the provisions of §4.129.  As regards the permanent rating recommendation, the Board must weigh the evidence in the year post separation VA assessments, the MEB and the VA pre-separation C&P exam in order to extrapolate an estimation of the ratable impairment at 6 months after separation.  DoDI 6040.44 specifies a 12 month interval for special consideration to VA findings, rendering the probative value of the later (2 year post-separation) VA evidence in this case somewhat diminished.  The Board recognizes, however, that the VA documentation reflects the stress of transition to civilian life which is intrinsic to the permanent rating recommendation.  The Board directed its attention to its permanent rating recommendation based on the evidence just described; especially the VA records a year post separation since they are post-separation and most proximal to completion of the 6 month TDRL period.  All members agreed that the VASRD §4.130 threshold for a 50% rating was not met (occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood).  The deliberation settled on arguments for a 10% vs. 30% permanent rating.

A Board majority determined the 10% rating description in VASRD §4.130 (occupational and social impairment due to mild or transient symptoms which decrease work efficiency, during periods of significant stress) was a better fit than the 30% description (occupational and social impairment with occasional decrease in work efficiency, and intermittent periods of inability to perform occupational tasks).  The majority judged that 30% rating is difficult to support given that there is no documentation that mood symptoms interfered with daily functioning and there was no evidence of occupational or social impairment at the time of the VA exam 2 years after separation.  The CI was reported by his commander to have done exemplary work in a ground job after being removed from flight status and prior to separation.  He endorsed PTSD symptoms within a year of separation, but had not been hospitalized or under psychiatric care and did not require medication for PTSD.  He was doing remarkably well in school (A grades in a challenging engineering curriculum) and interacted with other students.  He was functioning well as a father, husband, homeowner, and student.  His plan, stated prior to separation, to “move to Colorado, get a degree, and then get a job”, was seemingly on track.  Additionally, the CI consciously controlled his drinking in order to attend those classes in which he was excelling, indicating to the board majority a level of control over his actions, thus tempering the merits of “self-medication” aspects of the condition.  After due deliberation and consideration of all the evidence, and mindful of VASRD §4.3 (Reasonable Doubt), the Board by a 2:1 vote recommends a permanent rating of 10% for the PTSD condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  In the matter of the PTSD condition, the Board by a vote of 2:1 recommends an initial TDRL rating of 50%, and a permanent separation rating of 10%, coded 9411 IAW VASRD §4.130.  The single voter for dissent (who recommended a permanent separation rating of 30%) submitted the appended minority opinion.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified to reflect a 6-month period on TDRL with a disability rating of 50% (IAW §4.129 and DoD direction), then medically separated with a disability rating of 10%:

UNFITTING CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
PTSD	9411	50%	10%	
COMBINED	50%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120803, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

	Physical Disability Board of Review

MINORITY OPINION.  The AO recommends a permanent separation rating of 30%.  The CI had post-separation unemployment, vocational rehab, daily panic attacks, flashbacks and sleep dysfunction with alcohol abuse (alcohol dependence), tempered by the good functioning as a student 2 days a week and ability to be a good husband and parent.  The CI had no job and PTSD symptoms were consistently adjudged in the record as being at best in the moderate range of functioning.  Independent rating IAW §4.130 of the prior to separation exams would be 30%.  The VA evidence at 12 months post-separation indicated a comprehensive intake note detailing symptoms and a worse GAF than pre-separation assessments.  MSE documented sad and depressed mood and affect with crying, and the examiners’ assessment of “traumatic accident has left him with multiple, daily panic attacks and hallucinations and unable to function without the help of alcohol to get to sleep… Adjustment to civilian life has been difficult.”  The assigned GAF of 45 was in the range of serious symptoms and was worse than the prior to separation GAFs (NARSUM 55, C&P 50).  These findings clearly exceed the slight or transient symptoms envisioned by the 10% criteria.

The Board majority consensus that even though the CI was not employed, that there was no more than slight occupational impairment was speculative as it was based on school and family functioning.  School 2 days a week does not cleanly align with an assessment of mild or transient occupational impairment, as the responsibilities of a student vary significantly from an employee.  Given the lack of employment, difficulty adjusting to civilian life and the significant symptoms and moderate to poor functioning being adjudged by all providers (when formally evaluated), there is more than reasonable doubt to support a 30% rating at the 6 month post-separation timeframe.

The 30% rating description in VASRD $4.130 [Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal)] is a better fit with the evidence of record.  The AO strongly recommends a permanent separation rating of 30% (retired) for the PTSD condition.

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

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(TAPD-ZB), 

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for AR20130010809 (PD201201726)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to  constructively place the individual on the Temporary Disability Retired List (TDRL) at 
50% disability for six months effective the date of the individual’s original medical separation for disability with severance pay and then following this six month period no recharacterization of the individual’s separation or modification of the permanent disability rating of 10%.

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum as follows:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of temporary disability effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was separated with a permanent combined rating of 10% effective the day following the six month TDRL period with no recharacterization of the individual’s separation.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will provide 50% retired pay for the constructive temporary disability retired six month period effective the date of the individual’s original medical separation and adjusting severance pay as necessary to account for the additional TDRL time in service.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA