RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2014-01337
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20140605
Separation Date:  20060202

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SRA/E-4 (2T1/Vehicle Operations Craftman) medically separated for depressive disorder, not otherwise specified (NOS) associated with cognitive disorder NOS.  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards.  He was issued a temporary P4/S4 profile and referred for a Medical Evaluation Board (MEB).  The depressive disorder NOS associated with cognitive disorder NOS conditions, characterized as “medically unacceptable” and was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The PEB adjudicated “depressive disorder NOS associated with cognitive disorder NOS” as unfitting, rated 10%, with likely application of Department of Defense Instruction (DoDI) 1332.39 and VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “My initial diagnosis given by the Informal Physical Evaluation Board (IPEB) in 2006, category I unfitting conditions: “Depressive Disorder, not otherwise specified associated with cognitive disorder, not otherwise specified possibly related to blast injury (or anxiety) Social and Industrial Adaptability Impairment.  I was not diagnosed with Post-Traumatic Stress Disorder (PTSD) prior to my discharge from active duty.”

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 ratings for the unfitting depressive disorder NOS associated with cognitive disorder NOS conditions is are addressed below and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  In addition, the CI was notified by the Army that her case may be eligible for review of the military disability evaluation of her mental health (MH) condition in accordance with Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012 and whose MH diagnoses were changed during that process.  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 IPEB – Dated 20060202 | VA - based on Service Treatment Records (STR)
Condition | Code | Rating | Condition | Code | Rating | Exam
Depressive Disorder NOS, associated with Cognitive Disorder NOS | 9434 | 10% | Post-Traumatic Stress Disorder | 8045-9411 | 10% | STR
No Additional MEB/PEB Entries | Other x4 (Not in Scope) |
Combined:  10% | Combined:  10%
Derived from VA Rating Decision (VARD) dated 20070306 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY: The Board acknowledges the presence of posttraumatic stress disorder (PTSD) as a service-connected condition by the VA, but notes that the scope of its recommendations does not extend to conditions which were not diagnosed or in evidence at the time of medical separation.  This includes conditions which may have had early manifestations during active service, since such sub-clinical conditions cannot be correlated with a fitness determination requisite for a rating.

Depressive Disorder NOS associated with Cognitive Disorder NOS Condition.  The CI had a history of depression and associated PTSD symptoms which occurred after he sustained a blast injury while in theatre as a result of his Humvee being struck by a missile on 6 November 2004.  A head CT scan performed because of blast related headaches was negative.  The CI was diagnosed with rule out PTSD in April 2005.  Also in April 2005, a neurologist evaluation was performed and the CI was diagnosed with migraine headaches the occurred once a week and was treated with abortive anti-migraine medications.  He was followed closely by Family Advocacy and had a substantiated claim of spousal abuse in June 2005 which resulted in a referral to Life Skills and Alcohol and Drug Abuse Prevention Team (ADAPT).  He was continued on an anti-depressant medication (Celexa).  The CI underwent extensive neuropsychological testing on 29 July 2005 which demonstrated a variety of somatic complaints and dysfunctional negative emotions, anxiety, concern in health matters, low self-esteem and  internal conflict with regard to work.  The examiner further noted that features of a PTSD condition were significantly represented.  The examiner opined that the testing findings yielded evidence of mildly impaired short–term memory and a moderate depression with low self-confidence.  The examiner diagnosed post-concussion syndrome, somatoform disorder NOS, and PTSD with a Global Assessment Functioning (GAF) of 65 (some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships).  The CI was given a temporary P4/S4 profile and the commander’s statement noted that the CI’s medical condition interfered with his MOS duties and he had become unreliable.  The MEB narrative summary (NARSUM) exam approximately 4 months prior to separation documented that the CI reported cognitive changes, an inability to multi task, an inability to accept changes quickly and that in the past year he had received six letters of reprimand (LOR) for poor attention to detail.  He reported continued difficulty in functioning in a work environment.  The CI also had migraine headaches approximately twice weekly which were “incapacitating" and complained of equilibrium problems.  The examiner documented that the CI had continued difficulty with mood, short term recall, multitasking and executive function.  He diagnosed depressive disorder NOS, exacerbated by blast injury; cognitive disorder, secondary to blast injury and a GAF of 75 (if symptoms are present they are transient and expectable reactions to psychosocial stressors) with a moderate impairment for military service and a mild impairment for social, industrial adaptability.  The CI was hospitalized in a psychiatric in-patient unit for symptoms of binge drinking, depression, feeling overwhelmed with life and marital discord.  The examiner diagnosed depression and chronic PTSD.  The records from that admission are not available for Board review.  The CI was seen post discharge and the examiner noted that the CI reported feeling much better and wasn’t sure if it was his new psychotropic medication or because he had been away from his problems.  He was following up with the ADAPT program for an alcohol-related incident.  The examiner continued the diagnoses of depression and chronic PTSD.  In January 2006, the psychiatrist documented that the CI endorsed PTSD symptoms of hypervigilance, intrusive memories provoked by smells, poor concentration and depression.  The CI did not report for a VA Compensation and Pension (C&P) exam; therefore, there is no C&P exam evidence for the Board to review.  The VARD present for review documents that the VA granted service-connection for PTSD and rated it 10% based on the CI’s STRs.

The SRP concluded the MH diagnosis was changed or eliminated to the applicant's possible disadvantage in the disability evaluation process and; therefore, met the inclusion criteria in the Terms of Reference of the MH Review Project.  The PEB coded the depressive disorder NOS associated with cognitive disorder NOS as 9434 and rated at 10%.  The VA coded the PTSD as 8045 (residuals of traumatic brain injury with 9411) and rated at 10% based on the STR.  The CI suffered a traumatic event when his Humvee was struck by a missile meeting Criteria A for PTSD.  He endorsed intrusive memories of the event meeting Criteria B.  The board considered Criteria C for the PTSD diagnosis and look for evidence the CI had three symptoms of avoidance/numbing as required to meet that criteria.  Self-medication may account for avoidance, but the memory issues were most likely related to his cognitive disorder, he had a good relationship with his daughter and his affect was nearly always normal.  Psych testing was performed and mainly documents cognitive problems and that his memory function was mildly impaired, again most likely related to his cognitive disorder and depression; although testing revealed that “features of PTSD were significantly represented.”  Board members agree that the evidence does not support the CI met Criteria C for the diagnosis of PTSD; therefore, the diagnosis of depressive disorder was appropriate.

The PEB adjudication occurred prior to the promulgation of the National Defense Authorization Act 2008 mandate for DOD adherence to VASRD §4.129 and the service did not apply the §4.129 requirement.  The Board, IAW DoDI 6040.44 and DoDI guidance (which applies current VASRD §4.129 to all Board cases as appropriate), agrees that the stipulations of §4.129 are met in this case and will thus recommend a minimum 50% PTSD rating for a retroactive 6-month period on the Temporary Disability Retired List (TDRL).  Evidence from the time of initial separation, including the MEB NARSUM does not support a rating greater than 50%.  Therefore a rating of 50% is assigned for the reconstructed TDRL period IAW with VASRD §4.129.  The Board must then determine the most appropriate fit with VASRD 4.130 criteria at 6 months after separation for its permanent rating recommendation.  The most proximate source of comprehensive evidence on which to base the permanent rating recommendation in this case are the STR notes in December 2005 and January 2006.  A note prepared 3 months prior to separation documents that the CI was exercising regularly, had more energy, experienced no side-effects from his medication and his mental status exam was normal.  There was no evidence for review within a year after separation.  The next available post separation evidence was a C&P exam 6 years later that documented the CI was in a stable, long term relationship, was working full time and continued his psychotropic medications.  That exam utilized language that directly reflected a 10% rating.  The Board adjudged that the evidence supported a 10% rating after the 6-month reconstructed TDRL period.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a TDRL rating of 50% and a permanent rating of 10% for the depression NOS condition coded 8045-9434.

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.  As discussed above, PEB reliance on DoDI 1332.39 for rating depressive disorder NOS was likely operant in this case and the condition was adjudicated independently of that instruction by the Board.  In the matter of the depressive disorder related to blast injury condition, the Board unanimously recommends a service disability rating of 50% for a prescribed 6-month period of temporary retirement IAW VASRD §4.129; followed by a 10% permanent rating, coded 8045-9434, IAW VASRD §4.130.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified to reflect a disability rating of 50% for the prescribed period of temporary retirement (IAW §4.129), and then a permanent 10% rating, effective as of the date of his prior medical separation:

UNFITTING CONDITION | VASRD CODE | RATING
| | TDRL | PERMANENT
Depressive Disorder related to Blast Injury | 8045-9434 | 50% | 10%
COMBINED | 50% | 10%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 2010318, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
XXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAF/MRB

Dear XXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-01337.

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

							Sincerely,

XXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachments:
1.  Directive
2.  Record of Proceedings

cc:
SAF/MRBR
DFAS-IN

PD-2014-01337