RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02013
BRANCH OF SERVICE:  Army	BOARD DATE:  20150402
SEPARATION DATE:  20070802

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Health Care Specialist) medically separated for a behavioral health condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent S3 profile and referred for a Medical Evaluation Board (MEB).  The conditions characterized as “major depression, recurrent and posttraumatic stress disorder” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “posttraumatic stress disorder (PTSD), associated with major depressive disorder” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

 IPEB – Dated 20070424	VA* - (~2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posttraumatic Stress Disorder (PTSD), Associated with Major Depressive
Disorder	9411	10%	Posttraumatic Stress Disorder With Schizoaffective
Disorder	9411	50%	20070928	
Other x 0 (Not In Scope)	Other x 12 (equals SC, NSC & deferred)	
RATING:  10%	RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20071206 (most proximate to date of separation [DOS]).

Posttraumatic Stress Disorder (PTSD), Associated with Major Depressive Disorder Condition.  The CI deployed to Bosnia from March 2002 to September 2002 and to Iraq from 18 January 2004 through 14 February 2005.  There was no previous history of mental health problems.  He was a combat medic who experienced multiple combat stressors in both settings.  He developed nightmares, flashbacks and sleep difficulties after Bosnia.  Within 6 months of his return from Iraq, he was in the care of a psychiatrist and was taking medication for depression/anxiety.  He reported severe nightmares as a result of experiences in Iraq, and would awaken to find himself choking his wife.  He felt the need to sleep, “all the time” but could not rest longer than a couple hours.  He ruminated over events in Iraq.  He started drinking alcohol to help him fall asleep and was attending a substance abuse program.  He was admitted to a psychiatric hospital on 28 November to 9 December 2005, related to post-deployment issues and again in September 2006.  He received a diagnosis of severe PTSD and major depression.  The CI participated in a Partial Hospitalization program for three weeks after the initial hospital discharge, attended PTSD group therapy from April 2007 through separation, participated in individual therapy, and had psychotropic medications.

At the MEB narrative summary dated, 31 October 2006 (10 months prior to separation), the CI reported he had nightmares with night sweats and awakens once or twice a week, has three or four flashbacks per week, tried to avoid reminders of Iraq or Bosnia, was jumpy to loud noises, checked windows and doors nightly, and had some episodes of crying.  He felt ashamed and a failure with low self-esteem.  He had racing thoughts especially when he was home alone, was very forgetful, and had brief episodic suicidal thoughts.  He was taking two medications for mood and one for sleep.  He was concerned about his ability to function in a new job.  Mental status examinations (MSE), based on a 17 October psychiatry visit, noted psychomotor restlessness, dysthymic and anxious mood, and constricted and worried affect.  The psychiatrist rendered diagnoses of PTSD and major depression, recurrent with a Global Assessment of Function (GAF) of 55 (moderate impairment, symptoms).  He received a permanent S3 profile for PTSD.  

On the MEB History and Physical DD Form 2807, dated 28 November 2006, the CI indicated he had anxiety attacks, difficulty with sleep, and counseling for PTSD/severe depression.  The profiling section of the DD Form 2808, Report of Medical Examination, and dated 21 November 2006 listed a diagnosis of PTSD and history of depression/anxiety disorder.  The commander’s statement in March 2007, noted the CI, “had been able to cope while performing his combat medic duties…while this Soldier’s technical performance is acceptable, his overall mental state would be questionable in a hostile environment.”

At the VA Compensation and Pension (C&P) exam for PTSD, dated 28 September 2007, performed less than 2 months after separation, the CI reported his symptoms included anger, anxiety, and problems with concentration and insomnia.  He rated his mood as 5/10.  He was receiving individual psychotherapy, group therapy, and was taking psychiatric medication.  He was planning to attend college, and did not have a job, but he and his wife had a business selling Hawaiian food and jewelry and were planning to open a restaurant.  They had friends.  He drank nightly to go to sleep.  Brief MSE showed poor eye contact and a tendency to look away, slowed responses, vague visual hallucinations, poor eye contact, bad memory, flashbacks of Iraq, and slowed speech.  He was uncomfortable around other people, and quite untrusting and suspicious of others.  Psychological testing confirmed PTSD and raised questions of other psychiatric problems.  He met criteria for PTSD.  Diagnoses of PTSD (mild to moderate), schizoaffective disorder, and alcohol dependence were rendered with a GAF of 45 (severe impairment, symptoms).

During a follow-up visit for medication management, on 28 September 2007, the CI reported the psychotropic medication worked well to slow his thoughts and promote sleep.  He had taken it for 2 years and worried he was addicted to it, because without it he could not sleep.  He had tried reducing the dose but that was ineffective.  Titrating the dose slowly was recommended.

VA records, dated 21 October 2007, confirmed a visit to the emergency room due to an anxiety attack.  The CI reported he did not take his mental health medications regularly.  A VA note, written 2 days after the attack and signed by a nurse provider, documented a call to the outpatient psychiatry clinic from the CI’s wife.  She reported the CI was “retroing” to his behavior from 2 years previously, i.e. anger control problems, no conversation, no emotion, depression, and paranoia in the last 2-3 months.  He was not sleeping well, had hit the dog in the head which led to an anxiety attack, was using alcohol again and had been transported to the emergency room by ambulance.  The wife also informed the staff psychologist the CI had a volatile mood, memory problems, and issues with his psychologist.

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA adjudicated PTSD with a 9411 code but the PEB adjudicated the PTSD associated with MDD condition as unfitting with a disability rating of 10%.  The VA adjudicated the PTSD associated with schizoaffective disorder with a disability rating of 50%.  The Board first deliberated whether the DoD mandate for application of VASRD §4.129, as previously elaborated, was relevant to its recommendations in this case.  The clinical record provides enough evidence the CI’s condition arose as a result of highly stressful events that the Board agrees §4.129 is applicable.  The Board is therefore obligated to recommend a minimum 50% rating for a retroactive 6-month period on the Temporary Disability Retired List (TDRL).  The Board must then determine the most appropriate fit with VASRD §4.130 criteria at the end of the constructional TDRL interval for its permanent rating recommendation.

The Board next considered if a rating higher than 50% was warranted at the time of entry on the constructional TDRL period.  The next higher 70% rating requires “Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood.”  Board members agreed however that these criteria were not approached, and therefore a rating higher than 50% was not supported.

In regards to a recommendation at the time of removal from the constructional TDRL period, the most proximate source of comprehensive evidence in this case was the VA (C&P) examination performed 2 months after separation.  There was relevant VA outpatient and clinical provider evidence providing psychiatric details during the 6-month interval.  Especially since the C&P examination also reflects the stress of transition to civilian life, which is a core intent of §4.129, it carries the preponderance of probative value in the Board’s assessment of a fair permanent rating recommendation.  The service evaluations nevertheless serve as useful reference points and retain relevant probative value.  The Board considered if a rating higher than the 10% adjudicated by the PEB was justified.  The 10% rating specifies “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 §4.130 criteria for the 30% rating are “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, and for the 50% rating there is “reduced reliability and productivity.”  The Board considered that the CI continued to have difficulties post-separation, with anxiety, depression, anger, panic attacks, sleep, alcoholism, and volatile behaviors.  He continued his medication and group therapy but required an emergency room visit.  His VA C&P GAF score suggested severe symptoms of impairment, the examiner specifically stated.  A review of the medication profiles indicated the CI had at least a 2-year history of multiple psychotropic medications.  The Board agreed that the 50% rating most accurately depicted the condition at the time of removal from the constructional 6-month TDRL period.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends an entry TDRL rating of 50% and permanent disability rating after removal from TDRL of 50% for the PTSD condition, coded 9411.

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the PTSD condition, the Board unanimously recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129, as DOD directed, and §4.130; and a 50% permanent rating at 6 months 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 as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
PTSD (associated with MDD)	9411	50%	50%	
COMBINED	50%	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140424, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXXXXX, AR20150013697 (PD201402013)

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 recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 50%.

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:

	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 retired with permanent disability effective the day following the six month TDRL period.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, provide 50% retired pay for the constructive temporary disability retired six month period effective the date of the individual’s original medical separation and then payment of permanent disability retired pay at 50% effective the day following the constructive six month TDRL period.  

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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						     XXXXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)