RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: BRANCH OF SERVICE: NAVY

CASE NUMBER: PD0900050 BOARD DATE: 20100331

SEPARATION DATE: 20071116

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SUMMARY OF CASE: This covered individual (CI) was a E3/Field Medical Service Technician medically separated from the Navy in 2007 after five years of service. The medical basis for the separation was Post Traumatic Stress Disorder (PTSD). A Medical Evaluation Board (MEB) determined the CI had received the maximum benefit of military medical treatment but this had not restored him to a duty status. CI was referred to the Physical Evaluation Board (PEB), found unfit for continued Naval service, and separated with a 10% disability using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Navy and Department of Defense regulations.

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CI CONTENTION: ‘Department of Veterans Affairs rated 50% then reduced to 30%. Condition was worse than stated by the Army.’ ‘There was not enough time or treatment to determine the true severity of PTSD.’

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RATING COMPARISON:

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ANALYSIS SUMMARY:

The CI was diagnosed with PTSD after deployment to Iraq from March to October 2004 where he served as a combat medic with the Marines. On a post-deployment health assessment completed in September 2004 he noted that he had witnessed wounded and dead personnel--coalition, enemy, and civilian; and was involved in direct combat. He was referred to mental health but no psychiatric records were available; it is unclear when he was first seen. He was seen in a Family Practice clinic in May 2005 and referred to mental health for evaluation of PTSD and the MEB narrative summary (NARSUM) states he was evaluated by mental health in May 2005. Signs and symptoms of PTSD are noted in the outpatient notes and the NARSUM. In the spring of 2006 he had two episodes of violent acts against others associated with drinking alcohol. By late May 2006 his symptoms began to include suicidal ideation and he was admitted to the inpatient psychiatric ward from 22 to 31 May 2006. Records of this hospitalization are not available but a summary of his hospital course is included in the NARSUM. He was given Sertraline but this seemed to escalate his agitation and it was stopped after 2 or 3 days. Clonidine was used instead but this was discontinued prior to release form the hospital. After hospital discharge, he had a trial of Sertraline but it did not appear to help his symptoms and it caused sexual side effects so it was discontinued after several months. According to the MEB NARSUM, his mental status exam was normal except for poor impulse control. His global assessment of functioning (GAF) was rated at 50 and the NARSUM states he had a severe degree of industrial and military impairment. He also had severe civilian impairment. He did attend alcohol treatment that was mainly educational, level one, because he did not meet the definition of alcohol dependence but had abused alcohol.

VA Compensation and Pension (C&P) exam was completed in August 2008, nine months after his separation from service in November 2007. While the permanent rating is supposed to be based on the functional limitations at six months, this examination most likely represents how the CI was doing at six months after separation. While he did not have a C&P exam done near the time of separation he was evaluated clinically by the VA in April 2008 and entered treatment for PTSD. In April his GAF was 59 and at the C&P in August 2008 it was 50. The two evaluations were done by different providers, a social worker in April and a psychiatrist in August. Both evaluations reported the same symptoms. The one in April was completed by a social worker who failed to fully address or diagnose alcohol abuse even though she recorded a one month inpatient treatment for substance abuse. His military evaluation was done by a psychiatrist in June 2007 and the GAF at that time was also 50. The two VA evaluations report a very similar clinical picture with frequent moderate to severe symptoms of PTSD continuing. The CI did not appear to be helped much by medication although he did use it for several episodes. He also appeared motivated to get help by attending individual and group therapy and education both before and after separation. He was not employed and lived with his fiancée and her two children. He also received unemployment. While he did have a fiancée, he did not appear to have any other friends or much contact with his family. He avoided crowds and social gatherings and there appears to have been social dysfunction as well as occupational.

A permanent 30% rating appears warranted based on the April and August 2008 evaluations. He had been separated from the Navy because his PTSD caused the inability to perform the required duties and tasks of his job as a hospital corpsman and by August 2008 he was still unemployed and there is no evidence he was attending school. He did appear to have somewhat improved control of his behavior when comparing the VA C&P examination to that of the NARSUM. He appeared to be somewhat out of control, getting into trouble and behaving violently while on active duty. He did seem to be better able to control his actions, although he was still having problems with controlling spontaneous irritable and anger and that would make having a job difficult.

His symptoms in August 2008 were:

1. Persistent re-experiencing of the traumatic events with nightmares 3-4 times a week and intrusive thoughts, flashbacks and recurrent recollections.

2. Persistent avoidance of stimuli associated with the traumatic events including avoiding activities that remind him of the events, restricted range of affect, and markedly diminished participation in external events. He was unable to tolerate crowds.

3. Persistent symptoms of hyperarousal with difficulty falling and remaining asleep, hypervigilance, exaggerated startle, irritability, anger, difficulty concentrating when reading or studying. He became very nervous when someone walked behind him and had a hyperstartle response when he heard airplanes. He lived with his fiancée but slept in another room because he felt he needed to be close to the exits and he had on several occasions inadvertently pushed his fiancée while he was sleeping.

The substance abuse problem is part of his PTSD and he admitted he was using alcohol to deal with his symptoms. He underwent treatment and was in remission with no current problems at the time of the August 2008 evaluation. Alcohol abuse was considered to be in full remission.

Hyperthyroidism was diagnosed in May 2006 while he was admitted to the psychiatric ward and this may have contributed to his feelings of anxiousness and irritability but cannot explain the totality of his symptoms. His thyroid hormone levels were brought under control and his PTSD symptoms persisted.

Other conditions:

Graves disease would not have prevented further Navy service and is not separately unfitting. He did not meet the diagnostic criteria for diabetes, although he may progress to this in the future. So while diabetes may be an unfitting condition, elevated fasting blood glucose is not. According to the physician at the alcohol rehabilitation treatment center, the CI never met the criteria of alcohol dependence but did abuse alcohol. This is not a disability and is not ratable. It was secondary to his PTSD and will not be used to lower the rating of his disability due to PTSD. Mood disorder secondary to medical condition was secondary to his Graves disease and not separately unfitting. At the time of the VA evaluation in August 2008, his did not appear to have any significant mood disorder.

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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. After careful consideration of all available information, the Board unanimously determined that the CI’s condition is appropriately rated with an initial six month TDRL rating of 50% in retroactive compliance with VASRD §4.129 as DOD directed, followed by a 30% permanent rating for PTSD IAW VASRD §4.130. The TDRL period should commence at the time of original separation from service (20071117) and the permanent rating should be applied six months after that date.

The CI had significant, frequent, and moderate to severe symptoms of PTSD both at the time of separation from service and at the time of the VA evaluation nine months later. He was separated from the Navy because he was unable to perform the required duties of a hospital corpsman. His judgment was severely impaired and he was abusing alcohol, engaging in acts of violence, and was unable to conform to Navy standards of behavior. However, he did appear to have improved somewhat at the time of the VA evaluation as he did seem to be better able to control his actions. His alcohol abuse was in early but full remission, he did not report any further acts of violence, and he appeared to be in a successful romantic relationship. Nonetheless, he was unemployed, was not attending school, and did not appear to have any successful social relationships other than with his fiancée. He still had persistent re-experiencing of the traumatic events with nightmares three to four times a week along with intrusive thoughts, flashbacks, and recurrent recollections. He continued to have persistent avoidance of stimuli associated with the traumatic events and persistent symptoms of hyperarousal. He also continued to have problems with spontaneous anger and irritability that would make employment more difficult and limit the job choice to those that did not require working directly with customers.

When multiple mental health conditions are present, separate ratings are not applied for each condition. Instead, the overall functional occupational and social impairment is used to determine the appropriate rating percentage IAW the VASRD §4.126 and the General Rating Formula for Mental Disorders in §4.130. Depression or mood disorder does not appear to be a significant contributor to the CI’s functional impairment which is almost exclusively secondary to his PTSD.

The Board also considered Graves disease and Mood disorder due to a General Medical condition (Graves Disease) and unanimously determined that these conditions were not unfitting at the time of separation from service. Elevated fasting glucose and alcohol abuse are not disabilities and are not rated.

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RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows: TDRL at 50% for 6 months following CI’s prior medical separation (PTSD at minimum of 50% IAW §4.129 and DoD direction) and then a permanent 30% disability retirement as below.

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The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20090122, w/atchs.

Exhibit B. Service Treatment Record.

Exhibit C. Department of Veterans' Affairs Treatment Record.

DEPARTMENT OF THE NAVY

SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS
720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD DC 20374-5023

IN REP!.Y REFERTO

1850

CORB:003

26 April 2010

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

Ref: (a) DoDI 6040.44

(b) PDBR ltr of 12 Apr 2010

1. Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy for appropriate action.

2. On 23 April 2010, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) took final action in your case by accepting the recommendation of the PDBR. Your records will be corrected to reflect your placement on the Temporary Disability Retired List (TDRL) with a disability rating of 50 percent for a period of six months effective the date of your discharge in accordance with 38 CFR 4.129. Following six months on the TDRL, your records will reflect a final disposition rating of 30 percent with placement on the Permanent Disability Retired List.

4. The Secretary's decision has been forwarded to the Commander, Navy Personnel Command, who will make the appropriate changes to your military records and notify you once they are completed.

PDBR