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AF | PDBR | CY2012 | PD2012 00839
Original file (PD2012 00839.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXX        BRANCH OF SERVICE: NAVY
CASE NUMBER: PD1200839   SEPARATION DATE: 20030203
BOARD DATE: 20130514


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty EM3 (E4/Electrician’s Mate), medically separated for posttraumatic stress disorder (PTSD). Having suffered full thickness burns to his upper body, the CI was referred for a mental health evaluation, and was diagnosed with PTSD. When his PTSD could not be adequately rehabilitated to meet the requirements of his rating, he was referred for a Medical Evaluation Board (MEB), which forwarded no other conditions for Physical Evaluation Board (PEB) adjudication. The narrative summary (NARSUM) listed “Scars s/p skin graft” as a Category III condition and “Polysubstance dependence in full sustained remission” as a Category IV condition. The PEB adjudicated the PTSD condition as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals, and he was medically separated with a 10% disability rating.


CI CONTENTION: “This condition affects life daily.” The CI elaborated no specific contention in his application.


SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service or when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. 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 Naval Records.


RATING COMPARISON:

Service IPEB – Dated 20021211
 VA (11 Mos. Post-Separation) – All Effective Date 20030204
Condition
 Code Rating Condition Code Rating Exam
PTSD
 9411 10% PTSD 9411 70% 20040109
↓No Additional MEB/PEB Entries↓
 Tinnitus 6260 10% 20040109
0% X 3 / Not Service-Connected x 2
Rating: 10%
 Combined Rating: 70%


ANALYSIS SUMMARY: The Board’s authority as defined in DoDI 6040.44, resides in evaluating the fairness of Disability Evaluation System (DES) fitness determinations and rating decisions for disability at the time of separation. The Board utilizes service and VA evidence proximal to separation in arriving at its recommendations and DoDI 6040.44 defines a 12-month interval for special consideration of post-separation evidence. Post-separation evidence is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation.


Posttraumatic Stress Disorder. On 18 April 2001, while serving as an electrician aboard ship, the CI suffered full thickness electrical burns to the head, face and arms when he reset a circuit breaker, which immediately exploded. His burns were treated definitively with skin grafts and he returned to his ship on 30 June 2001. However, due to recurrent nightmares of the event, anxiety when around electrical equipment, and hypervigilance, he was referred for mental health evaluation, subsequently resulting in a diagnosis of PTSD. He entered an initial 8 month period of limited duty (LIMDU) in July 2001. After extensive systematic desensitization therapy, he was found fit for duty in March 2002 and returned to sea duty in April 2002. However, in June 2002, a small electrical shipboard fire occurred and the CI was unable to respond; he suffered a panic attack and collapsed into a fetal position. He was placed on a second period of limited duty (LIMDU) and he was referred for an MEB for PTSD. No medications were documented.

An undated MEB narrative summary (NARSUM) was completed sometime after June 2002 and before 28 October 2002; this was between 7 and 3 months prior to separation. At the time of this evaluation, the CI reported being “socially withdrawn,” especially after the incident, and had “few friends in the Navy.” The NARSUM reported that he became “significantly impaired in the use of electricity or electrical equipment.” The NARSUM noted “extreme anxiety in the form of pounding heart, nausea, trembling, sweating palms, and shortness of breath” when around electrical equipment, with both flashbacks and also recurrent nightmares of the event, initially 5-7 times per week after the initial event, but at the time of NARSUM, down to 1-2 per month. The NARSUM stated that “maximum benefits of outpatient therapy have been obtained,” and that his condition interfered with his ability to perform his duties. At the time of the MEB, the CI noted adequate function in his “everyday life,” but that he was terrified to return to his rating. He remained “terrified of electricity despite any safety precautions.” He reported nightmares of being electrocuted, noting that, onboard ship, he could not “touch anything” because “ships are just giant steel conductors.” The mental status examination (MSE) recorded in the NARSUM was normal except when the CI was discussing his accident, when his affect would become “anxious and agitated,” exhibiting “agitated psychomotor activity” and “pressured speech with an anxious tone.” There was no suicidal ideation, delusional or hallucinatory symptoms, speech disturbance, objective cognitive impairment, or other abnormalities. The NARSUM assigned a Global Assessment of Function (GAF, coded on Avis V) of 65, noting “marked” impairment of military duties, with the likely potential for panic attacks or other emotional reactions and moderate social and industrial impairment. Psychiatry clinic notes, from July 2002 through the date of separation on 3 Feb 2003, document that he was unable to discuss this incident with friends and would prefer to end a relationship instead. He noted that he was “scared to go into civilian life.” During this time, the CI had therapy sessions two to three times a month and GAF scores were 50 from August 2002 through October 2002, fluctuated between 50 and 65 in November 2002, and remained at 65 for four sessions through January 2003. According to the DSM-IV-TR, a GAF of 50 indicates serious symptoms or any serious impairment in social, occupational, or school functioning, and a GAF of 65 indicates some mild symptoms or some impairment in social, occupational, or school functioning, generally functioning well, with some meaningful interpersonal relationships. Service treatment records (STRs) document that, at a visit with his treating psychologist on
24 January 2003, the CI was apparently scared about going into civilian life, his symptoms were characterized as “low level,” and should “remain only mildly disruptive for the foreseeable future.” On this occasion, his MSE was normal, with mood described as “’happy and nervous with congruent affect,” and without suicidal ideation, delusional or hallucinatory symptoms, speech disturbance, cognitive impairment, or other abnormalities.

Eight months after separation, in October 2003, the CI first presented to the VA Medical Center (VAMC) Lufkin (TX) for treatment. The substance of these clinic visits were summarized in the VA Compensation and Pension (C&P) exam 3 months later, and noted that, since his separation, he had experienced “insomnia, nightmares, and fears of coming into contact with electrical equipment.” The VA clinic records documented that the CI “could not maintain employment in an auto parts store,” having worked only for 6 months, because he could not check batteries or shut down electrical equipment when closing the store. The CI last worked in September 2003, reporting, “it was apparently suggested that he resign.” The C&P examination reported that he was a full time student later during this period, and was living with his parents and supporting himself with his GI Bill benefits. He noted panic attacks when around electrical equipment. He noted guilt, difficulty concentrating, restlessness, avoidance of electrical equipment, and an inability to engage in any pleasurable activities. He reported nightmares of his incident occurring 1-2 times per month, awakening “terrified.” The MSEs for the VA clinic visits prior to the C&P exam were not recorded, but, during this period, he was diagnosed with PTSD and depression not otherwise specified (NOS), and was prescribed Trazodone and Citalopram by the VA. The previous clinical history reported at these visits is essentially equivalent to the events recorded in the CI’s service treatment records. He continued to report significant symptoms at two follow-up visits in October. He felt depressed, frustrated, and had poor concentration and he was easily distracted and irritable. The medication helped with sleep but he still felt depressed and tense and he experienced nightmares about the accident once or twice a month. He continued to have a persistent avoidance of electrical equipment. He reported an active social life and he was dating. Follow-up visits in December 2003 (as reported in the C&P examination), 10 months after separation, initially showed some improvement with medication but the side effects of sleeping long hours and feeling tired interfered with his school performance. He applied for a pipefitting job but he was not selected for it. He stopped taking his medications due to side effects and his symptoms increased. He lived with his parents because he was unemployed and he had trouble getting along with his mother. He still visited friends in a different town.

At the C&P exam 11 months after separation the CI reported continued nightmares concerning the event despite reportedly taking his medications. He noted that he currently would overreact when experiencing mild static electricity, with shortness of breath, chest pain, and rapid heart rate. He stated that, after leaving the job in the auto parts store, he enrolled in college. He was taking 16 credit hours but he was currently “burned out.” He stated that he “shot his truck with a gun” after feeling static electricity when brushing against the truck. He remained hypervigilant to his risk for electrical exposure, avoiding household appliances, light switches, or computers, especially during storms when there was a risk for the occurrence of lightning. At the time of this examination, the CI continued to live with his parents. He no longer went to visit friends in a different town and currently had only one female friend. He reported poor sleep and energy and was taking Trazodone and Celexa. The C&P MSE noted depressed mood and restricted affect, and the CI became irritable, frustrated, and tearful when discussing his symptoms. The GAF was assessed as 40, indicating some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. The VA described “severe PTSD symptoms” with nightmares, flashbacks, and intense psychological distress, noting also “significantly impaired” occupational and social functioning, noting that he was “unable to obtain and maintain gainful employment.”

The Board directs attention to its rating recommendation based on the above evidence. The PEB rating in this case was derived from DoDI 1332.39 and preceded the promulgation of the National Defense Authorization Act (NDAA) 2008 mandate for DOD adherence to VASRD §4.129. IAW DoDI 6040.44 and DOD guidance (which applies current VASRD §4.129 to all Board cases), the Board is obligated to recommend a minimum 50% PTSD rating for a retroactive 6 month period of Temporary Disability Retired List (TDRL). The Board must then determine the most appropriate fit with VASRD §4.130 criteria at six months for its permanent rating recommendation. The most proximate sources of comprehensive evidence on which to base the permanent rating recommendation in this case are: the VA mental health visits starting eight months after separation, followed by his initial C&P exam for PTSD, performed 11 months after separation. It weighed heavily any evidence which was timed with the 6 month rating benchmark, especially since these examinations carried specifically relevant probative value reflecting the stress of transition to civilian life, which is the core intent of §4.129.

In summary, at the time of the MEB NARSUM, the CI had been characterized as “significantly impaired” in the duties of his rating, with “marked” impairment in military duties and “moderate” social and occupational impairment. By the time of separation, his MSE was normal and his symptoms were “low level.” Although the CI described some difficulty establishing and maintaining effective work and social relationships, his condition did not meet the criteria for a rating greater than 50% at separation. Consequently, at separation, the Board has determined that placement upon TDRL with a rating of 50% is most appropriate IAW §4.130. E ight months after separation , the CI’s symptoms , and occupational and social impairment had worsened , with well documented deficiencies in work and mood , as he failed at work and he was newly diagnosed with depression by the VA . On the other hand, the VA clinic notes document that, in October 2003, he was enrolled in college, that he reported an “active social life” and that he was dating. At this time, 8 months after separation, his condition meets some criteria for a 30% rating and some criteria for a 50% rating. H is decrease in work efficiency with depressed mood, sleep impairment, occasional and situationa l panic attacks, meet the criteria for 30% IAW VASRD §4.130. However, his “occupational… impairment with reduced …productivity” and “disturbances of motivation and mood” meet some of the criteria for the higher 50% rating. Based on the totality of evidence, including the C&P exam 11 months after separation, the VA determined 70% rating under code 9411 because of “deficiencies in most areas, such as work, school, thinking, judgment, and mood.” He was unemployed, noted by the VA as “unable to obtain and maintain gainful employment.” In school, he was fatigued, perhaps due to medications, but described himself as “burned out.” His hypervigilance to his risk for electrical exposure, avoiding household appliances, light switches, or computers, reveals a failure to accurately assess a true threat versus an imaginary one. His judgment was poor as evidenced by shooting his truck, which demonstrates violent impulsivity. On examination, depressed mood and restricted affect were noted, as well as the CI becoming irritable, frustrated, and tearful. The VARD noted its determination of a 70% rating was based upon ”intense psychological and physiological distress,” avoidance, anhedonia, restricted affect, insomnia, irritability, hypervigilance, exaggerated startle response, guilt, with “significantly impaired” occupational and social functioning. He was unemployed, and “unable to obtain and maintain gainful employment.” He continued to live with his parents, he no longer went to visit friends in the different town, and he currently had only one female friend. No further mental health C&P examinations were completed. In February 2007, the VA determined the CI was not entitled to individual unemployability because the CI had failed to show for a scheduled VA examination and his current mental health status was not evaluated. Examination of the VASRD reveals that, at the time of the C&P examination 11 months after separation, he did meet many criteria for a 70% rating, as mentioned above, but also including impaired impulse control (shooting his truck), obsessional rituals (wearing gloves when touching household electrical switches), difficulty in adapting to stressful circumstances (“burned out” during his first school semester), and an inability to establish and maintain effective relationships. From the time of separation, we have evidence of a pattern of worsening occupational and social impairment. The Board examined thoroughly and discussed at great length which evidence would best apply for a rating at six months after the date of separation. After due deliberation, considering all of the evidence and mindful of VASRD §4.129, in the matter of the Posttraumatic Stress Disorder condition, the Board unanimously recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129 as DOD directed, and a 50% permanent rating at 6 months IAW VASRD §4.130.


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 the PTSD condition was operant in this case and the condition was adjudicated independently of that instruction by the Board. 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 a 50% permanent rating at six 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 discharge with severance pay be recharacterized to reflect TDRL at 50% for 6 months following his original date of separation, followed by permanent disability retirement, effective as of the date of his release from TDRL, with a permanent 50% disability retirement, as below:

UNFITTING CONDITION
 VASRD CODE RATING
TDRL PERMANENT
Post Traumatic Stress Disorder Condition
 9411 50% 50%
RATING
 50% 50%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120617, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record





XX
Director of Operations
Physical Disability Board of Review


MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
 COMMANDER, NAVY PERSONNEL COMMAND
                                         
Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref: (a) DoDI 6040.44
(b) PDBR ltr dtd 10 Jun 13 ICO X
(c) PDBR ltr dtd 20 Jun 13 ICO X
(d) PDBR ltr dtd 12 Jun 13 ICO X
(e) PDBR ltr dtd 20 Jun 13 ICO X

1. Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (e).

2. The official records of the following individuals are to be corrected to reflect the stated disposition:

         a. Xformer USN: Disability separation with a final disability rating of 20 percent (increased from ten percent) effective 30 April 2002.

         b. Sformer USN: Disability separation with a final disability rating of 20 percent (increased from ten percent) effective 3 December 2001.

         c. Xformer USN: Disability retirement with assignment to the Temporary Disability Retired List with a 50 percent disability rating (in accordance with VASRD 4.129) for the period 2 February 2002 through 1 August 2002, with assignment to the Permanent Disability Retired List with a 50 percent disability rating effective 2 August 2002.

         d. Xformer USMC: Disability separation with a final disability rating of 20 percent (increased from ten percent) effective 15 December 2003.
        
3. Please ensure all necessary actions are taken, included the recoupment of disability severance pay if warranted, to implement these decisions and that subject members are notified once those actions are completed.



                                                      XX
                                                      Assistant General Counsel
                                                      (Manpower & Reserve Affairs)

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