RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXX 	BRANCH OF SERVICE:  USCG 
NUMBER:  PD0900430	BOARD DATE:  20100303
SEPARATION DATE:  20021008
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SUMMARY OF CASE.  This covered individual (CI) was a Communications Chief Petty Officer medically separated from the Coast Guard in 2002 after more than 17 years of service.  The medical basis for the separation was Anxiety Disorder. 

Appropriate therapy failed to alleviate his symptoms and he was referred to the Coast Guard Physical Evaluation Board (PEB).  The PEB determined he was unfit for continued military service and he was then separated with a 10% disability for Anxiety Disorder using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Coast Guard and Department of Defense regulations.
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CI CONTENTION:  “I underwent (3) medical boards over a (3) year period for a multitude ailments.  The stress eventually led to me developing mental disorders.  The third medical board started after spending a short stay in the hospital where I was eventually diagnosed with both Major Depressive Disorder and Anxiety Disorder, Not Otherwise Specified.  My psychiatrist (Dr. D---) lists both of these as Axis I.  The Coast Guard chose only one of these in order to qualify me for the least amount of disability.  By choosing the Anxiety Disorder they were able to use the verbiage from the VASRD 9440 that puts me in the 10% range.  Clearly if you look at the verbiage for 30% of the same paragraph you'll see that it is more fitting since it mentions both the depressed mood and the anxiety.  Additionally, the cause of these two disorders, as diagnosed by my psychiatrist, was the stress I endured dealing with the other ailments he lists as Axis III and IV, and the associated medical boards.  At the very least I should have been found unfit for both Axis I disorders at an amount of 30% but, it is no stretch to say that the other medical conditions created those medical disorders and should be included as well.” 
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RATING COMPARISON:

Service PEB	VA (2 months after Separation)	
Condition	Code	Rating	Date	Condition	Code	Rating	Exam	Effective	
Anxiety Disorder                 (MEB Dx 3-3)	9413	10%	20020722	Major Depressive/Anxiety Disorder	9434	0%	20021213	20021009	
Major Depressive Disorder, Single Episode Moderate-Severe (MEB Dx 2-3)	Not on PEB Findings; Not Unfit						
Recurrent Angioedema and Urticaria (MEB Dx 1-3)	Not on PEB Findings; Not Unfit	Idiopathic Angioedema with Urticaria	7825	10%	20021213	20021009	
No PEB or MEB Entry.
	Obstructive Sleep Apnea	6847	50%	20021213	20021009	
	Hypertension	7101	10%	20021213	20021009	
	Left Elbow Tendinitis	5024-5206	10%	20021213	20021009	
	Cervical Spine Degenerative Joint Disease	5003-5290	10%	20021213	20021009	
	Premature Ventricular Contractions	7011	0%	20021213	20021009
	
	Low Back Condition	5295	NSC	20021213	20021009
	
TOTAL Combined:  10%	TOTAL Combined (Includes Non-PEB Conditions):    70%                                                                                  

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Analysis Summary:

Mental Health:
The CI was initially referred to the PEB in 2000 with Symptomatic Premature Ventricular Contractions (PVCs), Hypertension, and Recurrent Angioedema and Urticaria and was returned to an interim duty status for convalescence.  After a re-evaluation in 2001 he was again referred to the PEB with Obstructive Sleep Apnea, Symptomatic PVCs, Hypertension, and Recurrent Angioedema and Urticaria.  This second PEB determined his conditions were not disabling and he was returned to duty.

After the second PEB returned him to duty he went to sea for four days.  During that time he became very worried about his medical problems and when he got back he went to the emergency room (ER).  He was diagnosed with an adjustment disorder and was referred to mental health.  He was then diagnosed with major depressive disorder and anxiety disorder and was later referred to the PEB for this condition.  In 2002, this PEB determined he was not fit for continued service.

He went to the ER on 12 May 02 for overwhelming anxiety, depression, and difficulty coping.  He complained of classic neurovegetative symptoms of depression.  The diagnosis was adjustment disorder and he was put on quarters for 24 hours with follow-up next morning with primary care manager (PCM) and a psychiatry referral.  He did see his PCM the next morning, 13 May and was diagnosed with Depression, Not Otherwise Specified.  Prozac was started and he was placed on light duty: no sea duty.  He was seen by his PCM again 15 May and referred to psychiatry same day.  He was hospitalized 15-17 May for acute stress and anxiety with suicidal ideation (SI).  This is one day after the Psychiatric narrative summary (NARSUM) addendum was done one day prior to this and the hospitalization is therefore not mentioned in the addendum.  The general medical board dated 20020530 also does not mention this hospitalization and it seems apparent that the PEB did not know the CI had been hospitalized.  After a 20020607 visit to his PCM he was placed on light duty for 90 days with no boat/sea duty.  At a 20020712 Psychiatry clinic visit he was noted to be feeling better psychologically and emotionally, in good job now and awaiting USCG Personnel Command action.  He was still anxious and depressed for brief periods but no need for antidepressants or psychotherapy was noted.  His mental status exam revealed:  No psychosis, SI, cognitive impairment, judgment and insight good.  The diagnosis was Major Depressive Disorder, resolved; Anxiety Disorder, Not Otherwise Specified, with depressive overlay; and Occupational problem. 

Medical Evaluation Board (MEB) NARSUM 20020624 documented the diagnoses of Major Depressive Disorder and Anxiety Disorder were confirmed by the Head of Psychiatry at Naval Medical Center Portsmouth on 14 May 2002.  According to the Navy psychiatrist, the results of previous medical boards finding him fit for full duty and the fear of working on a boat with his medical condition (the allergy specialist stated that it is unsafe for him to work in such environment), were the cause of his depression and anxiety.  His mental condition worsened to the point of requiring hospitalization {disqualifying according to Medical Manual section 3-F.16.c.} on May 15, 2002.  The psychiatrist recommended that he be permanently removed from the boat environment.  It was the opinion of the psychiatrist that this patient's mental status was not expected to improve, even on antidepressant medication, as long as he had the fear of being sent to a boat.

During the Psychiatric Evaluation of 20020514 the Mental Status Examination noted: Well-groomed, anxious, looking as if he could cry, engaged in interview, cooperative, talkative.  There was evidence of psychomotor hyperactivity, attributed to anxiety.  No evidence of psychosis or suicidal or homicidal ideation.  He was cognitively intact to office testing and he was alert and fully oriented.  Reasoning and abstract thinking intact. Judgment and insight good.  Mood depressed and anxious, affect congruent by noticeable lability.

The diagnoses listed were:
Axis I. 	1. Major Depressive Disorder, Single Episode, moderate-severe, #296.22, Did Not Exist Prior to Enlistment (DNEPTS)  2. Anxiety, Disorder Not Otherwise Specified, moderate-severe, #300.00, DNEPTS
Axis II.	 No Personality Disorder, #V71.09
Axis III.	 Obstructive sleep Apnea; Recurrent Idiopathic Urticaria/Angioedema; Hypertension; Palpitations 
Axis IV.	 Chronic medical illnesses which arouse fear in patient; worries by patient of increased risk of mortality from illness; conflict with senior USCG medical-administrative personnel
Axis V: Current GAF 55

The psychiatrist recommended the CI was not psychiatrically fit for sea duty in the USCG, based on a combination of moderately severe psychiatric disorders.  These disorders were directly caused by the patient's apprehension over being forced by the USCG to go to sea despite evident concerns reportedly expressed by USCG and Navy physicians in the past regarding the angioedema/urticaria occurring at sea.  No medication or therapy would be expected to reverse these psychiatric disorders or make them improve or remit, while he is in a seagoing status.  His reaction to this stress over the previous two years of administrative reversal of his medical boards is expected.  His prognosis was poor regarding these disorders resolving while on active duty.  Last, these disorders had caused, by the patient's report, significant impairment to the point of almost embarrassing inability to perform duties of his rate and rating at sea.  He strongly recommended that the CI be immediately removed from sea duty while this case goes forward.

The psychiatrist also strongly recommended that Prozac antidepressant medication be discontinued.  No medication was recommended at that time.  Administrative removal from the ship pending medical board consideration was expected to help to alleviate some symptoms to a degree.  If symptoms persisted despite removal from ship, then medication might be needed.

Using an evaluation completed two months after separation the VA rated his mental health condition at 0% for symptoms that were not severe enough either to interfere with occupational and social functioning or to require continuous medication.  He was not taking any medication and was not receiving treatment for chronic psychiatric symptoms.  The VA psychiatrist determined both generalized anxiety disorder and major depressive disorder were in remission.

Conditions Considered by Previous PEBs
Four conditions had been evaluated by two previous PEBs which both determined the CI was fit for duty.  A medical evaluation board (MEB) was done 20000817 for Symptomatic Premature Ventricular Contractions (PVCs), Hypertension, and Recurrent Urticaria/Angioedema.  The PEB determined that the CI would likely become fit after a period of convalescence and he was returned to an interim duty status.  A second MEB was done 20010306 for Chronic Urticaria and Angioedema, Partially Controlled on Medication and Undue Side Effects from Medications Necessary to Control the Urticaria and Angioedema.  This MEB referenced the previous MEB.  The second PEB determined the CI’s medical impairments were not disabling.  The PEB specifically evaluated Obstructive Sleep Apnea; Recurrent Urticaria/Angioedema; Symptomatic PVCs; and Hypertension.

Of these four conditions, only one (Recurrent Angioedema and Urticaria) was also evaluated by the PEB that determined the CI was unfit for continued service.  The PEB found this condition was not unfitting.  He was considered unfit for a mental health condition that had not been considered by previous Boards. 

There is not sufficient evidence to support determining any of these conditions were unfitting at the time of separation. Obstructive Sleep Apnea is not considered disabling for service when "correctable by use of Continuous Positive Airway Pressure (CPAP) or surgical means" (MEDMAN 3.F.15.l).  Persistent hypertension is very rarely found to be disabling.  The CI’s condition is within the standards in MEDMAN 3.F.8.c(2).  A complete evaluation of the CI’s symptomatic PVCs was accomplished and his condition is considered adequately controlled.  He had a normal echocardiogram 20010727 and an exercise treadmill test on 20001025 yielded a result of 12.6 METS and no PVCs were seen during testing.  An extensive evaluation by cardiology found no evidence of organic heart disease.  His condition does not interfere with satisfactory performance of duty, including sea duty.  Recurrent Urticaria/Angioedema is not disabling unless it is "chronic, severe, and not amenable to treatment" (MEDMAN 3.F.l4_bb). The service treatment record (STR) thoroughly documents this as an intermittent condition that, while irksome is mild and clearly does not interfere with sea duty.

Other Conditions not considered by previous PEBs/not in Disability Evaluation System (DES) package Outside scope of PDBR
Left Elbow Tendinitis
Cervical Spine Degenerative Joint Disease
Low Back Condition
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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 determined by simple majority that the CI’s condition is most appropriately rated at 10% for 9413 Anxiety Disorder with Major Depressive Disorder.  The single voter for dissent (who recommended a 30% rating) did not elect to submit a minority opinion. 

The CI could perform his required duties when not at sea. However, he was not able to do so during sea duty.  He had a transient occupational impairment that interfered with duty performance while at sea but had no difficulties when not at sea and did not require any medications.  Occupational impairment due to transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress warrant a 10% rating.

The Board unanimously determined that obstructive Sleep Apnea, Symptomatic Premature Ventricular Contractions (PVCs), Hypertension, and Recurrent Urticaria/Angioedema were not unfitting at the time of separation from service. 

The other diagnoses rated by the VA (Left elbow Tendonitis; Cervical Spine Degenerative Joint Disease; Low Back Condition) were not mentioned in the Disability Evaluation System package and are therefore outside the scope of the Board.  The CI retains the right to request his service Board of Correction for Military Records (BCMR) to consider adding these conditions as unfitting.
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RECOMMENDATION: The Board therefore recommends that there be no recharacterization of the CI’s disability and separation determination.

UNFITTING CONDITION	VASRD CODE	RATING	
Anxiety Disorder with Major Depressive Disorder	9413	10%	
COMBINED	10%	
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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090706, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.