RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXX			BRANCH OF SERVICE:  MARINE CORPS
CASE NUMBER:  PD200900529			SEPARATION DATE:  20080315
BOARD DATE:  20100517
______________________________________________________________________________

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty LCpl (2311, Ammunition Technician) medically separated from the Marine Corps.  The medical basis for the separation was anorexia nervosa, restricting type.  He did not respond adequately to perform within his military occupational specialty and underwent a Medical Evaluation Board (MEB).  Anorexia nervosa, obsessive compulsive personality disorder, and social maladjustment were addressed in the narrative summary (NARSUM) and forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW SECNAVINST 1850.4E.  The informal PEB adjudicated the anorexia nervosa as unfitting, rated 10%; with application of the SECNAVINST 1850.4E and DoDI 1332.39 (E2.A1.5).  Obsessive compulsive personality disorder and social maladjustment were conditions which did not constitute a disability and were therefore not ratable.  The CI requested an informal reconsideration of his PEB; however, this did not change the disability rating.  He made no additional appeals, and was medically separated with a 10% combined disability rating.  

CI CONTENTION:  “Reevaluation”  He elaborates no specific contentions regarding rating or coding and mentions no additionally contended conditions.

RATING COMPARISON:

Service IPEB – Dated 20071120	VA ( 2 Mo. Prior Separation) – All Effective 20080316	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Anorexia Nervosa Restricting Type	9520	10%	Anorexia Nervosa, with Obsessive-Compulsive and
Dysthymic Disorders	9433-9520	60%	20080131	
Obsessive Compulsive Personality Disorder Traits	Category IV					
↓No Additional MEB / PEB Entries↓	Not Service Connected x 2	
Combined:  10%	Combined:  60%	

ANALYSIS SUMMARY:

Anorexia Nervosa, Restricting Type.  The rating formula for eating disorders bases ratings on the amount of weight loss below the expected minimum, hospitalization for artificial feeding (parenteral nutrition or tube feeding), and periods of physical incapacitation requiring bed rest.  While assigned to Okinawa, Japan, the CI was noted to be losing weight in the fall of 2006 and evaluation diagnosed anorexia nervosa, restricting type.  Eating patterns and emotional and cognitive patterns of the condition were present prior to entering service (calorie restriction, guilt after eating), but were reported to have intensified after entry onto active duty.  Despite several months of mental health counseling and medical management in the internal medicine clinic in Okinawa, there was no significant improvement in his insight into his condition or his eating behavior.  In the spring he lost more weight and was medically evacuated to the Naval Medical Center in San Diego, CA for continued evaluation and treatment.  
The NARSUM reported that he had lost 20 pounds from a baseline of 155 pounds to 135 pounds, a significant weight loss.  Other records reflect a baseline weight of 160 pounds, and a single service treatment record documented 170 pounds, both within the “ideal” body weight range for his 73 inch height.  His lowest recorded weight was 138 pounds at the time of admission to Naval Medical Center, San Diego on July 1, 2007.  On June 26 at Tripler Army Medical Center, his weight was 139.8 pounds.  A normal body mass index (BMI) ranges from 18.5 to 24.9.  The CI is 73 inches tall, and based on BMI calculations, the minimum normal BMI of 18.5 equates to 140 pounds for a male of his height.  The 1959 Metropolitan Life Insurance Company (MLIC) desirable weight tables are also cited by medical texts as a reference for healthy weights (and developed prior to the current trend to increasing obesity).  For a 73-inch male, MLIC range of desirable weight is from 157 to 175 pounds.  

Although a diagnosis of anorexia nervosa requires inability to maintain weight above the minimally normal weight (within 85% of expected ideal body weight) for age and height, the VA Schedule for Rating Disabilities (VASRD) criteria for rating higher than 10% requires weight loss well below the expected minimum weight (below 80% of minimum expected weight for the 100% rating and below 85% for the 30% and 60% ratings).  The CI’s reported minimum weight was 96% of the minimum expected weight based on the minimum normal BMI and remained above 85% of the MLIC desirable weight (133.5 pounds).  The CI’s condition did not attain the 100% evaluation.  While hospitalized, he did not require artificial feeding (parenteral nutrition, tube feedings) or bed rest, and his reported minimum weight of 135 pounds was well over the 80% of minimum expected weight stipulated for the highest rating.  With regard to the 60% and 30% rating evaluations, the CI’s minimum weight, at 96% of expected minimum, was well over the 85% of expected minimum weight.  A 26 September 2007 clinic note (after treatment) records his weight as 160.3 pounds (BMI 20.86; normal).  The VASRD rating formula for eating disorders also requires incapacitating episodes defined as a period during which bed rest and treatment by a physician is required.  Both the weight criteria and incapacitating episode criteria must be met for the 30% and 60% rating.  The 10% evaluation does not have a specific weight loss threshold, but specifies incapacitating episodes of up to two weeks duration per year.  

Medical evaluations did not demonstrate any impairing secondary medical conditions due to his restriction of caloric intake to maintain a low body weight.  He was an avid exerciser and used exercise to help maintain his low body weight.  He was observed to be exercising even when at his lowest weight (progress notes from June 2007), thus there were no incapacitating episodes requiring bed rest to attain more than a zero percent rating.  The VA, adjudicated a 60% rating based on the combination of dysthymia, obsessive compulsive disorder, and eating disorder, listing the code as 9433-9520 (dysthymia-anorexia nervosa).  The rating decision noted weight loss but did not assess the amount of loss below the expected minimum weight.  The rating decision noted extensive treatment but did not note the absence of a requirement for bed rest.  The rating decision cited the assessment of social impairment described by the compensation and pension (C&P) examiner that is not part of the formula for rating eating disorders.  The rating formula for eating disorders is based on physical manifestations of severe weight loss and physical incapacitation requiring bed rest.  However, eating disorders are often accompanied by other mental conditions that cause social and occupational impairment.  VASRD rating guidance takes this into account and allows for other mental conditions to be rated separately from the eating disorder (the rating criteria for anorexia nervosa do not rate the same impairments as the formula for rating other mental disorders).  The CI’s other mental disorders are discussed below.  The PEB rated only the unfitting anorexia nervosa condition.  All evidence considered, there is not reasonable doubt in the CI’s favor supporting a change from the PEB’s rating decision for the anorexia nervosa (9520).

Other Mental Conditions.  In addition to anorexia nervosa discussed above, the CI was diagnosed with dysthymia, personality disorder/traits and other developmental traits that existed prior to service.  While in Okinawa, the CI was diagnosed with dysthymia, a chronic low grade depression lacking the severity of major depression.  The psychiatrist at Tripler noted maladaptive personality disorder characteristics of the obsessive compulsive and avoidant types.  The psychiatry NARSUM also diagnosed obsessive compulsive personality traits.  At the time of the NARSUM, the CI denied previous psychiatric treatments; however, the VA C&P examiner six weeks prior to separation recorded a history of pre-service social phobia and obsessive compulsive traits for which the CI had at least one evaluation by a psychiatrist during adolescence.  The C&P examiner noted that the CI continued to have obsessive compulsive disorder, dysthymia, and mixed personality disorder with perfectionistic and schizoid traits.  The C&P examiner concluded the CI had a severe schizoid and compulsive personality structure. 

Personality disorders and traits are developmental conditions that do not constitute a ratable disability under the rules of the Disability Evaluation System (DES) and the VA compensation systems, but that may be unsuiting for military service and subject to administrative discharge.  Other than anorexia nervosa, no other ratable mental conditions were forwarded to the PEB for adjudication by the MEB psychiatry evaluation.  In addition to anorexia nervosa, the C&P examiner diagnosed obsessive compulsive disorder, and dysthymic disorder on Axis I of the five axis psychiatric diagnosis.  These conditions, along with the non-ratable personality traits / disorders contributed to the examiner’s global assessment of functioning (GAF) of 60 denoting moderate symptoms.  In his comments, the C&P examiner indicated that he believed much of the CI’s problems existed prior to entry into active military service (the examiner commented that the CI appeared to have maneuvered the timeframe of symptom onset to ensure service connection).  With regard to the C&P examination diagnosis of obsessive compulsive disorder, the Board noted that these features were diagnosed as non-ratable personality traits by the MEB psychiatrists and that these characteristics were also noted to have existed prior to service.  The Board also notes the fact that obsessive compulsive personality disorder is reported to specifically occur frequently with anorexia nervosa, restricting type as diagnosed in the CI.  

The Board concluded the CI’s obsessive compulsive characteristics were most likely personality based and were not separately ratable.  Further, if due to a ratable Axis I diagnosis, obsessive compulsive disorder, the condition existed prior to service, there were no non-eating related behaviors that were identified as interfering with duty performance, and the symptoms improved with relief of stressors indicating lack of permanent service aggravation.  The CI was also diagnosed with dysthymia.  At the time of the NARSUM, the CI reported experiencing some depressive symptoms while on Okinawa, but that these symptoms had resolved, denying all depressive symptoms, and reported feeling much better since leaving Okinawa.  The Board noted that although diagnosed in Okinawa with dysthymia, he was not referred for further care of dysthymia, and was not treated with medication.  The MEB psychiatry evaluation did not forward dysthymia as a condition not meeting medical retention standards.  The Board concluded there was no evidence that the depressive symptoms diagnosed as dysthymia were unfitting warranting a separate rating.  All evidence considered, there is not reasonable doubt in the CI’s favor supporting addition of any additional mental disorder as an unfitting condition for separation rating.

Remaining Conditions.  No other conditions were noted in the NARSUM, identified by the CI on the MEB physical or found elsewhere in the DES file.  The Board does not have the authority under DoDI 6040.44 to render fitness or rating recommendations for any conditions not considered by the DES.  The Board thus has no basis for recommending any additional unfitting conditions for separation rating.

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.  In the matter of the anorexia nervosa condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication at separation or permanently.  In the matter of other mental disorders, the Board unanimously agrees that it cannot recommend a finding of unfit for additional rating at separation.  The Board unanimously agrees that there were no other conditions eligible for Board consideration which could be recommended as additionally unfitting for rating at separation.

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: 

UNFITTING CONDITION	VASRD CODE	RATING	
Anorexia Nervosa Restricting Type	9520	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090828, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.

                             		

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW  
                                         BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATION
    	ICO XXX, FORMER USMC

Ref:   (a) DoDI 6040.44
             (b) PDBR ltr dtd 13 Jun 11

      I have reviewed the subject case pursuant to reference (a) and, for the reasons set forth in reference (b), approve the recommendation of the Physical Disability Board of Review Mr. XXX’s records not be corrected to reflect a change in either his characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board.