RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX					             	CASE:  PD-2014-00092	
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20070402		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Tactical Aircraft Maintenance Craftsman) medically separated for major depressive disorder (MDD).  The condition could not be adequately rehabilitated to meet the requirements of his Air Force Specialty (AFS).  He was issued a permanent S4 profile and referred for a Medical Evaluation Board (MEB).  The MDD diagnosis was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “[MDD], single episode, moderate, in partial remission” as unfitting, rated 10%, citing criteria of Department of Defense Instruction (DoDI) 1332.39.  Two additional conditions (“irritable bowel syndrome [IBS]” and “allergic rhinitis”) were PEB adjudicated as Category II (conditions that can be unfitting but are not currently compensable or ratable).  The CI made no appeals, and was medically separated.  

CI CONTENTION:  The CI requests consideration of “all MEB/PEB conditions.”  His complete submission is at Exhibit A.   

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 Veterans Affairs Schedule for Rating Disabilities (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:  
 
Service IPEB – Dated 20070207	VA* - (5 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
MDD	9434	10%	MDD w/ Generalized Anxiety Disorder	9434	30%	20070904	
IBS	Category II	IBS	7319	10%	20070823	
Allergic Rhinitis	Category II	Sinusitis	6513	NSC	20070823	
Other MEB/PEB Conditions  x 0 (Not in Scope)	Other x 3 	
RATING:  10%	COMBINED RATING:  60%	
* Derived from VA Rating Decision (VARD) dated 20071106 (most proximate to date of separation [DOS]). 

ANALYSIS SUMMARY: 

Major Depressive Disorder.  The narrative summary (NARSUM) references mental health (MH) treatment for which the source records are not found in the available service treatment record (STR), possibly sequestered for confidentiality reasons and not reincorporated.  Members agreed that the missing records were not critical to these proceedings since the key probative content is adequately summarized in the NARSUM.  There was a 2005 STR entry noting some irritability at work and a referral to Life Skills.  There were a series of later 2006 entries (last one 5 months pre-separation) that documented resolution of depression, “stable” MH symptoms, and normal mental status examinations (MSE) without mood or affect disturbance.  There was no STR evidence of psychotic or other acute psychiatric symptoms, alcohol/substance abuse, suicidal ideation or attempts, or psychiatric crisis/hospitalization.

The NARSUM was conducted 4 January 2006 (15 months pre-separation) and corroborated the 2005 onset of MH symptoms interfering with work as per the STR.  The first psychiatric referral was in April 2006 following disciplinary action (Article 15) for dereliction of duty, at which time the CI was diagnosed with MDD and entered MH treatment.  After intolerance of several medications he responded to an anti-depressant (Effexor) “which did decrease his daily anxiety and improve his mood somewhat.”  Concurrently with the NARSUM he was experiencing some increased irritability due to personal and work stressors, and a second medication (Neurontin, a mood stabilizer) was being added.  The NARSUM psychiatrist summarized the clinical course as “poor energy, depressed mood, trouble sleeping, loss of appetite and motivation during a several week period in 2005.  Since his initial episode, a mixture of these symptoms has been present in a less severe form.”  The NARSUM did not document a formal MSE, but the consistently normal MSE from subsequent STR evidence is noted.  The NARSUM also documented psychological testing (considered valid) which indicated “exaggeration of emotional symptoms ... may have reported more psychological symptoms than objectively exist ... Dependent and Avoidant Personality Traits and a tendency to have somatic complaints ... consistent with the clinical picture.”  The NARSUM examiner provided the Axis I diagnosis as applied by the PEB and listed the above personality traits on Axis II.   The Global Assessment of Functioning (GAF) assignment was 70 (slight to mild range of impairment); and, the DoDI 1332.39 based assessment of social and industrial impairment was “mild.”  

The commander’s performance statement noted that the CI “has a second job selling real estate and seemingly is very successful at it;” and, related the CI’s expressed concern that he could not make ends meet if he had to accept an overseas assignment (frequently required of the unit).  The commander indicated that this “inability to perform his primary duties off-station due to stress” rendered the CI non-deployable; but, stated, “I strongly recommend that [the CI] be returned to duty without restrictions and perform as a TSgt until his date of separation.”

A VA psychiatric Compensation and Pension (C&P) examination was conducted 4 September 2007 (5 months post-separation) and documented that the CI “continues to have trouble with depression and anxiety ... stressed about being out of the military.”  Crying episodes and sleep disturbance were the only specific symptoms elaborated.  The CI was on no medication and not in treatment.  The examiner documented, “He is now working as a real estate broker.  He has no difficulty with coworkers or supervisors.  There are no difficulties noted in his marriage.”  The MSE recorded depressed mood and affect; but, was otherwise normal without suicidal/homicidal ideation or other acute features, and cognition was intact.  The Axis I diagnosis was MDD and “generalized anxiety disorder” (no Axis II), and the GAF assignment was 60 (moderate range of impairment).  The VA examiner opined that the MH symptoms “do limit his ability to function at times,” and quoted VASRD §4.130 criteria for a 30% rating in the final assessment (notwithstanding the normal occupational and social functioning previously described).  The post-separation VA rating decision cited this latter opinion in support of a 30% rating.  Subsequent post-separation VA evidence documented continued successful employment without treatment and achievement of high level functioning (college instructor, post-graduate degree). 

The Board directed attention to its recommendations based on the above evidence and, first considered whether the provisions of VASRD §4.129 for any “mental disorder that develops in service as a result of a highly stressful event” were applicable to this case (as mandated by DoD).  Although there were contributory stressors that developed in service, members agreed that there was no service-connected event which was logically consistent with the meaning and purpose of §4.129; thus, it was not appropriate for this case.  

The Board then turned to deliberation of a fair rating recommendation at the time of separation.  Members agreed that VASRD §4.130 criteria for a 50% rating (“occupational and social impairment with reduced reliability and productivity”, and exampling acute features not in evidence) were not met.  Deliberations thus settled on recommendations for a 10% rating (“occupational and social impairment due to mild or transient symptoms which decrease work efficiency…only during periods of significant stress”) vs. a 30% rating (“occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks”).  Based on the NARSUM evidence, it is possible (albeit still speculative) that there was “occasional decrease in work efficiency” as per the 30% language, although there is no evidence for the stipulated “intermittent periods of inability” to meet duty requirements.  The commander’s statement did not support the presence of baseline occupational impairment, but only implicated the situational stress engendered by the threat of geographic relocation.  It was also noted that the STR evidence from the long interval between the NARSUM and separation suggest an improving course.  This impression is corroborated by the C&P evidence more temporally proximate to separation (absence of objective social or occupational impairment with no active treatment) and the overall post-separation course.  Additional factors to consider in this case were the probative value distraction raised by the psychological test interpretations, and the possible contribution to MH impairment by the non-ratable personality traits.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of the MDD condition.

Contended Conditions (IBS, Allergic Rhinitis).  There were sporadic STR entries beginning in 2004 for treatment of abdominal pain and diarrhea.  A gastroenterology consultant (12 months pre-separation) diagnosed IBS and recommended symptomatic treatment (no maintenance medications).  There were sporadic STR entries beginning in 2003 for treatment of sinus symptoms.  The last documented episode was in early 2005 (~2 years pre-separation).  The NARSUM listed a history of these conditions without further elaboration, and no medications for them were listed.  The post-separation VA examiner (general C&P from 23 August 2007) documented a 9-year history of abdominal pain with alternating diarrhea and constipation, present “more than two-thirds of the time” and treated intermittently with Imodium (anti-diarrheal), without elaboration of any specific occupational impairment.  The same C&P examination documented a 10-year history of chronic sinusitis “requiring antibiotic treatment occasionally,” but opined that there was “no pathology to render diagnosis.”  Neither of these conditions was profiled throughout service, and neither was implicated by the commander.  

The Board directed attention to its recommendations based on the above evidence; and, its main charge with respect to these conditions is an assessment of the fairness of the PEB’s determinations that they were not unfitting (e.g., fairly met the Category II criteria).  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  All members agreed that there was no performance-based evidence suggesting that either of the above conditions significantly interfered with duty performance.  Furthermore, both of them were subject to DoDI 1332.38 (E3.P3.3.3 - Adequate Performance Until Referral); which stipulates, “If the evidence establishes that the Service member adequately performed his or her duties until the time the Service member was referred for physical evaluation, the member may be considered fit for duty even though medical evidence indicates questionable physical ability to continue to perform duty.”  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of these conditions; thus none of them can be recommended for additional disability 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.  As discussed above, PEB reliance on DoDI 1332.39 for rating was operant in this case and it was adjudicated independently of that policy by the Board.  In the matter of the MDD and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended IBS and allergic rhinitis conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131223, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00092.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

								

Attachment:
Record of Proceedings