RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	   CASE:  PD-2014-00113
BRANCH OF SERVICE:  AIR FORCE 	SEPARATION DATE:  20060117

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Security Forces Member) medically separated for depressive disorder and headaches.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty (AFS).  She was issued a temporary P4S4 profile and referred for a Medical Evaluation Board (MEB).  “Chronic incapacitating headaches” and “depressive disorder” were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB, but the PEB derived two other conditions from the case file (alcohol abuse and personality disorder).  The Informal PEB adjudicated her depressive disorder as unfitting, rated 10 with a 10% deduction for aggravating factors for a 0% compensable rating, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The headache condition was determined to be Category II (conditions that can be unfit, but not compensable/ratable).  The alcohol abuse and personality disorder were determined to be Category III (not separately unfitting and not compensable/ratable).  The CI made no appeals and was medically separated.  

CI CONTENTION:  Her migraine condition continues to worsen and negatively impact her daily activities.  Her 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 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:  

IPEB – Dated 20051130	VA* - (~3Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Depressive Disorder…	9434	0%	Depressive Disorder	9434	10%	20060406	
Multifactor Headaches…	8199-8100	Cat II	Migraine Headaches	8100	0%	20060406	
Other MEB/PEB Conditions x 2 (Not In Scope)	Other x 1 	
RATING:  0%	COMBINED RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20060515 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:   

Depressive Disorder.  Treatment record demonstrated the CI was seen in the emergency department in April 2003 for pelvic pain.  She was also apparently evaluated by mental health and determined not to be in need of inpatient psychiatry treatment but was noted to have revealed symptoms “consistent with individuals struggling with the stress of military training.”  In March 2004, she was admitted to inpatient psychiatry for 3 days after expressing suicidal ideation.  At the time the CI reported a history of depressed mood due to situational factors.  Her mother was very ill, and she had felt increasingly sad and overwhelmed by this.  She was also having health problems, sinusitis, and gastrointestinal (GI) symptoms.  Her energy was low, concentration was poor, appetite was poor, and she was sleeping more and having crying spells.  She was discharged with the diagnosis of major depressive episode.  Her condition did not improve significantly.  She had two consecutive admissions into partial hospital program, and began treatment with medications.  However, within 2 months of medication treatment, her medications were discontinued due to her pregnancy in July 2004.  The CI continued in psychotherapy and her condition was stable for several months.  In May 2005, she was referred to outpatient alcohol abuse treatment, and in June she was again admitted to partial hospital program with the chief complaint of “drinking too much.”  At the time of admission she had resumed her antidepressant medication and was taking medication for headaches.  She provided a history of childhood verbal and physical abuse, which was previously diagnosed as PTSD and was currently considered resolved.  The narrative summary (NARSUM) was accomplished in November 2005, 2 months before separation.  The examiner noted that the CI was not being followed by psychiatry, was receiving services from the substance abuse program, and antidepressant via the primary care provider.  The NARSUM noted the CI was hospitalized once in March 2003 after expressing suicidal ideation (SI), and was discharged without medication.  She later decompensated and was admitted to partial hospital program and reported multiple different related stressors causing anger, anxiety and depressed mood.  It was also noted that the CI desired to leave the service and felt that her recruiter had lied to her.  She presented to the life skills program in May 2005 with complaint of feeling depressed and anxious secondary to job dissatisfaction, and by September 2005 she was ambivalent about staying in the Air Force.  A mental status examination was not documented.  The psychiatrist diagnosed depressive disorder NOS, and opined impact of military duty was mild and impact on civilian industrial adaptability would be mild.  Alcohol abuse was also diagnosed on Axis I.  An Axis II diagnosis of personality disorder NOS with cluster B traits was recorded and this condition was opined to have marked impact on military duties and “likely impact on her civilian adaptability is considerable.”  A Global Assessment of Functioning (GAF) score of 70 was recorded.  The VA Compensation & Pension (C&P) mental evaluation, approximately 3 months after separation, noted the CI was no longer on any medications or other form of mental health treatment.  She was living with a friend and was somewhat withdrawn.  She had poor energy, and had continued to sleep more than usual. She was not employed and had hopes of returning to school and possibly entering into a nursing program.  Mental status examination (MSE) noted her mood was somewhat depressed, and she stated her concentration was poor as she often daydreamed.  There was no evidence of psychosis, impaired thinking or judgment, or suicidal ideations.  The diagnosis of major depression, single episode was recorded on Axis I.  The diagnosis on Axis II was “None.”  A GAF of 70 was documented.

The Board directed attention to its rating recommendation based on the above evidence.  As recorded above, the PEB rated the condition of depressive disorder, NOS at 10%, coded 9434 (MDD) with a 10% deduction for contributing/aggravating factors.  The VA granted a 10% rating, coded 9434.  The Board first noted there was no specific, highly stressful service-related event to invoke §4.129 for a mental disorder due to traumatic stress.  The Board next considered the rating deduction.  The PEB’s AF Form 356 rationale for this determination is excerpted below.

The IPEB notes your personality disorder and alcohol usage, both non-ratable/non-compensable conditions under disability law/policy, and opine they significantly affect the severity of your depressive disorder. The Board opines were it not for the non-ratable/non-compensable conditions, your social and industrial adaptability impairment rating would be best described as none IAW DoD/VASRD guidelines.
All members agreed that the PEB’s deduction could not be upheld for multiple reasons.  The foundation for a diagnosis of personality disorder, on which the PEB deduction hinges, is very tenuous.  There is no documented evidence that the CI met DSM-IV diagnostic criteria for any personality disorder.  Prior to November 2005, no diagnosis of a personality disorder was recorded in the service treatment record.  It was not until 28 October 2005 that a provisional diagnosis of personality disorder NOS was noted.  The Board acknowledges that there were perhaps some characteristics suggestive of maladaptive traits, and a history of abuse is often associated with maladaptive behaviors; however, the treatment record is woefully deficient in providing sufficient evidence to support a diagnosis of a personality disorder.  The Board also noted the glaring absence of an Axis II diagnosis not only during her psychiatric inpatient admission, but also during her two month-long partial hospitalizations.  Lastly, the psychiatrist did not clinically extricate a disability level attributed to the personality disorder versus the depression; thus, a deduction could not fairly be apportioned.  All Board members agreed, there is sufficient evidence to support a disturbance in mood in which a personality disorder may have contributed negatively; however, there was insufficient evidence to support the notion that in the absence of a personality disorder, her depressive disorder would have had no impact on occupational functioning.  All members agreed that the PEB’s deduction could not be upheld for application to the Board’s recommendation.

The Board next proceeded with the rating recommendation IAW VARSD 4.130. The higher rating of 30% requires evidence of “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.”  The Board agreed the CI’s condition had stabilized in the 6 months before separation.  The service treatment record demonstrated an absence of emergency room visits for mental health issues, absence of psychiatric hospitalization, absence of a legal history and the absence of documented suicidal ideation or panic attacks in the 6 months before separation.   Both the NARSUM and C&P examiner opined that she had mild impairment due to her depression, and both recorded a GAF of 70.  The C&P exam, 2 months after separation, noted despite the absence of mental health treatment or psychotropic medication use, her impairment was considered mild.  Board members concluded her condition at the time of separation more closely approximated the 10% level of disability for “occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.”   After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a 10% disability rating (no deduction) for the depressive disorder, NOS.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the multifactorial headaches associated with inherited migraine headaches condition was a condition characterized as Category II, which are defined as conditions that could be unfitting but not currently compensable or ratable.  The Board’s threshold for countering fitness determination requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The Board noted Category II condition determinations are made when a condition either has no adverse impact on duty performance of existed prior to service.   The neurology consultation in April 2005 documented pre-service history of headaches which were as often as six or more a year of milder intensity.  However, in the month of March 2005, her headaches worsened, and on one occasion she passed out at work after feeling dizzy and lightheaded.  No specific cause was found for her passing out, and she had not passed out any time prior to this occasion.  The neurologist indicated that her headaches were chronic and multifactorial as some were due to depression, environmental and family issues, and to a smaller extent, migraines.  The neurologist recommended another trial of antidepressant medication (Remeron) for treatment of her depression.  This medication was noted to be an effective headache prevention medication as well.  Daily exercise and cognitive behavioral therapy was also recommended as prevention treatment.  The CI was advised to only use Zomig for migraine headaches as it does not work with non-migraine headaches.  Follow-up neurology visit in June 2005 recorded the CI’s report of dizziness and headaches.  The CI noted she had decreased the Remeron because she believed it was responsible for her dizziness.  However, after decreasing the medication her headaches gradually worsened.  The CI had not carried out the recommended behavioral therapy approach.  There was no indication from the record in evidence that the CI’s headaches were incapacitating.  Although the condition was profiled, headaches were not implicated in the commander’s statement and the condition was not judged to failed retention standards.  There was no performance based evidence from the record that the headache condition significantly interfered with satisfactory duty performance.  After due deliberation 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 the multifactorial headaches associated with inherited migraine headaches condition and so no additional disability rating are recommended.

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the depressive disorder NOS condition, the Board unanimously recommends a disability rating of 10%, coded 9434 IAW VASRD §4.130.  In the matter of the contended multifactorial headaches associated with inherited migraine headaches condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Depressive Disorder, Not Otherwise Specified	9434	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131226, 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-2014-00113.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

								

Attachment:
1.  Directive  
2.  Record of Proceedings  

cc:
SAF/MRBR