RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX		CASE:  PD-2014-00114
BRANCH OF SERVICE:  AIR FORCE		BOARD DATE:  20140626
SEPARATION DATE:  20071228

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty A1C/E-3 (4C031/Mental Health Technician) medically separated for major depressive disorder associated with anxiety disorder.  The condition could not be adequately rehabilitated to meet the requirements of her Air Force Specialty.  She was issued a P4 profile and referred for a Medical Evaluation Board (MEB).  The mental health (MH) condition, characterized as “major depression” and “anxiety disorder” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The MEB also identified and forwarded one other condition characterized as “episodic chest pain and palpitations.”  The Informal PEB adjudicated the major depressive disorder with anxiety disorder condition as unfitting and rated it 10% citing criteria of the VA Schedule for Rating Disabilities (VASRD).  The remaining condition, identified as “paroxysmal atrial tachycardia (PAT),” was adjudicated as a Category II condition, one that can be unfitting but is not currently compensable or ratable.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI writes: “PAT (Paroxysmal Atrial Tachycardia) have gotten worse.”

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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting major depressive disorder with anxiety disorder condition is addressed below; additionally the contended paroxysmal atrial tachycardia condition is within the Board’s defined DoDI 6040.44 purview and is reviewed below.  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 Military Records.

RATING COMPARISON:

Service IPEB – Dated 20071115	VA - (Exam ~ 3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive D/O with Anxiety D/O	9434	10%	Mental Conditions to include Major Depression, Anxiety and Panic D/O	9434	10%	20080313	
Paroxysmal Atrial Tachycardia (PAT)	Category II	Paroxysmal Atrial Tachycardia (PAT)	7010	0%	20080314	
Other X 0 (Not in Scope)	Other x 7	20080314	
Combined:  10%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20080620 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Major Depressive Disorder (MDD) with Anxiety Disorder Condition.  Available treatment records noted the CI first sought MH treatment with a civilian psychologist for symptoms identified as post-partum depression.  Family practice clinic (FPC) entry on 12 January 2007, indicated depressive symptoms began after the birth of her child in October 2006.  In December 2006, she started taking Prozac and reported some benefits but remained emotionally labile, felt worthless and cried easily.  The CI worried her child would stop breathing at night.  She had problems with sleep, appetite and headaches.  Follow up FPC visit on 13 August 2007, recorded the CI’s mood had improved.  She was recently diagnosed with PATs and hypothyroidism; medications were initiated for both conditions.  The CI was not evaluated by a psychiatrist prior to the psychiatry narrative summary (NARSUM) and reportedly stated after being initially recommended, her physician advised that a psychiatrist evaluation was not needed since she had improved.  At the psychiatry NARSUM on 12 September 2007, the CI reported she participated in one evaluation session with a civilian psychologist in October 2006 due to feeling depressed, low self-esteem and self-doubts about parenting.  She was dissatisfied with the provider’s clinical approach and did not return for treatment. In November 2006, her primary care manger (PCM) prescribed Prozac that improved her symptoms.  She discontinued the medication because she felt better; however, began having headaches and resumed the Prozac.  In June 2007, she had a panic attack, precipitated by her frustration of not being able to stop her daughter’s finger from bleeding after she had cut herself.  She continued to have panic attacks, sometimes twice per week in response to psychosocial stressors.  Her PCM switched her medication to Celexa; her anxiety continued.  The CI reported mild to moderate depressed mood, periodic crying episodes, sleep disturbance, decreased appetite, decreased energy, anhedonia, decreased libido and problems with concentration.  The mental status examination (MSE) was normal.  The psychiatrist diagnosed MDD single episode, moderate and anxiety disorder not otherwise specified, noted the CI did not meet diagnostic criteria for panic disorder or generalized anxiety disorder.  A Global Assessment of Functioning (GAF) score of 60 (borderline mild-moderate) was noted and social/industrial impairment was rated as minimal.  At the VA Compensation and Pension (C&P) evaluation on 13 March 2008, approximately 3 months after separation, the CI reported she was in treatment with a community psychiatrist and took a combination of psychotropic medications to address mood, sleep and anxiety symptoms.  The CI took Xanax as needed, for panic attacks and indicated she used the medication about three to four times a week.  She had panic attacks once or twice a week.  She had not been hospitalized or treated in the emergency room (ER).  The CI rated her mood at seven out of ten, noted her appetite had not improved much, but her sleep had improved.  The CI noted she began having nightmares of her abusive childhood about three to four months post-partum; they stopped about 2 months ago.  She was unemployed and was preparing to move out of state for her husband’s transfer.  The MSE was normal.  MDD, single episode, moderate and panic disorder without agoraphobia were recorded with a GAF of 63 (mild).

The Board directs attention to its rating recommendation based on the above evidence.  Both the PEB and the VA rated the condition the same, coded 9434, at 10%.  The Board first unanimously agreed that VASRD §4.129 was inapplicable in this case.  Both the NARSUM and the C&P examinations reported similar mental status examinations and GAF scores.  The NARSUM examination did not describe impairment in social or occupational functioning and assigned a GAF of 60 (borderline mild-moderate symptoms), and the VA assigned a GAF of 63 (mild symptoms but generally functioning well), 3 months after separation.  At the time of separation the Board agreed that the §4.130 threshold for a 50% rating (occupational and social impairment with reduced reliability and productivity) was not approached.  A rating of 30% requires “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.”  The records noted although, the CI received counseling for reporting late to work, the commander statement noted she was capable of performing all primary in-Garrison military duties without modification.  She was never hospitalized, never treated in the ER for MH concerns, did not report suicidal or homicidal thoughts and was responsive to treatment.  Three months after separation, the CI demonstrated a trajectory of steady improvement.  She slept better, stated her mood was 7/10, had fewer anxiety attacks and had remained in treatment.  The evidence at hand did not support the 30% rating.  The 10% description, “occupational and social impairment due to mild or transient symptoms which decrease work efficiency only during periods of significant stress, or; symptoms controlled by continuous medication,” more accurately reflects the CI’s condition at separation.  All evidence considered there is not reasonable doubt in the CI’s favor supporting a change from the PEB’s rating decision for the MDD, single episode, with anxiety disorder condition.  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 for the MDD with anxiety disorder condition.

Contended PEB Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that the condition of PAT was not unfitting.  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.  This condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  The condition was reviewed by the action officer and considered by the Board.  There was no performance-based evidence from the record that any of the 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 above noted contended condition.

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 MDD single episode associated with anxiety disorder condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended PAT condition, 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 20131220, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				

SAF/MRB

Dear XXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-00114.

	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