RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00776
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20070330

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Hospital Corpsman, medically separated for “major depressive disorder,” with a disability rating of 10%.

CI CONTENTION:  The CI requests for episodic headaches and chronic migraines, obsessive compulsive disorder, severe anxiety, insomnia right bundle branch block and joint pain.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 PEB - 20070220	VARD - 20071025	
Condition	Code	Rating	Condition	Code	Rating	Exam	
MDD, Severe, with Psychotic Features	9434	10%	Anxiety/Depressive Disorder	9400	10%	20070920	
Generalized Anxiety Disorder (GAD)	Cat III					
Episodic Headaches	Cat III	Headaches	8100	10%	20070913	
Degenerative Joint Disease of Hips	Cat III	Right and Left Hip Disability	5251	NSC	20070913	
Hyperlipidemia	Cat III	Hyperlipidemia
	7199-7114	NSC	20070913	
Asymptomatic Right Bundle Branch Block	Cat III	Right Bundle Branch Block (Asymptomatic)
	7099-7015	NSC	20070913	
Social Phobia	Cat III	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:  

Major Depressive Disorder (MDD).  The psychiatric narrative summary (NARSUM) was conducted in January 2007, less than 2 months before separation.  The examiner was also the treating psychiatrist, documented a 2-3 year history of depression with worsening over the past year.  The CI first presented to mental health (MH) on 12 December 2006.  He indicated he had felt depressed for about 3 years and that his depression had caused insomnia and fatigue.  He had problems with sleep, appetite, and concentration.  He was also socially withdrawn, and irritable, and he reported lack of pleasure in usual activities and decreased libido.  He had passive suicidal thoughts, wondered what it would be like if he were dead.  His depression caused conflicts with co-workers, and difficulty with keeping up with his work assignments.  He also reported several years of social anxiety and symptoms suggestive of obsessive-compulsive disorder (OCD).  His mental status examination (MSE) was normal with the exception of notable anxiety.  The psychiatrist diagnosed social phobia, generalized anxiety disorder (GAD), dysthymic disorder and MDD and started him on an antidepressant medication.  

At the NARSUM, approximately 1 month after his initial presentation to MH, the CI reported his depressive symptoms had continued.  He had restless sleep and daytime fatigue.  He had disturbing nightmares during which he felt as if someone was pushing on his neck or forcing him to kneel down and “denounce God.”  He lost ten pounds and concentration was difficult.  He reportedly described paranoid ideations which he reported had been present for several months.  He heard the voice of a single man who described the CI’s actions or instructed him to do things.  At times he felt compelled to obey the commands, because he feared that something bad would happened if he didn’t.  These hallucinations were distracting and sometimes interfered with his ability to perform his military duties.  The MSE noted that he was anxious and somewhat sad with a blunted affect.  His thought process was noted to be illogical, with looseness of association; however, his thoughts were goal directed.  He was oriented, and his memory and concentration were deemed grossly intact.  His thought content revealed auditory and visual hallucinations and paranoid delusions.  The diagnoses of MDD, severe, with psychotic features, social phobia, GAD and anxiety disorder NOS were recorded with a Global Assessment of Functioning score of 35 (some impairment in reality testing or communication).  The examiner also noted that the day after the NARSUM, the CI was admitted to the hospital.  The admission record dated 19 January 2007 noted that he was being admitted for worsening depression with suicidal ideation.  He reported a history of psychotic symptoms; however, psychotic symptoms were not present during the admission MSE.  The hospital discharge summary dated 24 January 2007 noted the CI had suicidal thoughts on admission which remitted “very quickly.”  He was depressed and was having nightmares.  It was noted that he was able to maintain his marriage and was living with his wife and two children.  The psychiatrist noted that the CI had attended his outpatient MH appointment where he reported increased delusional thinking and hallucinations, and was sent to the hospital voluntarily, for evaluation.  During the admission his antipsychotic medication was switched and in addition to his antidepressant medication, another medication was added for sleep.  The psychiatrist noted that his mood improved “a great deal” and he was no longer having psychotic-like symptoms.  The CI indicated he felt much better and he looked forward to leaving the Service.  The diagnosis of depressive disorder NOS was recorded and a GAF of 60 (cusp of mild) was assessed.  At discharge the examiner indicated the CI was no longer feeling suicidal, and had resolved himself to being separated from the Navy.  His mood was documented as “good.”  At the last documented psychiatry treatment visit on 20 March 2007, 10 days before separation, the CI noted that he had “good days and bad days.”  He tended to feel depressed when stressed and his psychotic symptoms were worse when depressed or stressed. The psychiatrist noted that the CI was aware that his psychotic symptoms were “not real” and he had not felt compelled to obey the voices.  The CI also had panic attacks when he had paranoid thoughts; however, episodes and frequency of attacks were not documented.   He slept fairly well.  His MSE was normal, but he was fidgety.  
The VA Compensation and Pension (C&P) mental examination was accomplished 6 months after separation.  The examiner reported that since separation, the CI had not received any outpatient MH treatment and had no hospitalizations since January 2007.  He had worked full-time since April 2007 as a blood lab technician and noted that his work was going relatively well.  The CI was also taking online classes through a University studying computer science.  He also helped his wife to raise his two children.  The CI reported he continued to take the medication prescribed at his last MH visit in March 2007 (he was given a 3-month supply of meds and should have run out in 3 months).  The diagnoses of depressive disorder NOS and anxiety disorder NOS were recorded with a GAF of 60.

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating under the 9434 code (major depressive disorder) and the conditions of GAD and social phobia were judged to be not separating unfitting (Cat III).   The VA combined the conditions of anxiety and depression and assigned a 10% rating using the 9400 code (generalized anxiety disorder).   All Board members first agreed that the preponderance of evidence did not support the application of §4.129.  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 due to  such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events.” The NARSUM examiner noted that the CI’s psychotic symptoms had continued, and he was admitted to the hospital for evaluation.  The CI was prescribed a different antipsychotic medication and noted significant improvement.  The GAF recorded at the NARSUM improved by nearly 30 points 5 days after the NARSUM, and the CI maintained the same GAF score 6 months after separation.  His mood symptoms had stabilized. The C&P exam noted that he was working full-time and was taking online college courses without any difficulties.  He was not in MH treatment and had not reported any significant psychiatric symptoms.  All Board members agreed, the CI’s condition at the time of separation, more closely approximated the 10% level of impairment for symptoms controlled by continuous medication.  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 psychotic features condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the conditions of GAD, social phobia, degenerative joint disease (DJD) of the hips, hyperlipidemia, episodic headaches, and asymptomatic right bundle branch block were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The VASRD rates MH conditions based on symptoms and not diagnoses.  Therefore, GAD and social phobia, although found to be not unfitting by the PEB, were considered in the rating of the primary MH condition.  Even if found unfitting, the conditions would not have been rated separately from the primary MH condition.  

The Board next considered the DJD condition.  The available records noted that the CI had hip pains in both hips without a history of trauma.  In January 2006 an MRI documented normal hips.  Records related to this condition were silent beyond 31 January 2006.  The treatment records documented a history of episodic headaches that occurred 2-3 times a week and were responsive to over the counter medication.  Treatment record was relatively silent for this condition.  The record demonstrated that in 2003 the CI was diagnosed with hyperlipidemia and was started on a cholesterol lowering medication.  There was only one entry in the service treatment record for this condition.  In 2003 he had an EKG that suggested a right bundle branch block, and underwent a cardiac stress test in March 2004 which was normal.    The degenerative joint disease (DJD) of the hips, hyperlipidemia, episodic headaches, and asymptomatic right bundle branch block were not reflected on the LIMFU or implicated in the commander’s statement and were not judged to fail retention standards.  There was no performance based evidence from the record that any of the contended conditions significantly interfered with satisfactory duty performance.  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 the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the MDD, severe with psychotic features condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended GAD, social phobia, degenerative joint disease (DJD) of the hips, hyperlipidemia, episodic headaches, and asymptomatic right bundle branch block 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.  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 20140206, 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) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 18 Apr 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXX, former USN