RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01291
BRANCH OF SERVICE:  NAVY	SEPARATION DATE:  20090828

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve, E-5, Officer Candidate, medically separated for “major depressive episode [MDE], severe without psychotic features, recurrent” as unfitting, rated 20% (30% with a reduction of 10% for existing prior to service [EPTS]) and “bulimia nervosa” as unfitting, rated 0%, (0% with a reduction of 0% for EPTS), with a combined disability rating of 20%.  

CI CONTENTION:  Her conditions continue to worsen and negatively affect her daily living.  Her 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 – Dated 20090513	VARD - 20091113  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
MDE, Severe without  Psychotic Features, Recurrent	9433	20%	Major Depressive Disorder, Bulimia Nervosa, and Alcohol Abuse	9521-9434	10%	20090911	
Bulimia Nervosa	9521	0%					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Major Depressive Episode.  Service treatment records (STR) note the CI was diagnosed with hypothyroidism in October 2008 and treated with thyroid medication.  Additionally, the CI reported she became depressed at age 11 after her parents’ divorce and had some family counseling briefly.  She was free of depression from ages 16-20.  She denied previous diagnosis and treatment of depression and psychiatric hospitalization.  She entered the military on a waiver for the thyroid disorder and began Officer Candidate School (OCS) 6 February 2009.  She was quickly aware she could not tolerate the stressors.  She underwent a personal fitness assessment and did not pass due to exhaustion and not eating for 2 days due to stress.  The first 3 days of training the CI reported she felt like a zombie and was pulled from the program and placed in Medical Hold for treatment of hypothyroidism.  She observed that hypothyroidism had similar symptoms to depression.  She did not return to training.  She was then moved to the Student Pool where she did “meaningless tasks,” like being a facilities manager.  

At the narrative summary (NARSUM), dated 1 February 2009, the CI reported she stopped her medication because it was “really messing me up…wasn’t eating…really depressed, felt like crap.”  She had insomnia and woke up feeling panicky 3-4 nights per week.  She had no energy no matter how much she slept.  Motivation was low and she had crying spells “all the time.”  She felt intermittently helpless and hopeless.  Her mood was “frustrated, anxious all the time.”  She reported she was a nail biter and pulled skin from her fingers and scabs “all the time.”  She was treated with a medication for depression.  Mental status exam (MSE) noted her mood was depressed and anxious.  She denied suicidal or homicidal ideation but had thoughts about self-harm due to desperation to leave the military.  Diagnoses of MDE, severe and Bulimia Nervosa were rendered with a Global Assessment of Functioning (GAF) of 60 (moderate bordering on mild impairment, symptoms.)  Stressors included problems with primary support group, problems related to social environment, and occupational problems.

She self-referred to mental health (MH) clinic in April 2009 because she had low energy that had not improved since discontinuing her medicine for hypothyroidism.  She was not sure she wanted to remain in training and remained in weekly therapy until July.  The Non-Medical Assessment noted the CI was away from current duties for treatment, evaluation and/or recuperation 1-2 hours per week.  She did not have good potential for continued service in her present physical and mental condition.  The MEB DD Form 2808, Report of Medical History, dated April 2009, noted she had been off thyroid medication for 3 months and had remained euthyroid.  The DD Form 2808, Report of Medical Examination listed a diagnosis of depression.

At the VA Compensation and Pension (C&P) examination for eating disorders, performed 2 weeks after separation, the CI reported her mood in the past month was “very depressed with about 4 panic attacks that year, normal appetite, did not like spending time with friends, slept like a dead person, and felt irritable.”  She did all the household chores and described herself as a “clean freak.”  Memory was good but she obsessed about small things.  She endorsed drinking and shopping sprees but no other symptoms of mania.  She felt down, sad, or blue most days but had no formal periods of incapacitation and enjoyed her new job.  The examiner noted depressive symptoms had a mild impact on social and occupational function with no problems on her job.  Additionally, the examiner stated her depressed mood and mild concentration issues might have caused a slight reduction inefficiency and productivity.  The examiner noted she was never formally diagnosed or treated for MDE or bulimia prior to the military. 

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the MDE independently of the bulimia and conferred a mental health rating of 30% for MDE; less 10% for EPTS, for a combined rating of 20%, coded 9433 (dysthymic disorder).  The Board agreed that the 9433 coding was possibly a typographical error by the PEB and the likely intention was a coding of 9434 (Major Depressive Disorder), since there was no reference in the CPF to dysthymia.  The VA opined the MDE, bulimia and alcohol abuse were intertwined and rated the condition at 10%, coded 9521-9434 (bulimia nervosa-major depressive disorder.)  Application of VASRD §4.129 is considered by the Board for all cases of Service connected psychiatric conditions resulting in separation; but, all members agreed that the ‘highly stressful event’ requisite for §4.129 was not satisfied in this case. 

The Board’s initial charge in this case is the evaluation of the PEB’s EPTS determination for MDE.  The Board’s authority for recommending a change in the service’s EPTS determination is not specified in DoDI 6040.44, but is considered adjunct to its DoD-specified obligation to review service fitness adjudications.  The Board could not find convincing evidence for a pre-existing formally diagnosed MH disorder (EPTS) although the entry (MEPS) physicals from October 2007 revealed the CI had received counseling after the parent’s divorce.  Emotional sequellae to divorce is a common occurrence in children and counseling is often recommended and does not connote the presence of a mental illness.  The Board cannot support a formal deduction for MDE, since both DoDI 1332.39 (6.11.3) and VASRD §4.22 stipulate, “if the degree of disability at the time of entrance into the service is not ascertainable in terms of the schedule, no deduction will be made.”  Either the MDE was clinically inactive on entrance, i.e. 0%, or it was not documented well enough to establish a §4.130 rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the MDE condition.  

Bulimia Nervosa.  At the NARSUM examination, the CI revealed she began to purge with her fingers after eating when she was 13.  She would completely binge on foods “once a month.”  If she has a stomach ache, “I will just take care of it.”  She was shorter and fatter than her stepsisters to whom she was compared.  In addition, when her parents divorced, she felt sad, and put on a lot of weight.  She felt relief when she learned that she had a thyroid disorder, which meant she could lose weight.  The CI reported she could not recall the last time she purged.  During a follow-up clinic visit, July 2009, the CI reported she had not purged in 38 days. 

At the VA Compensation and Pension (C&P) examination for eating disorders, performed 2 weeks after separation, the CI reported her medical problems included attention deficit disorder (ADD) and depression.  A primary care doctor provided her care and she took medications for depression and Attention Deficit Disorder.  She also acknowledged a history of binging and purging twice a day before joining the military that did not impact to her social or occupational functioning.  She gained weight after a strict dietary regimen prior to joining the military and was diagnosed with hypothyroidism.  Since discharge, she has worked and the job was going well.  She was working 50-55 hours per week and her coworkers and supervisors were “wonderful.”  She denied binging or purging at work and had not binged at all for 27 days while taking medication.  She denied missing work due to her eating disorder.  She was single but had a female roommate.  She reported heavy alcohol use, which started in the military and had gotten worse.  Her favorite hobby was remodeling and she was interested in restoring homes.  She went out with friends on weekends.  She talked to her mother and brothers daily.  The MSE was normal.  A diagnosis of MDE in partial remission, bulimia nervosa, and alcohol abuse were rendered with a GAF of 65 (mild impairment, symptoms.)  The examiner opined that her alcohol abuse was caused by her depression and bulimia.  The examiner noted her eating disorder had improved significantly since starting psychotropic medications.  There were no symptoms directly associated with her eating disorder affecting her social/occupational functioning.  The November 2009 VARD noted the CI had reported, on a statement signed September 2009, that she did not binge when her depression was controlled. 

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the bulimia condition at 0%, coded 9521 (Bulimia Nervosa) while the VA, as noted in the MDE discussion, included the bulimia with the MDE diagnosis and rated the condition at 10%, stating that symptoms were controlled by medication.  The Board noted that the Bulimia appeared to be dependent on the presence of the depression.  The C&P exam noted the medication had significantly improved her eating disorder to the point she had not purged in a month, was able to work more than 40 hours per week without purging or binging and had good personal relationships.  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 bulimia nervosa condition.  

BOARD FINDINGS:  

In the matter of the major depressive episode condition, the Board unanimously recommends a disability rating of 30%, coded 9434 IAW VASRD §4.130.  In the matter of the bulimia nervosa condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
Major Depressive Episode, Severe without  Psychotic Features, Recurrent	9434	30%	
Bulimia Nervosa	9521	  0%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140221, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 11 Mar 16 ICO XXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 2 Mar 16 ICO XXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 14 Mar 16 ICO XXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 14 Mar 16 ICO XXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 14 Mar 16 ICO XXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 14 Mar 16 ICO XXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (g) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.  

     c. XXXXXXXXXXXXXXX, former USMC: Assignment to the Temporary Disability Retired List for six months effective date of discharge with a 50 percent disability rating followed by transfer to the Permanent Disability Retired List with a final disability rating of 30 percent.

     d. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent disability rating effective date of discharge.

     f. XXXXXXXXXXXXXXX, former USMC: Assignment to the Temporary Disability Retired List for six months effective date of discharge with a 50 percent disability rating followed by transfer to the Permanent Disability Retired List with a final disability rating of 50 percent. 

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.