RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	    CASE:  PD-2014-01365
BRANCH OF SERVICE:  AIR FORCE  	SEPARATION DATE:  20080922

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O3, Family Physician, medically separated for dysthymic disorder, with a disability rating of 10%.  

CI CONTENTION:   The CI mentioned his injured right hand in his contention along with his initial rating from the Air Force and the VA.  His 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 - 20080724	VARD - 20090407	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Dysthymic Disorder	9433	10%	Major Depressive Disorder, Single Episode, Partial Remission with Medication and Adjustment Disorder with Depressed Mood	9400-9434	50%	20081202	
Adjustment Disorder with Mixed Anxiety and Depressed Mood	Cat III					
Avoidant and Narcissistic Personality Traits	Cat III					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Dysthymic Disorder.  According to service treatment records (STR), the CI began having adjustment problems after a deployment for humanitarian aid to Ecuador in August 2006.  He became hostile to colleagues, had marital and occupational problems and presented to mental health (MH) in September 2006.  In January 2007 he reported financial difficulties with complaints of poor sleep, poor memory, decreased energy, word finding problems, making odd decisions and irritability.  A sleep study was negative.  A report in February of substandard patient care, anger, and inappropriate interaction with patients resulted in his physician credentials being placed on hold.  A command-directed MH evaluation in March returned diagnoses of dysthymic disorder, depressive disorder, not otherwise specified (NOS) and avoidant personality traits.  He was treated with various medications for depression and began individual therapy in June.  He returned to psychiatric care in September when he learned his credentials would not be reinstated.  A new medication was initiated due to significant side effects (nightmares, a movement disorder.) but he developed suicidal ideation with a plan, resulting in a psychiatric hospitalization from 3 to 9 October.  He reported recurring depression since age 15 that lasted several weeks to several months, generally precipitated by situational stressors.  He was hospitalized for 2 weeks at age 19 for behavior misinterpreted as a suicide attempt.  In medical school he had received medication for depression.  After feeling overwhelmed on a residency rotation, he transferred to a research elective.  More overt problems began when he served as a physician in the military. 

The commander’s statement noted the CI’s condition did not allow him to perform his military duties, he was not credentialed, was not able to see patients and his symptoms impacted his ability to perform as a provider.  He had not worked as a physician since January 2007 and was working at a health and wellness center assisting with programs.  After removal from patient care, there were two peer reviews/formal credential hearings and disposition was pending to recommend revocation of his license.  He could not remain on active duty without a license and not practicing.

The narrative summary (NARSUM), dated March 2008, noted lab studies were negative and psychological testing showed results consistent with schizoid and avoidant personality disorders, a negative thinking style, dysthymic disorder and depression.  The CI reported he was still taking a medication for depression.  He was married and had a child.  Mental status examination (MSE) performed by a psychiatrist on January, 2008, was unremarkable.  An Axis I diagnosis of dysthymic disorder and an Axis II diagnosis for avoidant personality traits was rendered with a Global Assessment of Functioning (GAF) of 60 (moderate bordering on mild symptoms, impairment.)

At the VA Compensation and Pension (C&P) examination performed 2 months after separation, the CI reported he was discharged due to problems with professional performance and adjustment to the military.  The CI commented his parents had dissuaded him from joining the Air Force since he had problems with criticism.  He described a pattern of “personality conflict” with staff, stating he did not get along well with co-workers who did not like working with him.  Technicians were constantly changed.  He reported his first significant problems developed when he had difficulty bonding with his child and for the first 2 years did not want to hold him.  He and his wife were “more like roommates” and working on their personal issues.  He wanted to get away from the clinic and volunteered for deployment.  Progressive financial problems resulted in depression.  He became “very blunt” with patients who eventually filed complaints.  Documentation was poor with omissions in the record.  Command determined it was too risky for him to see patients due to “potential for harm” and his practice was stopped in January 2007.  

He reported reduced sleep, weight gain, and crying spells.  He stopped attending church since he was uncomfortable meeting people.  He did not associate with people and spent his time watching television, reading and playing video games.  He did not do anything with his wife and friends.  He had allowed his hygiene to deteriorate.  He was depressed part of the day 3 or 4 days a week.  He was taking medication but wanted to rely more on therapy.  He was having difficulty finding a job but the unemployment was stressful and he had applied for positions in stores.  He had applied for residency in pathology but had not been offered any interviews.  He knew pathology involved laboratory work and would not involve patient contact.  A physician retraining program would cost money he did not have.  He denied a history of treatment for depression or anxiety.  MSE was notable for a mild blunting of mood, limited range in affect, slightly distant but appropriate manner of relating, and visible tension.  He denied suicidal ideation.  An Axis I diagnoses included major depressive disorder (MDD), adjustment disorder with depressed mood and Axis II diagnosis of personality disorder NOS, mixed avoidant and passive-aggressive features with a GAF of 50 (serious bordering on moderate symptoms, impairment.)  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a diagnosis of dysthymic disorder and rated it at 10%, coded 9433 while the VA assigned a diagnosis of MDD and rated it 50%, coded 9434.  The Board opined there was no documented evidence the condition existed prior to service, noting no psychiatric diagnosis and treatment or occupational impairment prior to service.  Board members agreed with the PEB that adjustment disorder with mixed anxiety and depressed mood as well as avoidant and narcissistic personality traits were Category III conditions, not separately unfitting and not ratable or compensable by DoD policy.  PEB 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.  Disability associated with any psychiatric condition, regardless of the diagnosis or multiple diagnoses, is subsumed under a single rating using the same criteria IAW VASRD §4.130 general rating formula for MH conditions.  The Board considered if a rating higher than 10% was warranted at the time of separation.  The §4.130 criteria for a 10% rating is “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.”  A 30% rating requires “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.” A 50% rating required “reduced reliability and productivity.”  

The PEB based its rating on the CI’s continuing need for medication and therapy.  However, he never appeared stable on medication and often had significant reactions to the medication that led to new symptoms.  Deliberation settled on arguments between a 30% and 50% rating.  The CI stopped working as a physician in January 2007 until he separated in September 2008.  He was not credentialed and could not see patients.  His state license was not active.  He had conflicts with his wife and with the staff.  He was socially isolated and had no activities with his wife or with others.  He had been hospitalized within a year of separation for suicidal ideation.  He knew he could not see patients on a day to day basis.  He was not invited to interview.  Since discharge, he could not find employment.  The NARSUM examination documented impairment in the moderate range and the C&P examination documented impairment in the serious range, suggesting a deteriorating, unstable condition.  Board members agreed the CI showed signs of reduced reliability and productivity.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 50% for the dysthymia condition.  

BOARD FINDINGS:  In the matter of the dysthymia condition, the Board recommends a disability rating of 50%, coded 9433 IAW VASRD §4.130. In the matter of the contended adjustment disorder with mixed anxiety and depressed mood and avoidant and narcissistic personality traits, the Board 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 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	
Dysthymia Disorder 	9433	50%	
RATING	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140315, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-01365.

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 your separation be re-characterized to reflect disability retirement, rather than 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 determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

Attachment:
Record of Proceedings

cc:
SAF/MRBR
DFAS-IN