RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01386
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050920

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Cryptologic Linguist Specialist, medically separated for “major depressive disorder,” with a disability rating of 10%.

CI CONTENTION:  The CI made contends higher rating was received for service connected conditions.  The CI’s complete application 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 - 20050808	VARD - 2000210  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder, Social and Industrial Adaptability Impairment, Mild	9434	10%	Major Depressive Disorder	9434	0%	No Show	
Migraine Like Headaches	Cat II	Migraine Headaches	8100	30%	20051009	
Allergic Rhinitis	Cat II	Allergic Rhinitis	6522	NSC	20051009	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Major Depressive Disorder.  The service treatment records (STRs), the Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 7 July 2005, and the Addendum NARSUM from the Life Skills Center dated 15 July 2005 indicated the CI was referred to clinical psychology on 10 December 2003 from neurology for a history of daily, constant migraine headaches (see below), which began around 15 October 2003.  A mental status examination revealed a well-groomed, cooperative CI, who was oriented to person, place, time and situation.  Her mood was “good” with congruent affect.  Speech was normal and logical with no apparent language or thought process impairments and no suicidal or homicidal ideation.  Psychologic tests for depression and anxiety were in the range of normal.  The psychologist opined the CI’s condition involved an interaction of multiple factors that included constant migraine headaches and hepatitis C.  Cognitively, she reported some difficulty with concentration when she experienced intense headache symptoms.  The CI was frustrated with missing work, which resulted in her removal from her training program until the next sequence.  No Axis I diagnosis was made.  Education, biofeedback assisted relaxation and monitored sleep patterns because of shift-work were reviewed.  

The Addendum NARSUM in July 2005 noted the CI reported 8 months of a depressed mood, in part related to her chronic headaches, with restless sleep (with bizarre dreams), anhedonia, low energy, and poor concentration.  She also noted relationship and job stressors.  Treatment with Celexa (citalopram, an antidepressant medication) initially prescribed to help her headaches also improved her mood, but she discontinued the medication in late April 2005.  Celexa was resumed and the CI also benefited from depression management and pain management classes.  A mental status examination revealed a well-groomed, cooperative CI with normal psychomotor activity.  Speech was fluent and non-pressured.  Her mood was “getting better” with a mildly sad and frustrated affect, but with no lability and a normal intensity.  She was fully alert and oriented and her thoughts were linear, logical and goal-directed.  She had no auditory or visual hallucinations or delusions and she denied any suicidal or homicidal ideation.  The CI had fair insight and judgment as she recognized there was a problem and sought help.  The Axis I diagnosis was major depression, recurrent, moderate since she appeared to have had at least two episodes, separated by at least 2 months, of sadness with neurovegetative symptoms (insomnia, anhedonia low energy, and poor concentration), which caused clinically significant distress and impairment in her social and/or occupational functioning.  

At the time of the Addendum NARSUM there was inadequate evidence that her symptoms were a direct physiological effect of an underlying medical condition, though her symptoms were clearly exacerbated by her headaches.  Her Global Assessment of Functioning (GAF) was 55 (moderate symptoms or moderate difficulty in social, occupational or school functioning).  A revised temporary P4 profile was issued on 14 June 2005.  The CI was not world-wide qualified and the commander’s statement indicated she worked in her primary AFSC [Air Force Specialty Code], but her condition frequently impacted her ability to concentrate on the mission and she frequently had to go on breaks or take time off duty.  She often missed work or was not able to give 100% performance due to her condition, medical appointments, or treatment.  The CI failed to report for a VA C&P mental health examination on 25 October 2005 and rescheduled for 8 November 2005.  However, there is no mention in the STR whether or not that examination took place or whether there were any findings, if in fact, the examination did take place.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 9434 (major depressive disorder) for major depressive disorder, social and industrial adaptability impairment, mild.  The VA assigned a 0% rating (for failure to report for an examination) using code 9434 for a major depressive disorder.  The Board sought a route to a higher rating and discussed whether her condition warrants 30% rating, which requires “Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), 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).”  Board members felt that the depressive disorder was influenced by the migraine-like headaches (discussed below) and by itself, the depressive disorder, did not rise to a 30% level.  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 major depressive disorder condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the Air Force Category II conditions (conditions that can be unfitting but are not currently compensable or ratable) seasonal allergic rhinitis and migraine-like headaches 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 seasonal allergic rhinitis and migraine-like headaches were not profiled or explicitly implicated in the commander’s statement, although the commander did refer to the CI’s missing work for appointments and treatment.   

Seasonal Allergic Rhinitis.  There were no notes relating to the diagnosis of seasonal allergic rhinitis in the STR to review; however, there were several entries that indicated the CI took Claritin (loratadine, an antihistamine) and one entry that listed Allegra (fexofenadine, an antihistamine), both of which are allergy medications used to treat the condition.  According to the VA C&P examination report the CI noted the condition existed since 2003; it occurred eight times per year; and each episode lasted for 4 weeks and interfered with breathing through the nose, and [caused] hoarseness of the voice and shortness of breath.  On examination there was no nasal obstruction, no deviated septum, no partial loss of the nose or disfigurement, and no rhinitis of the nose or evidence of sinusitis.  The VA Disability Rating (VARD) indicated service records documented treatment for seasonal allergic rhinitis in 2003 and once in 2004, but there was no pathology at the VA examination to render a diagnosis of allergic rhinitis.  The aforementioned was reviewed and considered by the Board.   There was no performance based evidence from the record that the allergic seasonal rhinitis 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 seasonal allergic rhinitis contended condition; and, so no additional disability rating is recommended.

Migraine-like Headaches.  The CI was seen for neurology consultation in November 2003 because of a 3-week history of daily headaches without photophobia or phonophobia that made her feel week and nauseated; and, she missed work for 2½ weeks. The headaches were not responsive to medication for migraine headaches (Fioricet (butalbital, acetaminophen and caffeine), Zomig (zolmitriptan), and Imitrex (sumatriptan)).  The CI had a recent diagnosis of hepatitis C and had a family history of headaches.  A detailed neurologic examination was unremarkable.  She was prescribed Topamax (topiramate) for headache prevention; the Fioricet was discontinued; and she was referred to psychology (see above).  Shift work was suspected to be likely exacerbating her condition.  Vioxx (rofecoxib, a nonsteroidal anti-inflammatory drug (NSAID)) was added to the treatment protocol 5 days later.  Magnetic resonance imaging (MRI) showed diffuse dural enhancement (thickening of the membrane covering the brain) and a lumbar puncture was performed, which was normal but for a faint elevation of lymphocytes in one study.  Although West Nile encephalitis was considered, it was not proved and infectious disease and rheumatologic evaluations, despite an elevated ANA [antinuclear antibody], a marker of connective tissue disease, thought to be related to the elevated liver enzymes/hepatitis were otherwise normal.  The possibility that the hepatitis C test was a false positive was raised.  In March 2004 Botox (onabotulinumtoxinA, a paralytic agent) was discussed because of neck tension at the onset of the headache and muscle tension along the right temple area, but its use was deferred pending more definable explanations for the dural enhancement.  In May 2005 the CI reported vertigo for 2-3 weeks and the headaches continued.  In December 2004 the CI reported the headaches had come back after she stopped the topiramate because of some anxiety and moodiness.  A follow-up MRI in January 2005 indicated it was stable compared to a June 2004 MRI, and it showed a small area of pachymeningeal (dura-arachnoid) thickening/enhancement in the occipital parietal region (back and sides of the brain).  In February 2005 the CI reported having headaches again for the prior 2 months, which were worse in the preceding month, and were associated with nausea.  She indicated “work lets her go home” and she could “sleep it off.”  The Celexa dosage was increased and the CI was referred to behavioral health where in March 2005 her condition was viewed as an interaction of multiple factors.  She indicated took naproxen (an NSAID) for pain relief and self-managed the headaches through the use of caffeine by consuming up to eight diet sodas on a bad headache day and most effectively reduced headache pain by resting.  She missed a few days of work in the prior 3 months.  The Axis I diagnosis was pain disorder associated with both psychological factors and migraines.  At a follow-up visit, relaxation skills and general stress management options were discussed with the CI.  In April 2005 the CI reported dizzy spells and desired to discontinue the Celexa.  The neurologist indicated it had to be tapered over a week to prevent withdrawal and recommended Mobic (meloxicam, an NSAID) in its place.  At the VA C&P examination dated 19 October 2005 the CI reported recurring migraine headaches with sharp pain in the right temple and a dull ache in the neck.  The headache attacks averaged one a week and each attack lasted for 4 hours, which required her to stay in bed.  From a functional impairment she could not make quick movements, and it was hard to turn her neck.  The neurological examination was unremarkable.  After due deliberation, the Board agreed that the preponderance of the evidence with regard to the function impairment of the migraine-like headaches condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 8100 (migraine) and meets the VASRD §4.124a criteria for a 30% rating. 

BOARD FINDINGS:   In the matter of the major depressive disorder condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended allergic seasonal rhinitis condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  In the matter of the contended migraine-like headaches condition, the Board unanimously agrees that it was unfitting and unanimously recommends a disability rating of 30%, coded 8100 IAW VASRD §4.124a.  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 Disorder 	9434	10%	
Migraine-like Headaches	8100	30%	
RATING	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140319, 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-2014-01386.

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