RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX	CASE: PD-2014-01579
BRANCH OF SERVICE:  NAVY	SEPARATIONDATE:  20091117

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O-3, Surface Warfare Officer (Nuclear), medically separated for “vasovagal syncope” with a 10% disability rating.  

CI CONTENTION:  The CI contended for posttraumatic stress disorder (PTSD) to be considered. 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 based upon a 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.    

In addition, the Secretary of Defense Mental Health Review Terms of Reference directed a comprehensive review of Service members with certain mental health (MH) conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The MH condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.

RATING COMPARISON:  

SERVICE PEB - 20090727	VARD - 20100317	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Vasovagal Syncope	8299-8210	10%	Vasovagal Syncope	6204	0%	20090827	
Major Depressive Disorder	Category III	Major Depressive Disorder	9434	30%	20090910	
Post-Traumatic Stress Disorder	Category III	Post-Traumatic Stress Disorder	9411	NSC	20090910	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:  

Vasovagal Syncope. According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), since April 2008, the CI was being seen by internal medicine for ongoing evaluation of recurrent syncopal (fainting) episodes. They began while she was a student at the Naval Academy in 1999.  There was a prodromal period that began with a headache present for minutes or hours, followed by tunnel vision just prior to a loss of consciousness.  Other symptoms have included dizziness, lack of balance, and confusion. They tend to occur during periods without sleep and when under particular emotional stress.  An extensive workup by neurology, cardiology, and endocrinology, that included lab studies, neuroimaging, and electrical brain studies, was negative.  She had a 10-year history of hypoglycemia that was evaluated during a 72-hour inpatient hospitalization for hypoglycemic episodes.  The May 2009 NARSUM noted the CI had been treated in the internal medicine clinic for the past year with a medication for presumed vasovagal syndrome.  She reported there had been no further syncopal events, although she had two pre-syncopal events during moments of emotional distress.  She had been placed in limited duty status.

At the time of the MEB examination on 28 May 2009, the CI reported she periodically experienced shaking and intense headache, followed by passing out if she did not slow down.  A full night’s sleep, eating healthfully and minimizing time between eating helped but did not completely eliminate occurrences.  She noted she had been able to avoid a full black out since taking the medication but the warning signs had not gone away.  A strong headache was a precursor to blacking out and the syncope was associated with low blood pressure. 

The commander’s comments dated 28 May 2009, noted the CI was extremely competent and resourceful and had performed superbly under normal day-to-day operations.  She required daily medication, periodic blood tests, counseling, and had a routine that included a regulated diet and sleep cycle.  CI’s condition was aggravated by high stress and reduced sleep, and she periodically experienced trembling limbs and headaches followed by fainting if not immediately addressed.  Her performance on staff was commendable, but her condition prevented her from completing her obligation of sea service to the Navy.  At the VA Compensation and Pension (C&P) general examination performed 3 months before separation, the CI reported episodes of fainting, fatigue, and dizziness that flared up every 4 days, lasting 2-3 hours.  She had no attacks in the past year since taking the steroid medication.  Physical examination was normal.  

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and the VA identified the condition as vasovagal syncope but the PEB assigned a 10% rating, coded 8299-8210 (paralysis of tenth cranial nerve, incomplete, moderate) and the VA assigned a 0% rating, coded 6204 (peripheral vestibular disorders.)  Vasovagal syncope is not specifically identified as such in the VASRD.  Physiologically, the tenth cranial nerve (vagus nerve) innervates the heart (among many structures) and is involved in regulating pulse and blood pressure responses when changes are required to remain conscious, i.e., assuming an upright posture.  The Board members agreed that the PEB’s use of VASRD code 8210 (copied below for the reader’s convenience) for rating this CI’s neuro cardiogenic syncope was appropriate.

Rating under code 8210 entails a judgment call regarding the severity of incomplete paralysis, especially the “moderate” vs. “severe” distinction.  The CI reported she had not had a full blown black out episode since she started the medication.  She had not had an actual syncopal attack in over a year but continued to have prodromal symptoms of dizziness, shaking and intense headaches if stressed and without proper sleep and diet.  The commander noted that when she followed her prescribed treatment regimen, fainting episodes were aborted. Board members agreed that a fair threshold for the “severe” rating should entail functionally significant impairment encroaching on some occupational tasks.  Board members concluded therefore that the condition was precisely and accurately captured by the 10% rating of “incomplete, moderate, and that “severe, incomplete paralysis” did not correctly depict the condition at the time of separation, and the next higher 30% rating was thus not justified.  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 vasovagal syncope condition.  

Contended PEB Conditions: Major Depressive Disorder, PTSD.  The Board’s main charge is to assess the fairness of the PEB’s determination that major depressive disorder and PTSD were not unfitting. The PEB considered major depressive disorder and PTSD as Category III conditions, not separately unfitting and not contributing to the unfitting condition.  At the psychiatric NARSUM examination, the CI reported she was good at her job as a nuclear officer but she did not like the work and had disagreements with how operations were conducted.  Her increased stress triggered traumatic memories from her childhood in Africa, which was a politically unstable environment.  She had no history of psychiatric hospitalizations or prior use of psychotropic medications.  She had undergone various therapies as an outpatient in the psychology department since May 2008.  Psychiatric symptoms had significantly improved and were very beneficial in resolving traumatic memories and nightmares.  She did well in her limited duty assignment.  Mental status examination was unremarkable.  Diagnoses of PTSD (resolved) and major depressive disorder were rendered. The examiner recorded a Global Assessment of Functioning (GAF) score of 75-80 (transient symptoms, slight impairment.)  The C&P examination resulted in a diagnosis of major depressive disorder, mild with a GAF score of 65 (mild symptoms, impairment.)

Major depressive disorder and PTSD were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance-based evidence from the record that any of these 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 major depressive disorder and PTSD contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the vasovagal syncope condition and IAW VASRD §4.124, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the major depressive disorder and PTSD contended 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 20140305, 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 21 Jun 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:

		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN

						  	XXXXXXXXXXXXXXXXXXXX
	     				 	 	Assistant General Counsel
						 	(Manpower & Reserve Affairs)