RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01685
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20150521
SEPARATION DATE:  20061113

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Aviation Structural Mechanic) medically separated for major depressive disorder (MDD).  The CI’s MDD could not be adequately rehabilitated to meet the requirements of his Rating.  The CI was placed on limited duty and eventually referred for a Medical Evaluation Board (MEB).  The MEB forwarded “major depressive disorder, single episode, moderate degree” to the Physical Evaluation Board (PEB).  No other conditions were submitted by the MEB.  The PEB adjudicated “major depressive disorder” as an unfitting Category I condition, rated 10%.  The PEB also found “social anxiety” as a related unfit Category II condition.  The PEB further documented “paranoid and schizoid traits” as Category III:  “conditions that are not separately unfitting and do not contribute to the unfitting condition(s).”  Finally, the PEB found “nicotine dependence” and “personality disorder” as Category IV: “conditions which do not constitute a physical disability”.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the 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/Naval 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 IPEB – Dated 20061006	VA - (8 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder	9434	10%	Depressive Disorder NOS	9499-9434	30%	20070601	
Social Anxiety	Category II	Social Phobia	9499-9403	NSC	20070601	
Paranoid and Schizoid Traits	Category III	No VA Entry	
Nicotine dependence, personality disorder	Category IV	No VA Entry	
	Other x 0	20071002	
Combined:  10%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20070618 (most proximate to date of separation [DOS]).
VARD 20071029 denied service connection for DC 9499-9403 (social phobia).

ANALYSIS SUMMARY:

Major Depressive Disorder with Social Anxiety.  Difficulties with anger management and domestic violence were noted in treatment records beginning approximately 2004.  Mental health (MH) evaluations in March and April 2005, in the setting of domestic violence, diagnosed MDD and anxiety disorder (with social phobia and panic attacks).  Social anxiety, suicidal ideation and self-mutilation were noted to have existed prior to enlistment.  The CI reported fair to poor grades in high school and suspension for fighting.  He reported he felt uncomfortable in the classroom and uncomfortable with public speaking.  The CI reported having had 26 jobs between graduating high school and entering the Navy 4 years later.  He endorsed depressive symptoms and reported periodic suicidal ideation his entire life, but lately typically occurring when having conflicts with his wife.  Psychiatry records from 22 April 2005 and 25 April 2005 indicated he was fit for general military duty but due to medication treatment was not allowed to work on the flight-line.  The 17 June 2005 psychiatry encounter initiated a period of limited duty since medication treatment prevented work on the flight-line.  No traumatic stressor was noted.  Flight-line duty and deployment were restricted and treatment with medication and counselling was initiated.  Follow-up evaluations in December 2005 and February 2006 indicated he was doing well on medication with no recurrence of depressive symptoms, but with some residual low-grade chronic anxiety, especially in social settings, or crowded noisy locations.  Flight-line duty and deployment restrictions were continued.  Subsequent follow-up appointments recorded increased depressive and anxiety symptoms including feeling overwhelmed in groups, cognitive slowing and distractibility.  A MH clinic appointment on 15 June 2006 noted marked anxiety symptoms especially in social situations.  The CI reported he avoided crowds.  The examiner recorded that the CI could “Function adequately in command job, primarily able to remain to self and work on solitary assignments.”  Mental status examination noted anxious mood with appropriate affect.  The CI denied suicidal ideation.  Speech was fluent, logical and goal directed.  Thought processes were normal.  Cognition, memory, judgment and insight were intact.  Referral for MEB was initiated.

The psychiatry MEB narrative summary (NARSUM) prepared on 15 June 2006 described continued depressive and anxiety symptoms including dysphoria, irritability, loss of motivation, decreased concentration, social isolation and anxiety in groups.  The NARSUM examiner noted that an increase in medication dose in May 2006 had good effect for depressive symptoms.  The commander’s statement on 27 June 2006, noted the CI was not performing his duties as an aviation structural mechanic and was not worldwide assignable.  The MEB psychiatrist referred the CI for psychological testing (consult request dated 16 August 2006) stating that treatment with supportive psychotherapy and medications resulted in “…marked improvement, though still with baseline anxiety persisting, though manageable.”  Psychological testing on 22 August 2006 indicated a pattern of over-reporting symptoms limiting the diagnostic utility.  The psychologist concluded: “The above findings are most consistent with an individual who is motivated to exaggerate symptoms, at least to some extent, and whom has Axis I features of anxiety and depression plus possible Axis II features that have largely paranoid and schizoid qualities” (schizoid characterized by tendency to be a loner).

The MEB psychiatry NARSUM addendum on 27 September 2006, noted the personality traits identified during testing but also noted the CI had initially adapted successfully to the stresses of military service and concluded his current difficulties could not be attributed to any underlying personality disorder.  The MEB psychiatrist did not comment on the over-reporting of symptoms detected on psychological testing.  The MEB NARSUM addendum listed diagnoses of MDD, single episode, moderate (did not exist prior to service), social anxiety disorder, severe (existed prior to service but service-aggravated) and paranoid and schizoid personality traits (no personality disorder diagnosis).  The MEB psychiatrist estimated the degree of “industrial and military” impairment as severe and the degree of “civilian performance” impairment as moderate and a Global Assessment of Functioning (GAF) of 50 denoting moderate to severe symptoms.  At the time of the VA MH Compensation and Pension (C&P) examination on 1 June 2007, 6 months after separation, the CI was no longer receiving treatment or taking medications.  The CI reported he remained depressed with panic attacks whenever involved with a group of people.  He reported experiencing a sad mood for 2 hours each day for several months with sleep disturbance, decreased interest, decreased concentration, decreased appetite and feelings of guilt.  He reported constant worry with accompanying physical symptoms but he did not find the worry difficult to control.  He also reported symptoms consistent with social phobia and panic disorder with agoraphobia.  He denied any trauma exposure.  At the time of the examination, he was being trained as a welder.  He reported he had several friends from high school and was trying to get a new heavy metal band established with them.  On examination, the CI was normal in appearance (dress, grooming) and attentive with good eye contact.  The mood was “anxious about life in general” with full affect.  Thought processes and speech were normal.  There was no suicidal ideation.  The VA examiner diagnosed depressive disorder not otherwise specified noting criteria for MDD were not met.  Social phobia was also diagnosed.  The examiner noted the criteria for generalized anxiety disorder were not met because the CI did not find the worry difficult to control.  The examiner also concluded that the social phobia did exist prior to enlistment and was not caused by military service.  In an addendum on 17 July 2007, the examiner stated, “It is less likely as not that the veteran's pre-existing social phobia was either permanently aggravated by or advanced beyond his normal progression by the veteran's military service” (indicating in his opinion the condition was not permanently aggravated beyond natural progression).  The examiner indicated there was moderate impairment (with a GAF of 60 at the mild end of the moderate range) from the depression and social phobia.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the MDD (primary diagnosis) with social anxiety (related diagnosis) 10%.  The PEB indicated the social anxiety as a condition related to the primary unfitting depression but not separately ratable and made no deduction based on the existence of social anxiety prior to enlistment.  The depression and social anxiety are not separately ratable since such ratings would be based on the same social and occupational impairment and is prohibited by VASRD §4.14 (avoidance of pyramiding; the granting of more than one rating for the same impairment).  The VA rated the depressive disorder 30% based on the after separation VA examination.  Service-connection for social phobia was denied based on the VA examiners opinion the condition was not permanently worsened by service beyond its natural progression.  The Board noted that there was no traumatic event causing the unfitting MH condition and therefore concluded that application of VASRD §4.129, was not appropriate in this case.  All Board members agreed that at the time of separation, the §4.130 threshold for a 50% rating (or higher) was not approached.  Therefore the Board discussed whether the impairment more nearly approximated the 10% versus the 30% rating.  Social and occupational impairment consistent with a 30% evaluation (“Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks…”), could be surmised from some of the symptoms reported at the time of the MEB NARSUM including dysphoria, irritability, loss of motivation, decreased concentration, social isolation and anxiety in groups which was associated with distractibility, and decreased concentration.

While the MH records reported similar symptoms prior to entering service, the available records also indicated that the CI satisfactorily completed military training and satisfactorily performed his duties prior to March 2005 when he initially presented for treatment of depression and anxiety.  In fact, prior to his entry into the Disability Evaluation System, the CI reported he performed well with “4.0” performance evaluations with no disciplinary problems.  He went on to specifically cite his selection as “Safety Pro” of the quarter as well as “Bear Ace” of the month at his unit (this is not corroborated independently by evidence in the record; but is specific enough in claim to lend credence).  The CI was treated with multiple medications with dose adjustments over the following year but reported persisting social anxiety symptoms that interfered with working in groups.  Throughout the time of initial psychiatric evaluation all through the disability evaluation, the CI’s mental status continually prohibited his assignment to the flight-line as well as worldwide deployable.  The history and physical record in 2002 reflected baseline functioning (e.g. at the time the CI entered service) that did not raise concerns.  Although the NARSUM examiner noted an increase in medication dose (May 2006) had “good effect,” this was in context of a progressively unstable treatment progression – and can be interpreted as an indication of some stabilization of the CI’s MH condition – but not necessarily improvement of such.  In fact, the NARSUM psychiatrist stated in conclusion:  “Given his need for multiple anxiety and depressive medications and high doses for stability (still with residual depressive and anxiety symptoms in the face of this), it was deemed highly unlikely he would be able to be returned to a duty status to allow deployment on a worldwide basis or full utilization of his training.”  The NARSUM examiner went on to surmise, “The degree of industrial and military impairment is severe.  The degree of civilian performance impairment is moderate.”  One can logically translate this analysis to a severe occupational impairment.  Per VASRD rating criteria, this clearly translates to a mental health condition not controlled with medication.

The Board therefore concluded that the 30% rating best described the CI’s condition at separation.  The PEB listed personality disorder as a Category IV condition, a condition which does not constitute a physical disability; however, the CI was never diagnosed with a personality disorder on Axis II of the psychiatric diagnosis.  Paranoid and schizoid traits were diagnosed on Axis II of the psychiatric diagnosis and categorized by the PEB as Category III conditions that were not separately unfitting and did not contribute to the unfitting condition.  Personality disorders and personality traits diagnosed on Axis II are not ratable or compensable disabilities, but there is no evidence the PEB made a rating deduction for the Axis II conditions.  The VA C&P examination did not list any condition on Axis II of the psychiatric diagnosis.  The Board considered the MEB psychiatrist’s comment that the CI had initially adapted to military service after enlisting in 2002 before experiencing the major depression in April 2005 with aggravation of the social phobia.  The Board’s rating recommendation therefore is based on the occupational and social impairment without any reduction due to cited personality traits.  The Board also noted the diagnosis of nicotine dependence (cigarette smoking) is not considered a disability and did not interfere with service.  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 MDD with social anxiety condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  In the matter of the MDD with social anxiety condition and IAW VASRD §4.130, the Board by a majority concluded the evidence of the record described the CI’s social and occupational impairment at the time of separation that likely exceeded the 10% rating and more nearly approximated a 30% rating with consideration of reasonable doubt (§4.3).  The minority voter for dissent (who recommended a 10% rating) did not submit a minority opinion.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that the CI’s prior determination be modified to reflect permanent disability retirement as follows:

UNFITTING CONDITION	VASRD CODE	RATING	
Major Depressive Disorder with Social Anxiety	9434	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140409, 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 Aug 15 ICO XXXXXXXXXXXXXXX
       (c) PDBR ltr dtd 14 Aug 15 ICO XXXXXXXXXXXXXXX
	 (d) PDBR ltr dtd 17 Aug 15 ICO XXXXXXXXXXXXXXX
	 (e) PDBR ltr dtd 11 Aug 15 ICO XXXXXXXXXXXXXXX
	 (f) PDBR ltr dtd 18 Aug 15 ICO XXXXXXXXXXXXXXX

1.  Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (f).

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

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

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

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

     d. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability severance pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.

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

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.