RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-01866
BRANCH OF SERVICE:  AIR FORCE 	SEPARATION DATE:  20031203

SUMMARY OF CASE:  The available evidence of record reflects this covered individual (CI) was an active duty E-5 (Chaplain Assistant) medically separated for a mental health (MH) condition.  This condition could not be adequately rehabilitated to meet the requirements of his Air Force Specialty (AFS).  He was issued an S4 profile and referred for a Medical Evaluation Board (MEB).  The MH condition, characterized as “major depressive disorder…dysthymic disorder” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The MEB also identified and forwarded three other conditions for PEB adjudication; obesity, hypercholesterolemia, and personality disorder not otherwise specified (NOS).  The informal PEB (IPEB) adjudicated “major depressive disorder, associated with dysthymic disorder” as unfitting, rated 10%.  The remaining conditions were found to be Category III (not separately unfitting, and not compensable or ratable).  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI requested that the Board review all of his conditions.  The complete submission is at Exhibit A.    

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 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 20031014	VA - (# Mos. Pre/Post-Separation)  -or- based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder	9434	10%	Major Depressive Disorder	9434	30%	20040615	
Personality Disorder	Category III	No VA Entry	
Hyperlipidemia			
Obesity			
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 0	
Combined:  10%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20040802  
ANALYSIS SUMMARY:  

Major depressive disorder (MDD), associated with Dysthymic disorder.  Service treatment records (STR) noted the CI has had a long history of mental health (MH) problems.  During high school, before entering military service, he was treated with an anti-depressant for a mood disorder.  In 1991, he enlisted in the Air Force.  At his enlistment exam in July 1991, on Standard Form 93 (Report of Medical History), the CI checked “no” for “Depression or excessive worry” and for “Nervous trouble of any sort.”  He self-referred for counseling in June 1999 for stress and associated weight gain.101

In October 1999, he was diagnosed with Dysthymic disorder and personality disorder.  In February 2000, he was cleared for overseas deployment in support of Operation Southern Watch.  Two months later, in April 2000, he was medically evacuated from theater, due to failed duty performance and personality issues described as “got so bogged down in task detail, exclusion of multitasking, and passive-resistance to conflicts that substantial work was going undone.”  Mental status exam showed he was mildly anxious and depressed.”  He was treated for binge eating in 2000.  A profile dated December 2000 noted features were present, however duty performance from commander noted good progress.  During the period from 2001 to 2003, the CI was seen on numerous occasions for MH issues.  For 6 months, he intermittently attended a Feelings 101 Group.  He self-referred to Life Skills again in March 2002 and described experiencing his third depressive episode.  He reported each episode lasted several months and was precipitated by an event like relationship problems.  The CI reported his depression had been going on for 3-6 months and was having difficulty concentrating at work and had low frustration tolerance with customers.  He was treated with an anti-depression medication with remission of symptoms by May 2002.  Because of the chronic, persistent nature of the MH symptoms, he was given an S-4 Profile, and MEB was initiated.  The commander’s statement noted the CI’s condition affected his ability to complete duty requirements; he could not work more than one task at a time but worked full shifts.  Stress was contributing to his condition.

The MEB narrative summary (NARSUM) was dated 18 September 2003.  At that exam, the CI reported insomnia, sad mood, apathy, helplessness, reduced hope, anhedonia, excessive guilt, reduced energy, poor concentration, increased appetite, and reduced libido.  He reported worsening of his depression over the past 2 years.  He denied suicidal ideation and there was no history of violence.  He reported stress at work was “unbearable” due to increased ops tempo and inadequate training/resources.  He was behind on finances, work obligations and maintenance of interpersonal relationships.  He was taking two medications for depression.  

On mental status exam (MSE), he was well groomed and made good eye contact.  There was a mild increase in kinetics (fidgeting of extremities).  Speech was normal for rate, volume, and prosody.  His affect was moderately restricted to the dysphoric range.  The CI admitted to intermittent suicidal ideation, but did not have a plan or intent to kill himself.  There was no homicidal ideation, and there was no history of violence to others.  He denied any delusions or hallucinations.  Thought processes were logical, linear, and goal-directed.  Concentration and attention were good.  Memory was intact, and fund of knowledge was average.  The Beck Depression Inventory II (BDI-II) score was 47, indicating severe depression.  The Beck Anxiety Inventory (BAI) score was 30, indicating severe anxiety.  The Axis I diagnoses were: Major Depressive Disorder (moderate, recurrent, with atypical features), and Dysthymic Disorder.  His Axis II diagnosis was: Personality Disorder, not otherwise specified (NOS).  The Axis V global assessment of functioning (GAF) score was 60 (indicating mild to moderate symptoms, or moderate difficulty in functioning).  The CI’s social/industrial impairment was “Definite” and military impairment was “Marked.” 

The CI was medically separated from service on 3 December 2003.  Six months later, on 15 June 2004, he had a VA Compensation and Pension (C&P) exam.  The CI reported that he had not made any MH visits since his discharge but was still taking two medications for depression, prescribed by his family doctor.  He was divorced and unemployed.  He stated that he would like to work, and also “would like to go back to college.”  He complained of depressed mood, lack of enjoyment, poor concentration, and a tendency to isolate himself from others.  These symptoms appeared to be of mild to moderate severity, were present over the past year, and occurred on a weekly basis.  The CI reported that his MH medications (Wellbutrin and Lexapro) were working well, and he did not report any side effects.  On MSE, he was dressed appropriately, with good grooming and hygiene.  Eye contact was good, and there were no inappropriate behaviors displayed.  He was congenial and personable.  Memory and concentration were good.  Speech was fluent and well-articulated, with normal rate.  Thought patterns were logical, relevant, coherent, and goal directed.  He denied any hallucinations, delusions, or disorders of thought.  His mood was genuinely free of significant depression, anxiety, or anger.  The CI laughed and smiled at appropriate times.  He denied any suicidal thoughts, ideations, plans, or intent.  He reported no sleep impairment, panic attacks, or panic-like symptoms.  No obsessive or ritualistic behaviors were reported.  The examiner’s MH diagnoses were: Depressive disorder NOS (by history), and Personality disorder NOS, with avoidant and obsessive features (by history).  The GAF score was 55, indicating moderate symptoms, or moderate difficulty in functioning.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB initially assigned a disability rating of 30% for MDD associated with dysthymic disorder, coded 9434 (MDD) but subtracted 20% for personality disorder, an “aggravating/contributing factor”) and characterized it as Category III, conditions considered not separately unfitting and not compensable or ratable.  The PEB opines it significantly affected the severity of his major depressive disorder/dysthymia and concluded that were it not for the personality disorder condition, impairment would have been “mild” (i.e. consistent with a 10% rating).  The VA assigned a 30% rating for MDD.

The Board first considered the matter of the PEB deduction for personality disorder.  The Board noted that after the 2000 diagnosis of personality disorder, no specific behaviors were attributed to this diagnosis, yet it was often referenced, up to separation, as a diagnosis “by history.”  VASRD §4.130 provides that separate mental health ratings cannot be conferred without a medical opinion clearly defining distinct rating boundaries separating the disability attributable to each mental disorder.  No such input from a psychiatric examiner is in evidence; thus the Board could not fairly apportion a deduction even if the competing diagnosis were not in question.  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 next considered a §4.130 disability rating.  A rating of 10% requires “occupational and social impairment due to mild or transient symptoms during periods of significant stress; or symptoms controlled by continuous medication.”  A rating of 30% is described by “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks,” while a 50% rating requires “reduced reliability and productivity.” The Board determined that the September 2003 MEB exam was just 11 weeks before the date of separation (DOS), and therefore had significant probative value.  Both the history and MSE provided a report of symptoms that met criteria for MDD for 2 years prior to the MEB.  The examiner noted the CI had worked as a Chaplain’s Assistant for 6 years.  The GAF assignment of 60, indicating moderate symptom description, and clinical course argue against a characterization of the severity as mild or transient, and it is clear that symptoms were not completely controlled on medication.  The evidence does not provide a correlation of acuity with degree of stress, and that element of the 10% description is thus not relevant.  The 30% description (“occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks”) is a better fit with the occupational functioning in evidence.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30%, coded 9434 for the MDD condition.  

Other PEB Conditions.  The IPEB found two other conditions as Category III (not separately unfitting, and not compensable or ratable). These two other conditions were: Hyperlipidemia, and Obesity.  As noted above, the Board’s main charge with respect to these conditions is to assess the appropriateness of the PEB’s adjudication.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  These two conditions was thoroughly reviewed by the action officer and considered by the Board.  The Board determined that these conditions were not specifically profiled, nor was it judged to fail retention standards.  There was no indication from the record that 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 hyperlipidemia and obesity conditions.   

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.  The Board surmised from the record or PEB ruling in this case that no prerogatives outside the VASRD were exercised.  In the matter of the MDD condition, the Board unanimously recommends a disability rating of 30%, coded 9434 IAW VASRD §4.130.  In the matter of the contended hyperlipidemia and obesity 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. 

RECOMMENDATION:  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 his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Major Depressive Disorder (MDD)	9434	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140422, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SAF/MRB
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-2014-01866.

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