RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-02027	
BRANCH OF SERVICE:  AIR FORCE  	SEPARATION DATE:  20030811		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Financial Management and Comptroller Apprentice) medically separated for a major depressive disorder (MDD) condition. The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS).  He was referred for a Medical Evaluation Board (MEB).  Two mental health conditions, characterized as “MDD and Dysthymic Disorder” were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “MDD” as unfitting, rated 10%, citing criteria of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD) and Department of Defense (DOD) guidelines.  The PEB adjudicated “dysthymic disorder” as Category II (can be unfit, but not compensable/ratable), existed prior to service (EPTS) without service aggravation, rated 30% less predisposing contributory and aggravating factors of 20% for a remaining compensable rating of 10%.  The CI made no appeals and was medically separated. 

CI CONTENTION:  The applicant requests consideration of all MEB/PEB conditions in his application.  His 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/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 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 20030620	VA - (2 Mos. Pre-Separation)  -	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder	9434	   30
  -20
10%	Major Depression	9434	50%	20030627	
Dysthymic Disorder	CAT II					
Other x 0 (Not In Scope)	Other x 2		
RATING:  10%	RATING:  50%	
Derived from VA Rating Decision (VARD) dated 20030818 (most proximate to date of separation [DOS]).   

ANALYSIS SUMMARY:  

Major Depressive Disorder and Dysthymic Condition.  Service treatment records (STR) noted the CI reported first reported decreased sleep to Primary Care in September 2001 and again in 2002.  He was treated with sleep aids and education regarding sleep hygiene without improvement.  He presented to the Life Skills Support Clinic on 4 February 2003 with a report of depression for 2 years that was worsening over the past 5 to 6 months.  One year earlier he began to have visual hallucinations of “shadows” that progressed to human forms occurring 5-8 feet from his bed.   There were recurring episodes of anger and irritability.  He reported awakening to violent episodes (cuts and scrapes on his body, the apartment looking like a bar brawl had occurred) over the past five nights associated with memory loss.  He reported visual and auditory hallucinations that occurred as he was falling asleep.  He described decreased energy, motivation, concentration, appetite with weight loss of 15 lbs. in the past 2 months, and worsening hopelessness.  He reported racing thoughts and increasing paranoid thoughts in the past few days.  He denied being under the influence of drugs or alcohol.  Stressors included family conflicts as well as conflicts between him and his supervisor.  He indicated that his Air Force experience was dominated by difficulties getting along with supervisors but he denied any Article 15s.  He denied a history of legal problems, violence, driving under the influence of alcohol or mental health (MH) treatment prior to the military.  There was a family history of schizophrenia.  He appeared mildly depressed with a blunted affect and speech was somewhat slowed and in a monotone. He received an S4T profile.  The CI was admitted to the inpatient psychiatric unit due to safety concerns after the violent episodes.  He was discharged after 3 days with a diagnosis of psychosis not otherwise specified (NOS) and major depression.  Sleep and perceptual disturbances resolved but he continued to have intermittent thoughts of paranoia.  He was compliant with treatment and attended over 10 outpatient MH follow-up visits.  The CI’s command confirmed that he had problems with past supervisors but overall had been “an excellent troop.”

The narrative summary (NARSUM), dated 14 March 2003, noted his mood had failed to improve and his hopelessness had worsened.  He endorsed symptoms of depression, including intermittent thoughts of ending his life.  He denied a plan and was able to contract for safety.  There were no recurring nightmares of intrusive thoughts of past abuse.  He did report hypervigilance, guarding in interpersonal situations, and almost always feeling nervous.  Mental status exam (MSE) noted a depressed mood, severely restricted affect of moderate intensity, and thought content filled with hopelessness.  He denied hallucinations or paranoid delusions.  He was taking medication for depression, psychosis, and sleep.  His maternal grandfather had schizophrenia and paranoia.  Psychological testing suggested a depressive and anxiety disorder with significant schizoid, avoidant, depressive and dependent personality traits.  An Axis I diagnosis of major depressive disorder (MDD) and dysthymic disorder with avoidant, dependent, and schizoid traits was rendered.  Global Assessment of Functioning score was 50 (moderate bordering on severe impairment, symptoms.)  The commander’s statement noted the CI had a medical condition that restricted him from performing all required tasks, was not deployable and not been able to perform normal day-to-day duties required of his assigned AFS.  

At the VA Compensation and Pension (C&P) exam, dated June 2003, performed 2 months before separation, the CI reported weekly visits to psychiatrist and therapist.  He was taking two medications for depression and two medications for psychosis/mood stabilization.  The CI has felt increasingly down and sad and had lost interest in sports.  He reported he sees the facial features of shadowy figures either as he is going to sleep or just awakening in the morning.  He continued his job in finance but was placed in a less stressful job with less responsibility.  He had no close friends and stayed mostly to himself.  He planned to return to college and specialize in finance and sports.  A brother had attempted suicide twice.  During MSE, the CI sat formally with decreased eye contact, flat affect (no smiles) during the interview, depressed mood, and constricted affect. An Axis I diagnosis of major depression and was rendered with a GAF score of 49 (serious symptoms, impairment). No Axis II diagnoses or traits were noted. The psychiatrist examiner noted the CI was on a number of medications with persisting symptoms, and therefore he could not support the diagnosis of schizophrenia or psychosis. 

The Board directed attention to its rating recommendation based on the above evidence.  As recorded above, the PEB rated the condition of MDD at 30% coded 9434 with a 20% deduction for less predisposing aggravating/contributing factors, thus, a final 10% rating.  The VA rated the condition at 50%, also coded 9434.  First, the Board noted there was no specific, highly stressful service related event to invoke §4.129 for a mental disorder due to traumatic stress.  All Board members agreed the provisions of §4.129 were not applicable.  The Board next considered the rating deduction. The PEB noted the condition of “dysthymic disorder existed prior to service (EPTS) without service aggravation as Category II.  The Board considered the PEB’s deduction was related to the Category II condition.  The Board cannot support a formal deduction for dysthymia disorder, however, since both DoDI 1332.39 (6.11.3) and VASRD §4.22 stipulate, “If the degree of disability at the time of entrance into the service is not ascertainable in terms of the schedule, no deduction will be made.”  Either the dysthymia disorder was clinically inactive on entrance, i.e. 0%, or it was not documented well enough to establish a §4.130 rating.  Furthermore, 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.  Also, there was no history of a mental health diagnosis or treatment prior to entry into the military.  Therefore, a deduction predicated on a mental health condition, EPTS, is without merit and not supported.  All members agreed that the PEB’s deduction could not be upheld for application to the Board’s recommendation.  

The Board next proceeded with the rating recommendation IAW VARSD 4.130. The higher rating of 30% requires evidence of “Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks”.   A rating of 50% requires reduced reliability and productivity.  The C&P exam documented several 50% threshold symptoms that included constricted affect, depressed mood, isolation and no close friends.  He could only work in a low stress job.  Both the MEB and C&P exams recorded similar functional scores of 50 and 49, respectively, connoting moderate-severe impairment.  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 MDD 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the MDD condition, the Board recommends a disability rating of 50%, coded 9434 IAW VASRD §4.124. In the matter of the contended dysthymia disorder condition, 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, effective as of the date of his prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
MDD	9434	50%	
COMBINED	    50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140502, 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-2014-02027.

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