RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02454
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20150626
SEPARATION DATE:  20070116

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Fire Controlman) medically separated for migraine headaches and depressive disorder.  These conditions could not be adequately rehabilitated to meet the physical requirements of his Rating and he was referred for a Medical Evaluation Board (MEB).  “Classical migraine, without mention of intractable migraine,” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “classic migraine headaches with aura” and “depressive disorder” as unfitting and rated 10% and 10% respectively, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  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 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:

IPEB – Dated 20060921	VA* - (~4 Months Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Classic Migraine Headaches with Aura	8100	10%	Migraine Headaches	8100	10%	20070501	
Depressive Disorder	9434	10%	Adjustment Disorder with Mixed Anxiety and Depressed Mood, Claimed as Depression	9499-9440	0%	20060912	
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 13	
RATING:  20%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20070726 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Migraine Headaches Condition.  Review of the service treatment record (STR) noted that the CI’s headaches began in approximately January 2006.  The first evaluations in evidence for headaches were at the end of June 2006, and were 5/10 in severity and associated with photosensitivity.  Headaches were described as “daily” and although they were responsive to Tylenol when they first began, increasing severity ultimately required initiation of prescription abortive and prophylactic medications.

The CI reported on 11 July 2006 (6 months prior to separation) that headaches improved with darkness and sleep, but that his current headache (present for 2 days) was not improving.  Severity was 7/10, and he “just wants bed rest today.”  Exam at that time observed him to appear uncomfortable.  He was placed on quarters for 24 hours.  Follow-up the next week indicated that his current headache was 4/10 in severity, but that he was “feeling fine” and the current medication for acute headache was helpful in reducing the severity.  A medication to prevent migraine headaches was first prescribed on 19 July 2006.  On 24 July 2006 the CI reported some headache relief with medication, but was still experiencing them.  Although he appeared to be “in no acute distress” he was placed on quarters for 72 hours.

At the narrative summary (NARSUM) evaluation on 28 July 2006 the CI reported that narcotic medication relieved acute severe headaches but did not prevent their occurrence.  Headaches could last a few hours, but the more severe ones could last the whole day.  A psychology entry on 31 July 2006 noted the CI to be “pain free.”  At a psychiatry visit on 16 August 2006, the CI reported a current headache for 2 days.  The provider diagnosed migraine headaches, and the CI was “released w/o (without) limitations.”  At a follow-up with internal medicine on 28 August 2006, the CI was observed to be in no distress, and was released without limitations.

At the VA Compensation and Pension (C&P) exam on 14 September 2006 (4 months prior to separation) the CI complained of daily headaches, and noted that they “could last for several days or several weeks.”  Headaches were sometimes associated with visual changes but not nausea or vomiting.  Abortive medication was partially helpful.  At another C&P exam on 1 May 2007 (4 months after separation) the CI reported that he continued having headaches approximately every 3 days, and that current prophylactic and abortive medication provided “good results.”  Since separation from the service he experienced one severe headache that lasted for 2 days.  When headache symptoms were present, he was able to perform his activities of daily living, “although with difficulty.”  At a VA primary care clinic visit on 13 June 2007 (5 months after separation) the CI complained of low back pain but made no mention of headaches.  A detailed review of systems was negative for headaches.  A VA primary care clinic entry on 28 September 2007 (8 months after separation) documented a review of systems that was negative for headaches.  The active medication list did not include any migraine-specific drugs.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA each assigned a 10% rating under the 8100 code (migraine headaches).  A 10% rating requires “characteristic prostrating attacks averaging one in 2 months over the last several months” while the next higher 30% rating stipulates an average frequency of prostrating attacks of once a month.  When rating headaches under the diagnostic code 8100 (migraine headaches), VA guidance uses the clear English definition of prostrating.  The standard dictionary definition of “prostration” is “utter physical exhaustion or helplessness.”  In deliberating the frequency of prostrating attack, the Board noted that abortive and prophylactic medications were not started until July 2006 (soon after the CI first presented for care), and that subsequent evaluations reported benefit.  While there were two documented quarters entries, they were near the time migraine medications were first prescribed.  Between the time of the final internal medicine note on 28 August 2006 and separation, there were no STR entries reflecting management of migraines.  The C&P exam in May 2007 noted the occurrence of one prostrating headache during the 4 months since separation, and indicated that headaches did not prevent performance of activities of daily living.  The Board agreed with the PEB and the VA that the described clinical picture could not be reconciled with the 30% rating.  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 migraine headaches condition.

Depressive Disorder Condition.  Review of the STR found that the CI presented on 19 October 2005 (3 months after service entry) with complaints of insomnia, sadness, homesickness, poor concentration and decreased appetite.  He indicated that he joined the service to support his mother and siblings.  A medication for sleep was helpful and was discontinued by the CI within 2 months.  However, the CI followed-up with psychiatry in May 2006 (8 months prior to separation) with sleep difficulty, depressed mood, fatigue and lack of motivation.  He also noted being “sad and lonely” and without any friends.  He reported being behind in training and wondered if he was “just wasting my time.”  A diagnosis of depression was rendered and an antidepressant medication prescribed.  Sleep and mood subsequently improved, but the psychotropic medication dose was increased.

At follow-ups in June 2006, symptoms were responding to the medication and to counseling.  The CI indicated he was being held back in training due to his difficulty with the English language.  Although he was “bored” with his assignment location, he was looking forward to a Rating reclassification.  He reported that his best friend was departing, but he found another friend to socialize with.  In July 2006 the CI reported that he stopped his antidepressant medication and sleep aid despite their helpfulness with sleeping.  He requested medical discharge.  A psychiatrist on 31 July 2006 reported that mood symptoms were now “minimal” and that significant fatigue and insomnia could be largely due to recently diagnosed anemia.

The psychiatric NARSUM addendum on 22 August 2006 (5 months prior to separation) reported that significant psychological stressors included separation from his family, financial problems and poor English comprehension (that contributed to academic performance issues).  Although improvement in depressed mood occurred, suboptimal response to psychotropic and sleep medications was reflected by fatigue and insomnia which was considered to possibly be due to recently identified anemia.  Mental status examination showed normal appearance, slow speech and normal mood with reserved affect.  Hallucinations, delusions and thoughts of harm were absent, while orientation, memory and judgment were intact.  The examiner rendered a diagnosis of depressive disorder, and stated that once anemia and migraines were adequately treated, the depression could be more accurately assessed.  The current Global Assessment of Functioning (GAF) score was 65, connoting mild symptoms or impairment.

At the VA C&P exam on 12 September 2006 (4 months prior to separation), the CI reported that he failed school in the Navy because he couldn’t read English.  His main sources of stress were events at home, including his mother, stepfather, brother and girlfriend.  He was not taking any medication for depression.  After separation, he hoped to attend college or work in the field of electronics.  Mental status exam showed a mildly dysthymic mood but was otherwise normal.  The examiner rendered a diagnosis of adjustment disorder with mixed anxiety and depressed mood, and assigned a GAF of 73 (transient and expected reactions to psychosocial stressors, no more than slight impairment in functioning).  C&P evaluations 4 months after separation indicated the CI was unemployed but was looking for a job.  VA preventive medicine and primary care screening exams on 13 June 2007 (5 months after separation) were negative for depression.  Psychiatric referral was not considered necessary.  A VA primary care clinic entry on 28 September 2007 (8 months after separation) documented a review of systems that was negative for depression.  The active medication list included no psychotropic drugs.  Referral for psychiatric evaluation or care was not considered necessary.

The Board directed attention to its rating recommendation based on the above evidence.  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.

Under the 9434 code (major depressive disorder) the PEB assigned a 10% rating, while the VA coded analogously to 9440 (chronic adjustment disorder) and rated at 0%.  Board members agreed that the 50% rating (“occupational and social impairment with reduced reliability and productivity”) was not described by the evidence, and deliberation settled on arguments between a 10% and 30% rating.  The §4.130 criteria for a 10% rating is “Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.”  A 30% rating requires “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.”  The Board considered that one or two threshold symptoms of a 30% rating were variably present (depressed mood, sleep disturbance), but in the context of GAF scores reflecting only mild or minimal functional impairment.  While academic difficulties were reported, these were likely due to language comprehension issues (i.e., not on the basis of mental symptoms).  Although the CI complained of loneliness and family separation, social functioning appeared to be relatively intact.  The Board concluded that the “intermittent inability to perform occupational tasks” stipulation of the 30% rating was not present, and that the condition was best described by the 10% rating criteria.  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 depressive disorder 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 classic migraine headaches with aura condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the depressive disorder condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  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 20140422, 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 29 Sep 15

      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:

- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN