RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02651
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20150528
Separation Date:  20061011

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Fire Controlman) medically separated for somatization disorder.  The condition could not be adequately rehabilitated to meet the physical requirements of her Rating.  She was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  “Undifferentiated somatoform disorder” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded two other conditions (unspecified personality disorder and intractable migraine) for PEB adjudication.  The Informal PEB adjudicated “somatization disorder” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  Gastro esophageal reflux (GERD), tachycardia and intractable migraine were determined to be Category III (conditions that are not separately unfitting and do not contribute to the unfitting condition) and personality disorder was adjudicated as a 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 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 20060713	VA* - (~1 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Somatization Disorder	9421	10%	Dysthymic Disorder (claimed Depression with Anxiety, also claimed as Somatization Disorder)	9433	10%	20060907	
GERD	Cat III	GERD with Hiatal Hernia	7399-7346	10%	20060907	
Tachycardia	Cat III	Erratic Heart Rate with Chest Pain	7099-7000	NSC	20060907	
Intractable Migraine	Cat III	Migraines	8100	0%	20060907	
Personality Disorder	Cat IV	Bi-Polar With Schizoid Tendencies	8432	NSC	20060829	
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 12	
RATING:  10%	COMBINED RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20061113 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Somatization Disorder.  The CI reported that she had been depressed for most of her life.  She had a suicide attempt at age 16, when she injected snake venom and drank some bleach after the murder of her friend.  She first came to Mental Health (MH) in 2002, when due to complaints of back and leg pain, Pain Management was unable to determine any specific etiology for her recurrent pain.  She was psychiatrically hospitalized in a military hospital for a week due to feelings of being overwhelmed due to stress.  The CI was then followed on ship by MH from 10 August 2004 to 5 November 2004.  The psychologist noted an extensive psychological history which included several diagnoses (adjustment disorder, personality disorder, and rule out somatization disorder) and that the CI received regular psychotherapy for 5 months following the last hospitalization.  The psychologist opined the CI’s believed “healing” ability demonstrated schizotypal traits, but did not rise to the level of delusions.  The mental status examination (MSE) showed fair insight and judgment with intermittently tangential thoughts.  The examiner diagnosed:  Axis I Adjustment disorder with anxious and depressed mood, rule out dysthymia, possible somatization disorder; Axis II personality disorder-schizotypal and borderline traits; and Axis III-long history of vague somatic complaints.  He further recommended that the CI was psychologically fit and suitable for full duty.  The diagnosis was changed to mild dysthymia on 15 September 2004 with an Axis II- personality disorder not otherwise specified with schizotypal traits and Axis III - long history of vague somatic complaints.  The CI continued to report symptoms of low energy, poor concentration, absent libido, worthlessness, anhedonia and sadness.  She underwent extensive neuropsychological testing on 23 March 2006 and the examiner concluded that the findings “did not reflect a pattern expected with her history of a mild head injury or for that matter, any other neuropathological process.” The examiner further opined that the MMPI-2 profile suggested a selective exaggeration of MH symptoms and that it was also notable that she had a history of suspected somatization.  The examiner documented that it was also possible that the CI was “exaggerating symptoms in order to secure secondary gain.”  The commander’s statement indicated that the CI was absent 15 hours per week for treatment and that she had no assigned duties because her condition put her and others at risk.  The MEB narrative summary (NARSUM) addendum, approximately 6 months prior to separation, documented that the CI reported a dysphoric mood for 2 years and endorsed derealization (an alteration in the perception or experience of the external world so that it seems unreal) and depersonalization (the feeling that you're observing yourself from the outside).  The MSE showed a slow and deliberate speech with a slight stutter; blunted affect; a “down” mood; slowed, but linear thought process; and impaired judgment and insight.  The examiner documented that the psychological testing conducted in March 2006 had results which were equivocal and therefore not inconsistent with the diagnosis of somatization disorder.  The examiner noted that the CI was educated on the nature of somatization disorders, but her insight did not increase and her symptoms did not improve.  The prognosis for somatization disorder was poor and the Global Assessment of Functioning (GAF) was 35 (inability to function in almost all areas).  There was a severe degree of industrial, military and civilian performance impairment.  The VA Compensation and Pension (C&P) exam approximately a month prior to separation documented that the CI reported symptoms of depressed mood, crying, lack of energy, early morning awakenings, difficulty remaining asleep, confusion and feelings of hopelessness and anxiety.  The CI was taking medications prescribed for her psychiatric condition.  The MSE showed a significantly depressed mood and affect; fair insight and judgment, poor eye contact, and an overall depressed look.  The examiner opined that the CI suffered from a dysthymic disorder, had been significantly depressed for years, that there was no evidence to support a diagnosis of bipolar disorder, and her anxiety was part of her depression.  The examiner further opined that he was unable to be certain about the presence of a possible somatization disorder, because this was by definition a longitudinal diagnosis and he had no way of appreciating whether or not her symptoms were specious (misleading) or not.  The GAF was 60 (moderate difficulty in social, occupational, or school functioning).  The examiner indicated that the CI was capable of working on a full-time basis from a MH point of view.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the somatization disorder as unfitting, rated 10%, coded 9421 (somatization disorder).  The VA coded the dysthymic disorder (claimed depression with anxiety, also claimed as somatization disorder) as 9433 (dysthymic disorder), rated 10%.  There was clear evidence in the service treatment record (STR) that the CI had a severe somatization/dysthymic disorder.  The neuropsychologist opined that the MMPI-2 profile suggested a selective exaggeration of MH symptoms and that it was also notable that she had a history of suspected somatization.  He further documented that it was also possible that the CI was “exaggerating symptoms in order to secure secondary gain.”  The MEB examiner opined that the prognosis for somatization disorder was poor and that the GAF was 35.  There was a severe degree of industrial and military impairment and a severe degree of civilian performance impairment.  The VA C&P examiner opined that the CI suffered from a dysthymic disorder and had been significantly depressed for years.  The GAF was 60.  The examiner documented that the CI was capable of working on a full-time basis from a MH point of view.  The Board agreed that the VA C&P exam was closer to separation, more clearly represented the CI‘s condition at the time of separation and adjudged that this exam had the higher probative value.  The Board considered the 30% rating criteria of “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal)” versus the 10% rating criteria of “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.”  The Board agreed that the CI’s symptoms more closely aligned with 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 somatization disorder.

Contended PEB Conditions.  The contended conditions adjudicated as not unfitting by the PEB were GERD, tachycardia, intractable migraine and personality disorder.  The PEB adjudicated GERD; tachycardia and intractable migraine as Category III (conditions that are not separately unfitting and do not contribute to the unfitting condition).  The PEB also adjudicated the personality disorder condition as a Category IV (conditions which do not constitute a physical disability).  The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications.  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.

GERD Condition:  The CI was seen by Gastroenterology for reports of daily reflux symptoms which were triggered by spicy foods and that she had nocturnal symptoms.  She was given medication and underwent an endoscopy which revealed a hiatal hernia.  An abdominal CT scan performed in February 2003 was normal.  She underwent a gastric 24 hour ph. test and manometry which were normal.  The MEB examiner noted that Gastroenterology had no real diagnosis for her reflux but that she was on numerous medications for her symptoms.  The VA C&P examiner opined that although the CI reported that she had GERD symptoms, these symptoms did not cause a functional impairment. 

Tachycardia Condition:  The CI reported that her heart rate would accelerate with a resultant shortness of breath and chest tightness.  She underwent an extensive work-up for tachycardia which included several invasive tests (two trans-esophageal echocardiograms and two cardia catheterizations) and several noninvasive tests.  The exhaustive cardiac testing produced no diagnosis except for benign tachycardia which was treated with medication.

Intractable Migraine:  The CI was noted to have a history of typical migraines in February 2004 and was given medication to take at onset of the migraines.  The neurologist noted that the CI reported migraine headaches for 9 years and had increased in intensity to occurring on a daily basis.  They were intensified by physical activity and relieved by rest.  She was seen in the emergency room for migraines six times between December 2005 and March 2006 along with being closely followed by Neurology.  The CI was prescribed a variety of medications to control the migraine headaches.  She was not placed on LIMDU for migraine headaches.  She underwent an electronystagmography (ENG performed to detect disorders in the inner ear that cause problems with balance and orientation) which was normal.  The MEB NARSUM addendum documented that there was no sign of post-traumatic headache and that the CI had not been compliant with her migraine medication.  There was no documentation in the STR that she had prostrating episodes caused by the migraine headaches.

Personality Disorder:  This contended condition was discussed under the unfitting somatization disorder.  To separate this condition and adjudicate it as a separately unfitting condition would be pyramiding as specified by §4.14 Avoidance of pyramiding (the evaluation of the same disability under various diagnoses is to be avoided).

The MEB examiner documented that the CI had undergone more than 30 imaging studies including brain MRI’s and upper endoscopy testing.  She had additionally undergone multiple medical procedures including cardiac catheterization, endoscopy and a lumbar puncture that contradicted her symptoms.  He further documented that “it is concerning that she continues to make herself available for invasive studies.”  The examiner also strongly opined that “she is undergoing unnecessary and potentially dangerous medical tests that increase her likelihood of injury or death.”

None of these conditions required a LIMDU.  The commander’s statement only noted that the CI’s “condition” put her and others constantly at risk; however he did not document a specific condition.  None of these conditions were judged to fail retention standards.  All were reviewed by the Board.  There was no indication from the record that any of these conditions significantly interfered with satisfactory duty performance.

After due deliberation 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 contended GERD, tachycardia, intractable migraine and personality disorder conditions and, therefore, no additional disability ratings can be recommended.

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 somatization disorder condition and IAW VASRD §4.71a, the Board recommends no change in the PEB adjudication.  In the matter of the GERD, tachycardia, intractable migraine and personality disorder contended conditions; the Board unanimously recommends no change from the PEB determinations of not unfitting.  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 20140523, 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 2 Dec 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:

- 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)