RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02746
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060117

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a reserve E4, Heating, Ventilation, and Air-Conditioning (HVAC) Technician, medically separated for “major depressive disorder, mild social and industrial adaptability impairment” and “migraines,” rated 10% and 10% respectively, with a combined  disability rating of 20%.  

CI CONTENTION:  The CI made no specific contention.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 based upon a 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.  

In addition, the Secretary of Defense Mental Health Review Terms of Reference directed a comprehensive review of Service members with certain mental health (MH) conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The MH condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.  

RATING COMPARISON:  

SERVICE PEB - 20051102	VARD - 20070423	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder, Mild Social and Industrial Adaptability  Impairment	9434	10%	Major Depressive Disorder	9434	70%	20070130	
Migraines	8100	10%	Migraine Headaches	8100	30%	20070207	
Histrionic Personality Traits	Cat III	See 9434	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Major Depressive Disorder (MDD).  According to service treatment records (STR) and the mental health Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had symptoms of depression starting while deployed in the summer of 2002.  She was initially seen by a military psychiatrist in September 2003 where she related continued depressive symptoms on Elavil and medications were adjusted.  The CI had episodes of depression, mood swings, anxiety symptoms with no reported stressors identified, and anhedonia to various degrees through March 2004.  Despite treatment with medication and therapy, the CI’s mental health conditions did not improve sufficiently to meet the requirements of the CI’s military specialty and she was referred to an MEB.  The MEB forwarded mental health diagnoses of “depressive disorder not otherwise specified (NOS), anxiety disorder NOS, somatoform disorder NOS, and Axis II: no diagnosis with histrionic personality traits” for PEB adjudication.  

The MEB MH NARSUM examination on 26 May 2004, 20 months prior to separation, noted multiple somatic complaints, frequent episodic depression, frequent episodic anxiety, and an ongoing difficulty tolerating stress.  “There were frequent emergency room visits for both migraine and GERD (abdominal complaints).”  On mental status examination (MSE) her mood was often depressed and her affect was frequently tearful.  There was no suicidal ideation, delusions, hallucinations or other symptoms suggestive of psychosis, speech disturbance, objective cognitive impairment, or other abnormality.  

The Axis I diagnoses were depressive disorder NOS; anxiety disorder NOS; and somatoform disorder NOS.  Axis II indicated no diagnosis with histrionic personality traits and the Global Assessment of Functioning (GAF) was 60 (moderate symptom range 60-51).  The psychiatrist stated there was marked military impairment with mild social/industrial impairment.  The psychiatrist’s disposition noted that the CI “suffers from intermittent symptoms of anxiety and depression with associated somatic complaints. … She demonstrates extreme difficulty tolerating stress. … Her psychiatric illness is likely to follow a waxing and waning course, with significant periods of social and occupational impairment.”  An update memorandum from the psychiatrist dated 29 July 2005, 6 months prior to separation, indicated there had been no changes in the CI’s condition.  

There was an undated commander’s “member utilization questionnaire” that indicated the CI had been a productive worker prior to deployment and recommended the CI for retention in a non-UTC position since the CI was non-deployable.  

There was a 19 September 2005 life skills clinical note, 6 months prior to separation, that indicated the CI noted persistent depressed mood and episodic anxiety since being seen the week prior for a panic attack.  She continues to struggle with energy and motivation to complete tasks during the day.  She had taken methylphenidate (Ritalin) for one month and did not note any improvement in daytime performance.  MSE showed a “depressed” mood with a dysphoric/tearful affect and was otherwise normal.  The psychiatrist assessed the GAF at 60.  

There was a consult to psychiatry from the FPEB, dated 24 October 2005 requesting an evaluation stating “During today's hearing the Board was concerned with her risk of suicidal ideation as (the CI) stated on two occasions that she does not want to be alive.  Please evaluate her suicidal ideation and whether she may need further evaluation or management.”  That evaluation showed a diagnosis of major depression with an MSE indicating a sad and tearful mood with congruent affect and the CI denied suicidal and homicidal ideations.  The GAF was 60 (moderate symptom range).  

At the 30 July 2007 VA Compensation and Pension (C&P) evaluation, performed 12 months after separation, the CI reported symptoms of depression with crying spells, decreased energy, decreased concentration, panic attacks, sporadic auditory hallucinations, and suicidal ideations.  The examiner documented, “They seem to be moderately severe in nature.  She has them all the time.”  She recently stopped taking her antidepressants since she had a baby.  The CI had a boyfriend and a five month old child, and tended to isolate herself from friends and family.  The CI was working full time at the post office and reported having problems functioning there because of difficulty with concentration and difficulty getting along with people.  The MSE was notable only for a depressed mood and blunted affect.  Insight, judgement and impulse control were fair.  There was no active suicidal ideation, delusional or hallucinatory symptoms, or other symptoms suggestive of psychosis, speech disturbance, objective cognitive impairment, or other abnormality.  The diagnosis was major depression and the GAF was 45 with “moderately severe symptoms.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the major depressive disorder condition 10%, coded 9434 (MDD), citing mild social and industrial adaptability impairment,” likely IAW DoDI 1332.39 in effect at the time.  The Formal PEB (FPEB) added remarks that the CI “suffers from intermittent symptoms of anxiety and depression, and periods of social and occupational impairment during periods of significant stress.”  The SECAF Personnel Council added follow-up appointment information through August 2005 stating:  “the (CI) reported having a "relatively stable mood" and that she ‘[was] coping well.’  The (CI) continues to report periodic suicidal ideation and her condition is expected to follow a chronic ‘waxing and waning’ course.  

The VA rated the MDD condition 70%, coded 9434, based on the VA C&P examination 12 months after separation, citing occupational and social impairment, with deficiencies in most areas.  

The MEB forwarded mental health diagnoses of “depressive disorder NOS, anxiety disorder NOS, and somatoform disorder NOS and the PEB rated “major depressive disorder.”  The diagnosis of anxiety disorder NOS was eliminated from the final FPEB determination.  This case therefore meets the inclusion criteria in the Terms of Reference of the Mental Health Diagnosis Review Project.  

The Board noted that there was no traumatic event causing the unfitting mental health condition(s) and therefore concluded that application of VASRD §4.129 was not appropriate in this case.  Although the CI was diagnosed with three mental health conditions (MEB diagnoses), a single §4.130 rating is applied based on the overall occupational and social impairment due to the symptoms from all mental health conditions.  The FPEB assessment that major depression was the predominant MH condition appeared reasonable and correct.  

The Board adjudged that the NARSUM examination and STR had the highest probative value for rating at separation and that the VA examination indicated post-separation worsening.  The FPEB awarded a 10% rating.  The 10% VASRD criteria are “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 higher VASRD 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.”  All Board members agreed that at the time of separation, the §4.130 threshold for a 50% rating was not approached, and deliberations focused on the 30% versus 10% criteria.  

The commander’s statement described good work effort prior to the CI’s deployment and recommended retention in a non-UTC position; however, it was undated and did not appear to describe the CI’s occupational functioning after deployment.  

The Board deliberated if the CI’s symptoms indicated only mild/transient symptoms or decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or if that decrease was occasional and not related to “periods of significant stress.”  

The Board majority adjudged that the CI’s frequent (non-migraine) emergency department visits were intermittent periods of inability to perform occupational tasks most likely at least partially related to her mental disorder (including somatoform disorder NOS); that the CI’s “extreme difficulty tolerating stress” appeared to be for circumstances that would be less than “periods of significant stress” as used in the VASRD criteria; a GAF in the moderate symptom range; and the CI’s likely “waxing and waning course with significant periods of social and occupational impairment” more closely aligned with the disability picture of the 30% rating criteria.  Board consensus was that the CI’s condition at the time of separation supported the higher 30% disability rating, and that her level of impairment was best described as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily).  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 30% for the MDD condition, coded 9434.  

Migraines.  According to the STR MEB NARSUM, the CI’s migraine condition began in approximately 2002 and she was diagnosed with migraine headaches by neurology in April 2003.  Treatment did not result in improvement sufficient to allow unrestricted duty and the CI was referred for an MEB.  The MEB forwarded “migraines” for PEB adjudication.  

The MEB NARSUM examination on 4 August 2005, 5 months prior to separation, noted complaints of headaches with having been on several abortive medications and trying a new medication.  The examiner noted frequent emergency department visits for migraines.  The CI had a prior normal CT of the head.  The CI underwent sinus surgery in July 2005 that did not help her migraines.  

A telephone consult from the neurologist dated 24 October 2005 indicated the CI had previously had “severe debilitating migraines” that were well controlled on a new medication (Zonegran) and that the CI “is well controlled now with very few migraines, to none at all.”  At the 7 February 2007 VA C&P evaluation, performed 13 months after separation, the CI reported migraines with nausea, vomiting, and photophobia that occurred three times per week.  Medications did not relieve the headaches.  MRI was reported as negative.  Neurologic examination was normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The FPEB rated the migraine condition 10%, coded 8100 (Migraine), citing mild social and industrial adaptability impairment.”  The FPEB added remarks that the CI “suffers from migraines for which her provider sees her every 6 weeks.”  He states since starting her on Zonegran, she is well-controlled and experiences "very few migraines to none at all."  Her provider also states she does very well as long as she takes her suppressive migraine medication.”  The SECAF Personnel Council noted no emergency treatment since April 2005 and referenced a neurologist’s note, dated 8 November 2005, stating:  “(the CI) currently is starting a new medication and will need follow up to see how effective this is for migraine.  She is responding well to abortive treatment of migraine and [thus] is improving with continued treatment."  

The VA rated the migraine condition 30% coded 9434, based on the VA C&P examination 13 months after separation, citing use of abortive medication and characteristic prostrating attacks occurring on an average of once a month over the last several months.  

Rating guidance under diagnostic code 8100 is based on the frequency of “prostrating attacks” over the “last several months.”  The VASRD does not further define prostrating attacks; however, commonly accepted definitions include “utter physical exhaustion or helplessness” (Webster's New World Dictionary of American English), “complete physical or mental exhaustion” or “extreme exhaustion or powerlessness” (Dorland's Illustrated Medical Dictionary).  Review of the record did not show prostrating headaches occurring on average once per month, or more frequently, over the last several months prior to separation to support a rating higher than the 10% adjudicated by the PEB.  

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 condition.  

BOARD FINDINGS:  In the matter of the MDD condition, the Board majority recommends a disability rating of 30%, coded 9434 IAW VASRD §4.130.  In the matter of the migraine condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  The single voter for dissent recommended no change to the MDD rating and did not elect to submit a minority opinion.  There were no other conditions within the Board’s scope of review for consideration.  

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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Major Depressive Disorder	9434	30%	
Migraines	8100	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140606, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR

Dear 

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-02746.

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 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