RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02814
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20060430

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Organizational Automotive Mechanic, medically separated for “anxiety disorder, NOS with PTSD features,” with a disability rating of 10%.

CI CONTENTION:  The CI request consideration of all conditions.  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.  

RATING COMPARISON: 

SERVICE PEB - 20060224	VARD - 20060502	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Anxiety Disorder NOS with PTSD Features	9413	10%	Major Depressive Disorder, Generalized Anxiety Disorder With Panic Attacks and Obsessive Compulsive Disorder and Mixed Personality Disorder	9400-9434	30%	20060228	
Major Depressive Disorder	Cat II					
Obsessive Compulsive Disorder	Cat IV					
Personality Disorder	Cat IV					
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 7 	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Anxiety Disorder NOS with PTSD Features.  According to the service treatment records (STR) and the mental health (MH) Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s first encounter with MH occurred after he was hospitalized in March 2005 secondary to making suicidal statement to his girlfriend over the telephone.  The CI was kept overnight for observation and was discharged to outpatient care for follow up.  Approximately 3 weeks later, he was hospitalized again overnight after he expressed suicidal ideation (SI).  An outpatient psychiatry consultation was conducted on 31 March 2005 and recorded the CI’s report of increased depression and stress post hospitalization.  He indicated that he felt people were making fun of him and they continued to ask him questions about why he was “stupid enough to go to the hospital.”  The CI also reported he had some difficulty with another service member, and he felt that his supervisor disliked him.  At the time of the evaluation the CI denied SI or homicidal ideation (HI) and reported that he was having problems with sleep secondary to anxiety.  He also reported symptoms related to depression which were mostly attributed to problems with his girlfriend who was no longer showing interest in him.  At the time he was diagnosed with an adjustment disorder and borderline/avoidant personality traits.  His medications were adjusted and he was referred to talk therapy.  In April 2005, he was diagnosed with depression, not otherwise specified and had a plan to continue with treatment.  

The CI was stable enough to deploy in a non-combat capacity in August 2005 for approximately 2 months before being medically evacuated.  On 28 September 2005, the CI was evaluated for the first time during deployment and reported his symptoms returned in July 2005.  He noted that his condition was stable with medication but that he gradually discontinued treatment.  He reported that all of his symptoms were related to his marital problems, and that his worse symptom was insomnia.  He noted that he had fleeting thoughts of suicide without a plan or intent.  Two days later, the CI was admitted to the hospital for acute SI, and was stabilized overnight.  However, due to his inability to contract for safety and continued SI, he was evacuated to Germany for continued care and disposition.  The CI’s condition could not be rehabilitated enough to allow for continued service, therefore, he was referred to the MEB.  

At the NARSUM dated 5 February 2006, approximately 2 months before separation, the CI endorsed symptoms of sadness, irritability, and other symptoms associated with depression and anxiety.  He had intermittent SI, and the psychiatrist noted that he had no history of suicidal attempts.  He also reported symptoms of obsessive/compulsive disorder and chronic symptoms of borderline personality traits, opined to be the primary focus of his initial treatment.  It was noted that his mood symptoms had improved for a period of time with medication treatment and by extension, his personality disorder traits also improved.  At the time of the NARSUM, the CI was taking psychotropic medication.  The examiner noted that his symptoms increased after deployment and had not improved since that point.  The mental status examination (MSE) recorded depressed mood and blunted affect and no other significant findings.

The VA Compensation and Pension (C&P) mental examination was accomplished 3 weeks after the NARSUM.  The examiner noted the CI had no combat experiences, ambushes or firefighters and did not have a combat action ribbon.  The CI reported problems with sleep and anxiety; he worried a lot and this contributed to his sleep issue.  He reported panic attacks at least once a week; however, these were not described nor was there any indication that they were impairing.  He continued to report intermittent SI and reportedly stated that he had some suicide attempts and wrist cutting behaviors (not documented in the STR).  There was no evidence of visits to the ER or any additional hospitalizations beyond October 2005.  He had continued his psychotropic medications.  It was noted that his wife was currently pregnant and he was in his second marriage.  The MSE was unremarkable with the exception of depressed affect and psychomotor retardation (slowness).  The examiner documented occasional panic attacks, sleep problems, anxiety and irritability.  The examiner recorded mild industrial impairment and moderate social impairment.  Diagnoses included major depressive disorder, GAD with panic attacks and OCD.  The examiner noted that his condition did not meet criteria for the diagnosis of PTSD and that all of his conditions existed before he was deployed to Iraq.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition of anxiety disorder with PTSD features, coded 9413 (anxiety unspecified) at 10%.  The VA used the analogous coding of 9400-9434 (GAD with MDD) and granted a 30% rating.  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 Category II major depressive disorder, recurrent condition contributed to the overall mental health pathology; however, it could not be recommended for additional rating IAW VASRD 4.14 (avoidance of pyramiding).  Regardless of diagnosis, VARSD §4.130 rates conditions based on symptoms, and therefore, all symptoms related to mental health are considered in the rating scheme.  

The Board proceeded to rate under §4.130 and compared the NARSUM, the non-medical assessment (NMA) and the C&P examination.  The NARSUM recorded repeat hospitalizations due to SI and noted that his symptoms worsened during the 2 months of deployment; however, it was noted in post-evacuation documentation that the CI’s condition was directly related to marital issues and that he had discontinued medication.  The MSE was unremarkable with the exception of blunted affect and depressed mood.  The Global Assessment of Functioning (GAF) score was recorded in the mild range (55-65).  The NMA noted that the CI was able to function well as a mechanic in a low to no stress environment, but that he seemed to lose his focus during stressful situations.  The commander noted that his production at work was lacking because of the time he spent at medical appointments.

At the C&P examination, the CI reported panic attacks at least once a week; however, these were not described nor was there any indication that they were impairing.  He continued to report intermittent SI.  There was no evidence of visits to the ER or any additional hospitalizations beyond October 2005.  He had continued his psychotropic medications.  It was noted that his wife was currently pregnant and he was in his second marriage.  The MSE was essentially normal.  The examiner credited occasional panic attacks and problems with sleep, but also stated industrial impairment was mild.  Although, the CI reported continued symptoms, clinical evidence demonstrated that his condition was stable, and was transient in nature, brought on during periods of significant stress.  His medications appeared to have been effective in controlling his symptoms since there was no additional hospitalizations and no recorded visits to the ER in the 6 months before separation.  There was no indication that the CI had any significant MH problems, ER visits or psychiatric hospitalization in the 18 months after separation.  After careful deliberations, Board majority agreed, at the time of separation the CI’s symptoms was most reflective of the 10% disability level (mild, transient, and well controlled by the continuous use of medication).  Therefore, there was insufficient evidence to justify a rating higher than 10% at the time of separation.  After due deliberation, and considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the cyclothymic disorder condition. 

Contended PEB Conditions:  Personality Disorder NOS and Obsessive-Compulsive Disorder.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The PEB categorized both condition as conditions which do not constitute a physical disability.  The Board agreed that the personality disorder is not a physical disability IAW DoDI 1332.38, which states personality disorders do not constitute a physical disability, and are therefore, not compensable or ratable. However, the condition of OCD is considered a physical disability, but in this case, the condition did not rise to the level of being unfitting.  The OCD was not profiled and was not implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the cyclothymic disorder condition and IAW VASRD §4.130a, the Board majority recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  In the matter of the contended personality disorder NOS and obsessive-compulsive disorder 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.  The Board majority 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 20140611, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

MINORITY OPINION:  The minority voting member disagrees with the majority’s recommendation that anxiety disorder, not otherwise specified (NOS) with PTSD features be assigned a 10% rating at separation.  The minority voter recommends a 30% rating.

The CI’s mental health condition began (September 2004) 20 months prior to separation receiving antianxiety, antidepressant and sleep medications during this period.  The CI was hospitalized and then medically evacuated from Iraq (October 2005), during his second deployment, due to anxiety, depressing and a suicide ideation, 7 months before separation.

The commander’s non-medical assessment, 5 months prior to separation, implicated the CI’s mental health condition stating the CI can work under a low stress environment but the CI loses focus during stressful situations.

The MEB NARSUM performed 2 months prior to separation, documented the CI with anxiety disorder NOS with a GAF of 55-65 (moderate to mild symptoms).  However, the examining psychiatrist opined the CI should be placed in a low stress work environment.  The examiner documented the CI had been treated with antianxiety, antidepressant and sleep medications, prior to his deployment to Iraq [second], where the CI’s psychiatric symptoms increased during the deployment and have not improved since that point.

The VA C&P examination, 2 months after separation, diagnosed the CI with major depressive disorder and generalized anxiety with a GAF of 50 (serious symptoms), citing:  decreased self- confidence, depressed affect, psycho motor retardation, lots of anxiety, occasional panic attacks and nightmares, lots of sleep problems and irritability; granting a 30% rating.

§4.130 criteria consist of:
	10% rating is “symptoms controlled by continuous medication,” and
	30% rating is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks”

Based on 4.3 (reasonable doubt), the minority finds the aforementioned evidence is indicative of a 30% mental health condition with occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.

RECOMMENDATION:  The Board minority, therefore, 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:

CONDITION	VASRD CODE	PERMANENT RATING	
Anxiety Disorder NOS with PTSD Features	9413	30%	
COMBINED	30%	

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 21 Oct 16

      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 USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC