RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02927
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20050603

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Personnel, medically separated for “major depressive disorder” rated 30% but received a 20% dedication for less aggravating/contributory factors from personality disorder and noncompliance with therapy resulting in a disability rating of 10%.

CI CONTENTION:  “Please consider 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 confined to 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 - 20050420	VARD - 20051215	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder …	9434	  30%
-20%
 10%	Major Depressive Disorder w/Anxiety Disorder, NOS; Axis II Per History Personality Disorder	9434	30%	20050811	
Personality Disorder	Cat III					
Low Back Pain	Not Adjudicated	Low Back Pain	Not Service Connected	
Migraines		Migraines	8100	30%	20051201	
Urinary Tract Infections		No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:

Major Depressive Disorder, Recurrent, Moderate (Including Axis II Personality Disorder).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s major depressive disorder condition began in June 2002 following mental health symptoms that began in basic training.  The service entry history and physical showed no complaints or diagnosis of any mental health diagnosis.  The CI was seen for emotional issues in June 2000 with a diagnosis of adjustment disorder.  In January 2001 and May 2002 she was hospitalized for history of depression and suicidal ideation and gestures.  In June 2002 the CI was diagnosed with major depressive disorder, recurrent, moderate.  The CI was treated with multiple and varied medications and therapy.  The Axis II diagnosis of personality disorder was added in February 2002 and the CI was again hospitalized for high suicide risk and was referred for an MEB.  The MEB forwarded “AXIS I:  major depressive disorder, recurrent, moderate; AXIS II:  personality disorder, not otherwise specified as illustrated by her chronic patterns of impulsivity, recurrent suicidal ideation, affective instability, and stress-related paranoid ideations; and AXIS III:  low back pain, migraines and frequent urinary tract infections” to the PEB.

At the MEB NARSUM examination dated February 2005, 4 months before separation, the CI reported worsening anxiety.  History indicated a diagnosis of major depressive disorder, recurrent, moderate.  She was also on numerous medications and therapy of very limited benefit.  The CI began experiencing severe anxiety symptoms and difficulty sleeping in October 2004 after arriving at her new duty station.  On evaluation at the Life Skills Support Center she reported a significant history of depressive symptoms (depressed mood, anhedonia, poor sleep, poor appetite, poor energy, poor concentration, feelings of worthlessness and occasional suicidal ideation but without plan or intent) and medications were changed.  The NARSUM indicated that the CI had “been very noncompliant with appointments but has repeatedly emailed and telephoned Dr. X. with complaints of anxiety and depression.”  On 2 February she was seen by mental health feeling suicidal with a plan and she was admitted to a civilian psychiatric hospital.

The mental status examination showed the CI displayed depressed blunted affect and cried through all parts of the interview.  There was mild psychomotor retardation, and she admitted to active plans of harming herself such as cutting her wrist or overdosing.  “Insight and judgment appear to be poor at this time.”  There was no evidence of a thought disorder, and cognition and memory were intact.  The mental health diagnoses were (Axis I) major depressive disorder, recurrent, moderate; and (Axis II) personality disorder, not otherwise specified (NOS).  The Global Assessment of Functioning (GAF) was 25 (in the serious impairment range) and the psychiatrist indicated military impairment was marked and social/industrial impairment was definite.

The commander’s statement from February 2005 indicated that the CI was unable to accomplish her duties “due to the overarching emotional problems she's displayed, she fails to maintain focus to complete her work” and had missed work for medical appointments often without notice.  Treatment notes following the NARSUM indicated continuing therapy with a GAF of 55 (moderate symptom range) improving to a GAF of 75 and a change of diagnoses to Axis I:  major depressive disorder, recurrent, in partial remission; plus anxiety disorder NOS Profile:  S-4T; with Axis II remaining personality disorder NOS.  Of note, the CI was recommended to be placed on the “High Interest” log as she had missed 2-3 appointments.

At the VA Compensation and Pension (C&P) examination in December 2005, 6 months after separation, the CI reported sleep disturbance, low energy, a variable mood, and guilt over not working.  She denied anxiety symptoms and denied suicidal or homicidal ideations.  The mental status examination showed a mildly constricted affect with a tearful mood.  There was no evidence of any thought disorder and insight and judgement were adequate.  The psychiatrist diagnosed major depressive disorder, recurrent moderate; anxiety disorder, NOS; and Axis II per history, personality disorder, not otherwise specified.  GAF was assessed at 60 (in the moderate symptom range).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 30% rating coded 9434 (major depressive disorder), deducting 20% (as noted above) for a combined 10% disability, citing “…the severity of the member's unfitting condition (major depressive disorder) has been directly aggravated by her underlying personality disorder, and by her documented noncompliance with attending appointments scheduled by her mental health provider.”  The VA assigned a 30% rating also coded 9434 based on the VA C&P examination 6 months after separation, citing symptoms of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.

The Board first addressed if the provisions of VASRD of §4.129 (mental disorders due to traumatic stress) were applicable in this case.  The Board determined that the major depressive disorder was not due to a “highly stressful event” as used in the VASRD, and that §4.129 is not applicable in this case.  The Board next considered its §4.130 rating recommendation at the time of separation.  The service treatment records and the VA exam supported occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks supporting a rating of 30%.  The NARSUM was the single examination potentially supporting a rating above 30%, but was considered a snapshot in time and not indicative of the CI’s overall disability picture.

The Board next deliberated on the PEB’s deductions from their 30% “current rating” for major depressive disorder for personality disorder and noncompliance.  It must first be noted that, regardless of fitness considerations, the personality disorder condition is not compensable IAW DoDI 1332.38 (E5.1.3.9.2) or VASRD §4.9.  There was no evidence of pre-existing mental health symptoms or diagnoses for any existed prior to service (EPTS) rating deduction.  Although DoDI 1332.39, in effect at the time (rescinded), made some provisions for noncompliance deductions, there is no VASRD-compliant path for deductions in mental health ratings for noncompliance.  IAW DoDI 1332.38, deductions must be under accepted medical principles and be predicated on medical facts that are so reasonable and logical as to create a virtual certainty that they are correct.  The Board adjudged that the personality disorder was not compensable and that there was not sufficient evidence for a rating deduction from 30%.  After due deliberation, and in consideration of all the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the major depressive disorder condition, coded 9434.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended Axis III conditions of low back pain, migraines and frequent urinary tract infections were not unfitting (the Axis III conditions from the MEB were not addressed by the PEB and that was considered an implied finding of not unfitting).  Axis III describes physical problems that may be relevant to diagnosing and treating mental disorders, and there was no NARSUM or MEB indication that any of the Axis III conditions failed to meet retention standards.  Only back pain was profiled or implicated in the commander’s statement, and it was addressed as not significantly interfering with duty.  Neither of the other condition (migraines and frequent urinary tract infections) was profiled or mentioned in the commander’s statement.  There was no performance-based evidence from the record that any of the contended conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB’s implied fitness determination for the contended low back pain, migraines and frequent urinary tract infections conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the major depressive disorder, recurrent, moderate condition, the Board unanimously recommends a disability rating of 30%, coded 9434 IAW VASRD §4.130.  In the matter of the contended personality disorder, low back pain, migraines and frequent urinary tract infections 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 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, Recurrent, Moderate	9434	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140613, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR THE DIRECTOR, AIR FORCE REVIEW BOARDS AGENCY

SUBJECT:  Physical Disability Board of Review Recommendation on	  Case Number PD-2014-02927

	In accordance with Title 10 § 1554a and in compliance with DoDI 6040.44, the Physical Disability Board of Review (PDBR) adjudicated the disability rating accompanying the medical separation of the covered individual from the United States Air Force.  After carefully reviewing the application and medical separation case file, the PDBR recommended modification of the disability rating previously assigned to reflect a combined rating of 30% rather than 10%, without re-characterization of the separation.

I have reviewed the application and Record of Proceedings and I recommend you accept this proposed decision.

As a reminder, a copy of your decisional documents must be provided to the PDBR at the following address:

	Sincerely,

Attachments
1.  Record of Proceedings
2.  Case File