RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03325
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20141230
SEPARATION DATE:  20031104

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Avionics Systems Journeyman) medically separated for major depressive disorder (MDD).  The CI’s mental health (MH) condition could not be adequately rehabilitated to meet the requirements of her Air Force Specialty (AFS).  She was issued a temporary S4 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded the following Axis I conditions to the Physical Evaluation Board (PEB) IAW AFI 48-123 and 44-113:  “maj depressive disorder/recurrent/moderate; anxiety disorder NOS; alcohol dep.”  The MEB also forwarded “borderline personality traits” as an Axis II condition.  No other conditions were submitted by the MEB.  The PEB adjudicated the referred Axis I conditions, less the alcohol dependence condition, as a single unfitting condition (for rating purposes), “major depressive disorder associated with anxiety disorder,” rated 30% disabling.  The PEB then deducted 20% from this rating for “aggravating/contributing factors,” yielding a net compensable rating of 10% for the CI’s unfitting MH condition.  The PEB determined the Axis I “alcohol dependent” condition as Category III “conditions that are not separately unfitting and not compensable or ratable.”   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 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 IPEB – Dated 20030912	VA - (~7 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder	9434	10%	Anxiety Disorder	9400	30%	20040524	
Alcohol Dependence	Cat III	No VA Entry	
Other x 0 (Not In Scope)	Combined:  40%	
Combined:  10%		
Derived from VA Rating Decision (VARD) dated 20040702 (most proximate to date of separation [DOS]).
ANALYSIS SUMMARY:

Major Depressive Disorder.  Review of the service treatment records (STRs) showed that the CI received her first MH evaluation in July 1998, at which time she reported symptoms of depression.  The STR was silent until February 2002 when she sought private psychiatric consultation and counseling.  She reported that during the previous 6 months she had extreme moods, difficulty with sleep, decreased appetite and energy, loss of interest, depression, crying spells, suicidal ideation, withdrawal and anxiety.  She acknowledged a history of multiple rapes and a chaotic upbringing.  She had been drinking 2-4 beers per night and feared the loss of her new marriage.  Diagnoses of major depressive disorder with anxious features, posttraumatic stress disorder (PTSD) and borderline personality disorder were rendered.  She was treated with antidepressant, sleep and mood-stabilizing medications, and counseling.

Due to the possible effects of psychotropic medications, in May 2002 she was removed from her job on the flightline and placed in administrative duties with an S4T profile.  In June 2002 she underwent a command-directed mental health evaluation and began to receive MH care from providers.  It was noted that she had been a “stellar performer at work earning top recognition in her shop and in her field.”

During the next year she was treated in the MH clinic with counseling and psychotropic medication management for diagnoses of depression and anxiety.  A psychiatrist’s note on 20 December 2002 (10 months prior to separation) indicated that she “has had long hours” but her “work performance has been maintained and she is interacting well with others.”  On 3 January 2003 her mood symptoms were noted to have worsened, but “occupational functioning is good.”  On 28 February 2003 (8 months prior to separation), in the context of continued symptoms of depression, a divorce and her son’s behavioral issues, the examiner reported “work performance has been adequate if not good.”

On an occupational health assessment on 25 March 2003, the CI noted that she was profiled for anxiety disorder, but denied that she was limited in her work for health reasons.  On 9 April 2003, the CI was hospitalized for 30 days at a civilian facility for excessive alcohol use and active suicidal ideation.  After hospital discharge, she continued counseling and medication management and also participated in alcohol abuse treatment for a new diagnosis of alcohol dependence.  At a follow-up on 13 June 2003 (5 months prior to separation), the psychiatrist reported that she was “exercising again, socializing, attending church and AA.”  She denied any recent alcohol use.  However, she was “falling asleep at work” which was thought to be a medication side effect.

An abbreviated MEB physical examination on 17 June 2003 noted that the CI was recently diagnosed with bipolar disorder.  On 21 July 2003 (3 months prior to separation), an MH care provider concluded that the alcohol dependence was in early full remission.  A psychiatry note on 25 July 2003 reported recurrent symptoms of depression including depressed mood, poor sleep, crying spells and decreased interest.  A psychotropic medication was added to her regimen.

At the narrative summary (NARSUM) exam on 1 August 2003 (3 months prior to separation) the CI reported her symptoms of depression, anxiety and fleeting suicidal thoughts had not remitted despite treatment for the past year.  She endorsed increased need for sleep and daily crying episodes.  She had not been able to perform the duties of her AFS since June 2002 and was taking three psychotropic medications.  The examiner indicated that during the April 2003 hospitalization the CI revealed a “ten year history” of alcohol abuse that included becoming intoxicated (15-18 beers) 3 to 4 days each week.  She was not in contact with her parents, had married three times, but was currently the single parent of an 8-year-old.  She lived on base, had a small group of friends she occasionally spent time with, and had recently declared bankruptcy.  Although the examiner stated that her condition resulted in “occupational withdrawal and difficulty,” no details regarding the CI’s recent or current job performance were provided.  Mental status exam (MSE) revealed a depressed mood and restricted affect, but was otherwise normal.  Diagnoses of MDD (recurrent, moderate), anxiety disorder not otherwise specified, alcohol dependence and borderline personality disorder were rendered and a Global Assessment of Function (GAF) of 60 was assigned (connoting moderate symptoms or impairment).  The examiner stated that the date of onset of MDD was February 2002, and was not attributed to substance abuse.  External precipitating events included marital difficulties, financial difficulties and being a single parent.  The date of onset of the anxiety disorder was also considered to be February 2002, but the examiner stated “it is currently undeterminable whether anxiety is primary, due to a general medical condition, or substance induced.”  Regarding alcohol dependence, the examiner noted that this was manifested by continued alcohol use despite its negative effects, but also indicated that the CI was abstinent for 3 months.

The final psychiatry note in evidence on 14 August 2003 reported the persistence of depression, low energy and decreased concentration.  The antidepressant medication dosage was increased.  No statement about functioning was made.  The final alcohol program treatment notes in August 2003 stated that “treatment goals are continually being met.”  On 28 August 2003 (2 months prior to separation), the last MH note in evidence indicated that ongoing depressive symptoms included irritability, depressed mood, decreased energy, and feelings of worthlessness.  An assigned GAF was 60.  There was no statement about occupational or social functioning.

At the VA Compensation and Pension (C&P) mental disorders exam on 24 May 2004 (7 months after separation) the CI expressed some confusion about why she was there.  “She does not feel that she is depressed….”  She acknowledged “being depressed and drinking heavily at one point while in the service,” but was alcohol free for the past 14 months.  She reported a childhood history of physical and sexual abuse, neglect, counseling “off and on,” drinking and intermittent depression and anxiety.  She also reported sexual harassment in the military, abusive relationships with men and three failed marriages.  After entry into the military, she increased her drinking to manage her symptoms.  At the time of her psychiatric hospitalization, she described being in a “trance” of which she was not aware, giving away possessions and checking her medications to see which would kill her.  Informing her therapist of this resulted in her immediate hospitalization.  She reportedly was not drinking at the time of hospital admission, but had recently stopped and was “detoxing”; her date of abstinence was on 27 March 2003.  She was diagnosed with bipolar disorder while hospitalized.  Since separation, she took no medication and received no counseling.  Although she denied depression, she endorsed constant worry about many things that interfered with sleep, sadness and a “terrible attention span” which interfered with her love of reading.  Her crying spells had decreased significantly, although she could still become teary-eyed.  She lived alone with her son, had friends and worked full-time as an office manager.  She attended church 3-4 times per week, which gave her a sense of support and optimism.  The MSE was normal except for appearing tense and anxious.  The examiner opined the military exacerbated her symptoms of depression and anxiety, and that “her alcohol abuse is seen as secondary to her anxiety and mood symptoms and used as a way to cope and self-medicate.”  The CI was thought to be minimizing her symptoms, but met criteria for a diagnosis of generalized anxiety disorder (GAD).  A GAF of 59 was assigned (moderate symptoms or impairment).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB initially assigned a disability rating of 30% for MDD associated with anxiety under the 9434 code (MDD), but subtracted 20% for alcohol dependence, which was considered not compensable or ratable (but was an “aggravating/contributing factor”).  The PEB concluded that, were it not for the alcohol dependence condition, impairment would have been “mild” (i.e. consistent with a 10% rating).  The VA assigned a 30% rating for anxiety disorder under the 9400 code (GAD).  The Board notes that the disability associated with all psychiatric conditions, regardless of the diagnosis, is subsumed under a single rating using the same criteria IAW VASRD §4.130.  Therefore the Board’s recommended disability rating is unaffected by the different psychiatric diagnoses adjudicated by the PEB and the VA (i.e. MDD or anxiety disorder).

The Board first considered the matter of the PEB deduction for alcohol abuse.  While the PEB’s latitude to apply DoDI 1332.38 E5.1.2.1 is not disputed, this instruction states that uncomplicated alcoholism is “not ratable in the absence of an underlying ratable causative disorder.”  The Board considered that the NARSUM examiner did not attribute MDD to alcohol abuse, but could not ascertain if anxiety was attributable to alcohol abuse.  While these conclusions could imply that “an underlying ratable causative disorder” of the alcohol abuse was present, the NARSUM did not explicitly state so.  However, the C&P examiner clearly addressed this issue, and firmly stated that the alcohol abuse was a result of the CI’s other underlying Axis I diagnosis.  Furthermore, at the time of the NARSUM evaluation (upon which the PEB based a 30% rating), the CI was abstinent from alcohol for 3-4 months, by which time the effect of alcohol on mental health symptoms was negligible or absent.  Moreover, post-NARSUM outpatient notes prior to separation confirmed the persistence of problematic depressive symptoms and no change in GAF scores, in the context of ongoing abstinence from alcohol.  The Board therefore concluded that imposing a deduction for alcohol dependence was not supported because there was an underlying, causative, ratable condition; and because alcohol use had ceased in time to assess symptoms and functioning solely attributed to MDD and anxiety.

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.  The Board next considered a §4.130 disability rating.  A rating of 10% requires “occupational and social impairment due to mild or transient symptoms during periods of significant stress; or symptoms controlled by continuous medication.”  A rating of 30% is described by “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks,” while a 50% rating requires “reduced reliability and productivity.”  The NARSUM exam identified no 50% threshold symptoms, but did note three 30% threshold symptoms.  GAF scores were consistently suggestive of moderate symptoms or impairment, and despite discontinuation of alcohol, symptoms prior to and soon after the NARSUM required escalation of antidepressant medication.  Regarding occupational functioning however, there was no commander’s statement and the NARSUM lacked relevant details.  Leading up to the time of hospitalization, occupational functioning as described by a psychiatrist was generally good.  By the time of the VA C&P exam, symptom improvement (but not remission) was evident in the context of no psychiatric treatment.  Although a GAF score was consistent with previous scores, and there were two 30% threshold symptoms, occupational functioning was intact, and she socialized and was heavily engaged in her church.  The Board concluded that, relevant to the time of separation, the evidence just elaborated was most accurately described by the 30% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the MDD condition, coded 9434.

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 MDD associated with anxiety disorder condition, the Board unanimously recommends a disability rating of 30%, coded 9434 IAW VASRD §4.130.  There were no other conditions within the Board’s scope of review for consideration.
RECOMMENDATION:  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 her prior medical separation: 

UNFITTING CONDITION	VASRD CODE	RATING	
Major Depressive Disorder Associated with Anxiety Disorder	9434	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140522, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

Dear XXXXXXXXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-03325.

	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 (210) 565-2273 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,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR
DFAS-IN