RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03717
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050706

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Health Services Management Apprentice, medically separated for “depressive disorder” with a disability rating of 10%.

CI CONTENTION:  The CI contends that she was given a higher rating for her conditions by the VA.   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 - 20050511	VARD - 20051011	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Depressive Disorder	9434	10%	Major Depressive Disorder	9434	30%	20050802	
Tobacco Habituation	Not Unfitting 	No VA Placement	
Alcohol Abuse			
Personality Disorder			
Dependent, Histrionic, and Borderline Personality Traits			
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Depressive Disorder.  The service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 14 March 2005 indicated the CI had a history of outpatient and inpatient treatment for behavioral health issues.  The diagnosis of an adjustment disorder with depressed mood was made based on symptoms of crying, decreased concentration and insomnia, which began in 2001, after the CI reported she was almost sexually assaulted.  Symptoms continued into 2002 when her husband was first deployed.  Various medications were tried including Paxil (paroxetine, an antidepressant), Restoril (temazepam, to treat insomnia), and Ambien (zolpidem, a sedative).  The NARSUM indicated the CI’s first psychiatric admission was in 2002 at which time she was diagnosed as having a personality disorder and malingering.  Lexapro (escitalopram, an antidepressant medication) was added to the treatment protocol for depression and Elavil (amitriptyline, an antidepressant) was added in 2003.  The CI was admitted in 2005 for post-partum depression marked by crying spells.  A note dated 31 January 2005 indicated the CI was released from the hospital on 22 January 2005 and had three suicidal behaviors and experienced two hallucinations in the prior week after she stopped her medications that were “making me sick.”  As a result she voluntarily went in for inpatient hospitalization.  The NARSUM indicated the CI attempted to kill herself for the third time in a month on 29 January 2005.  On examination she was alert and oriented, was in moderate distress and was tearful.  She had a minimally increased rate of speech and mildly increased kinetics with fidgeting.  Her mood was “anxious, not good” and her affect was restricted to the dysphoric (unease, dissatisfaction, or at least some sad (feeling down, blue, worthless, upset, hopeless and frustrated)) range.  Thought processes were logical, linear, and goal-directed without suicidal ideation, homicidal ideation, hallucinations, or delusions when hospitalized.  Her judgment and insight were fair and the Folstein Mini-Mental Status Examination (to determine cognitive impairment) was normal at 30/30.  Her Global Assessment of Functioning (GAF) score on admission was 52 (moderate symptoms) and was 62 (some mild symptoms) on discharge and her social/industrial impairment was mild-moderate, and her military impairment was marked.  Continued psychiatric management and outpatient alcohol treatment were recommended.  Effexor (venlafaxine, an antidepressant) and Seroquel (quetiapine, an antipsychotic medication for mood instability and insomnia) were added in February 2005.  Behavioral health counseling continued; Seroquel was discontinued due to nightmares.  The CI was admitted to the hospital for a depressive disorder, alcohol dependence, unspecified personality disorder and borderline personality disorder in April 2005 and was admitted again in May 2005 for an overdose of 13 pills of Klonopin (clonazepam, for seizures, panic disorder, and anxiety).  At a behavioral health session on 2 June 2005 the CI denied suicidal or homicidal thoughts, had plans for the future, and was to continue supportive counseling.  

A P4 profile was issued in May 2004 for pregnancy, which was due to expire on 29 January 2005.  The commander’s statement was undated and indicated the CI was working in her primary Air Force Specialty (AFS), but her illness, when it manifested itself, did affect her ability to perform her duties including an inability to perform full shifts and being worldwide qualified.  When her illness was controlled, she was an excellent performer.  However, her current condition made her presence for duty somewhat unreliable.

At the VA Compensation and Pension (C&P) examination for Mental Disorders dated 2 August 2005, performed 1 month after separation, the CI reported a depressed mood, about 4 hours of fitful sleep each night, and “horrible” concentration.”  She lost 40 pounds over the prior several months some of which was related to pregnancy, had crying spells “all the time,” and suicidal thoughts once in a while, as well as three suicide attempts.  A mental status examination revealed the CI had a depressed mood with an affect congruent with her mood.  Her speech was logical with a small amount of spontaneity; and the rate and flow of speech were within normal limits.  She was able to manage activities of daily living.  There was no evidence of hallucinations or delusions, but she did note that periodically she heard crying and thought that her baby was crying at times.  She was not seen as dangerous to self or to others and was alert and oriented to time, person, place, and situation.  She was aware of recent events; her remote memory was grossly intact; and her insight and judgment seemed fairly good.  Her Axis I diagnosis was major depressive disorder, recurrent; her Axis II diagnosis was rule out borderline personality disorder; and her GAF score was 53 (moderate symptoms).  The examiner opined the CI’s depression was moderate to moderately severe and did cause impairment in her life; therefore, she was recommended to seek treatment and have her medication reassessed.

The Board directed attention to its rating recommendation based on the above evidence.  The Board first deliberated whether Veterans’ Affairs Schedule for Rating Disabilities (VASRD) §4.129 (for any “mental disorder that develops in service as a result of a highly stressful event”) is applicable to this case.  All members agreed that the depression was not related to a highly stressful event, although the CI reported she was almost sexually assaulted in 2001.  However, that topic did not arise in subsequent evaluations in the service treatment record or in the VA C&P examination.  Therefore, the Board determined that the depression was independent of any highly stressful event and VASRD §4.129 is not applicable in this case.  The Board then turned to deliberation of a fair rating recommendation at the time of separation derived from criteria of VASRD §4.130 and based on the disability evidenced in the service treatment record at the time of separation.  The PEB assigned a 30% rating using code 9434 (major depressive disorder) for a Category I depressive disorder, not otherwise specified, civilian social and industrial impairment definite.  The PEB then subtracted 20% for less aggravating/contributory factors and opined the CI’s personality disorder significantly affected the severity of the depressive disorder.  The VA assigned a 30% rating using code 9434 for a major depressive disorder.  The Board discussed whether the PEB’s subtraction of 20% was appropriate and supported by facts in the record.  The CI’s commander indicated she was working in her primary AFS and when her illness was controlled, she was an excellent performer, which was supported by her annual performance reports.  While the behavior associated with a personality disorder may have played a role in the CI’s depressive symptomatology at the beginning of her enlistment, with time the depression was exacerbated by her husband’s deployments and childbirth; and, many therapeutic interventions were less than effective.  The Board members discussed DoDI 1332.38 E4.A1.1.3.7.4. (Every effort must be made to distinguish symptoms and impairment resulting from personality disorder or mal-adaptive traits from impairments based on other psychiatric conditions) and concluded the depressive disorder symptoms played the major and a very significant role in the CI’s overall condition and the final rating is determined based on those symptoms; therefore, Board members determined that no subtraction is warranted.  A 30% rating IAW DoDI 1332.38 E4.A1.1.3.7.3. (Diagnostic and Statistical Manual of Mental Disorders IV) initially assigned by the PEB and favored by the Board is consistent with an “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), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).”  The Board then sought a route to a higher rating at 50%, which requires “Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.”  However, the CI’s condition did not rise to that level since she neither had flattened affect, speech difficulties, panic attacks, difficulty understanding commands, nor impairment of memory or judgment.  However, she did have disturbances of mood and was not infrequently depressed, but those symptoms were likewise addressed in the 30% rating criteria.  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 depressive disorder condition, coded 9434.  

Contended Category III Conditions-Tobacco Habituation, Alcohol Abuse, Personality Disorder, and Dependent, Histrionic, and Borderline Personality Traits.  The Board’s main charge is to assess the fairness of the PEB’s determination that the Air Force Category III Conditions (conditions that are not separately unfitting and not compensable or ratable) tobacco habituation, alcohol abuse, personality disorder, and dependent, histrionic, and borderline personality traits contended conditions were not unfitting.  The tobacco habituation, alcohol abuse, personality disorder, and dependent, histrionic, and borderline personality traits conditions were not profiled or explicitly implicated in the commander’s statement and were not judged to fail retention standards.  However, each of the aforementioned conditions is not a physical disability and are not compensable or ratable.  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 fitness determination for the any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the depressive disorder condition, the Board unanimously recommends a disability rating of 30%, coded 9434 IAW VASRD §4.130.  In the matter of the contended tobacco habituation, alcohol abuse, personality disorder, not otherwise specified and dependent, histrionic, and borderline personality 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	
Depressive Disorder	9434	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140806, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

PDBR PD-2014-03717

MEMORANDUM FOR THE CHIEF OF STAFF

	Having received and considered the recommendation of the Physical Disability Board of Review and under the authority of Title 10, United States Code, Section 1554a (122 Stat. 466) and Title 10, United States Code, Section 1552 (70A Stat. 116) it is directed that:

	The pertinent military records of the Department of the Air Force relating to XXXXXXXXXXXXXXXXXXXXX, be corrected to show that:

		a.  The diagnosis in her finding of unfitness for Depressive Disorder, VASRD code 9434, was rated at 30% rather than 10%.  

		b.  On 5 July 2005, spouse-only coverage under the Survivor Benefit Plan based on full retired pay was established.

		c.  She was not discharged on 6 July 2005 with entitlement to disability severance pay; rather, on that date, she was released from active duty and on 7 July 2005, her name was placed on the Permanent Disability Retired List.