RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	    CASE:  PD-2014-03753
BRANCH OF SERVICE:  Army  	Seperation date:  20080511

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Medic, medically separated for major depressive disorder, with a disability rating of 10%.  

CI CONTENTION:  The CI has asked for consideration of all conditions. The applicant’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 - 20080402	VARD - 20081015	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder with Psychotic Features	9434	10%	Major Depressive Disorder, Severe with Psychosis and Stress Induced Menorrhagia	9434	30%	20080702	
Chronic Knee Pain	Not Unfitting	Degenerative Disease of the Left Knee	5260	0%	20080702	
		Right Knee Condition	5260	NSC	20080702	
Occupational Adjustment Problems	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Major Depressive Disorder with Psychotic Features.  Service treatment records noted the CI presented to the emergency room (ER) in July 2006 with a report of depression that was worse over the past few weeks.  She had a similar episode in September 2005.  In the ER, she easily became tearful and was admitted to the hospital.  She also began to feel increasingly suspicious and paranoid towards others.  According to the narrative summary (NARSUM) examination, dated March 2008, she was so impaired she could not perform her military duties.  While inpatient she expressed fears of rape and being left alone with males.  She was diagnosed with major depression with psychotic features and treated with medicines for depression and for psychosis.  After discharge she was seen as an outpatient.  After tapering medications she had another episode of depression and paranoia in November 2007.  

The CI was readmitted to the hospital 8 November 2007 after she had increasing depressive symptoms, paranoid thoughts, suicidal ideation, guilty feelings, and a lack of trust for anyone.  She was having paranoid thoughts that she “might have been raped.”  She reported she wanted to return home because she was homesick.  Her medications were changed and by 17 November 2007, paranoid thoughts and auditory hallucinations had stopped.  At this point she became very tearful as she recalled being raped.  She discussed the incident with details and sobbed uncontrollably.  She reported she had been raped by three active duty soldiers.  Her mood/symptoms regressed by 21 November 2007 and she was depressed with paranoid/psychotic thinking.  She vacillated between memories of rape and uncertainty of her thoughts.  She had been drunk the night of the incident and had “blacked out” but in the morning found she was traumatized in her vaginal area.  She felt guilty and blamed herself.  She was focused on returning to duty and was discharged 26 November 2007and agreed to follow up.  

She requested a taper off medication since she had been stable.  After a 2-week leave to her home country, she returned with symptoms of paranoia, suspiciousness, and depression.  She was uncomfortable at work and did not trust her co-workers, thinking that everyone at work was talking about her.  While in her home country, she felt the equivalent of the CIA was following her.  Her paranoia peaked at the airport coming back and officials observed her acting strangely.  Her medications were restarted and she returned to baseline within weeks.  A diagnosis of bipolar disorder was considered because she had suggestive symptoms of mania.  Several medication changes resulted in stabilization.  She did not believe she had a “major psychiatric illness,” so she continued only with medicine for depression.  

The commander’s statement noted the CI was a hard working Soldier always willing to take on any challenges that her superior gave her…she desired to leave the military and expressed feelings of being uncomfortable and uneasy during the past few months but not fully explaining why.  The NARSUM, dated March 2008, completed by her treating psychiatrist in March 2007, noted she was stable without active psychotic symptoms.  She had light duty in her duty area to limit stressors with no social or occupational problems within 2-3 months.  She was compliant with medications for depression and psychosis.  A diagnosis of major depressive disorder with psychotic features was rendered.  No Global Assessment of Functioning (GAF) score was documented.  

At the VA Compensation and Pension (C&P) examination performed 3 months after separation, the CI reported her symptoms began in 2005 when she was gang raped.  She did not report it and had to work in the same department as her assailant.  She kept the assault secret between 2005-2007.  She did have nightmares.  The CI reported she was fearful and her symptoms interfered with intimacy with her husband.  She had depression and anxiety.  Since leaving the military she felt less pressure.  She was taking medications for depression and was mentally stable but the examiner felt she minimized her symptoms and was defensive about revealing her symptoms.  She was attending college and finishing a Master’s Degree.  She had been married for a week and her social life consisted of time with her husband.  Her leisure activities included visiting his friends, reading and watching television.  She enjoyed science and math and was fluent in four languages.  MSE showed her to be anxious and somewhat agitated.  Affect was one of anxiety and depression.  She was unemployed.  The examiner opined she had significant occupational impairment including her social anxiety and depression but she could work and attend college.  A diagnosis of MDD with psychosis was rendered with a GAF of 50 (serious bordering on moderate impairment, symptoms.)  

At a psychology consult, dated January 2009, the CI again reported sexual assault that occurred while she had been drinking and involving more than one guy.  She did not report it since she thought no one would believe her.  She had remembered parts of it but had tried to convince herself it did not happen.  She reported intrusive memories and cried during the interview as she discussed the rape. She also reported fear, avoidance of rape scenes in movies, difficulty trusting people, a lack of friends, hypervigilance, and guilt.  She often did not want her husband to touch her.  The MSE noted a dysthymic mood and affect, but she denied suicidal ideation.  She was interested in therapy.  A diagnosis of PTSD and depression was rendered with a GAF of 50.  VA outpatient notes indicate she remained in therapy, attending over 40 outpatient visits through April 2011.

At a follow-up patient orientation group a week after the consult, the CI noted she slept from 8am-2pm daily and took melatonin to assist with her sleep.  She was still trying to complete a Master’s Degree.  MSE noted she appeared depressed, was quiet, and sat in a corner.  In a therapy session September 2009, she reported she accepted the rape had really happened.  

The Board directed its attention to its rating recommendation based on the above evidence.  Under the 9434 code (major depressive disorder), the PEB assigned a 10% rating, and the VA assigned a 30% rating.  The Board first considered whether the provisions of VASRD §4.129 (mental disorder due to a highly stressful event) were applicable for the unfitting MH condition.  Regardless of final PEB mental health diagnosis, §4.129 does not require a PTSD diagnosis, but is utilized to determine if a mental disorder is due to a highly stressful event that is severe enough to bring about the veteran’s release from active military service.  The Board determined the CI’s unfit MH condition had its onset after she was raped, and therefore §4.129 is applicable.  Accordingly, the CI must then be placed into constructional TDRL with a minimum 50% rating followed by a TDRL removal rating 6 months later IAW the VASRD, DoDI 6040.44 and DoD guidance.

All members agreed that the VASRD §4.130 (MH rating) for the CI’s TDRL placement was not assessed higher than a 50% rating.  After due deliberation and consideration of all of the evidence, and mindful of the VASRD §4.3 (reasonable doubt), the Board unanimously recommends a rating of 50% for the MDD condition at TDRL placement.  The Board then determined the §4.130 MH rating at TDRL removal for the permanent rating recommendation.

The Board determined the most proximate source of comprehensive evidence, to evaluate the CI at TDRL removal, was the psychology consult of January 2009.  She discussed the rape and its impact on her emotions, endorsed many PTSD symptoms, complied with anti-depression medication, and expressed an interest in therapy to overcome her feelings.  A diagnosis of PTSD was added to the MDD diagnosis.  She had several chronic 30% threshold symptoms (anxiety, suspiciousness, and depression) reported prior to the MEB and at the C&P examination.  Though the examiner opined the CI appeared to be functioning pretty well, had some meaningful relationships and was taking medication with good response.  The CI was diagnosed with Axis I PTSD and a GAF of 50 (serious symptoms) and determined to have depression, suspiciousness, anxiety, sleep difficulty and other PTSD symptoms.  The Board therefore concluded that the 30% rating most accurately depicted the condition at the time of removal from TDRL.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a TDRL placement rating of 50% and permanent disability rating after removal from TDRL of 30% for the MDD disorder.

Contended Chronic Knee Pain, Occupational Adjustment Problems.  The Board’s main charge is to assess the fairness of the PEB’s determination that chronic knee pain and occupational adjustment problems were not unfitting.  

Occupational Adjustment Problems.  The Board noted in accordance with VASRD 4.130 Schedule of Ratings-Mental Disorders, Occupational adjustment problems is not a recognized psychiatric diagnosis (not under Axis I or Axis II), and therefore not a ratable condition.  

Chronic Knee Pain.  The CI reported bilateral knee pain that began during military service in 2004.  The DD Form 2808, Report of Medical Examination, dated 15 February 2008, noted a full range-of-motion of both knees with bilateral crepitus, right greater than left.  A diagnosis of bilateral knee pain was rendered.  The C&P examination noted the CI had a normal gait, could stand up to 4 hours and could walk 2-3 miles.  C&P examination showed the use of orthotic inserts for walking.  

The chronic knee pain and occupational adjustment problems were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.   There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation 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 chronic knee pain and occupational adjustment problems contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the MDD disorder, the Board unanimously recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129 and §4.130; and a 30% permanent rating at 6 months IAW VASRD §4.130.  In the matter of the contended chronic knee pain and occupational adjustment problems conditions, the Board 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, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Major Depressive Disorder	9434	50%	30%	
RATING	50%	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140716, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160009335, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to constructively place you on the Temporary Disability Retired List (TDRL) at 50% disability for six months effective the date of your original medical separation for disability with severance pay and then following this six month period re-characterize your separation as a disability retirement with the combined disability rating of 30%.  Enclosed is a copy of the Board's recommendation and record of proceedings for your information.

The constructive TDRL period and the re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing you 50% retired pay for six months from the date of your original medical separation and then 30% disability retired pay effective the date following the constructive six month TDRL period, minus the amount of severance pay you were previously paid at separation.

The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO}, XXXXXXXXXXXXXXXXXXX.

A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,

 

Enclosure