RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03799
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20040416

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Yeoman, medically separated for “major depressive disorder, recurrent, severe, with psychotic features” with a disability rating of 10%.

CI CONTENTION:  The CI requested 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 - 20040219	VARD - 20050426	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder, Recurrent, Severe, with Psychotic Features 	9434	10%	Major Depressive Disorder With Anxiety And Somatoform Disorder	9434	70%	20050304	
Somatoform Disorder, NOS	Cat II					
Anxiety Disorder, NOS 						
Colonic Dysmotility 		Duodenal Diverticulum, Claimed of Enterogastritis and
Duodenitis	7307-7305	20%		
Chronic Abdominal Pain						
Ventral Incisional Hernia	Cat III	Status Post Ventral Hernia Repair and Residual Scar	7339	20%		
Hypertension		Hypertension	7101	0%		
Irritable Bowel Syndrome		Irritable Bowel Syndrome	7319	NSC		
Chronic Hepatitis C		Hepatitis C 	7354	20%		
Specific Phobia	Cat IV	No VA Placement	
Personality Disorder, NOS with Borderline Narcissistic,
Passive-Aggressive, and Dependent Traits		No VA Placement	
Hyperlipidemia		No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Major Depressive Disorder (MDD) and other Mental Health conditions.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) mental health (MH) narrative summary (NARSUM), in 2001, the CI’s anxiety escalated and he had panic attacks that were precipitated by intense stress or interpersonal conflict.  When stressed he reported that he heard voices of a man telling him to harm others and himself.  He was admitted to the local hospital’s psychiatric unit after he reported suicidal ideation associated with financial, occupational and health stressors, and specifically in response to sexual harassment allegations made by female co-worker.  Approximately 6 weeks after hospitalization, his MH condition was in full remission; however, his depression with psychotic symptoms returned within a couple of months, and he continued with a cycle of stability and reoccurrences related to multiple stressors.  Despite treatment, the mental health condition could not be adequately rehabilitated to meet the requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded the following MH conditions, “major depressive disorder, recurrent, severe, specified as with psyc, somatoform disorder, not otherwise specified, specific phobia, and personality disorder NOS w/Borderline Narcissistic, passive-aggressive” for PEB adjudication.  

According to the NARSUM, in October 2001, the CI reportedly admitted to some improper conduct towards a female co-worker but no formal charges were made.  He noted that his job had caused him considerable stress.  He had problems with supervisors and co-workers.  He also had marital problems due to financial difficulties since filing bankruptcy in 1999.  He had chronic GI issues and had undergone multiple medical evaluations without a clear etiology.  On 3 October 2001, the CI was admitted to inpatient psychiatry as noted above.  His condition stabilized and fully remitted within a month post hospitalization; however, his stressors returned around December 2002 and he was again admitted to psychiatry due to command hallucination.  On 22 January 2003, the CI phoned his psychologist to advise that the Navy wanted him to return to work tomorrow and he stated, “I can’t do it.”  He reported that he was suicidal and felt unable to go to work.  He was admitted to the hospital.  The CI attended intensive outpatient partial hospitalization program after hospital discharge and was attending this program at the time of the NARSUM.

At the NARSUM examination on 5 February 2003, approximately 14 months before separation, the CI endorsed symptoms of recurrent depression, anxiety, perceptual disturbances, and somatic symptoms.  He also had a phobia of public toilet use, he noted he felt unsafe in them.  Mental status examination (MSE) was unremarkable with the exception of a somewhat inappropriate affect and guarded judgment.  The examiner documented two community hospital admissions, and the CI was currently enrolled in a partial hospitalization program.  It was noted the CI reported multiple medical conditions and symptoms.  The examiner acknowledged that there may have been an underlying GI disorder; however, opined that “The symptoms complaints and level of dysfunction are in excess of what would be expected from the history, physical examination, and laboratory findings.”  The diagnoses of MDD, recurrent, severe with psychotic features, somatoform disorder NOS (manifested by a combination of symptoms reflecting pain disorder with both psychological and medical conditions), anxiety disorder NOS, and specific phobia (fear of using public toilets) were recorded.  In addition to the above noted Axis I diagnoses, the CI was also assessed with borderline personality disorder and personality disorder NOS with narcissistic, passive-aggressive, and dependent traits.  On 18 June 2003, the psychiatrist submitted an addendum to the NARSUM that detailed treatment history and response, as well as occupational functioning.  He was under pressure to return to work where he had not worked since April 2002.  It was noted that in May 2003 he requested to return to work in a part-time capacity while continuing his outpatient therapy.  Three days after returning to work on part-time status, his symptoms re-emerged and he was again admitted to the inpatient unit for command auditory hallucinations telling him to kill people.  During the admission, the CI reported that he had received little benefit from the partial program and that he “faked it a lot.  It was just someplace to go instead of going back to work.”  The CI was stable at discharge and was mandated to live in the barracks.  Going forward, the CI’s symptoms remained stable, and there were no report of suicidal or homicidal ideation, panic attacks, or hallucinations.  His MSEs were all unremarkable.

The GI addendum to the NARSUM prepared by the general surgeon on 22 October 2003, 6 months before separation, noted that since submission to the MEB, the CI had not requested medication for pain for his abdominal symptoms, and had not sought care from the service for chronic abdominal pain.  The physician opined that the CI’s condition of irritable bowel syndrome (IBS), formally diagnosed as colonic dysmotility, had improved secondary to submission of the MEB, and MH treatment.  At the time of the addendum, the CI was working 4 hours daily in maintenance administration.  

At the 4 March 2005 VA Compensation and Pension (C&P) examination, 11 months after separation, the CI reported he had continued to have good response to his psychotropic medications and had good response to talk therapy.  He had no evidence of post separation psychiatric hospitalization.  He was not employed.  MSE documented depressed mood and affect.  The examiner noted judgment was not impaired, and there was no report of obsessions, delusions, or psychotic symptoms present during the exam.  The CI reported panic attacks as often as 8 times per month, and stated his short-term memory “is completely gone.”  He reported that he continued to have intermittent auditory hallucinations and suicidal and homicidal ideation.

The Board directed attention to its rating recommendation based on the above evidence.  The formal PEB rated the condition of major depressive disorder coded 9434 at 10%, and recorded the conditions of somatoform disorder NOS, anxiety disorder NOS and colonic dysmotility, and chronic abdominal pain as conditions contributing to the unfitting condition (CATII).  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 VA used the same code but rated the condition at 70%.  The Board first considered the PEB’s opinion that the colonic dysmotility and chronic abdominal pain were CATII conditions.  In the review of evidence, it was noted that the psychiatrist opined that the CI was suffering from a somatoform condition, and indicated his pain condition was best explained by a somatoform disorder.  Board members concluded, the chronic abdominal pain symptoms constituted the somatoform disorder and should have been subsumed under the somatoform disorder condition and not viewed as separate conditions.  The Board also noted the GI addendum which was written several months after the psychiatry examination, noted the colonic dysmotility was associated with the IBS condition which was found not unfitting and is discussed below in the contended conditions section.  Next, the Board noted there was no specific, highly stressful service related event to invoke §4.129 for a mental disorder due to traumatic stress.  

The NARSUM recorded two hospitalizations secondary to suicidal ideation without intent, 2-3 years prior to separation.  The STR demonstrated the CI’s condition had remitted for 1 year after the second admission.  However, stressors returned and he was admitted for the 3rd time secondary to suicidal thoughts, nearly 2 years prior to separation.  The record demonstrated that his condition was responsive to medications; however, with the introduction of stressors, he responded with suicidal ideation and reported auditory hallucination.  The addendum to the NARSUM recorded an additional hospitalization nearly 1 year prior to separation, and there was no documented evidence that the CI sought treatment in the ER in the year prior to separation.  There was no report of significant MDD symptoms in the year prior to separation.  The Board considered the absence of suicidal and homicidal ideation in the 11 months before separation, absence of documented visits to the ER, no additional hospitalizations in nearly 12 months, and stability of his condition in the 11 months prior to separation, and his ability to return to work in his military occupational specialty (MOS) on a part-time basis.  The Board also noted the transient nature of his condition, and the temporal relationship of his symptoms to life stressors.  

After considerable deliberations, Board members agreed that the CI’s condition at the time of separation was stable and responsive to medication.  Board members concluded that the CI’s condition did not justify a rating higher than the 10% disability rating for “Occupational and social impairment due to transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress.”  The Board acknowledged the reported deterioration of his condition post separation, documented in the C&P examination; however, also noted multiple inconsistencies recorded in that examination and absence of hospitalization for his reported suicidal, homicidal, and psychotic symptoms.  

As noted above, VARSD §4.130 bases its rating on symptoms and not diagnoses, thus, all symptoms related to MH (somatic or psychological) were considered in the rating of the MDD condition.  In consideration of the above statement, the Board opined that the somatoform disorder NOS, anxiety disorder NOS, and chronic abdominal pain conditions were integral components of the MDD condition and could not be recommended for additional ratings IAW VASRD§ 4.14 (avoidance of pyramiding), and IAW §4.130.  

After due deliberation, and considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the major depressive disorder condition. 

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the ventral incisional hernia, hypertension, irritable bowel syndrome, and chronic hepatitis C conditions were not unfitting.  The ventral incisional hernia, irritable bowel syndrome, and chronic hepatitis C conditions were not profiled, and although, the commander’s statement (CS) implicated the GI conditions, in part, as the cause of loss of work, the statement was completed prior to the CI’s return to work, and 7 months prior to the GI NARSUM that noted the CI had not required nor sought treatment for his condition since the month prior to the CS.  The ventral incisional hernia, irritable bowel syndrome, and chronic hepatitis conditions were not judged to fail retention standards.   

The hypertension condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  The Board considered the CAT IV conditions of specific phobia, personality disorder, NOS with borderline, narcissistic, passive-aggressive, and dependent traits, and hyperlipidemia adjudicated by the PEB as conditions that do not constitute a disability.  DoDI 1332.38.E2.1.25, states “To constitute a physical disability, the medical impairment must be of such a nature and degree of severity as to interfere with the member’s ability to adequately perform his or her duties.”  The Board, agreed these conditions do not satisfy the definition of DoDI 1332.38.  Additionally, IAW DoDI 1332.38, personality disorders are not considered a physical disability and are therefore, not ratable or compensable.

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, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the Major Depressive Disorder condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended ventral incisional hernia, hypertension, irritable bowel syndrome (colonic dysmotility), and chronic hepatitis C, specific phobia, personality disorder, NOS with borderline, narcissistic, passive-aggressive, and dependent traits, and hyperlipidemia conditions, the Board unanimously agrees that it cannot recommend them for additional disability rating.  There were no other conditions within the Board’s scope of review for consideration.  

The Board, 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 20140818, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 11 Aug 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 USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN