RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04018
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20091012

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Machinist Mate, medically separated for “adjustment disorder with mixed disturbance of emotions and conduct” with a disability rating of 10%.

CI CONTENTION:  “My original condition was major depressive disorder.  My doctor processed my medical discharge using adjustment disorder as the condition rendering me unfit for duty.  I am currently rated at 100% service connected disability with the VA for major depressive disorder which has been consistent or worsening since my diagnosis in the military.  Also, my PDBR consisted of two officers, grade O-3 and O-4.  The letter I received with this form stated that my board should have consisted of three people, grade O-5, O-6, or civilian equivalents.  I did not rebut the decision since I would be medically discharged more quickly by not doing so.  Finally, in the doctor's report of my PDBR, I found numerous mistakes, which leads me to believe she was confusing me with another patient.”  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 - 20090805	VARD - 20100120	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Adjustment Disorder with Mixed Disturbance of Emotions and Conduct	9440	10%	Major Depressive Disorder, Single Episode Moderate	9434	50%	20091124	
Generalized Anxiety Disorder	EPTS					
Social Phobia	EPTS					
Occupational Problem	Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:   

Adjustment Disorder with Mixed Disturbance of Emotions and Conduct.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s adjustment disorder began 2007 after the unexpected death of her mother.  The first record in evidence is a primary care note dated 18 September 2007.  It noted that her mother had passed away accidentally 3 months earlier and that the CI remained symptomatic after fleet and family support counseling.  She requested more formal counseling.  Her mental status examination (MSE) was consistent with bereavement and she was offered counseling.  Her next primary care encounter was a routine health visit on 15 October 2007.  She was noted to have continued bereavement, but declined further intervention.  She was placed on 6 months of limited duty (LIMDU) on 15 September 2008; she was limited to being within 30 minutes of a military treatment facility, no overnight duty, and no weapons access.  The record then falls silent until a discharge summary from a psychiatric intensive outpatient program which was dated 15 December 2008.  It covered a treatment period from 1-12 December 2008.  She was noted to have poor coping skills and maladaptive behavior to stressors, but returned to (limited) duty.  She entered a second LIMDU on 27 February 2009.  

The mental health MEB NARSUM was dated 21 May 2009 and relied on an examination dated 8 May 2009, 5 months prior to separation.  It recorded that the CI had strained family relationships and felt guilt over her mother’s death.  She denied past or present suicidal ideation or self-mutilatory behavior.  She was noted to have pervasive and sometimes debilitating discomfort with social interaction which predated her enlistment.  This was aggravated while aboard the ship and associated with panic symptoms.  These lasted 5-10 minutes and occurred 3-4 times/week.  She felt depressed and trapped and self-referred for outpatient psychiatric treatment (above).  She was diagnosed with a major depressive disorder (MDD) first episode and placed on her first LIMDU.  She noted that she had been introverted and “unpopular” in high school.  She avoided people who irritated her and public situations.  Prior to accession, she was employed as a delivery driver for UPS.  She had joined hoping to be a pilot and was disappointed in her current occupation.  Her mother had encouraged her to remain in the military, but was now deceased.  She found the military “stupid” and anticipated returning to her home and was actively seeking civilian employment.  There was no history of treatment prior to the military, psychiatric hospitalization, or suicide attempts.  On examination, she was restricted and aloof.  Her mood was “blah” and passive-aggressive and stubborn behavior was noted.  Thought content was notable for guilt and unresolved anger which was self-directed.  Her global insight was poor.  She was noted to take minimal risk and isolated herself from interpersonal interaction with a “heightened awareness of emotional threat.”  She was considered stable for outpatient treatment.  It was noted that she remained in group and individual therapy.  It was also noted that she was “adamantly resistant to resuming her military obligations as a machinists mate.  She focused on post military plans of seeking employment in her home state.”  She was diagnosed with an adjustment disorder with mixed disturbance of emotions and conduct.  She was also diagnosed with two conditions which existed prior to service (EPTS): generalized anxiety disorder (GAD) and social phobia.  She was also thought to have a personality disorder not otherwise specified (NOS) with Cluster C traits (including avoidant behavior).  She was also noted to have severe impairment in social situations including the military and planned to seek employment in her pre-enlistment job, that of a UPS driver.  The Board determined that the CI suffered from Axis I disorders which were not present at enlistment, but were aggravated by her pre-existing social phobia and maladaptive character traits.  She was determined to have an unstable mood, but to no longer meet the criteria for a major depressive disorder (MDD).  It was noted that her overall symptoms remained “severe.”  She remained on multiple medications.  

At the VA Compensation and Pension (C&P) general examination performed on 12 November 2009, 1 month after separation, the CI reported that she was employed with UPS and planned to start school in January.  
She was friendly and had good eye contact.  She was neatly groomed and appeared to be in no psychological or physical distress.  She was alert and attentive.  Her speech was clear.  The limited mental status examination was normal.  The VA mental health C&P examination was performed on 24 November 2009, 6 weeks after separation.  The CI reported emotional abuse from her sister and father in childhood and that both had substance abuse problems.  Her mother had drowned after an overdose of alcohol and drugs.  She was working as a supervisor at UPS and planned to return to college in January to study engineering.  She reported being sad and empty nearly every day, lack of pleasure, fatigue, and feelings of worthlessness.  She reported a past history of panic attacks when in enclosed spaces and the examiner thought that these would recur if re-challenged.  She reported that she was scared to apply for a job (although she was working for UPS which she had planned to do prior to separation).  On examination, she was well groomed and dressed casually.  Her mood was mostly flat, but somewhat sad and plaintive.  Her affect was congruent and restricted.  The mental status examination was otherwise normal.  Her scores on the Beck’s Depression Inventory and Anxiety Index were both in the severe range.  She was diagnosed with MDD, GAD, and Panic Disorder.  The MDD occurred in the service, the GAD was aggravated in service, and the criteria for the Panic Disorder were not currently met.  A mental health follow up noted on 11 January 2010, 3 months after separation, documented that the CI was currently employed and attending a local community college, majoring in engineering.  The VA mental health C&P dated 12 August 2013 recorded that the CI had changed her major to electro-mechanical technology (engineering was too difficult) and had attended classed for a total of 5 years (2 were prior to service).  She had a 3.6/4.0 GPA.  She had worked as a supervisor at UPS from November 2009 until March 2011 when she left due to poor academic performance (implied that this was prior to the change in her major) at school and problems with a male co-worker.  She then worked in a work-study program from May 2011 until October 2012.  In her last year of work, she reported losing 1-2 days of work/week due to depression and anxiety.  No lost time from work was recorded for the period prior to this including the first year after separation.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the adjustment disorder with mixed disturbance of emotions and conduct at 10%, coded 9440 (chronic adjustment disorder).  An occupational problem was a related Category II condition.  GAD and social phobia were unfitting, but pre-existing conditions.  Category III conditions (not separately unfitting and not contributing to the unfitting condition) included weight gain and a personality disorder.  The VA rated the MDD, single episode, moderate, condition at 50%, coded 9434 (MDD).  The Board noted the multiple diagnoses listed by the PEB, some of which were EPTS or Category III.  However, the relative contribution of each was not specified in the PEB or the NARSUM.  Accordingly, a deduction for their contribution to the overall impairment under VASRD §4.130 cannot be determined.  The MEB NARSUM documented that the CI had no interest in continuing her naval occupation and was pursuing the same job post-separation that she had prior to accession.  The initial VA mental health C&P documented that she was working at the same company, but as a supervisor, a higher level of responsibility.  She planned on returning to college which she did at the start of the semester following separation.  A VA mental health C&P in 2013 documented that she continued the same job until 2011 when she changed jobs to focus on school.  There was no documentation that she had lost work due to the mental health condition for the first 2 years after separation.  The criteria for a 10% rating are “occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.”  This is clearly met as she was on medications at the time of separation and remained on them.  The criteria for a 30% rating are “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).”  The CI met the requirement for “intermittent periods of inability to perform occupational tasks” prior to separation.  
It was documented that she was “adamantly resistant” to resuming her military obligations and was focused on post-military employment.  This employment, which began shortly after separation in a different state, was apparently satisfactory as she kept the job for 17 months and was in a supervisory position, which would require interaction with others.  She was also taking classes at a local community college.  The level of function in evidence proximate to separation does not support a 30% rating.  After due deliberation, 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 mental health condition.  

BOARD FINDINGS:  In the matter of the mental health condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  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, with attachments
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