RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00226
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090330

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Pharmacy Specialist, medically separated for “major depressive disorder [MDD]” with a disability rating of 10%.

CI CONTENTION:  The CI contends mental health, left shoulder, irritable bowel syndrome, post-traumatic headaches and bilateral elbow pain.  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 on 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 - 20090212	VARD - 20100303	
Condition	Code	Rating	Condition	Code	Rating	Exam	
MDD	9434	10%	Acquired Mental Disorder	9499-9435	10%	20091224	
			Post-Traumatic Stress Disorder	9411	NSC		
Left Shoulder	Not Unfitting	Left Shoulder Condition	5010	10%	20091230	
Irritable Bowel Syndrome		Irritable Bowel Syndrome	7399-7319	10%	20091210	
Post-Traumatic Headaches		Post-Traumatic Headaches	8100	0%		
Bilateral Elbow Pain		Right Elbow Condition	5299-5024	10%	20091230	
		Left Elbow Condition	5299-5024	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Major Depressive Disorder.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) mental health (MH) narrative summary (NARSUM), the CI was trained in infantry, but never reported to an infantry unit due to injuries.  Following an MOS Medical Review Board his MOS was changed to a pharmacy technician and he performed duties in this MOS for 6 months.  He then worked for 6 months as a Tax Return Assistant between 2007 and 2008.  He was not deployed to a combat zone.  The psychiatric evaluation for the MEB performed on 27 January 2009 was requested during the MEB process for orthopedic problems.  The CI reported a many year history of depressive symptoms but had no history of MH treatment prior to 2008.  He had attended a few counseling sessions with a social worker in July and August 2008, then stopped the sessions.  He was seen in the emergency room on 5 January 2009 for exacerbation of depression symptoms due to the suicide of a cousin and reported stressors of marital problems, financial problems, physical health problems and work problems.  He was started on an antidepressant medication.  At a follow up psychology visit on 23 January 2009, the CI reported distressing recollections of a suicide of a fellow trainee on the firing range in 2006.  He was given diagnoses of post traumatic stress disorder (PTSD) and mood disorder based on recollections of both suicides, anxiety, irritability, insomnia, flashbacks, and nightmares.  At the MEB MH NARSUM examination on 27 January 2009, 2 months prior to separation, the CI reported a variable mood with intermittent depression, frequent irritability with regard to supervisors, and frequent anxiety.  The MH examiner noted the CI’s company commander spoke negatively of him and the commander indicated the CI was “constantly trying to deceive command.”  His affect was noted to be irritable and depressed.  He denied suicidal or homicidal ideation (SI/HI), with rare SI in times of stress.  Thought processes were normal and there was no evidence of delusions or hallucinations.  Speech, concentration, memory and judgment were satisfactory and insight was noted as partial because the examiner noted the CI “believes he suffers from chronic mental symptoms which impair his ability to function in the military.”  The Axis I diagnosis was depressive disorder (d/o), NOS (not otherwise specified), chronic and on Axis II antisocial personality traits were noted.  Additional notes by the MEB psychiatrist are excerpted below.  

He presents with a claim of having PTSD in January 2009 related to an event of 2006, knowing that he is in the medical board process, with no mention in any visit with any provider of this problem prior to this  This includes evaluations in 2008 by three different mental health providers over several visits  He has made conflicting statements to various providers at different times and does not appear to be a totally forthright individual. 

The MEB psychiatrist continued that a diagnosis of PTSD was unwarranted at the time.  The CI was determined to fall below retention standards due to the depressive d/o, NOS and was described as having “occupational and social impairment due to mild or transient symptoms” which caused decreased “work efficiency and ability to perform occupational tasks during periods of significant stress.”  The MEB forwarded “depressive disorder NOS chronic” for PEB adjudication.

The MEB NARSUM examination on 30 January 2009 noted the CI disagreed with the MEB psychiatrist’s comments regarding the commander’s statements.  The CI felt that he was being persecuted by his command.  He reported he went through an administrative board for an “Other Than Honorable Discharge” and the Board unanimously recommended he be retained. 

On 28 August 2009, 5 months after separation, the CI was admitted as a psychiatric inpatient.  The admission history notes the CI reported he was first treated for depression in 2007 and the examiner noted a first use of marijuana in early adolescence and he “started using crystal meth at around age 20.”  The CI was admitted for worsening depression symptoms and recent SI and a suicide attempt of cutting his left arm (reported by his father) and on admission he was noted have elevated blood pressure and heart rate, pressured speech, and reported not sleeping for days.  The diagnosis was bipolar disorder.  The CI was transferred to a partial hospitalization program after stabilization but he was non-complaint with the program and left against medical advice (AMA).  

At a MH evaluation for state disability on 5 November 2009, 7 months after separation, the CI reported new historical facts of 8 suicide attempts by various methods from 2007 to June 2009.  He denied any use of alcohol or street drugs and denied any history of treatment for substance abuse.  The CI was on psychotropic medications.  The Axis I diagnoses were PTSD and bipolar disorder NOS.  The MH examiner indicated the CI’s MH symptoms were “somewhat controlled by his medications.”  The MH examiner noted no functional impairments due to the MH condition and indicated the CI’s abilities to understand and remember work related instructions, to sustain concentration and persistence, to interact with others and to adapt to changes in the work environment were not impaired by a mental illness. 

At the 24 December 2009 VA Compensation and Pension (C&P) evaluation, performed 9 months after separation, the CI reported he had PTSD as a child because his mother was physically and emotionally abusive, but he was not diagnosed with PTSD in childhood.  He reported he used marijuana heavily in high school and skipped a lot of school.  He reported he was an above average student in school but also thought he had attention deficit disorder (ADD) because he was an underachiever in school, but was not ever diagnosed with ADD.  He reported that twice in 10th grade he was admitted to an inpatient psychiatric facility for drug and behavior problems.  He reported being prescribed psychotropic medications by a psychiatrist at that time which he did not take for long due to side effects.  He also reported at age 20 he was in an inpatient drug rehabilitation program but left after 4 days.  The CI reported he was ordered to have a psychiatric evaluation by his command in 2007 and in 2008 he was diagnosed with PTSD by a psychiatrist.  The CI reported he had PTSD due to having to see burn victims at a stateside Army hospital as a pharmacy technician and also due to his cousin’s suicide in 2008.  The VA MH history noted the CI denied current drug abuse, but medical records noted he recently reported “smoking pot and abusing painkillers” and had tested positive for cocaine 3 months earlier breaking his VA narcotic contract.  Inpatient drug rehab was strongly advised but he declined.  Two hospitalizations in the summer of 2009 were noted – records were available for one (which appears to be the same as the hospitalization in August to September 2009 noted above) and diagnoses of bipolar disorder and polysubstance abuse were noted, along with leaving AMA.  The CI was taking multiple psychotropic medications.  The VA examiner noted the CI reported “many symptoms that are varied and follow no clear pattern.”  There was a history of bipolar disorder, but “no episodes of genuine mania have occurred exclusive of drug abuse” and although the CI denied a history of drug abuse “records indicate a long history of such that just recently caused him to be in violation of his narcotics contract.”  The CI reported a history of panic attacks and “records indicate that at times pt’s panic attacks are related to drug withdrawal.”  The MSE noted the CI was casually dressed, cooperative and friendly.  His speech was hyperactive and loud.  Mood was anxious with a full affect.  Thought process and content were normal and he was fully oriented.  Attention, concentration, and memory were intact.  There was no inappropriate behavior, hallucinations, delusions or obsessive compulsive behaviors noted.  His judgement, insight and impulse control were poor, with no violent episodes.  He did report SI as indicated above, but no HI.  The CI was not considered a reliable historian.  Standardized testing was performed and the MH examiner considered the results “probably invalid.”  The Axis I diagnoses were polysubstance abuse; bipolar disorder by history, not confirmed and Axis II was personality disorder, NOS with Cluster B traits (borderline, antisocial).  The VA MH examiner concluded as excerpted below.

Presently pt continues to struggle with long term drug abuse, including abuse of prescription painkillers.  He has a hx of Bipolar Disorder  which could not be confirmed based on the results of this clinical interview and testing.  Rather, pt’s drug abuse and maladaptive personality traits are the most salient aspect of this pt’s presentation.  Any significant impairment in occupational or social functioning is due to his personality disorder and/or consequences of drug abuse.  Regarding…pt’s depression, pt at this time does not meet criteria for Major Depression Disorder.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the major depressive disorder 10%, coded 9434 (major depressive disorder), citing meets criteria for 10% rating based on mild or transient symptoms.  The VA rated the acquired mental disorder 10% analogously coded 9499-9435 (mood order, NOS), based on the C&P examination 9 months after separation, citing occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.  The VA did not service-connect PTSD, also based on the C&P examination 9 months after separation, citing the CI did not have a combat stressor or stressor otherwise meeting the definition of a Criterion A stressor for a diagnosis PTSD.

The Board reviewed the case to see if a higher rating was supported.  The MEB psychiatrist used the language of the VASRD §4.130 10% rating criteria to describe the CI’s disability due to his MH condition at the time of separation.  The Board noted the CI was hospitalized after separation, however, the post separation records documented a diagnosis of polysubstance abuse at the time and at the later C&P examination, the examiner indicated the CI did not meet diagnostic criteria for PTSD or major depressive episode, but the CI did have ongoing difficulties due to active substance abuse and a personality disorder.  According to DoDI 1332.38 uncomplicated substance use disorders and personality disorders are conditions that do not constitute a physical disability and are not eligible for disability rating.  The Board concluded from the total evidence in record that at separation the MH disability was best approximated by the 10% criteria as recommended by the MEB psychiatrist.  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 major depressive disorder condition.  

Contended PEB Conditions:  Left Shoulder, Bilateral Elbow, Post-Traumatic Headaches (HAs), and Irritable Bowel Syndrome (IBS) Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.

Left Shoulder.  According to STR and the MEB Orthopedic NARSUM, the CI reported injuring his shoulder in a motor vehicle accident prior to entering the service, which required rotator cuff surgery, and he received a waiver to join the military.  He re-injured his left shoulder in 2008 and dislocated it again.  Shoulder X-rays showed mild degenerative changes.  Shoulder MRI showed evidence of repeated injury due to dislocation and old changes to the biceps and rotator cuff tendons.  He had a second surgery in August 2008 and after that he reported no further dislocations, but continued with pain, popping and grinding.  He reported the pain was constant but aggravated by activities.  At the MEB examination performed on the DD Form 2807-1 and 2808 (Report of Medical History and Examination) in December 2008 the physical exam showed decreased left shoulder internal and external rotation and extension with decreased strength.  The exam noted well healed surgical scars.  The left shoulder ROM was documented as flexion and abduction compared with the right side limited approximately 20 degrees (normal 180).  There was no muscle atrophy.  Testing for impingement was positive.  There was no evidence of instability, but there was pain with instability testing.  Muscle strength was 5/5.  The MEB NARSUM examiner opined that the condition was medically unacceptable and forwarded to the PEB for adjudication as medically unacceptable.  The commander’s statement did not directly implicate this condition as preventing the CI from performing his military specialty; however, this condition was permanently profiled (U3).  The MEB NARSUM examiner indicated the shoulder instability and pain, left worse than right was medically unacceptable and the MEB forwarded the “shoulder instability and pain secondary to shoulder dislocations and traumatic rotator cuff tear” condition to the PEB as medically unacceptable.  Left shoulder MRI on February 2009 showed mild rotator cuff tendinopathy without any other acute changes or new findings compared with the previous MRI reports.  At the VA C&P Joints examination on 30 December 2009, 9 months after separation, the CI reported left shoulder pain aggravated by activity.  The physical exam showed full strength of the muscles of the upper right arm and shoulder.  Left shoulder ROM was 120 degrees of flexion and abduction.  There was pain and crepitus with motion.  Testing for impingement was negative.  There was no additional loss of motion with repetitive use.  Left shoulder X-rays showed degenerative changes.  The Board concluded the preponderance of the evidence with regard to the functional impairment of the left shoulder condition favors its recommendation as an additionally unfitting condition at separation and eligible for Service disability rating.  

The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  Although there was insufficient limitation of motion to support a rating under the 5201 code, Board members agreed a 10% rating was justified coded as 5003 for painful, limited motion of single major joint with imaging evidence of degenerative arthritis.  There was no malunion or recurrent dislocation of the humerus following the surgery in 2008 to justify a higher rating under the 5202 code (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under the 5203 code (clavicle or scapula, impairment of).  After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of the left shoulder condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5003 and meets the VASRD §4.71a criteria for a 10% rating.  

The bilateral elbow, post-traumatic HAs, and IBS conditions were given U2, P2, and P2 profile designations on the permanent profile, respectively.  The MEB NARSUM examiner determined the HAs and IBS conditions met retention standards.  The MEB orthopedic examiner determined the bilateral elbow condition met retention standards.  The aforementioned conditions were reviewed and considered by the Board.  Profile designations of “2” indicate a condition that requires some limitations, but is not in all cases disqualifying for continued military service.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded there was insufficient cause to recommend a change in the PEB fitness determination for the conditions so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the MDD condition and IAW VASRD §4.130, the Board, , recommends no change in the PEB adjudication.  In the matter of the contended left shoulder condition, the Board unanimously agrees that it was unfitting and recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  In the matter of the contended bilateral elbow, post-traumatic headaches, and irritable bowel syndrome, 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Major Depressive Disorder	9434	10%	
Left Shoulder Instability and Pain	5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150324, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20170003450 (PD201500226)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA