RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00245
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20070615

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Munitions Systems Apprentice, medically separated for “bulimia nervosa, purging type, associated with major depressive disorder,” with a disability rating of 10%.

CI CONTENTION:  The CI made no specific contention.  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 - 20070502	VARD - 20071116	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bulimia Nervosa, Purging Type, associated with Major Depressive Disorder	9521	10%	Major Depressive Disorder with Bulimia nervosa	9521-9434	100%	20070911	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:  

Bulimia Nervosa, Purging Type, associated with Major Depressive Disorder.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI presented to the Base clinic in late December 2006 with report of bulimic symptoms and was diagnosed with bulimia nervosa purging type.  Two weeks later, she returned to the clinic reporting suicidal ideation with plan to cut her wrist with a kitchen knife.  The provider diagnosed her with major depression and bulimia nervosa.  The CI was referred to inpatient psychiatry due to suicidal ideation (SI) where she remained for 7 days.  After discharge, a decision was made to admit her to a 28-day inpatient eating disorders program for rehabilitation.  The CI was treated with medication to target her depressive and anxious symptoms, and she participated in talk therapy with a therapist.  Despite treatment, her condition did not improve sufficient enough to allow continued service and she was therefore, referred to the MEB.  The MEB forwarded “bulimia nervosa, purging type, associated with major depressive disorder,” for PEB adjudication.  

The MEB NARSUM examination on 7 March 2007, 3 months prior to separation, noted since the CI’s discharge from the eating disorders program on 27 February 2007, she had 3 visits with her therapist.  She continued to have residual symptoms of depression and anxiety that included sleep disturbance, poor concentration, poor appetite, and some irritability and persistent worry.  However, she reported that globally, her symptoms had improved since beginning treatment.  The CI also reported that her bulimic condition was much better controlled.  She denied binging or purging since entering the eating program.  At the time of the MEB, the CI worked as a munitions troop on Base.  She noted she had some frustrations with her job, but was interested in remaining on active duty.  The mental status examination (MSE) was unremarkable.  The diagnoses of bulimia nervosa, purging type, and major depressive disorder, single episode, moderate were recorded.  A Global Assessment of Functioning (GAF) score of 55-60 (moderate) was assessed.  The psychiatrist opined that the CI’s condition was “potentially disqualifying”, but that her overall prognosis was fair to good.  Recommendation was for continued psychotherapy and medication management.

At the 11 September 2007 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI’s chief complaint was documented as “My self-esteem is a problem.  I feel very insecure about my body.”  The examiner noted that the CI “looked quite depressed” while in the waiting room.  The CI indicated that she had been admitted to the eating disorder program in 2007 but stated it was not helpful except that she was purging less.  Her symptoms at the time of the examination were low self-esteem, excessive sleep, frequent sadness, and continued bulimia.  She stated that many times she would rather not get out of bed.  The CI was not taking her prescribed antidepressant medication because she did not like the “flat emotional effect it gives,” and she no longer needed the medication for sleep.  She had not been hospitalized or treated in the emergency room since the 2007 hospitalization, 6 months before separation.  The CI was working as a hostess and a waitress in a men’s strip club and reportedly stated she works there because the money is good.  She plans to go to college in the spring of 2008 to become a dietician.  She noted that she enjoys crafts, taking walks, and going fishing.  Her day consisted of going to work, to the gym, and sleeping the rest of the time.

The MSE noted no disturbance in orientation or thought processes; however, her affect was recorded as flat, and mood was depressed and anxious.  The psychologist opined that the CI’s judgment was “severely impaired by the veteran’s emotional problem”, but treatment had improved her insight.  Memory and concentration were documented as diminished, and the CI reportedly admitted to SI without a plan.  The examiner documented that the CI was considered competent for VA purposes and was capable of performing activities of daily living.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition of bulimia nervosa associated with MDD, coded 9521 (bulimia nervosa) at 10%.  The VA used the analogous coding of 9521-9434 (MDD with bulimia) and granted a 100% rating.  First, the Board noted there was no specific, highly stressful service related event to invoke §4.129 for a mental disorder due to traumatic stress. All Board members agreed the provisions of §4.129 were not applicable.  Regardless of the diagnosis, 4.130 rating is based on symptoms independent of diagnosis, therefore, all mental health symptoms were considered in the rating.  The Board first acknowledged the great disparity in the ratings of the PEB and VA.

The Board next proceeded to rate under §4.130 and compared the NARSUM, the Non-Medical Assessment (NMA) and the C&P examination.  The NARSUM recorded one hospital admission due to SI and noted that her symptoms improved with medication and after inpatient treatment in the eating disorders program.  The MSE was unremarkable and the GAF score was recorded in the moderate range.  The NMA dated 2 weeks after the NARSUM, noted that the CI’s medical condition allowed her to perform all primary in-garrison military duty without restrictions, limitations or work-a-rounds.  The commander recommended that she be allowed to remain enlisted and in her current position.  The Board also considered the CI’s letter written to the IPEB in March 2007.  The CI did not indicate that she felt her condition at the time had interfered with her ability to perform her duties or that her symptoms were significant in any way.

At the C&P examination, 3 months after separation, the CI reported low self-esteem, excessive sleep, frequent sadness, and continued bulimia, with less purging.  She reported low motivation; however, she was working, going to the gym, and had plans of attending college in the near future.  The MSE recorded was not consistent with the evidence.  It was noted that she had impaired judgment; however, there was no objective evidence to support that opinion.  She had not been hospitalized, had not been dismissed from her job, had no legal history, and no clinical evidence representing impaired judgment, such as impulsivity.  The CI was reportedly “intermittently suicidal”: however, there was no evidence that she sought care in the ER, was hospitalized beyond the January 2007 hospitalization, or ever attempted suicide.  The examiner documented that she was fully oriented and there was no evidence of psychosis.  The GAF score was not consistent with the CI’s level of functioning.  A 100% disability level is appropriate whenever there is evidence of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place; memory loss for names of close relatives, own occupation or own name; none of which was present in this CI.  Based on the objective evidence of that examination, there was insufficient evidence to support a rating higher than 10%.  The CI was stable, and despite the reported SI during the examination, she was not referred for inpatient treatment.  

Although, the CI reported continued symptoms, clinical evidence demonstrates that her condition was stable, and was mild or transient in nature, brought on during periods of significant stress (weight gain).  There was no indication that the CI had any significant MH problems, ER visits or psychiatric hospitalization in the 18 months after separation.  After careful deliberations, the Board agreed, at the time of separation the CI’s symptoms was most reflective of the 10% disability level (mild or transient, and improved with medication).  Therefore, there was insufficient evidence to justify a rating higher than 10% at the time of separation.

The Board noted the PEB coded the CI’s condition under the bulimia code but used rating language reflective of the general 4.130 rating scheme.  The VASRD separates out eating disorders and provides a unique set of evidence for rating the disability.  A 10% rating under the 9521 code is for evidence of “binge eating followed by self-induced vomiting or other measures to prevent weight gain, or resistance to weight gain even when below expected minimum weight, with diagnosis of an eating disorder and incapacitating episodes of up to 2 weeks total duration per year.”  The higher rating of 30% requires evidence of “self-induced weight loss to less than 85 percent of expected minimum weight with incapacitating episodes of more than 2 but less than 6 weeks total duration per year.”  The VARD notes that “an incapacitating episode is a period during which bed rest and treatment by a physician are required.”  The Board found no evidence in the STR that would justify a rating under this code.  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 bulimia nervosa associated with major depressive disorder condition.

BOARD FINDINGS:  In the matter of the bulimia nervosa, purging type, associated with major depressive disorder condition and IAW VASRD §4.130a, the Board 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 20150325, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00245.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings