RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01358
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20030108

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Meteorological and Navigation Systems Journeyman, medically separated for “major depressive disorder,” with a disability rating of 0%.

CI CONTENTION:  “Please review the attached personal letter and medical records.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20021213	VARD - 20090413	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder	9434	0%	No VA examination in evidence	
Personality Disorder	Cat III		
Alcohol Dependence			
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  	

ANALYSIS SUMMARY:  

Major Depressive Disorder.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s mental health condition began in July 2002 after the CI experienced relationship problems with his fiancée for about 3 months.  At a mental health evaluation on 17 July 2002 the CI complained of excessive worry related to school, his mother’s health, and his upcoming marriage.  He additionally reported restlessness, easy fatigability, episodic tremors, abdominal distress and/or nausea with a 30 pound weight loss, irritability, and difficulty concentrating/sleeping.  The examiner’s Axis I diagnosis was generalized anxiety disorder and treatment consisted of Paxil (paroxetine, an antidepressant) and psychotherapy was recommended.  Thereafter, Klonopin (clonazepam for anxiety) was added to the medication protocol.  The CI had a psychiatric evaluation on 6 August 2002 after having a fight with his fiancée at which time he was reported to be disorganized in his behavior and labile in his mood and attitude.  Treatment consisted of Ativan (lorazepam for anxiety).  On 9 August 2002 the CI was noted to be alcohol dependent based on development of tolerance to 9-10 beers, blackouts “3 or 4” times and “4-5” attempts to quit.  The CI attempted suicide involving alcohol and anxiolytics (Klonopin) and was hospitalized from 21-25 August 2002.  While in the hospital he attempted suicide using blades he brought to the ward.  Multiple lacerations and significant bleeding resulted in anemia.  His physical injuries were attended to and he was subsequently transferred to a major military treatment facility where he was hospitalized until 3 September 2002.  He was then transferred to a Level III Alcohol Rehabilitation Department Residential Program for alcohol dependence where he stayed until discharge upon program completion on 4 October 2002.  Psychological testing on 24 September 2002 revealed a profile consistent with his experiencing multiple vague somatic complaints and moderate levels of depression and anxiety.  He also had a number of maladaptive personality characteristics such as immaturity, narcissism, cynicism, and pessimism.  The CI underwent a series of psychiatric visits in November 2002; however, he was seen in the Emergency Room on 8 December 2002 for suicidal ideation due to stressors, and having been arrested drinking alcohol and driving.  A psychiatry resident diagnosed the CI with a depressive disorder, alcohol dependence and personality disorder with a Global Assessment of Functioning (GAF) score of 69 (some mild symptoms or some difficulty in social, occupation, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships).  The CI was determined to have stabilized and was discharged.  Thereafter CI was seen regularly by a psychiatrist, who prescribed Antabuse (disulfiram to prevent drinking alcohol), as well as by alcohol abuse counselors.  The MEB forwarded “alcohol dependence,” “major depressive disorder,” and “personality disorder” for PEB adjudication.  

The 1 November 2002 MEB NARSUM examination, 2 months prior to separation, noted complaints of alcohol dependence, depression, and personality disorder traits.  Mental status examination revealed a thin, well-groomed individual who made good eye contact and answered questions spontaneously.  Speech was of normal rate, rhythm, and tone.  There was neither increased nor decreased psychomotor activity nor was the CI distractible.  Mood was moderately depressed and anxious.  Affect was congruent and appropriate with mood and at times the CI appeared tearful and withdrawn.  Thought process was logical and goal-directed.  Thought content was without suicidal or homicidal ideation and without auditory or visual hallucination or elicited delusions.  The CI was oriented to person, place, time, and self.  Intellectual function was average.  Insight and judgment were both poor.  Physical examination was unremarkable except for multiple well healed lacerations bilaterally on the wrists and antecubital fossae (inner elbows) as well as his anterior neck.  The examiner’s Axis I assessment included alcohol dependence, manifested by occupational, social and legal difficulties, with continued use despite increases in anxiety and depression and previous inpatient rehabilitation treatment; major depressive disorder, single episode with atypical features of obsessions, mood reactivity, and a pattern of interpersonal rejection sensitivity; and a partner relation problem.  The Axis II assessment was a personality disorder, not otherwise specified, with narcissistic and borderline traits as evidenced by impulsivity, serious self-mutilation, manipulative behavior, excessive response to relationship problems, and self-reported very poor self-esteem—all aggravated by the disinhibition of alcohol use.  His GAF score was 45 (serious symptoms or any serious impairment in social, occupation or school functioning) given his serious social and occupational impairment.  The examiner noted the CI’s personality traits and alcohol use very likely contributed to his primary depressive disorder and suicide attempts.  The CI was to remain on antidepressant therapy with Prozac (fluoxetine, an antidepressant).  An MEB Addendum dated 9 December 2002 the CI noted he would rather be dead than in jail after being arrested for public intoxication.  However, at a psychiatry visit, the CI reported he regretted drinking.  On mental status examination, he was polite and cooperative with a normal rate, volume, and prosody of speech.  He exhibited no abnormal psychomotor active.  His mood was mildly depressed and his affect was euthymic, appropriate and non-labile.  He denied suicidal or homicidal ideation as well as auditory and visual hallucinations.  His though process were linear and logical, and he was goal oriented and directed.  He had no tremor or flushing and did not smell of alcohol.  He seemed to have good insight into the fact that his responses to stimuli were extreme, then did not exercise good judgment (drank instead of calling a friend).  His GAF score was 65 (some mild symptoms).  Prozac and Antabuse were prescribed and arrangements were made to follow-up with problem-oriented therapy and the Army substance abuse program.  There was no VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the major depressive disorder condition 0%, coded 9434 (major depressive disorder), citing mild social and industrial adaptability impairment with a current rating of 10% and a deduction of 10% for contributory/aggravating factors.  The PEB further opined “were it not for the non-ratable/non-compensable condition, the member’s social and industrial adaptability impairment rating would best be described as none, IAW DOD/VASRD guidelines.”  The VA remotely determined the anxiety, bipolar disorder or depression conditions were not service-connected, based on no evidence to support that the CI has been clinically diagnosed with an “anxiety disorder, bipolar disorder, or a depressive disorder.”  Members discussed whether a 10% rating which requires “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,” was appropriate since the NARSUM examiner noted serious social and occupational impairment.  The CI’s overall disability was clearly related to alcohol dependency, enough such that it significantly contributed to the seriousness of his condition, which in the absence of alcohol would warrant the 10% rating.  However, the VASRD does not offer an option of a deduction, which the PEB used.  Therefore, a 10% rating is reasonable and is consistent with the intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events)” was warranted.  While the CI had a depressed mood, anxiety, and suspiciousness, the record did not note panic attacks per se.  However, his overall condition did not rise to the 30% level, again taking into account the alcohol disinhibition contributed to and exacerbated a fair portion of his overall symptomatology and was a driving force to his potentially self-destructive activity on more than one occasion.  Furthermore, at the time of the MEB Addendum the CI’s overall status was improved, and he reported he regretted drinking.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the major depressive disorder condition, coded 9434.  

Contended PEB Conditions:  Personality Disorder and Alcohol Dependence.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  No profile was in the record that addressed either condition nor did the commander’s statement explicitly address either condition.  Both conditions were Category III (conditions that are not separately unfitting and not compensable or ratable).  Because the CI’s alcohol dependence required rehabilitation, hospitalization, and follow-up therapy, it did have a negative effect on performance; however, since it is a Category III condition, it is not separately unfitting and not compensable or ratable.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions; and so, no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the major depressive disorder condition, the panel unanimously recommends a disability rating of 10%, coded 9434 IAW VASRD §4.130.  There were no other conditions within the panel’s scope of review for consideration.  

The panel 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%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150615, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01358.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

Attachment:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR