RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01367
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20031121

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve O3, Obstetrical Nurse, medically separated for “major depressive disorder (MDD)” with a disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  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 - 20030729	VARD - 20050112	
Condition	Code	Rating	Condition	Code	Rating	Exam	
MDD	9434	10%	Depressive Disorder/Anxiety	9434	NSC	20040508	
Breast Cancer S/P Total Mastectomy and Chemotherapy	7627-7625	Category II	Simple Mastectomy, Left Breast S/P Carcinoma	7626	30%		
Hysterectomy	7619		Residuals, S/P Total Vaginal Hysterectomy	7618	30%		
Math/Learning Disorder	Category III	No VA Placement	
Adjustment Disorder		No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Major Depressive Disorder.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s major depressive disorder condition began in 2000 during flight school after suffering decompression sickness, which was treated with hyperbaric oxygen.  She previously had treatment for PTSD (posttraumatic stress disorder) following Operation Desert Storm (ODS).  On examination the CI had a depressed mood and a tearful affect with increased worry/rumination.  She had poor concentration, but good insight and judgment.  There was no suicidal or homicidal ideation.  Cognitive-behavioral techniques for mood management were recommended in January 2001.  Further evaluation of the CI’s symptoms were not consistent with PTSD, but were those of a major depressive disorder.  Treatment with Celexa (citalopram, an antidepressant medication), spiritual focus, and cognitive techniques improved sleep and mood, but she had communication problems with her co-workers.  By April 2001 her mood had improved with full affect and in May 2001 she had a euthymic mood and full affect with good insight and judgment.  Her major depressive disorder was determined to be in remission and no further behavioral health intervention was recommended.  On 29 March 2002 the CI was evaluated for anxiety which began as soon as she found out she had breast cancer.  On mental status examination the CI was noted to have twitching of the leg.  Her affect was sad and tearful at times and anxious.  The Axis I diagnosis was a history of depression, adjustment disorder with depressed mood and anxiety with a GAF (Global Assessment of Functioning) score of 60 (moderate symptoms). Celexa and Klonopin (clonazepam to treat anxiety) were recommended as treatment.  In June 2002 the CI underwent a Command Directed Evaluation due to difficulties with memory/concentration, which impaired her ability to perform assigned duties despite intensive orientations and explanation of expectations.  A neuropsychological assessment was carried out because of concerns regarding the CI’s neurocognitive status.  She experienced difficulty in measures requiring “cognitive flexibility” and “multi-tasking.”  It was recognized that her recent medical problems may have exacerbated her deficits, given both her physical fatigue and subjective distress.  Rather “prickly” by nature, her relationships were apt to be impacted by a readiness to perceive offense or insult.  The examiner diagnosed a “Learning Disorder” and recommended the CI’s removal from direct patient care duties be continued.  Her GAF score was 60 (moderate social/occupational impairment).  Psychotherapy and coping with emotion skills acquisition and utilization continued.  A note dated 5 November 2002 indicated the CI had increased anxiety with work and the dose of Effexor (venlafaxine, an antidepressant) was increased.  In March 2003 the CI complained of daily fatigue, which was felt to be multifactorial, although medication may have been contributory since a complete blood count and thyroid stimulating hormone were normal.  

Despite treatment with medication and psychotherapy, the CI’s major depressive disorder condition did not improve sufficiently to meet the requirements of the CI’s military specialty and she was referred for a Medical Evaluation Board (MEB).  The MEB forwarded “major depression, single episode, moderate” for PEB adjudication.  

The undated MEB NARSUM examination noted complaints of fatigue post hysterectomy and breast cancer surgery as well as a history of depression and anxiety.  On mental status examination the CI was pleasant, cooperative, and soft spoken with a dysphoric mood and anxious affect.  There was a full range of thought process and thought content that was logical, linear, and goal directed.  There was no suicidal or homicidal ideation, no audio-visual hallucinations, and no delusions.  She tended to focus extensively on health concerns and how she felt she was treated unfairly.  She displayed very prominent externalization of blame and demonstrated limited psychological insight.  The examiner noted the CI denied a depressed mood and loss of interests, which were hard to believe and not consistent with observation.  She did admit to being easily upset, having crying spells, increased sleep, increased appetite, low energy and extreme fatigue, psychomotor retardation, and trouble with concentration.  She also tended to be sensitive to slights and was suspicious of others motives.  Her Axis I diagnosis was major depression, single episode, moderate and her GAF score was 51 (moderate symptoms).

At the 8 May 2004 VA Compensation and Pension (C&P) Mental Disorders evaluation, 6 months after separation, the CI reported vague symptoms of anxiety and depression where she became anxious most of the time, restless and was tired with difficulty concentrating.  She also noted her mind went blank and she was also irritable, had muscle tension and sleep disturbances, as well as a lack of energy and appetite along with hopelessness and helplessness.  She denied nightmares or flashbacks related to her service during ODS or a history of assault as a child.  On mental status examination she was childlike at times, but very dramatic at other times.  Her speech was slow and deliberate.  Her mood was anxious and affect was somewhat anxious.  Thought content was without any auditory or visual hallucinations.  There was no paranoia and no suicidal or homicidal ideations.  Cognitively she was alert and oriented to person, place, time, and situation.  Memory was intact.  Concentration, insight, and judgment were fair.  The Axis I diagnoses were depressive disorder NOS and anxiety disorder NOS, and her GAF score was 65 (mild symptoms).  However, at a 21 May 2004 VA mental health examination, the CI was diagnosed with PTSD and was placed on a waiting list for treatment.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the major depressive disorder condition 30%, coded 9434 (major depressive disorder), citing definite social and industrial adaptability impairment.  However, the PEB subtracted 20% for aggravating/contributing factors, for which it opined that math learning and adjustment disorders significantly affected the severity of her depressive disorder and if it were not for the non-ratable/non-compensable condition, the member’s social and industrial adaptability impairment rating would best be described as mild IAW DoD/VASRD guidelines.  Therefore, the PEB found the member unfit with a disability rating of 10%.  The VA rated the major depressive disorder condition not service-connected, coded 9434, based on the VA C&P examination 6 months after separation, citing not incurred/caused by service.

The panel considered whether the provisions of VASRD §4.129 (Mental disorders due to traumatic stress) were applicable.  In accordance with VASRD §4.129, when a mental disorder that develops in service as a result of a highly stressful event is severe enough to bring about the CI’s release from active military service, the rating agency should assign an evaluation of not less than 50% and schedule an examination within the 6-month period following the veteran’s discharge to determine whether a change in evaluation is warranted.  Symptoms of posttraumatic stress disorder were not present while the CI was on duty in the Air Force, although the CI had deployed during ODS and received treatment after deployment.  However, the diagnosis of breast cancer with subsequent surgeries was emotionally and psychologically challenging.  Nevertheless, all panel members agreed that the evidence of the record did not support a traumatic stressor, albeit the stresses of deployment to a combat zone, although considerable under the best of circumstances, do not automatically equate to the §4.129 standard of “a highly stressful event,” as the cause of the mental condition for which application of VASRD §4.129 would be appropriate.   

Panel members then discussed whether the 30% rating initially assigned by the PEB was appropriate and agreed it was so since there was definite social and industrial adaptability impairment.  However, panel members felt that the subtraction of 20% was not indicated since the CI served 8 years of active duty and the math/learning issue was considered EPTS.  More importantly, the CI’s math/learning limitation was determined by neuropsychological testing, but the fact that she was status post a total abdominal hysterectomy and breast cancer surgery and reconstruction along with postoperative treatment with tamoxifen was not addressed as contributing factors for her math/learning deficits that clinically became more evident after the breast surgery.  Furthermore, recent articles in the medical literature have noted that tamoxifen appeared to be related to a decrease in cognitive performance especially related to verbal memory and executive functions including information-processing speed, and has been associated with “brain fog”.  Additionally, the PEB referred to the adjustment disorder as a factor for its subtraction, but failed to note that the adjustment disorder was in the continuum of the CI’s response to her surgeries, which was initially diagnosed as a major depressive disorder and was also the NARSUM diagnosis.  Therefore, panel members felt that no subtraction is warranted and the CI’s rating of 30% is reasonable.  However, the CI also had several components of a 50% rating, which requires “Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships,” especially since she was removed from clinical duties.  Nevertheless, the panel members felt the 30% rating was overall fair and accurate relative to her disability at the time of separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the major depressive disorder condition, coded 9434.  

Contended PEB Conditions.  Breast Cancer Status Post Total Mastectomy and Chemotherapy, Hysterectomy, Math/Learning Disorder and Adjustment Disorder.   The panel’s main charge is to assess the fairness of the PEB’s determination that the breast cancer status post total mastectomy and chemotherapy and hysterectomy were not unfitting.  The math/learning disorder and the adjustment disorder are not physical disabilities.  After treatment for breast cancer the CI was placed on a profile limiting her work hours, which was noted in the commander’s statement. Neither the hysterectomy nor the math/learning disorder nor the adjustment disorder were profiled or addressed in the commander’s statement. However, although the math/learning disorder and the adjustment disorder were not judged to fail retention standards, mathematics disorder was listed as an Axis I diagnosis on the MEB Report.  Furthermore, the math/learning and adjustment disorder were opined to significantly affect the severity of the CI’s disorder.

Breast Cancer Status Post Mastectomy and Chemotherapy.  The CI noted a dimpling of the left breast since 1 October 2001 after having undergone a total abdominal hysterectomy.  A mammogram showed microcalcifications scattered throughout the left upper outer quadrant of the left breast and a biopsy revealed ductal carcinoma in-situ (DCIS).  On 13 February 2002 the CI underwent a left quadrantectomy (a segmental or partial mastectomy) followed 8 days later by drainage of a seroma (postoperative fluid).  Because DCIS was noted at the surgical margin, the CI underwent a left simple mastectomy with unipedicled TRAM (transverse rectus abdominus myocutaneous (a muscle of the abdominal wall and skin)) flap reconstruction on 19 March 2002. Postoperative tamoxifen (to reduce the chance of breast cancer recurrence) was prescribed.  When the wound was just about healed, she was recommended to have a graded return to work over 6-8 weeks.  In November 2002 the CI was on a 5-hour work day.  A note dated 23 July 2003 indicated that open postoperative wounds took several weeks to eventually heal satisfactorily and she had abdominal pain and weakness after the TRAM operation.  Although the surgery presented significant challenges for her, she was considered to be clinically cured.  

Hysterectomy.  The CI underwent a total abdominal hysterectomy for symptomatic uterine fibroids (benign muscle tumors) and a Burch culposuspension for stress incontinence in October 2001.  Computerized tomography (CT) of the abdomen and pelvis were normal on 22 January 2002.  A note dated 23 July 2003 indicated metromenorrhagia (prolonged or excessive uterine bleeding) which was the indication for the hysterectomy was cured, but the CI still remained anemic (low blood count).  At the VA examination on 8 May 2004 the CI stated that she had postoperative bleeding and temporary respiratory arrest and since that time her thinking was not clear. 

Math/Learning Disorder and Adjustment Disorder.  According to DoDI 1332.38, paragraphs E5.1.3.3 and E5.1.3.9.4, these conditions do not constitute a physical disability 

There was no performance-based evidence from the record that the breast cancer, reconstruction and tamoxifen treatment and the hysterectomy conditions significantly interfered with satisfactory duty performance at separation.  While the math/learning disorder contributed to the CI’s performance, her job difficulties developed after having undergone the hysterectomy and breast and reconstruction surgeries and placement on tamoxifen, which contributed to her concerns related to the adjustment disorder and subsequent major depressive disorder.  Nevertheless, the math/learning disorder and adjustment disorder are not considered physical disabilities.  Therefore, after due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any 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 30%, coded 9434 IAW VASRD §4.130.  In the matter of the contended breast cancer status post total mastectomy and chemotherapy, hysterectomy, math/learning disorder, and adjustment disorder conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Major Depressive Disorder	9434	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150611, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01367.

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 your separation be re-characterized to reflect disability retirement, rather than 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 determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at XXXXXXXXXXXXXXXXXXX to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

Attachment:
Record of Proceedings