RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02354
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20030902

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Ship's Serviceman, medically for “major depressive disorder, severe, with psychotic features,” and “post-concussional (sic) headache syndrome,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI made no specific contention.  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 - 20030520	VARD - 20040707	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder, Severe, with Psychotic Features	9434	10%	Major Depressive Disorder with Psychotic Features Secondary to Post-Concussion Syndrome	9434	10%	20030721	
Post -Concussion Headache Syndrome	8045-8199-8100	10%	Post-Concussion Headache Syndrome	8045	10%		
Status Post Concussion	Cat II 					
Traumatic Brain Injury	Cat II					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

Major Depressive Disorder, Severe, with Psychotic Features.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s major depressive disorder condition began in July 2002 after falling off a truck.  Since the accident she has experienced tearfulness, irritability and the presence of multiple unrecognized voices that “mumble” to her.  She also discovered her husband had an extramarital affair, which intensified her depression and worsened the auditory hallucinations.  She developed suicidal ideation with a plan to hang herself.  She was admitted to inpatient psychiatry and treated with anti-depression and anti-psychotic medications.  The MEB forwarded “major depressive disorder, severe, with psychotic features, secondary to traumatic brain injury for PEB adjudication.

The 08 April 2003 MEB NARSUM examination, 5 months prior to separation, noted complaints of auditory hallucinations that were quieter, less intense and frequent but still interfere with social and occupational functioning.  She continued to take two anti-psychotic and an anti-depressant medications.  She received group therapy three times weekly and remained in psychiatric care.  She remained socially isolated although she was able to care for her child.  Mental status examination showed quiet speech with diminished rate and intensity, alternately tense and even affect, ongoing auditory hallucinations, and no suicidal ideation.  Symptoms had improved.  The Naval NARSUM Board members opined “the patient [CI] has now received the maximum benefit of military medical treatment and that, even after an eight month period of limited duty, this has not restored her to a duty status.  It is the opinion of the Board that the diagnoses above are correct. The patient is now handicapped in that she is unable to perform the duties of her rate.  A diagnosis of major depressive disorder, severe with psychotic features, secondary to traumatic brain injury was rendered.  Impairment for military severe was severe.  Impairment for civilian industrial capacity was moderate.

The 25 April 2003 non-medical assessment, 4 months before separation, documented the CI was placed in a position not appropriate for her rank and experience in which she answered telephones and sorted paper.  The commander stated, the CI “is an average sailor and contributes only marginally to our mission due to her extensive need for time off to receive [psychiatric] counseling.”

At the 21 July 2003 VA Compensation and Pension (C&P) evaluation, performed 1 month before separation, the CI reported continued auditory hallucinations.  Her mood had improved and she denied suicidal ideation; however, she was very worried and stressed out about her finances.  She utilized the three aforementioned psychotropic medications.  Mental status examination showed a worried and anxious affect, depressed mood, and auditory hallucinations.  Her sleep was impaired without her medications.  A major depressive disorder diagnosis with psychotic features secondary to post-concussion syndrome in partial remission was rendered.  A Global Assessment of Functioning score of 55 (moderate symptoms) was assessed.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the major depressive disorder condition, separate and distinct from the post-concussion headache syndrome, at 10%, coded 9434 (major depressive disorder).  The VA initially rated the major depressive disorder secondary to post-concussion syndrome condition 10%, analogously coded 8045-9403 (traumatic brain injury-dementia due to trauma), based on the C&P examination 1 month before separation, citing mild to transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress.  The subsequent 16 April 2004 VA Rating Decision also rated the major depressive disorder secondary to post-concussion syndrome condition 10%; however, invoked a code change to 9434 (major depressive disorder), citing the VA mental health examination provided conflicting diagnoses of major depressive disorder with psychotic features secondary to post-concussion syndrome.  The CI was scheduled for a follow-on C&P examination but failed to report and a rating change could not be determined.

Application of VASRD §4.129 (highlight stress event) is considered by the panel for all service connected psychiatric condition cases resulting in separation.  All members agreed that the requisite for §4.129 was not satisfied in this case.  The panel then considered if there was evidence for a §4.130 rating higher than the 10% assigned by the PEB.

The §4.130 criteria for a 10% rating is “mild to transient symptoms or symptoms controlled by continuous medication,” for a 30% rating is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks,” while criteria for a 50% rating requires “occupational and social impairment with reduced reliability and productivity.” Both the MEB NARSUM and the more proximal C&P examination noted the CI’s psychiatric symptoms had improved.  However, auditory hallucinations and social isolation were still present, she continued to receive psychiatric therapy, and was prescribed and still utilized three psychotropic medications.  Both examiners diagnosed a moderate level of impairment for civilian activity.  There was no evidence in the record which denied the CI’s auditory hallucinations.  The panel majority determined the CI’s level of disability met criteria for a 30% disability rating.

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.

Post-Concussion Headache Syndrome.  According to STR and the MEB NARSUM, the CI’s headache condition also began in July 2002 from the truck fall.  The CI sustained a right-sided head injury/concussion with chronic, severe headaches and generalized weakness with intermittent memory loss and dizziness.  A cranial CT scan was normal but she was still diagnosed with post-concussion syndrome.  Anti-epilepsy medication did not stop the headaches.  The CI reported hearing voices.  MEB forwarded “post-concussion headache syndrome” for PEB adjudication.

The MEB NARSUM Addendum Post-Concussion Syndrome examination on 08 April 2003, 5 months prior to separation, noted complaints of headaches 2 times a month, associated with photophobia and nausea.  She reported a headache with 6/10 pain and left upper extremity weakness and was taking a trial of medication.

At the 21 July 2003 VA Compensation and Pension (C&P) evaluation, performed 1 month before separation, the CI reported continued headaches.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the headache condition 10%, analogously coded 8045-8199-8100 (brain disease due to trauma-migraine headaches).  The PEB also listed status-post concussion and traumatic brain injury as Category II conditions (contributing to the primary unfitting condition but were not separately ratable).  Impairments from these conditions are properly subsumed under the overall rating of the post-concussion headache syndrome condition IAW VASRD §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  

The panel agreed the CI reported two headaches per month without evidence of prostrating attacks or stoppage of work or activity to alleviate her headache.  The panel agreed that there was no headache evidence higher than the 10% rated by the PEB.

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 post-concussion headache syndrome condition.

BOARD FINDINGS:  In the matter of the major depressive disorder condition, the panel majority recommends a disability rating of 30%, coded 9434 IAW VASRD §4.130.  In the matter of the post-concussion headache syndrome condition and IAW VASRD §4.241, the panel recommends no change in the PEB adjudication.  In the matter of the contended status-post concussion and traumatic brain injury conditions, the Board unanimously recommends no change from the PEB determinations as Category II conditions.  The single voter for dissent recommends no change and elected to submit the appended minority opinion.  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	30%	
Post-Concussion Headaches	8045-8199-8100	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150913, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 12 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 02 Aug 17 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 07 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 31 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 31 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 14 Jul 17 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (g) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.      

     c. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Temporary Disability Retired List for six months beginning date of discharge with a 60 percent combined disability rating and a final rating after six months of 20 percent.  

     d. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 60 percent rating (increased from 20 percent) effective date of discharge.       

     e. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 40 percent rating (increased from 20 percent) effective date of discharge.
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

	XXXXXXXXXXXXXXXXXX
	Acting	

MINORITY OPINION:  In rating the CI’s post-concussion major depressive disorder IAW VASRD rules in effect at the time (§4.130, and 8045 [brain disease due to trauma]), the minority member placed probative value on the MEB NARSUM done on 08 April 2003 (5 months before separation), the Non-Medical Assessment (NMA), and the VA C&P examination done on 21 July 2003 (1 month before separation), for indicators of occupational and social impairment.

At the MEB NARSUM examination the CI reported that her mood was "fine", her post-concussional auditory hallucinations were still present, but her medications were significantly reduced from one day out of every four or five days.  Although auditory hallucinations were of much less intensity, and far less frequent, they continued to significantly hamper social and occupational functioning.  She was severely socially isolated but she assumed primary care-taking duties over her sixteen month old child.

In the NMA 2 weeks later, the commander wrote the CI was an average worker and sailor, considering her physical and emotional limitations.  She answered phones, sorted paper, and contributed marginally due to her extensive need for time off to receive counseling.  The minority member opines that these statements are consistent with mild occupational impairment, and notes that her impairment was due more to missing work, rather than mental health related reasons.

The VA C&P examination was most proximal to the date of separation, therefore most probative for occupational and social impairment.  The CI’ Axis I diagnosis at the time was major depressive disorder with psychotic feature due to post-concussional syndrome (in partial remission).  The examiner reported she continued to have auditory hallucinations and headaches due to her post-concussional syndrome, however her depressive symptoms were more related to transition from the Navy and concerns over finances and future income.  The examiner further opined that the symptoms did not meet the full diagnostic criteria for major depressive disorder and assessed she was in partial remission.  The VA granted an evaluation of 10 percent based upon this examination, for 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.  The minority member concurs with the VA rating, coded 8045-9304, as well as the PEB rating of 10 percent, as a fair and accurate rating for the post-concussional major depressive disorder condition at the time of separation.

Consistent with the DoDI 6040.44 standard that Physical Disability Board of Review recommendations are fair and equitable to both the Service and the CI, the Secretary is respectfully requested to consider the minority recommendation that there be no modification or re-characterization of the CI’s disability and separation determination.