RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02432
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20050624

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, AEGIS Display Technician, medically separated for “major depressive disorder” and “human immunodeficiency virus,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION:  “Please consider all condition.”  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 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 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 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 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.  In addition, the Secretary of Defense Mental Health Review Terms of Reference directed a comprehensive review of Service members with certain mental health (MH) conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The MH condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.

RATING COMPARISON:  

SERVICE PEB - 20050422	VARD - 20051206	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder	9434	10%	Anxiety Disorder with Depressive Features	9434-9400	30%	20050803	
Human Immunodeficiency Virus	6351	10%	Human Immunodeficiency Virus (HIV) Infection	6351	10%	20050803	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Major Depressive Disorder.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI initiated his first contact with mental health (MH) professionals in 1999.  The 5 August 1999 MH clinic encounter documented the CI “had just been informed of very bad news by his CO [commanding officer], who recommended that he be seen at this facility for medical and psychiatric clearance prior to return to San Diego.  On interview at this clinic, member was appropriately distraught but able to discuss his situation fully.  While surprised and saddened by the information he was given, he was more concerned about ‘abandoning’ his ship-mates and his parents' welfare than he was of himself; he also expressed concern about the future of his naval career.”  The past psychiatric history was non-contributory.  The mental status examination (MSE) was unremarkable.  The diagnoses listed Axis I:  No diagnosis; Axis II:  No diagnosis; Axis III:  HIV [human immunodeficiency virus] sero-conversion; Axis IV:  Lack of and misinformation about his condition; and Axis V:  global assessment of functioning (GAF) of 75 (transient symptoms).  The examiner opined the CI suffered from no condition which warranted Medical Board action, was fully accountable for his behavior, and was safe to be returned to duty and to travel back to San Diego without escort.  

The 20 August 1999 MH services encounter documented “He is here for his initial HIV positive evaluation and was told while in the Pacific (near Hawaii) on the USS Higgins.  He knows that he must come off the ship at this time and is very concerned because his is a seagoing rate.  He has been promoted rapidly because this is a rate in a great demand both in the Navy and in the civilian community.  He reports that his detailer has told him that if he does not change rates, he will be ‘administratively separated’ from the Navy because he cannot go to sea.  Staff on 2-west are working with him regarding new assignments and cross rating to a non-seagoing rate.  He is very concerned about not being able to continue on the work that he is qualified already to do in the military.”  At the 13 July 2000 psychiatry evaluation, the CI hand no complaints and stated that he was doing well.  “He will be quitting smoking and wants to continue taking Wellbutrin [antidepressant buproprion, also Zyban for smoking cessation] for that reason.”  The MSE was unremarkable.  The diagnoses listed Axis I:  R/O [rule out] Major Depression in remission; Axis II:  No Diagnosis; Axis Ill:  HIV positive; Axis IV:  None identified; Axis V:  GAF current = 85 (minimal symptoms), highest in past year = 85.  The treatment plan documented “1. Continue Wellbutrin 75 mg PO BID.  2. Follow up in about 12 weeks.  We will re-evaluate and if his symptoms are still in remission we will begin to taper off.”  

In the 6 January 2005 primary care encounter, the CI complained of symptoms of anxiety, anger, etc. that were not as well controlled with the antidepressant Zoloft 100 mg.  He denied suicidal ideation (SI) or homicidal ideation (HI).  The assessment listed mood disorder and the provider increased the Zoloft 100 mg to 150 mg.  The 24 January 2005 psychiatry evaluation documented “Pt. seen for F/U [follow-up] of depression.  He has reduced his Zoloft from 150 mg/day down to 50 mg/day.  This was due to his feeling “Discombobulated” in association c [with] his Zoloft use.  He reports having had some persistent trouble with concentration, sexual side effects (↓ libido he associates c [with] Zoloft), & decreased energy to get out & socialize like he would like to do.  The patient reports that he feels the 50 mg/day Zoloft is helpful for his mood lability & prefers not to entirely D/C [discontinue] the Zoloft despite having sexual side effects, ↓ energy, & concentration.  The patient endorsed previously being on Wellbutrin & p [after] having benefit from it he felt he no longer needed it and self D/Cd [discontinued].  He verbalized an interest in using it again in addition to the 50 mg/day Zoloft.”  The MSE documented “A&O [alert and oriented] X 3.  Cognition grossly intact.  Well dressed & well groomed.  Good eye contact.  Speech non-pressured c [with] reasonable spontaneous quantity.  No PMR [psychomotor retardation] or PMA [psychomotor agitation].  Mood ‘Frustrated but better than I felt on the 150 mg/d dose.’  Affect was mood congruent, stable, & reasonably reactive to themes discussed.  TC [thought content] No SI [suicidal ideation].  No HI [homicidal ideation].  Perceptions intact.  TP [thought process] L/L/GD [linear/logical/goal directed].  Insight was estimated as average.  Judgement & impulse control grossly intact.”  The diagnoses listed Axis I:  Depression not otherwise specified (NOS), V code (behavioral health condition is related to presenting problem) phase of life problem; Axis II:  Personality Disorder (PD) NOS, cluster B traits; Axis III:  (see record); Axis IV:  Stress of chronic illness; Axis V:  GAF of 65 (mild symptoms).  The plan was to continue Zoloft 50 mg/day and to start (resume) Wellbutrin 100 mg/day.  

In the 2 February 2005 MEB NARSUM examination by psychiatry, 5 months prior to separation, the CI stated "I'm depressed, anxious, and feel discombobulated."  The CI reported that “he first developed depressive and anxiety symptoms which ultimately lead to his seeking help … in January of 2003.  His symptoms were described as:  anger, irritability, mood swings, feeling of isolation, loss of interest in activities, decreased appetite, decreased concentration and memory, and thoughts of suicide without a specific plan.  The patient also described persistent anxiety symptoms experienced as a sense that others avoid him and are disappointed in him.  This is in contrast to his 4.0 fitness reports.  Despite the reassurance, the patient described investing immensely in trying to do a better job in hopes of feeling more of a team member in the work environment.  Such investment in his performance was described as being exhausting and ultimately negatively impacting on his personal life.  He described a marital separation and loss of friends.  The patient participated with individual and supportive therapy.  He also attempted to get resolution of such symptoms with use of pharmaceutical intervention.  This provided minimal improvement with interpersonal communication.”  Psychotropic medications were Zoloft and Wellbutrin.  The MSE documented “Alert and oriented to person, place, and time.  His cognition was grossly intact.  The patient was dressed and groomed appropriately.  He had fair eye contact.  His speech was with a slight decrease in rate, decrease in tone, and was with limited spontaneous quantity.  No PMR.  Slight PMA.  He was initially guarded but this was reduced as the interview progressed.  His mood was described as ‘discombobulated.’  His affect was with constricted range, mood congruent, and with some instability.  Thought content was without active suicidal ideation but patient endorsed having passive suicidal interest of generally not existing.  His perceptions were grossly intact.  His thought process was linear, logical, and goal directed.  Insight was limited.  His judgement and impulse control were grossly intact.”  The diagnoses listed AXIS I:  Major Depressive Disorder, Severe, without psychotic features; Anxiety Disorder, NOS; AXIS II: No diagnosis, Obsessive-Compulsive personality traits; AXIS III: Human Immunodeficiency Virus, Chronic Patellar Femoral Syndrome, Bilateral Knees, Chronic Diarrhea; AXIS IV: Occupational, interpersonal, and intrapersonal stress; AXIS V: GAF of 50 (serious symptoms).  The psychiatrist opined “Current Status: The patient presently manages his finances.  He is able to get himself to and from his job.  The patient is not able to manage effective relationships.  He remains separated from his spouse.  He has no close friends.  Work effectiveness reportedly limited that he feels alienated and overly self-conscious in the work environment.  He described not functioning adequately when he is supposed to teach in front of a class or when he must confront someone at work.  He avoids conversing with others. … The degree of social/industrial impairment is moderate.”  

On 22 February 2005 the Commanding Officer's comments, nonmedical assessment (NMA), documented the CI “has been a top performer during his tour at ATRC.  He qualified to instruct within 30 days, a full month ahead of the mandated norm, and has met every milestone that has been assigned to him.  He has instructed over 250 hours in the display element and has provided mentorship for 25 students.  He has been a motivated and dependable Sailor and continues to be an asset to this command.”  The 3 August 2005 mental disorders VA compensation and pension (C&P) evaluation by psychiatry, 1 month after separation, documented “A review of the veteran's claim files indicates that he is to be examined for major depression and anxiety.  The service medical records include some notes from 1999 and 2000, documenting anxiety and depression, in part related to recent diagnosis of HIV positive.  The veteran reports he has been receiving outpatient psychiatric treatment since the 2002 on a regular basis and has been taking Zoloft and Wellbutrin.  The anxiety symptoms are present in a pervasive fashion since that time.  The veteran is easily upset and easily angered.  He has difficulty relating to others and often gets into confrontations.  He is socially phobic, being uncomfortable in meeting new people, being in front of groups, or having conversations.  He often has feelings of dread, concerning social contract and will isolate himself from others.  Symptoms are present on a sustained basis, ‘every day I have to push myself.’ The veteran also reports episodic depressive symptoms that appear to be present for a few days, intermittently, related to situational stress.  During these periods, the veteran will feel self-pity, will eat to excess, and will feel fatigued and sometimes have difficulty concentrating.  Both sets of symptoms have been present at a moderately severe degree without much improvement or deterioration over time.  The veteran also reports difficulty reconnecting with his family and difficulty sustaining relationships with friends because of anxieties and insecurities as noted above.  The veteran has been at his new job only for a couple of days.  It involves automated services for building contractors.  He has been spending a lot of time with his new boss, but has been fairly anxious.  He also found himself falling asleep, despite his efforts to fight fatigue.  The veteran lives alone.  When not working, he watches TV and plays video games.  He attempts to go to the gym, but sometimes is too nervous around people to do so.  The veteran is able to do routine household activities such as shopping, food preparations, appointments, etc.  He tends to procrastinate in paying bills.  When he is out and about, he is reasonably comfortable because most of his contacts are with strangers.  When people are known to him, he become anxious.  The objective findings documented “The veteran arrived on time for his interview.  He is casually dressed and neatly groomed, wearing shorts, T-shirt and sneakers.  Intelligence is above average.  Thoughts are well organized with no evidence of psychotic contents or process.  Mood is one of mild depression.  The veteran appears to be moderately uneasy and anxious by observation today.  Formal mental status testing revealed intact cognition.”  Memory was intact.  The diagnoses listed Axis I:  Anxiety disorder with depressive features; Axis II:  No personality disorder diagnosed; Axis III:  Physical diagnosis deferred; Axis IV:  stress – mild; Axis V:  GAF current of 57 (moderate symptoms), highest in past year of 57.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 9434 code (major depressive disorder) citing major depressive disorder.  The listed Category II condition (anxiety, depression) was considered to contribute to the major depressive disorder.  The VA assigned a 30% rating under the 9434-9400 codes (major depressive disorder-generalized anxiety disorder) based on the VA C&P examinations 1 month after separation, citing anxiety disorder with depressive features, pervasive anxiety symptoms (easily upset and angered, difficulty relating to others, often gets into confrontations, socially phobic, and isolates yourself), episodic depressive symptoms related to situational stress (self-pity, fatigue, eats to excess, difficulty concentrating), moderately uneasy, anxious, and mildly depressed mood by examination, intact cognition, well organized thoughts, and taking Zoloft and Wellbutrin.  The panel considered the evidence.  Panel members agreed that the criteria for 50% were not approached and deliberations centered on 10% versus 30%.  The description for a 30% rating is “Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal).”  With regard to a 30% rating, the panel noted symptoms of depressed mood (episodic related to situational stress) and anxiety (pervasive) that supported the 30% rating, while suspiciousness, panic attacks, chronic sleep impairment, and mild memory loss were absent.  On formal mental status testing, memory was intact.  

The panel then considered the descriptions of the 10% disability rating “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 panel noted that the stress of chronic illness (HIV) met the “significant stress” requirement for the 10% rating.  There is no indication in the record that he did not meet duty requirements.  To the contrary, the Commanding Officer's comments in the NMA documented the CI “has been a top performer … qualified to instruct … a full month ahead of the mandated norm … has met every milestone … assigned to him … has been a motivated and dependable … and continues to be an asset to this command.”  Approximately 1 month after separation, the CI was working providing automated services for building contractors.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the MH condition.  

Human Immunodeficiency Virus.  According to the STR and MEB NARSUM, the CI was notified of human immunodeficiency virus (HIV) seroconversion (detectable HIV antibodies) in 1999.  The 20 August 1999 MH services encounter documented “He is here for his initial HIV positive evaluation.”  Human T lymphocytes are functionally divided into, cells that provide help for other immune cells (CD4 helper T cell), and those that mediate cellular cytotoxicity (CD8 cytotoxic T cells).  The HIV virus selectively targets, infects, and depletes activated, expanding CD4 T cells.  The initial CD4 cell count was 660 cells/mm3.  The normal CD4 cell count range falls within 500 to 1400 cells/mm3   (broad range reflects CD4 cell count is product of 3 variables:  the white blood cell count, the percentage of lymphocytes, and the percentage of lymphocytes that bear the CD4 receptor).  The initial CD4 percentage was 36% (CD4 percentage of >29 percent corresponds to absolute CD4 count >500 cells/mm3).  The initial plasma viral RNA (viral load) was 5,500 copies/mL.  The HIV-1 RNA quantification (eg, viral load testing) is routinely used in the management of persons infected with HIV.  The CD4 cell count correlates with viral RNA measurements (in general, the higher the CD4 cell count, the lower the viral RNA).  The 4 April 2005 MEB NARSUM addendum by infectious disease (ID), 3 months prior to separation, recounted the history and interventions.  “Since 1999, he was on antiretroviral therapy briefly in 2002, but other than that has not been on antiretroviral therapy and has maintained good CD4 counts, most recently 494, and 28% in January of 2005.  His HIV RNA level has fluctuated between 2,000 and as high of 30,000 off medications.  His past medical history and concurrent medical history during the past 5-1/2 years includes serologic evidence of remote hepatitis B infection.  Concurrent conditions include gingivitis, anal fissure, and herpes simplex infection.”  The physical examination revealed follicular papules (face, chest, and back), perirectal skin tag, fissuring between his toes, no significant lymphadenopathy (enlarged lymph nodes), and was otherwise unremarkable.  The diagnoses listed HIV infection, remote history of hepatitis B infection without active hepatitis, herpes simplex infection, intermittent anal fissuring, tinea pedis, intermittent history of gingivitis, and anxiety, depression.  The physician documented “This petty officer has had HIV infection documented for over five years.  He has maintained a low normal CD4 count and percent without needing antiretroviral therapy.  He has evidence of active HIV infection, and will need to be followed quarterly for evidence of CD4 count decline, and assess the need for antiretroviral therapy in the future.”  The 3 August 2005 general medical VA compensation and pension (C&P) evaluation, 1 month after separation, documented “Since 1999, he has had a gradual decrease in CD4 counts and was began on Trizivir (abacavir, lamivudine and zidovudine).  He had a very good response with CD4 counts over 800 but resulted in elevated liver enzymes and was told that he had a fatty liver and after one year on Trizivir this was discontinued.  He has not been on medications for the past two years.  His CD4 counts are now less than 500 and he has had a decrease in his percent from CD4/CD8 from 32% to 23%.”  The CI complained of general fatigue, falling asleep very easily, and night sweats.  “He also found he had problems with loose stools and urgency; workup has been negative.  He was diagnosed with ‘functional diarrhea’ [chronic or recurrent diarrhea not explained by structural or biochemical abnormalities] and has occasional incontinence over the past five years.”  The CI reported a history of hemorrhoids and perianal herpes and “he is not sure when he has flareups whether it is hemorrhoids or herpes.”  “He has no suspicious opportunistic infections and no other/specific opportunistic infections.”  The CI was currently working as an electronics control contractor who inspected buildings.  The physical examination revealed minimally prominent, nontender, anterior cervical/submandibular lymph nodes and mildly tender hemorrhoids and was otherwise unremarkable.  The diagnoses listed HIV disease, fatty liver and elevated liver enzymes secondary to Trizivir therapy, functional diarrhea, herpes of the perianal area, and hemorrhoids.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 6351 code (HIV-related illness) citing HIV infection.  The VA assigned a 10% rating under the 6351 code (HIV-related illness) based on the VA C&P examinations 1 month after separation, citing HIV infection, CD4 counts, CD4/CD8 percents, no suspicious opportunistic infections or other specific opportunistic infections, and had not been on medications for the past two years.  The panel agreed the constellation of objective medical symptoms, subjective complaints, and CD4 (T4) cell counts exceeded the 0% rating (asymptomatic, following initial diagnosis of HIV infection, with or without lymphadenopathy or decreased T4 cell count) under the 6351 code.  The symptoms, complaints, medications history, and T4 cell counts in the MEB NARSUM and VA C&P examinations were consistent with the 10% rating (following development of definite medical symptoms, T4 cell of 200 or more and less than 500, and on approved medication[s], or; with evidence of depression or memory loss with employment limitations) under the 6351 code.  The panel agreed the constellation of symptoms (opportunistic infections), complaints, medications history, and T4 cell counts did not approach the 30% rating (recurrent constitutional symptoms, intermittent diarrhea, and on approved medication(s), or; minimum rating with T4 cell count less than 200, or hairy cell leukoplakia, or oral candidiasis) under the 6351 code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the HIV infection condition.  

Contended PEB Category III Conditions:  Chronic Patellar Femoral Syndrome Bilateral Knees, Herpes Simplex Infection, Intermittent Anal Fissuring, Remote History of Hepatitis B Infection Without Active Hepatitis, Intermittent History of Gingivitis, Lower Leg Pain When Running, Intermittent Truncal, Facial Acne, Chronic Diarrhea, and Tinea Pedis.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The contended Category III conditions were not implicated in the nonmedical assessment (NMA) and were not judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  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 mental health condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the HIV infection condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended chronic patellar femoral syndrome bilateral knees, herpes simplex infection, intermittent anal fissuring, remote history of hepatitis B infection without active hepatitis, intermittent history of gingivitis, lower leg pain when running, intermittent truncal, facial acne, chronic diarrhea, and tinea pedis conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150830, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC

		
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	     				  Acting