RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02463
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060620

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Visual Information Journeyman, medically separated for “major depressive disorder, recurrent, moderate in severity, with eating disorder” 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 - 20060505	VARD - 20070911	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder with Eating Disorder	9434	10%	Bulimia Nervosa, Panic Disorder and History of Major
Depression	9521	10%	20070828	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: 10%	

ANALYSIS SUMMARY:  

Eating Disorder, NOS.  The PEB combined the major depressive disorder and eating disorder conditions as a single unfitting condition coded 9434 (Major depressive disorder) and rated 10%. The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the disability evaluation system (DES) or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the major depressive disorder and eating disorder conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s eating disorder began as a teenager manifested by restricted intake.  In addition to restricted intake, the CI began purging in January 2004 which included self-induced vomiting and laxative use.  She stopped the laxative use soon after that.  In 2004 she was started on an antidepressant presumably to assist with purging.  The CI reported that this provided no relief and she self-discontinued it.  The CI presented to the life skills clinic for an intake appointment in February 2006 and she was referred for a MEB within 3 weeks.  

The 28 February 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of self-induced vomiting 3 to 10 times per week.  She denied any history of hematemesis, coffee-ground emesis, epigastric pain, blood in stool, menstrual irregularities or history of bingeing.  Her weight at the time of the MEB NARSUM was reported to be 136 lbs and her reported lowest weight was 134 lbs (BMI 21 – normal).  The physical examination showed normal weight.  

At the 28 August 2007 VA Compensation and Pension (C&P) evaluation, 14 months after separation, the CI reported that she continued to purge, particularly if she thought too much about her weight.  She denied bingeing.  The physical examination showed a normal mental status examination.  No weight was recorded at the C&P evaluation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the major depressive disorder with eating disorder 10%, coded 9434 (Major depressive disorder (MDD), citing mild social and industrial impairment.  The VA rated the condition as “bulimia nervosa, panic disorder and history of major depression” 10% coded 9521 (Bulimia nervosa), based on the VA C&P examination 14 months after separation, citing  evidence of “binge eating followed by self-induced vomiting or other measures to prevent weight gain.”  

Panel members agreed that the evidence reasonably justified that the functional limitations of the eating disorder contributed to the CI’s inability to perform her military duties, and accordingly a separate disability rating is recommended.  The panel noted that the CI denied binge eating and that she did not have a history of behavior “to prevent weight gain or resistance to weight gain even when below expected minimum weight” to justify a minimum rating under code 9521 (bulimia nervosa).  There were no other applicable codes for this condition.  

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 major depressive disorder with eating disorder.  

Major Depressive Disorder (MDD).  According to the STR and the MEB NARSUM, the CI’s depression began in January 2004, about the time of the death of her best friend.  In October 2004 she had a 3-day psychiatric hospitalization due to suicidal ideation (without suicide attempt).  She was on an antidepressant for 6 months and self-discontinued it.  The CI had a recurrence of her depressive symptoms starting in January 2006.  Because of the concurrent eating disorder it was decided to immediately proceed to MEB.  

The enlisted performance report (EPR) dated 30 September 2005, 10 months prior to separation, reports the CI’s performance of assigned duties was “The exception. Absolutely superior in all areas.”  Her conduct was rated to be “Exemplifies the standard of conduct.”  Her ability to supervise and lead was noted to be “Highly effective.”  Both her rater and her additional rater found her ready for promotion.  

The 28 February 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of depressed mood, feelings of worthlessness with decreased concentration and energy.  She denied suicidal ideation.  Mental status examination showed a well-groomed appearance, good eye contact, normal speech and no signs of agitation or psychomotor retardation.  Affect was full ranging and non-labile.  Thought process was linear and goal-directed, insight and judgement were both intact.  Memory was intact.  

At the 28 August 2007 VA C&P evaluation, 14 months after separation, the CI reported she was not undergoing mental health treatment and was on no psychotropic medication at that time.  She reported that she had one or two days per month when she felt severely depressed and would close herself off in her bedroom and tell her family that she did not want any contact.  Over the preceding few months her mood had been mostly okay, not unusually tearful, motivation was average.  She was not participating in many of her chosen interests but attributed that to being pregnant at the time.  Mental status examination showed her appearance and grooming were neat.  She made good eye contact, had normal psycho motor activity, speech was normal, mood was euthymic and affect was appropriate with no lability.  Judgement and insight were good.  Thoughts were coherent, logical and goal-directed.  There was no flight of ideas or loosening of associations.  There was no suicidal or homicidal ideation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the major depressive disorder with eating disorder 10%, coded 9434 (Major depressive disorder (MDD), citing mild social and industrial impairment.  The VA did not separately rate the MDD condition but included in the “bulimia nervosa, panic disorder and history of major depression” and coded it only as bulimia nervosa, based on the VA C&P examination 14 months after separation, citing evidence of “binge eating followed by self-induced vomiting or other measures to prevent weight gain.”  

Panel members agreed that although there was a diagnosis of MDD, there was no evidence of significant occupational or social function, there was no evidence of transient symptoms which decreased work efficiency and the condition did not require continuous medication to control symptoms to justify a 10% under the general rating formula for mental disorders.  

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 major depressive disorder with eating disorder.  

BOARD FINDINGS:  After due deliberation, and considering all of the evidence, the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bundled major depressive disorder with eating disorder.  There were no other conditions within the panel’s scope of review for consideration.  

The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150814, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-02463.

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,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings