RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2016-00657
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20041217

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Aerospace Maintenance Technician, medically separated for “major depressive disorder associated with dysthymia” 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 - 20041029	VARD - 20050525	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder Associated with Dysthymia	9434	10%	Major Depressive Disorder	9434	10%	STR	
Personality Disorder, Not Otherwise Specified	Cat III	Personality Disorder	9499-9410	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Major Depressive Disorder Associated with Dysthymia.  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 December 2002.  In April 2004 the CI was diagnosed with an adjustment disorder with mixed anxiety and depression and an occupational problem as well as a personality disorder.  

In July 2004 the CI was evaluated at the Life Skills Support Center where he had a dysphoric mood (unease or dissatisfaction) and restricted affect with somewhat poor insight.  He reported passive suicidal ideation and homicidal ideation without plan or intent.  Treatment consisted of Lexapro (escitalopram, an antidepressant) and a safety plan.  In August 2004 the Axis I diagnosis was revised to a major depressive disorder, single episode, severe with psychotic features and dysthymia.  As a result an S-4T profile was issued.  The Lexapro dose was increased on 23 August 2004 and the CI was counseled accordingly.  Risperdal (risperidone, an antipsychotic medication) was added to the treatment protocol on 31 August 2004.  

The 15 September 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of depressive symptoms, chronic insomnia, and chronic poor self-esteem.  Mental status examination showed the CI was alert and oriented to person, place, situation, and date.  He was cooperative and his speech pattern was of a normal volume, tone, and rate.  His mood was dysphoric and irritable and his affect was tearful and somewhat flat.  Thought process was linear and goal-directed.  Thought content was remarkable for passive suicidal ideation and paranoid ideation.  He experienced ideas of reference and experienced bizarre delusions.  Insight was poor.  There was no loosening of associations.  Judgment was impaired as evidenced by his refusal to heed psychological advice including improving social and recreational functioning.  Impulse control was intact.  Abstraction was good and intelligence was estimated to be above average. The examiner noted the CI experienced paranoid ideation, severe depressive symptoms, violent and suicidal ideations, and intermittent psychotic symptoms.  The Axis I diagnosis was a major depressive disorder, single episode, severe with mood-incongruent psychotic features, characterized by a strong dysphoric mood, and recurrent passive suicidal ideation.  Stressors included relationship loss, financial problems, work stress, and social isolation.  His military impairment was marked as was his impairment for social and industrial adaptability.  The psychologist examiner opined that the CI’s paranoid, depressive, and psychotic symptoms would likely have deleterious effects on his social and occupational life in the future.  The CI “may be able to benefit from long-term psychotherapy and alleviate his sense of social isolation, leading to an improved prognosis.”  Additionally, the CI had a dysthymic disorder with early onset, characterized by a chronic depressed mood, insomnia, and fatigue.  The examiner opined that the CI’s symptoms, which had an onset 3 years earlier, were in response to financial problems, social isolation, and ostracism.  “Premorbid difficulties with social function, dysthymic mood, and characterologic problems” made the CI “vulnerable to depression.”  The military impairment for the dysthymia was mild as was the impairment for social and industrial adaptability.  The CI’s Axis II personality disorder NOS with cluster A traits (social awkwardness and social withdrawal) was characterized by a reduced capacity for close relationships.  His military impairment for the personality disorder was marked and moderate for impairment for social and industrial adaptability.  The CI’s GAF score was 35 (some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood)  and the highest GAF score in the prior year was 60 (moderate symptoms).

On 24 September 2004 the CI reported his mood improved with Lexapro.  For many years he had “paranormal” experiences to include rare sightings of ghosts moving furniture and a cat shadow on the wall.  He also reported hypnopompic (a state of consciousness leading out of sleep) and rare hypnogogic (consciousness at sleep onset) [hallucinations] when waking from a dream.    He discontinued the risperidone due to having “weird dreams.”  The psychiatrist felt there was no clear evidence of an Axis I psychotic disorder.  The CI’s GAF score was 65 (some mild symptoms).  Lexapro and ongoing counseling was continued.  At a psychiatric visit on 7 October 2004 the CI reported less stress at work, being less irritable, continued low energy, and improved sleep as well as improved interpersonal relations at work after being transferred to a new job site; however, he still felt depressed.  His GAF score was 70 (some mild symptoms).  On 27 October 2004 the CI report improved energy, fluctuating sleep, and an even mood (“not depressed, normal, not happy”).  
He also reported long term paranoia about others without clear delusions.  His GAF score was 70-80 (mild symptoms-transient and expectable reactions to psychosocial stressors).  On 6 December 2004 the CI reported an “alright” mood, improved appetite, improved energy, fluctuating sleep, and less paranoia.  His GAF score was 80 (transient symptoms; slight impairment) and the Lexapro was continued.  

There was no VA examination in evidence proximate to separation.  However, on 9 February 2005 the CI underwent a psychosocial assessment.  He indicated he became depressed in 2001-2002 as a result of 9/11, financial problems, friends who stole from him, being away from family, and not having a lot of friends.  On examination he was neatly groomed in casual attire.  His mood and affect were on the somber side.  He was verbal, polite, and cooperative.  He acknowledged having anger management issues and had resentment toward people he worked with in the military.  On 14 February 2005 he underwent a psychiatric evaluation.  A mental status examination revealed the CI to be alert and cooperative, but somewhat ill at ease with guardedness and poor self-image.  He felt he was forced out of the military.  There was no active psychotic features and he denied hallucinations.  His affect was tense and dysphoric, although vegetative functions were fairly intact.  He was not suicidal or homicidal and was in full contact with a clear sensorium.  Memory was somewhat impaired with poor attention.   His Axis I diagnosis was history of depressive disorder and Axis II was personality disorder.  His GAF score was 65 (some mild symptoms).  He was not interested in resuming antidepressant medication, but he was to continue with some counseling.  On 14 April 2005 the CI felt well and had no signs of active depression.  After an altercation with his girlfriend, the CI was admitted to the hospital from 1 July 2010, less than 7 months after separation, to 31 July 2010 for major depressive disorder.  Treatment consisted of Seroquel (quetiapine, an atypical antipsychotic drug used in combination with antidepressants) and venlafaxine (an antidepressant).  On discharge his GAF score was 60 (moderate symptoms or moderate difficulty in social, occupational, or school functioning).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the major depressive disorder condition 10%, coded 9434 (major depressive disorder).  The PEB determined that the CI’s “social and industrial adaptability impairment [was] best described as definite,” warranting a 30% rating, but found that the CI’s “personality disorder, a non-ratable/non-compensable condition under disability law/policy,” “significantly affected the severity of the major depressive/dysthymic disorder.”  The PEB deducted 20% from the rating based on the personality disorder’s contribution to the overall mental health picture, resulting in a 10% rating for the depressive disorder condition.  The PEB also noted significant evidence that the mental health condition may have existed prior to service; however, it opined it was not conclusive.  The VA rated the major depressive disorder condition 10%, coded 9434, based on service treatment records, citing a stable mood and a GAF score of 80 (if symptoms are present, they are transient and expectable reactions to psychosocial stressors; no more than slight impairment in social, occupational, or school functioning), indicative of slight impairment.  

The panel considered whether the provisions of VASRD §4.129 (mental disorders due to traumatic stress) were applicable.  The panel noted that there was no traumatic event, although the CI was deployed, there was no evidence that the CI was exposed to combatant operations, hostile fire, indirect fire, an IED blast, or other highly stressful events, which caused the unfitting mental health condition.  Therefore, panel members concluded that application of VASRD §4.129 was not appropriate in this case.  Panel members noted the significant disparity between the NARSUM psychologist’s GAF score reporting and subsequent higher GAF scores once the CI had been treated with Lexapro for his depression.  Even at subsequent VA mental health screenings and evaluation, the CI noted continued improvement in the depression, albeit he had been separated from military service, until he had an altercation that resulted in a month long hospitalization post-separation.  
Nevertheless, panel members agreed with the PEB rating of 30% marked by “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), 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).”  However, a 50% rating is not warranted since it 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,” despite the CI’s having have disturbances of mood and difficulty in establishing and maintaining effective work and social relationships.
 
Members then agreed that it is impossible to separate the social and occupational impairment due to the ratable and un-ratable personality disorder diagnosis.  Both DoDI 1332.38 E2.1.1 (accepted medical principles) and VASRD §4.22 (rating of disabilities aggravated by active service) require a degree of certainty for justifying such deductions that is not achievable in this case without undue speculation.  Panel members agreed that its recommendation is based on the overall impairment in evidence as subject to Service rating and will be confined to the major depressive disorder associated with dysthymia.  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 associated with dysthymia, coded 9434.  

Contended PEB Condition:  Personality Disorder, Not Otherwise Specified.  The panel’s main charge is to assess the fairness of the PEB’s determination that personality disorder, not otherwise specified, was not compensable, but could be administratively unfitting.  Personality disorder is a condition not constituting a physical disability, IAW DoDI 1332.38 E5.1.3.9.2 or VASRD §4.9 (congenital or developmental defects).  Therefore, the panel has no basis for recommending the personality disorder as unfitting.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition; and so, no additional disability rating is 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 personality disorder, not otherwise specified condition, the panel unanimously agrees that it cannot recommend it for a disability rating.  There are 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 Associated with Dysthymia	9434	30%	

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

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Dear XXXXXXXXXX

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-00657.

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.  The Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

I 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 (210) 565-2273 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.