RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00845
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20071119

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Contracting Craftsman, medically separated for “dysthymic disorder” and “narcolepsy,” rated 10% each, with a combined disability rating of 20%. 

CI CONTENTION:  Her mental disorder was misdiagnosed and she should have been rated for bipolar disorder.  She also had 10 narcolepsy attacks per week and her rating should be changed.  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB – 20070926 	VARD - 20080320	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Dysthymic Disorder	9433	30% -20% = 10%	Bipolar Disorder	9432	70%	20080207	
Borderline Personality Disorder	Cat III					
Narcolepsy	8108	10%	Narcolepsy	8108	10%	20080207	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%  	

ANALYSIS SUMMARY:  

Dysthymic Disorder.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was hospitalized after a suicidal gesture on 1 April 2007 after having an argument with her boyfriend who was stationed in Iraq.  The CI impulsively took ten tablets of "cough medicine."  Up until this time she had no history of any previous psychiatric hospitalizations.  She had been seeing a civilian psychiatrist since September 2006, for anxiety, depression, and paranoia.  At the 1 May 2007 MEB NARSUM examination, 6 months prior to separation, the CI reported racing thoughts, paranoid feelings, suicidal thoughts, and multiple suicide attempts in the past.  The CI endorsed periods of excessive spending, engaging in excessive sexual activity, speeding in her car, and sometimes feeling like physically hurting someone and lashing out.  The examiner noted that she was on Effexor, Lexapro, Risperdal, and Provigil.  The examiner observed a fidgeting, cooperative individual who was a poor historian.  Her affect appeared anxious, non-liabile but intense.  She also had perceptual abnormalities to include illusions and occasional auditory hallucination during times of stress.  The examiner concluded by stating that her symptoms were largely due to a personality disorder.  

On 15 May 2007, the CI’s commander commented that her medical condition did not interfere with her in-garrison military duties provided she remained on medications and her daily schedule was not modified.  However, the commander said the CI was non deployable, had missed 10 days work out of the previous 90 due to her condition, and her work performance had declined.  

At the 7 February 2008 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported that after discharge she divorced, became engaged, and was then pregnant with twins.  She was employed as a cashier at Panera Bread, participated in most family events, and only engaged in activities outside the house when obligated to do so.  Her paranoia interfered with her relationship with her fiancée, often accusing him of unwarranted infidelity.  The examiner documented the following in the mental status examination (MSE): abstract reasoning was concrete, attention was inefficient at times, judgment was intact but at times poor, mood was irritable, affect was euthymic, and thought content included suicidal thinking.  

At the 23 July 2008 VA C&P examination, 8 months after separation, the CI stated that she was having hallucinations, was having difficulty with personal hygiene, and was not able to deal with the stress of work, resulting in verbal reprimands and her eventual quitting.  The examiner, in the MSE, noted a normal affect, unremarkable thought content and judgment, and normal insight.  The examiner concluded that the CI’s symptoms posed a serious impairment in social, occupational, and familial function as well as her judgment, thinking, and mood.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the dysthymic disorder 30%, then deducted 20% for “aggravating/contributing factors” for a rating of 10%, coded 9433 (persistent depressive disorder (dysthymia)), citing definite social and industrial adaptability impairment.  The VA rated the mental health disorder 70%, coded 9432 (bipolar disorder), based on the C&P examination 3 months after separation, citing occupational and social impairment, with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood.  

The panel examined the record to determine the presence of a borderline personality disorder contributing to her more significant condition of dysthymic disorder (rule out bipolar disorder not otherwise specified).  The panel noted that the diagnoses of dysthymia and borderline personality disorder were not made until entry into the MEB process at the time of the NARSUM.  Previous diagnosis were adjustment disorder with depressed mood, depression not otherwise specified (NOS), major depressive disorder with psychotic features, and bipolar disorder.  The panel noted no diagnosis of borderline personality disorder throughout the mental health history from 2002-2007, nor post-separation under VA care.  The panel observed that personality disorders arise in adolescence with significant impairment evident at a young age.  The record contains multiple fitness reports and awards showing exceptional performance prior to the onset of her mental health condition in 2006.  Dysthymic disorder (rule out bipolar disorder NOS) and more specifically bipolar disorder, in contrast, arise during young adulthood and precipitate a rapid decline in functioning.  The CI’s history most closely aligns with bipolar disorder.  Panel members agreed that the PEB deduction of 20% for aggravating contributing factors was not substantiated in this case.  

The panel majority assessed her impairment in multiple spheres and found decreased efficiency in work documented in the commander’s comments, problems in family relationships as demonstrated by conflicts with significant others, repeated documentation of irritable mood, poor judgment including over-spending and impulsive sexual activity, and problems thinking to include suicidal ideation and hallucinations.  A rating of 30% would be assigned if there were only occupational and social impairment with occasional decrease in work efficiency.  A rating of 50% would not take into account that the CI condition included deficiencies and impairment in most areas of her life, not just social and occupational functioning but also impairment of her mood, judgment, and thinking.  The panel majority agreed that the CI’s occupational and social functioning was most consistent with a 70% rating for occupational and social impairment, with deficiencies in most areas.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 70% for the dysthymic disorder, coded 9433.    

Narcolepsy.  According to the STR and MEB NARSUM, the CI had a longstanding diagnosis of narcolepsy.  Her main symptoms were described as excessive daytime sleepiness and hyper somnolence.  A sleep study performed in April 2006 supported the diagnosis of excessive daytime sleepiness.  She was treated with Provigil.  The commander makes no mention of a sleep disorder.  The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the narcolepsy condition 10%, coded 8108 (narcolepsy), citing the condition was only partially controlled.  The VA also rated the narcolepsy condition 10%, coded 8108, based on the C&P examination 3 months after separation, citing a confirmed diagnosis of epilepsy with a history of seizures.  The panel notes that the minimum rating for narcolepsy is 10%.  To be rated higher than 10%, there would need to be documentation of distinct episodes of sudden onset of sleep during the day.  Panel members agreed that the evidence did not support a rating higher than the 10% PEB rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the narcolepsy condition.  

BOARD FINDINGS:  In the matter of the dysthymic disorder, the panel majority recommends a disability rating of 70%, coded 9433 IAW VASRD §4.130.  The single voter for dissent submitted the appended minority opinion.  In the matter of the narcolepsy condition and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  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, the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Dysthymic Disorder	9433	70%	
Narcolepsy	8108	10%	
COMBINED	70%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 2017218, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

Minority Opinion:

The minority member first considered the random 20% deduction from the CI’s 30% PEB rating and noted that the CI had a history of various mental health diagnosis.  The final diagnoses were dysthymic disorder and personality disorder.  The minority member noted that the various symptoms associated with these two disorders were not categorized as belonging to one or the other condition and there was no history of a mental health disorder found on the induction examination to support an EPTS deduction.  Therefore, the arbitrary 20% deduction from the PEB rating was not supported by the evidence.  The minority member then considered the rating based on the evidence and timeline outlined below.

In August 2002 the CI started receiving mental health treatment at Moody Life Skills Center.  On 18 April 2006, in the family practice clinic, after being placed on Adderall for treatment of her narcolepsy, the CI was noted to have “paranoia of her boyfriend being unfaithful.”  The examiner advised her to stop taking the medication.  

In September 2006, the CI started seeing a civilian psychiatrist in an outpatient clinic for anxiety, depression, and paranoia.  On 10 October 2006, a psychiatric treatment note showed that the CI was no longer experiencing paranoia.  On 1 April 2007, the CI was hospitalized for a suicide gesture when she “impulsively took ten tablets of cough medicine.”  Her hospital course was described as unremarkable.  

On 1 May 2007 her Enlisted Performance Report for the period 29 April 2006 - 28 April 2007 showed exceptional performance with recommendations of immediate promotion from both her NCOIC and commander.  The CI was noted to be a superior performer, an expert contract administrator, mission focused, a physical training leader for 17 military personnel, actively pursuing a Bachelor’s Degree in Business Administration, and “pilot” for the squadron Christmas party planning committee.

At the 1 May 2007 MEB psychiatric NARSUM examination, the CI reported “difficulty with concentration, poor memory, social withdrawal, low motivation, and low energy.”  The CI also reported a history of a suicide attempt in 2002, when she overdosed on cold medication that did not lead to hospitalization or mental health treatment.  She also reported a history of impulsive spending and sexual promiscuity.  She stated “that she forgets important things such as appointments, meetings, and projects.”  She also stated “she gets very irritated very easily and any interruptions cause her to become very agitated.”  She denied panic attacks, but endorsed hypnopompic hallucinations (occur in the waking up stage of REM sleep) and auditory hallucinations of a voice in her left ear.  The CI’s psychosocial history showed that she was married at age 18 and divorced by age 21 [she was 25 at separation].  The examiner noted that she denied any work-related problems and did not have any apparent difficulties with coworkers.  The mental status examination noted that she was groomed, alert, fully oriented and cooperative, but made poor eye contact and fidgeted significantly.  Her mood was “accepting” but her affect was anxious and intense.  There was no active suicidal or homicidal ideation, intent, or plan.  She had perceptual abnormalities to include illusions and auditory hallucinations during times of stress.  Her thought process was goal directed.  Her judgment and insight were poor.  She had no obvious deficits in attention, concentration, or memory.  Her Global Assessment of Functioning score was 55 to 60, which indicated moderate symptoms.

On 11 May 2007, at the family practice clinic, the examiner noted that the CI had a depressed mood and flat affect, but was appropriately dressed and groomed, and her attitude was cooperative.  There were no suicidal or homicidal tendencies and no preoccupation with violent thoughts.  

On 15 May 2007, the commander stated that the CI’s medical condition would allow her to perform all primary military duties without restrictions as long as she remained on medications, but noted that the CI’s condition caused tardiness.  The commander also noted that the CI’s work performance had slightly declined and that she had a problem consistently focusing on the immediate task at hand and opined that her lack of mental concentration and focus could possibly result in inappropriate procurements for the government.  

At the 24 August 2007 neurological examination, the CI’s recent and remote memories were normal, attention span and concentration were normal, language was normal, and she had “good naming, repetition and comprehension.”  There was no other applicable pre-separation evidence in the case file.  

Under the schedule for ratings of mental disorders, the 30% rating for occupational and social impairment, with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, was fully supported by the record, but the CI also had a history of depressed mood, flattened affect, and impaired judgment (impulsive buying and sexual promiscuity).  Her commander noted that although she could do the primary functions of her job, her performance had slightly declined and she had problems consistently focusing on what she was doing.  

The minority member found that the evidence was most consistent with occupational and social impairment with reduced reliability and productivity due to her impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective social relationships, performance decline, and problems with consistent focus on the task at hand. 

Although the CI was noted to have some deficiencies in work, family relations, judgment and mood, these deficiencies did not lead to obsessional rituals which interfered with routine activities.  The CI’s speech was never described as illogical, obscure, or irrelevant.  The CI denied a history of panic attacks and her depression did not affect her ability to function independently, appropriately, or effectively.  There was no evidence of spatial disorientation in her record or evidence that she neglected her personal appearance or hygiene.  There was no evidence that she had difficulty adapting to work or a work-like setting, although her performance had slightly declined.  However, the minority member does acknowledge that the CI did have a history of suicidal ideation with at least two attempts or gestures, and impaired impulse control, but the CI’s psychiatric symptoms did not lead to occupational and social impairment with deficiencies in most areas to support a 70% rating.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel minority recommends a disability rating of 50% for the dysthymic disorder, coded 9433. 

The panel minority recommends the CI’s prior determination be modified as follows; and, the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Dysthymic Disorder	9433	50%	
Narcolepsy	8108	10%	
COMBINED	60%	

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

XXXXXXXXXXXXXXXXXX

Dear Applicant:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-00845.

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 XXXXXXXXXXXXXXXXXX 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.

		

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings