RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-00960
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20081105

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Aerospace Medical Service Journeyman, medically separated for “dysthymic 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 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 - 20080919	VARD - 20090128	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Dysthymic Disorder	9435	10%	Dysthymic Disorder 	9433	30%	20081211	
Schizotypal Personality Disorder	Cat III					
Atypical Chest Pain	Not Unfitting	Intercostal, Neuralgia	5399-5321	0%	20081104	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Dysthymic Disorder.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s mental health (MH) disorder began in April 2006 when she reported concentration/attention problems and depressive symptoms.  On the MH clinic intake form she reported depression since an early age, but did not think she was currently depressed even though she said she felt dead from the neck up.  She always felt like she was strange and socially odd, felt nervous around others, had problems remembering and had “lost a few years between “7-16.”  She added she had an odd family and was against taking medication.  Mental status examination (MSE) showed depressed mood, flat affect, monotone voice, picked at her clothes and was distracted.  Screening studies were consistent with moderate depression.  Intelligence quotient (IQ) was 130, performance IQ was 138, verbal IQ was 119, but she scored poorly in digit span and in letter-number sequencing.  Working memory was at the 32nd percentile.  A diagnosis of dysthymic disorder and possible schizoid traits was rendered.  Treatment was terminated per her request but she returned in November 2007 and saw a new psychologist. 

At her 10 January 2008 follow-up, she described talking to inanimate objects and talking about things unrelated to the conversation.  The MSE showed flight of ideas, flat/restricted mood, affect inappropriate to content and speech and thought that was at times circumstantial or tangential.  Psychological testing on 22 January 2009 showed underreporting so significant the test was invalid, though suggestive of somatization disorder.  The CI described a number of somatic complaints, including tunnel vision, flight of ideas, rapid speech, perseveration and getting minor traffic violations, which taught her to drive late at night.  She displayed similar symptoms during a 28 January 2008 visit.   

The 27 July 2008 MEB NARSUM examination, 3 months prior to separation, noted the CI had not returned to the MH clinic since February 2008.  She described her depression as “not even less than mild” and was not sure about continuing therapy.  The examiner noted her thoughts tracked in several directions. She was taking no medication.  Multiple somatic complaints and work up were noted in her medical records, showing a somatic tendency, though not meeting full criteria for somatization disorder.  Her MEPS physical did not document MH problems.  Medical evaluations, including neurological and neuroimaging assessments, were negative.  The MSE showed circumstantial or tangential speech and thoughts with some flight of ideas.  Mood was upset and affect was not congruent with mood and thought content.  She denied suicidal/homicidal ideation.  An Axis I diagnosis of dysthymic disorder, early onset and existing prior to service (EPTS) with mild impairment was rendered along with an Axis II schizotypal personality disorder, also EPTS, with definite social impairment and marked military impairment.  The Global Assessment of Functioning (GAF) score was 55 (moderate symptoms).  The examiner noted the CI had very unusual thinking processes and lacked insight into her MH issues.  The examiner was uncertain whether the diagnosis was schizotypal personality disorder or prodromal schizophrenia and noted the dysthymia (depression) could be negative psychotic symptoms.  

Although the CI was “a good solid Airman who perform[ed] her assigned duties well” and had an “overall excellent job performance…and strong support from her immediate supervisors,” the commander had concerns that the medical condition made the CI “unsuitable for continued military service.” 

At the 11 December 2008 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported receiving psychotherapy to help cope with depressed affect and separation problems.  She continued to have constricted affect.  Her general presentation was odd and muted.  She reported constant depressive symptoms that affected her daily functioning and resulted in her being unmotivated and interrupted daily tasks.  She reported being afraid to be in groups of people and felt she would be hurt by the mob because she had researched mob action.  She described a 5-year history of sleeping 10-20 hours per day with poor motivation.  Treatment included medication in September 2008 with poor response, but there was good response to psychotherapy, which she received as often as twice per month.  She had not been hospitalized or made emergency room visits for psychiatric problems.  She reported being unemployed since leaving the military because she was mentally incapable of working.  She was single and had a significant other but that relationship was ending.  However, she had several other friendships and volunteered at the Humane society.  The MSE showed abnormal affect and mood with flattened affect.  She was “odd” and did not express much feeling.  She did not understand why MH professionals found her thinking odd.  There were signs of suspiciousness and felt she was unjustly separated as a result of a diagnosis given by a female civilian MH person.  Judgment was impaired but suicidal ideation was absent.  A diagnosis of Axis I dysthymia and Axis II personality disorder with schizotypical traits was rendered with a GAF score of 60 (moderate bordering on mild symptoms).  The examiner noted anxiety, suspiciousness and sleep impairment caused occupational and social impairment with decrease in work efficiency though generally functioning well.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the MH disorder 10%, analogously coded 9435 (mood disorder NOS).  The VA rated the MH disorder 30%, coded 9433 (dysthymic disorder) based on the C&P examination, citing occupational and social impairment with occasional decrease in work efficiency/occupational tasks.  

Application of VASRD §4.129 was considered by the panel for this case, but members agreed that the ‘highly stressful event’ requisite for §4.129 was not satisfied in this case.  The panel discussed whether the CI’s MH disorder was permanently service aggravated and subject to rating.  Although the CI reported a history of depression, the entry history and physical did not reveal depression or any other mental illness.  There was no known documentation of evaluation for, or treatment of, a mental disorder prior to entry into the Service.  The CI did not report depressive symptoms until 14 months post-entry into the service.  As of August 2008, her commander reported excellent overall performance. Therefore, the panel agreed with the PEB that the MH disorder was permanently service aggravated.  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 “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.” 

The NARSUM examination noted flattened affect, circumstantial and tangential speech, suspiciousness, impaired judgment and other symptoms of psychosis.  The examiner was uncertain if the psychosis symptoms reflected early stages of schizophrenia or schizotypal personality disorder.  Clinical findings of the C&P examination were similar, noting flat affect, abnormal mood, odd thinking, impaired judgment, sleep impairment, anxiety and suspiciousness.  She continued to report depression.  A range of psychotic symptoms were present during multiple interviews.  Paranoid schizophrenia was diagnosed within months of separation.  However, the commander reported excellent job performance and the CI did not miss work.  The panel majority agreed that despite the MH disorder, the CI was capable of good work, had not required psychiatric hospitalization, had secured a job after separation in a gas station, was planning to attend college and showed symptoms consistent with a 10% disability.  Socially, she had several friends and was volunteering.  After due deliberation, considering all 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 MH disorder.  

Schizotypal Personality Disorder (SPD) and Atypical Chest Pain.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting. The PEB noted SPD per DODI 1332.38 is a condition of a developmental nature that does not constitute a physical disability and is not ratable in the absence of an underlying ratable causative disorder.  The atypical chest pain was not profiled, implicated in the commander’s statement or judged to fail retention standards. There was no performance-based evidence from the record the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the MH disorder and IAW VASRD §4.130, the panel majority recommends no change in the PEB adjudication. The single voter for dissent recommends modification to 30% with re-characterization but did not elect to submit a minority opinion.   In the matter of the contended schizotypal personality disorder and atypical chest pain condition, the panel majority recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.

	

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-2017-00960.

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.