RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01163
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050718

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Communication Computer Systems Craftsman, medically separated for “major depressive disorder [MDD], chronic, associated with dysthymic disorder and post-traumatic stress disorder [PTSD]” with a disability rating of 10%.   

CI CONTENTION:  “My condition has continued to get worse.  I am unable to work and have spent significant time in hospitals.”  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 - 20050525	VARD – 20070709 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
MDD, Chronic, Associated with Dysthymic Disorder and PTSD	9434	10%	Dysthymic Disorder with Major Depression	9433	30%	20070212	
			PTSD	9411	NSC	20070212	
Personality Disorder NOS with Avoidant and
Borderline Features	Cat III	Personality Disorder	9499-9435	NSC	20070212	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

MDD, Chronic, Associated with Dysthymic Disorder and PTSD.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI had pre-service history of mental health (MH) issues that included a childhood history of sexual abuse and MH counseling in adolescence (disclosed on service entry physical).  She entered service in 1991 and there are STR entries addressing MH complaints from at least as early as 1993.  She nevertheless performed well without significant MH issues until a 2002-2003 deployment to Korea, concurrent with significant domestic stressors.  During that period she presented several times with depression and suicidal ideation, although she did not require admission.  She was diagnosed with “depression, NOS [not otherwise specified]” and was followed regularly in behavioral health after redeployment.  Post-deployment MH notes documented an Axis I diagnosis of “MDD, recurrent” and an Axis II diagnosis of “personality disorder, NOS, with avoidant and borderline traits.” 

In March 2004 the CI underwent a 4-day psychiatric admission for active suicidal ideation.  For the next year she followed an overall stable course, complying with outpatient treatment, but continued to suffer decompensations.  In December 2004 she underwent another 3-day psychiatric admission for active suicidal ideation; and, shortly afterwards in February 2005, was admitted for 2 weeks to a partial hospitalization residential unit.  There were numerous MH treatment notes over this period.  The CI would rapidly stabilize and resume high functioning at work after these crisis admissions.  Her Axis I and II diagnoses remained unchanged from above. Her mental status examinations (MSE) demonstrated some mood lability and intermittent suicidal ideation, but were otherwise normal with no acute features or cognitive impairment.  Global Assessment of Functioning (GAF) scores ranged from 50 to 65 (mostly in the range of moderate impairment).  

The 22 April 2005 MEB NARSUM psychiatric examination, 3 months prior to separation, stated, “The patient continues to have problems in mood management with frequent suicidal ideation fluctuating in intensity and at times becomes overwhelming.” She was being treated with two medications (Cymbalta and Seroquel), and a third (Depakote) was being added for additional “mood stabilization for comorbid depressive symptoms and her personality disorder.”  The NARSUM MSE recorded a “low” mood and a “full” affect with “passive suicidal ideation (chronic plan),” but was otherwise normal with intact cognition.  The Axis I diagnoses were “MDD, recurrent, mild currently,” “dysthymic disorder,” “partner relational problems,” and “history of PTSD.” The latter diagnosis appeared throughout STR entries, but was not elaborated in available evidence and was presumably grounded in childhood sexual abuse.  The Axis II diagnosis of “personality disorder, NOS with avoidant and borderline features” was also not elaborated upon; nor, was there any opinion with regard to its contribution to the overall psychiatric impairment.  The GAF assignment was 55 (mid-moderate) and the DoDI 1332.39-derived assessment of social and industrial impairment was “severe.”  The NARSUM psychiatrist opined that the CI “will be able to retrain in a new non-military field” and noted she was slowly improving, but “unfortunately the rate of improvement and frequency of impairment is not compatible with continued military service.”

Notwithstanding all of the above, the NARSUM psychiatrist stated, “She is thought highly of by her supervisors and is a productive member of the USAF.”  This was elaborated with statements from prior supervisors that ranked her as a top performer and deemed her competent to retain a top secret security clearance.  This was further corroborated by her July 2004 – July 2005 enlisted performance report that endorsed excellent to exceptional performance across all categories (overall 5, highest rating).

There were two MH entries in evidence over a 2-month period after separation documenting improved symptoms with totally normal MSE’s and GAF assignments of 75 (no more than slight impairment).  There was no subsequent evidence until a 12 February 2007 VA psychiatric Compensation and Pension (C&P) examination, 19 months after separation (thus temporally compromised in probative value).  This documented that there had been no interim hospital admissions and that the CI was employed full-time as a computer specialist.  The only occupational impairment recorded was “decreased concentration, increased absenteeism.”  The MSE was significant only for mood disturbance (no suicidal ideation) and the GAF assignment was 65 (mild impairment).

The panel directed attention to its recommendations based on the above evidence, noting that the provisions of VASRD §4.129 for any “mental disorder that develops in service as a result of a highly stressful event” were not applicable to this case.  The PEB rated the MDD 30%, coded 9434 (MDD), invoking the DoDI 1332.39 criterion of “definite” impairment (contrasting with the NARSUM assessment as “severe”).  The PEB, however, arrived at a final rating of 10% after applying a 20% deduction for the contribution from the personality disorder that is non-compensable IAW DoDI 1332.38 (E5.1.3.9.2).  The PEB opined the personality disorder “significantly affects the severity of your depression and associated condition [and] were it not for the non-ratable/noncompensable condition, your [DoDI 1332.39 social and industrial impairment] would best be described as mild [a 10% criterion IAW DoDI 1332.39].” 

The VA rated the MH condition 30%, coded 9433 (dysthymic disorder), referencing the temporally remote C&P evidence and applying the applicable VASRD §4.130 criterion “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.”  The VA did not service connect personality disorder or PTSD.  

The panel first deliberated the applicability of the above PEB deduction.  In that regard it was agreed that the PEB’s basis for the deduction was overly speculative from a clinical standpoint.  There was no evidence in the NARSUM (or elsewhere in the STR) for the details and severity of the personality disorder, and there was no professional opinion regarding the degree of its effect on the severity of the rated condition.  Furthermore this deduction is not countenanced by the VASRD (on which the panel must base its recommendation), nor was it endorsed by any DoD directive in effect.  The panel thus concluded the deduction was not applicable to its recommendation.

Having so concluded, the panel turned to deliberation of the appropriate rating recommendation under that condition.  By policy the panel may not lower the PEB’s baseline rating after rejecting the applicability of a PEB deduction, and members furthermore agreed the psychiatric disability was not fairly assessed at 10% under VASRD criteria.  Members thus deliberated whether the evidence was better aligned with the §4.130 criteria for a 30% rating (as quoted above) or with criteria of the next higher 50% rating, “occupational and social impairment with reduced reliability and productivity” referencing such symptoms as flat affect, stereotyped speech, frequent panic attacks, deficits in comprehension and memory, impaired judgment, mood disturbance, and difficulty with establishing relationships.  The panel noted the CI’s superior performance between her occasional decompensations, her stable course with no decompensations and full employment in the period following separation, and the absence of any of the referenced symptoms for a 50% rating.  Members thus agreed the evidence was best aligned with the 30% criteria.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a 30% rating for the major depressive disorder (and associated Axis I conditions) under code 9434.

BOARD FINDINGS:  In the matter of the major depressive disorder (and associated Axis I conditions), the panel recommends a disability rating of 30%, coded 9434 IAW VASRD §4.130.  There are no other conditions within the panel’s scope of review for consideration.

The panel recommends 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 the date of prior separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Major Depressive Disorder with Dysthymic Disorder and History of Post-Traumatic Stress Disorder 	9434	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170213, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

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

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-01163.

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.

						Sincerely,

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings