DEPARTMENT  OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON  NAVY  YARD  DC 20374-5023

IN REPLY REFER TO

1850
CORB:003
19 Feb 20

From: To:

Director, Secretary of the Navy Council of Review Boards PD-2017-02567

Subj:	PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr of 28 Oct 19

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy for appropriate action.

2.	On 12 February 2020, the Assistant Secretary of the Navy took action in your case by accepting the correct recommendation of the PDBR.	Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Physical Evaluation Board from 20 to 30 percent with assignment to the Permanent Disability Retired List.

3.	The Assistant Secretary's determination, which represents final action in your case by the Department of the Navy, was sent to the Navy Personnel Command, for correction of your records as stated above.	You will be notified once those changes are complete.

RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXX		CASE: PD-2017-02567 BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20090909

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty O3, Nurse Corp Officer, medically separated for “dysthymic disorder with atypical features” with a disability rating of 20%.

CI CONTENTION: “The disability rating was originally 30%, but reduced to 20% by the board. The severity of the depression at the time of the medical board was under realized by the board. 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 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 -20090601	VARD - 20100108	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Dysthymic Disorder with Atypical Features
Rating	30%
EPTS Deduction -10%
Total Rating	20%	
9433	
20%	
Major Depressive Disorder	
9434	
50%	
20091119	
Alcohol Dependence with Physiologic Dependence	Cat IV	No VA Placement	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 60%	

ANALYSIS SUMMARY:

Dysthymic Disorder with Atypical Features. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI detailed a history of mental health (MH) symptoms her entire life with feelings of being ostracized and isolated throughout her childhood and adolescence. On the 11 July 2002 military enlistment physical, the CI reported no MH history/symptoms or medications and was found qualified for service. At her brother’s wedding in 2004, she become intoxicated and was brought to the emergency room (ER) for SI. She was briefly hospitalized and discharged to outpatient care. Shortly after, she attended Officer Indoctrination School and reportedly saw a psychiatrist 2-3 times, but was cleared for military service.

The CI deployed to Iraq from the fall of 2006 to April 2007, and although she had no life- threatening events or combat experiences, she had a “job with a lot of stress” which increased depressive symptoms to the point where she put a loaded weapon to her head on repeated occasions. She did not report hypervigilance, intrusive nightmares or flash backs. The CI sought MH treatment and was placed on anti-depressant, anti-anxiety, and sleep medications by a primary care provider. Due to social and occupational problems, she became suicidal on her birthday and sought care in the ER on 19 May 2008. She had a plan and intent to commit suicide, but was escorted home and did not attempt suicide. At a psychiatric evaluation the next day, the mental status examination (MSE) noted a “crappy” mood and that the CI was tearful at times, but all other findings were normal. The Axis I diagnosis was depressive disorder, not otherwise specified (NOS) with an Axis II diagnosis of borderline personality traits (rule out personality disorder), and a global assessment of functioning (GAF) assignment of 60 (moderate impairment, symptoms).  The psychiatrist deemed her psychiatrically fit for duty.

During the 10 March 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported a history of chronic depression, worse in the last 2 years, but stable on medication (Effexor), with a history of MH treatment and alcohol abuse. She had been sober for the previous 7 months and had no current suicidal ideations. The MEB NARSUM examination the next day, noted active SI which was “tempered by her access to care, and her decreased occupational stress.” She was working in an administrative capacity and not in patient care. The MSE showed poor eye contact, emotional lability, poor mood and dysphoric and reactive affect. She denied current SI, but endorsed chronic suicidality and reactive suicidal thoughts. She did not have audio or visual hallucinations and there was no evidence of delusions. The remainder of the examination was normal. The psychiatrist noted the CI was unable to work in her designated profession as a nurse and that she was “volatile in her actions with others, and this is not conducive to her position as an officer.” The Axis I diagnoses were moderate, single episode, moderate major depressive disorder (MDD); dysthymic disorder with atypical features; and alcohol dependence with physiologic dependence, in remission. The GAF assignment was 45-50 (serious symptoms, impairment).

The 10 April 2009 non-medical assessment (NMA), 5 months before separation, noted the CI was working outside of her medical specialty, but using her nursing knowledge as a medical record quality reviewer and had performed well in the position with one absence since July 2008. Although she was concerned for herself for future stress control and access to controlled substances, the NMA stated that at no time was there concern for the safety of her patients or workmates by the immediate chain of command.

At MH visits after the MEB NARSUM to the date of separation, the CI was stable, with improvement attributed to new medication, therapy, and removal from stressful occupational environments. At a psychiatric follow-up examination on 19 June 2009, 3 months prior to separation, the CI reported “100%” improvement in mood, anxiety, and reactive symptoms. She was forward thinking, planning on taking the law school entrance examination, and had a steady boyfriend who she looking forward to marrying in 6 months. There was no change in her diagnosis and continued medications were recommended for at least 2 years with stable symptoms before considering pregnancy; psychotropic medication use would be long-term.

At the 11 November 2009 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported her history of depression with exacerbation of symptoms while in Japan. She related that she had a problem with drinking prior to the military, but started to drink more heavily 3 months prior to deployment to 18 months after. She experienced some flashbacks, hypervigilance, and startle reaction, but these symptoms completely abated after 4- 6 months. She had been sober since August 2008, and stated that the changed to Effexor in December 2008 was “life changing” with significantly improved mood and decreased irritability.

She was “fairly happy” with her life, was about to go on her honeymoon, and denied depressed mood, sleep or appetite problems. On MSE, the CI was well-groomed and in no acute distress. She was cooperative with good eye contact and was gregarious. Mood was described as “okay,” and affect was euthymic. Speech and thought process and content were normal, and she denied any SI, manic symptoms or psychotic symptoms. The VA examiner documented “no significant post traumatic stress disorder symptoms” and an Axis I diagnosis of recurrent, moderate MDD and alcohol abuse in full remission, with a GAF score of 80 (slight/transient impairment). The CI was assessed to be functioning well in all areas, with absent or minimal symptoms, and no more than slight impairment in social and occupational capacity.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the MH condition 30%, 9433 (dysthymic disorder) and applied an EPTS deduction of 10% for a final 20% rating. The PEB listed MDD as a related diagnoses (Category II) contributing to the disability in this case, and panel members agreed that this was not a separate condition which could be reasonably justified as separately unfitting or ratable IAW VASRD §4.130. The VA rated MDD at 50%, coded 9434 (major depressive disorder) for a 6-month period, based on the C&P examination, citing VASRD §4.129 (mental disorders due to traumatic stress) and assigned a 10% rating 6 months after separation based on occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. The CI filed a Notice of Disagreement, and on 29 November 2010, the VA increased the rating to 50%, citing occupational and social impairment with reduced reliability and productivity.

The panel considered whether the provisions of VASRD §4.129 were applicable, and noted that the stresses of deployment to a combat zone, although considerable under the best of circumstances, do not automatically equate to the §4.129 standard of “a highly stressful event.” In this case the record supports the CI’s MH condition was aggravated by service but was not the result of a highly stressful event and concluded that application of §4.129 was not warranted. While MH providers agreed the CI’s dysthymic condition existed prior to service based on the CI’s reported history, there was no evidence of impairment related to a MH diagnosis documented on the service entrance physical or evidence that the CI was treated with medication for any MH condition at the time of enlistment. No more than a 0% EPTS rating is supported for a formally diagnosed MH condition for which symptoms are not severe enough to interfere with occupational and social functioning or require continuous medication. Thus, it was not even clear to the panel from the available documentation, whether there was a formally diagnosed MH condition prior to enlistment, despite the CI’s self-report of MH symptoms then. Therefore, the panel does not recommend any EPTS deduction, and agreed that a 30% rating was supported at separation for 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). There was no evidence of occupational and social impairment with reduced reliability and productivity to support a 50% rating. After due deliberation, considering all the evidence and mindful of VASRD
§4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the dysthymic disorder, coded 9433-9434.

BOARD FINDINGS: In the matter of the dysthymic disorder with atypical features, the panel recommends a disability rating of 30%, coded 9433-9434 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 medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Dysthymic Disorder With Atypical Features	9433-9434	30%	

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20170117, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record