RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02875
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20051114

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Munitions Systems Craftsman, medically separated for “major depressive disorder, single episode without psychotic features” with a disability rating of 10%.  The PEB then deducted 10% for aggravating/contributing factors for a final disability of 0%.

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 - 20050901	VARD - 20060126	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder…	9434	0%	Major Depressive Disorder, Single Episode	9434	10%	20050610	
Narcissistic Personality Disorder	Cat III	Narcissist Personality Disorder	9499-9432	NSC		
Bilateral Carpal Tunnel Syndrome	Cat II	Right Carpal Tunnel Syndrome	8515	10%*		
		Left Carpal Tunnel Syndrome	8515	10%		
Hyper Mobility Joint Syndrome, ETPS	Cat II	Patellofemoral Syndrome w/Recurrent Lateral Instability	5257	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

*VARD 20060330 increased right carpal tunnel rating to 50%; VARD 20071129 proposed to decrease rating to 10%; VARD 20080711 decreased the rating to 10%.  

ANALYSIS SUMMARY:

Major Depressive Disorder (MDD).  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s mental health (MH) condition began in August 2004.  He was initially evaluated by family practice and reported a 6-month history of anxiety and difficulty sleeping, feeling depressed with decreased energy and motivation, weight loss, forgetfulness, and being easily upset.  He was diagnosed with major depression and treated with antidepressant medication.  The CI was evaluated in the life skills support center in February 2005 and reported improvement in his depression symptoms.  He desired to be discharged from MH care and be cross-trained, and was referred to a psychiatrist.  Psychological testing performed on 16 February 2005 supported Axis I diagnoses of major depressive disorder (MDD), recurrent, moderate; anxiety spectrum disorder; and, Axis II diagnosis of narcissistic personality traits.  A permanent S4 profile was recommended.  Psychiatric evaluation on 17 February 2005 indicated an Axis I diagnosis of MDD, single episode, without psychotic features and also an Axis II diagnosis of narcissistic personality disorder.  

The 4 April 2005 MEB NARSUM examination, 7 months prior to separation, was performed by the CI’s treating psychiatrist, and noted complaints of depression.  Current prescriptions included a daily antidepressant and sleep aid as well as an anti-anxiety medication as needed.  During the mental status examination, the CI described his mood as “beige and not black and dark” and his affect was anxious.  He denied suicidal or homicidal ideation, and the remainder of the evaluation was unremarkable.  The Axis I diagnoses were MDD, single episode, moderate, without psychotic features; and an Axis II diagnosis of narcissistic personality disorder with a Global Assessment of Functioning (GAF) of 65 (mild symptoms, impairment).  The provider indicated the CI’s depressive symptoms were improved on his current medications and recommended continued psychiatric treatment.  Additionally, it was noted that the CI remained non-deployable and that the MDD did not exist prior to service and was not permanently aggravated by service, while the narcissistic personality disorder did exist prior to service and was permanently aggravated by service.  

At the 10 June 2005 VA Compensation and Pension (C&P) examination, 5 months before separation, the CI reported he was being released from the military due to his MH condition.  The examiner referenced service psychiatric findings, and specifically noted that a 31 May 2005 evaluation indicating that medications had “controlled both his panic disorder and major depression,” but that he continued to have “low-grade dysthymia related to chronic pain and possible Axis II issues.”  The mental status examination showed “no evidence of significant depression” but revealed “meticulousness and a high degree of concern for himself, his medical and his condition of future employment.”  The examiner further commented that the CI seemed to have a mostly successful military career and there was no other functional information available for review.  Psychiatric follow-up visits in July 2005 to September 2005, noted improvement in symptoms, with visits indicating that the MDD was in partial remission.  

The commander’s statement dated 24 August 2005, implicated the CI’s MH condition as impairing the successful performance of his duties, and noted that although he could not deploy or work in his primary military specialty, he was doing full shifts and had not missed work due to his condition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the MDD 10%, coded 9434 (MDD) and noted that the narcissistic personality disorder was a “non-ratable-non-compensable condition."  The PEB deducted 10% for aggravating/contributing factors and remarked that “were it not for the non-ratable, non-compensable condition your S&I [social and industrial] rating would best be described as none.”  The VA rated the MDD 10%, coded 9434, based on the C&P examination, citing “overall symptomatology and reported treatment regimen.”  

The panel first considered whether the provisions of VASRD §4.129 (mental disorders due to traumatic stress) were applicable in this case and concluded there was no traumatic event which caused the CI’s MH condition.  Members next deliberated over a rating recommendation IAW VASRD §4.130, and agreed that there was evidence of MH symptoms controlled by medication to support a 10% rating, but no evidence of “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks” to support a higher rating.  Although a contribution to occupational impairment from the non-ratable personality disorder may have been a factor in this case, panel consensus was that it was overly speculative to attribute the total MH disability from two co-morbid conditions to the non-ratable personality disorder alone.  The NARSUM examiner indicated the personality disorder had existed prior to service, however, the CI reported he was in good health and on no medications at his enlistment physical.   While on active duty, he was diagnosed with MDD at his first primary care evaluation for MH symptoms, and it was following this diagnosis that he was treated with multiple psychotropic medications, which he remained on at the time of separation.  Therefore, members agreed that a 10% without any rating deduction was appropriate.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the MDD, coded 9434.

Contended PEB Conditions: Narcissistic Personality Disorder, Bilateral Carpel Tunnel Syndrome (CTS), Hyper Mobility Joint Syndrome.

Narcissistic Personality Disorder.  The panel notes that any disability due to the personality disorder is subsumed in the panel’s VASRD §4.130 MH rating recommendation, which sanctions a single MH rating based on total occupational and social impairment.  Moreover, IAW DoDI 1332.38, a personality disorder is a condition not constituting a physical disability and is not a condition was eligible for service disability rating.  

Bilateral CTS and Hyper Mobility Joint Syndrome.  The panel’s main charge is to assess the fairness of the PEB’s determination that the bilateral CTS and hypermobility joint syndrome conditions were not unfitting.  The contended conditions were not judged to fail retention standards and were assigned U2 and L2 profiles.  A “2” profile designation indicates a condition which requires some physical limitations, but is not in all cases disqualifying for continued military service.  The commander’s statement specifically implicated only the MH condition as preventing the CI’s full performance of his duties.  The family practice summary written on 1 April 2005, and cited by the MEB NARSUM, indicated that the CI was on an exercise restricting profile, but was “able to perform his AFSC duties from a physical standpoint.”  There was no performance-based evidence from the record that the contended conditions 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 contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the major depressive disorder, the panel recommends a disability rating of 10%, coded 9434 IAW VASRD §4.130.  In the matter of the contended narcissistic personality disorder, bilateral carpel tunnel syndrome, hyper mobility joint syndrome conditions, 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.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Major Depressive Disorder, Single Episode without Psychotic Features	9434	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170321, 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-2017-02875.

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 modification of your assigned disability rating without re-characterization of your 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 direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  This will not result in any change to your separation documents or the amount of severance pay you are entitled to.  Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.

						Sincerely,

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachments:
1.  Directive
2.  Record of Proceedings