RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX		CASE: PD-2017-03369 BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20080104

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Sonar Technician, medically separated for “obsessive compulsive disorder” with a disability rating of 10%.

CI CONTENTION: Mental health continues to worsen and negatively impact daily activities. 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 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 Physical Evaluation Board (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 - 20071026	VARD - 20080623	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Obsessive Compulsive Disorder [OCD]	9404	10%	
OCD with Trichotillomania and MDD	
9404	
10%	
STR	
Trichotillomania	
Category II					
Major Depressive Disorder [MDD], Recurrent, Severe						
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 10%	
	
ANALYSIS SUMMARY:

Obsessive Compulsive Disorder (OCD). According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was referred for counseling and psychological testing in January 2007 due to anxiety, panic, compulsions and obsessions, and crying spells, which had started several month earlier and affected his relationships with others. He had no previous history  of  psychiatric  symptoms,  but  family  history  included  OCD,  depression  and anxiety.

Diagnoses of panic disorder, OCD and cyclothymic disorder were rendered with a Global Assessment of Functioning (GAF) score was 55 (moderate symptoms, condition.)

In the winter of 2007, the CI sought psychiatric care for worsening anxiety, reporting palpitations, sweating, shortness of breath, jitteriness, an impending sense of doom, and insomnia. There was no precipitating stressor for the anxiety attacks, which occurred several times a day and interfered with military duties. The attacks were preceded by compulsive cleaning, arranging and ordering of physical objects as well as obsessive counting behaviors, and often became worse if order and environment structure were disturbed.

On 16 March 2007, the CI began a 6-month period of limited duty with intensive outpatient therapy, however, symptoms were resistant to therapeutic trials of maximally dosed medications. To relieve his anxiety, he would obsessively and compulsively pull out body hair, despite pain and denuding of skin. As the anxiety intensified, he also developed daily periods of depressed mood. An August 2007 psychiatry follow-up visit recorded persistent OCD and trichotillomania with modest improvement. When the benefits from medication would wear off, he became more labile (emotions that are easily aroused) and reactive.

During the 1 October 2007 MEB NARSUM examination, 3 months prior to separation, the CI reported depressive symptoms that entered remission but flared again by late summer of 2007, with recurring thoughts of his own death. With support of weekly to bi-weekly visits with his psychologist and psychiatrist, hospitalization was held in abeyance. He was taking Paxil (depression, anxiety), Anafranil (OCD), and Klonopin (anxiety), and fully compliant with treatment interventions. The mental status examination (MSE) noted patches of skin on his extremities that were denuded of hair. His mood was dysphoric and anxious with a tearful affect and thoughts were notable for obsessions of perfection as well as a need to count objects compulsively. He had thoughts of his own death, and judgment and insight were fair, but impulse control marginal. He sat slouched forward, at times holding his head in his hands. Diagnoses of OCD, MDD, and trichotillomania were rendered with a GAF score of 35 (major impairment in several areas). The examiner noted severe impairment. During psychiatry follow-ups on 30 November and 21 December 2007, the CI reported he was “not feeling physically ill today or experiencing physical pain today.”  There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the OCD 10%, coded 9404 (OCD). The Navy PEB also listed trichotillomania and MDD as related Category II conditions (contribute to the primary unfitting condition but not separately ratable). Panel members agreed that the impairment from these conditions was properly subsumed under the overall rating for the OCD IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited). The VA also rated the OCD 10%, coded 9404, based on the STR, citing mild or transient symptoms. The panel considered the provisions of VASRD §4.129 (mental disorders due to traumatic stress), and agreed there was no evidence of a traumatic event or stressor causing the unfitting mental health condition, and that application of VASRD §4.129 was not appropriate in this case.

The MEB NARSUM examination and STR showed the CI’s condition was responsive to treatment, resulting in remission and avoidance of hospitalization. Despite a flare-up, symptoms of anxiety and depression receded with intensive outpatient therapy. The CI appeared in distress during the MSE and showed evidence of denuded skin, anxiety, depression and compulsive thinking. Medications offered modest improvement and symptoms worsened in the absence of medication. Treatment records prior and proximal to separation showed the CI kept appointments and reported he was not feeling ill or feeling physical pain. There were no further STRs in evidence post-separation. The panel majority agreed symptoms most closely met criteria for 10% disability as adjudicated by the PEB. After due deliberation, considering all the evidence

and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded there was insufficient cause to recommend a change in the PEB adjudication for the OCD.

BOARD FINDINGS: In the matter of the OCD and IAW VASRD §4.130, the panel majority recommends no change in the PEB adjudication. The single voter for dissent submitted the appended minority opinion. 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.

The following documentary evidence was considered:

Minority Opinion. The minority dissents from the majority recommendation for a 10% rating of the OCD condition, premised on its opinion that the CI was responsive to treatment corroborated by the CI’s last three psychiatric visit self-assessment forms that documented the CI was not feeling ill and was not in physical pain. The minority voter asserts that these self-assessment forms garner low probative value and concedes that the CI had ongoing/unresolved occupational and social impairments with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks to more fairly support a 30% rating under the provisions of VASRD §4.130 at the time of separation.

Although the CI was moderately responsive to treatment prior to the MEB NARSUM, the MEB NARSUM, 3 months prior to separation, revealed ongoing/unresolved psychiatric issues. During the MSE, the CI had patches of hair stripped from his extremities which the STR evidence showed was precipitated by his mental health condition. The CI’s mood was dysphoric (generalized dissatisfaction with life), was anxious with a tearful affect, had obsessions of perfection thoughts, had thoughts of his own death, felt the need to count objects compulsively, and had marginal impulse control. The psychiatrist examiner rendered a GAF score of 35 (major impairment in several areas) and noted the CI’s industrial and military impairment were severe. Additionally, the examiner opined, “The CI’s civilian performance impairment was also severe…though over time-likely measured in years-with intensive psychotherapy augmented by pharmacotherapy to control his anxiety, obsessions, compulsions, and dysphoria-his prognosis may improve.”

The CI visited the same psychiatrist (MEB NARSUM examiner) twice in November and once in December 2007 just 2 months to 2 weeks prior to separation. The CI’s self-assessment forms stated the CI did not feeling ill and was not feeling physical pain. The minority voter places low probative value on those three self-assessment forms for three reasons. First, the STR showed the CI visited the same psychiatrist 18 times and submitted 18 self-assessment forms within 10 months of separation. In literally 18 of 18 submissions, the CI indicated that he was not feeling ill. In 5 of 18 submissions, the CI stated he did not feel any pain; otherwise, he felt right knee pain or had a headache. The CI submitted these self-assessments concurrent to the receipt of his limited duty due to OCD, receipt of his non-medical assessment that implicated his mental health condition as overwhelming/duty limiting, and receipt of on-going psychiatric counseling and psychotropic medication prescribed by the same psychiatrist. Secondly, the MEB NARSUM, performed by the same psychiatrist, documented the CI had severe industrial, military and civilian mental health impairments. Lastly, there was no post-MEB NARSUM evidence that showed the CI’s mental health impairment had improved proximate to separation.

The minority’s position is that the MEB NARSUM was the most comprehensive and proximate to separation examination that documented the CI’s severe mental health impairment without subsequent evidence of improvement. It is speculation to determine the CI’s mental health impairment had improved based on the three post-MEB NARSUM self-assessment forms, then render a 10% mental health rating.

The Secretary is respectfully requested to consider the minority recommendation that 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	
Obsessive Compulsive Disorder	9404	30%	

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 20May20

From: 

Director, Secretary of the Navy Council of Review Boards 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr dtd 28 May 19

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation
{reference (b)) to the Department of the Navy on 5 Mar 2020 for appropriate action.

2.	On 20 March 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR of no change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.

Copy to: PDBR