RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04187
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20071205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Personnel Craftsman, medically separated for “major depressive disorder [MDD]” with a disability rating of 10%.

CI CONTENTION:  “I served 17 years and 4 months never receiving a bad EPR.  I received four Air Force Good Conduct Medals.  This justifies receiving more than 10%.  I request higher rating and military retirement.”  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 - 20071011	VARD - 20080620	
Condition	Code	Rating	Condition	Code	Rating	Exam	
MDD	9434	10%	MDD	9434	10%	20080426	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

MDD.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s mental health (MH) condition was initially evaluated in 1999.  In February 2003, his Axis I diagnosis was depressive disorder, NOS.  He was admitted to the hospital in 2003 for suicidal ideation, although he only stayed for 23 hours.  He subsequently had therapy over the years for anger control issues, personality conflicts, conflicts at work, relational problems and adjustment disorder with mixed anxiety and depressed mood with partner relationship and occupational problems.  At times, he was treated with Paxil and Wellbutrin (antidepressant medications), and later on with Prozac (antidepressant medication).  In June 2006, he complained of worsening irritability and insomnia after a reassignment to be near his terminally ill mother.  He was restarted on Prozac and psychotherapy, but his mood remained dysthymic.  He complained of anger and recurrent nightmares and associated work conflicts in January 2007, and was hospitalized for homicidal ideation in February 2007, where he was diagnosed with recurrent depression.  After 3 days of hospitalization, he was engaged in intensive outpatient treatment, individual therapy, and continued medication.  He discontinued treatment when he felt stable.  In June 2007, his wife miscarried and he had feelings of victimization and emotional pain.  

During the 23 August 2007 MEB NARSUM psychiatric addendum examination, 4 months prior to separation, the examiner assessed that the CI’s character pathology contributed significantly to his overall psychiatric functional impairment, and that depression alone likely would make up only a mild social industrial impairment, whereas the severity of his personality disorder resulted in a more definite impairment.  The recurrent and increasing severity and lack of motivation and his continuous need for MH treatment made his prognosis for a full remission guarded.  His military impairment was marked and social/industrial impairment was considerable.  The 4 September 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of a dysphoric mood most of the day for the prior 12 months, recurrent nightmares 3-4 times a week, and feeling hopeless and worthless.  The CI reported continued worsening, a depressed mood, irritability, restless sleep, decreased interest, increased feelings of hopelessness, and decreased energy and concentration, but he denied recurrent suicidal or homicidal ideations.  As a result, he had difficulties with functioning at work, which was noted by recurrent complaints from his supervisors and chain of command.  The mental status examination (MSE) revealed a well-groomed male, who was cooperative, maintained good eye contact and had a normal volume and rhythm to his speech.  There was no increase or decrease in psychomotor activity.  His mood was sad and frustrated, and affect was intense and congruent with a restricted range.  His sensorium was clear, and he was alert and oriented times four.  His recall of recent and remote events was intact, insight was fair and judgement was good.  Thought processes were logical, coherent, and goal directed with no flight-of ideas or looseness of associations.  He denied any hallucinations, delusions, or homicidal/suicidal ideations.  The Axis I diagnosis was moderate, recurrent MDD “as manifested by multiple episodes of consistently depressed mood and significantly decreased energy, concentration, motivation, and sleep that had an impact on social and occupational functioning.  The most recent episode resulted in profound hopelessness.”  The Axis II diagnosis was personality disorder not otherwise specified, “as manifested by a chronic and pervasive pattern of narcissistic and paranoid traits that indicated a sense of entitlement, lack of empathy, a pervasive history of distrust of others, reluctance to confide in others out of fear that it would be used against him, and a tendency to bear grudges, and to be unforgiving of insults.”  His current General Assessment of Functioning score was 60 (moderate symptoms) and 65 (some mild symptoms) for the year.  

At a MH evaluation in November 2007, 1 month prior to separation, he was diagnosed with a narcissistic personality disorder, and at a follow-up visit where he received behavioral and interpersonal psychotherapeutic invention, he was assessed as having a phase of life or life circumstance problem, narcissistic personality disorder, and dysthymic disorder (depressive neurosis).  At an MH clinic visit on 13 November 2007, it was noted that the CI was treated with Prozac, Seroquel (for sleep), and Geodon (for mood disorders).  Nightmares were controlled with the Seroquel and he preferred Tylenol PM (a pain reliever and antihistamine) to Geodon, when concerned about oversleeping.  He denied thoughts of hurting anyone or himself.  The MSE revealed his mood was euthymic, but frustrated and his affect was constricted.  Grooming was normal, and there were no behavioral abnormalities.  Cognitive function was normal and thought processes were not impaired.  He had no suicidal tendency, although he had a history of chronically recurring suicidality.  He had no preoccupation with violent thoughts and no homicidal tendencies.  The examiner’s assessment was recurrent major depression, in partial remission. 

At the 26 April 2008 VA Compensation and Pension (C&P) mental disorders examination, less than 5 months after separation, the CI reported sleeping poorly and being easily irritable and mad.  He felt very depressed at times and had a hard time concentrating.  He had been working as an insurance agent since February 2008.  He enjoyed riding his motorcycle and walking with his wife, but had few friends and did little socially.  The MSE showed a mildly depressed mood, good eye contact and appropriate affect.  He was free from any paranoid symptoms and was not considered suicidal or assaultive.  He had difficulty concentrating on serial 7’s.  His judgment and insight appeared to be fair, and he did not have any thought disorders.  The Axis I diagnosis was major depressive disorder (very mild) with a GAF score of 80 (transient symptoms and expectable reactions to psychosocial stressors).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the MDD 10%, coded 9434 (MDD), citing mild social and industrial adaptability impairment.  The VA also rated the MDD 10%, coded 9434, based on the VA examination, citing mild or transient symptoms.  Panel members first agreed there was no traumatic event causing the unfitting MH condition and therefore concluded that application of VASRD §4.129 was not appropriate in this case.  A higher 30% MH rating requires evidence of “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), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, [and/or] mild memory loss (such as forgetting names, directions, recent events).”  The panel noted that despite medication, frequent counseling and two hospitalizations, at the time of separation, the CI still had recurrent MDD, but it was determined to be in partial remission.  At the NARSUM examination, he had significant family stressors, and the examiner noted that his character pathology also contributed significantly to the overall social and occupational impairment that would have been otherwise mild.  The MSE was normal and the GAF showed mild to moderate symptoms.  At the VA MH examination, 3 months after separation, the MDD was determined to be very mild since separation, with his condition and GAF score improved.  He worked full-time, and enjoyed a hobby as well as time with his wife.  Therefore, the panel majority felt there was insufficient evidence to support a rating higher than 10%.  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 MDD.  

BOARD FINDINGS:  In the matter of the major depressive disorder 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 voter noted the CI prior to separation had many years of MH interventions for issues related to anger control, personality conflicts, conflicts at work, and family relationship problems including a divorce, a miscarriage by his new wife, and a terminally ill mother.  He was depressed and had two hospitalizations.  At the NARSUM examination, 3 months prior to separation, his Axis I diagnosis was MDD, recurrent, moderate as manifested by multiple episodes of consistently depressed mood and significantly decreased energy, concentration, motivation, and sleep that had an impact on social occupational functioning, while 1 month prior to separation, the examiner’s assessment was major depression, recurrent in partial remission with use of antidepressant and sleep medications.  At the VA MH examination, less than 5 months after separation, he still was diagnosed with MDD, but it was considered to be very mild since he was working as an insurance agent.  However, at subsequent MH visits, the CI noted he was still depressed and could not continue in a job for any extended period whether he could not produce sufficiently as an insurance agent or whether he could not remain in the job for physical reasons.  

VASRD §4.126 (evaluation of disability from mental disorders) states:

(a) When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 
(b) When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment.

Therefore, the minority voter determined the overall disability picture prior to separation was consistent with a 30% rating, and no higher, based on the CI’s history of a depressed mood, suspiciousness, chronic sleep impairment, and occasional decrease in work efficiency as well as intermittent periods of an inability to perform occupational tasks both prior to separation as well as post-separation.  Although the CI had issues related to motivation and conflict at work, his personality traits, which are not considered in the realm of a physical disability, did contribute to his overall MH condition, and not to consider the behavior related to those issues in the total rating would be inconsistent with his overall MH status prior to separation.  Furthermore, despite the apparent improvement noted at the VA C&P examination and the generous GAF score reflective of post-separation employment, albeit short-lived as noted in subsequent outpatient MH visits, a 30% rating is fair, accurate, and more reasonable than a 10% rating assigned by the PEB or the 10% rating assigned by the VA based on its examination, 5 months after separation.

Thus, the minority voter recommends the ROP be modified as follows:

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 MDD, coded 9434.

BOARD FINDINGS:  In the matter of the major depressive disorder, 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 medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Major Depressive Disorder	9434	30%	

	

SAF/MRB
3351 Celmers Lane
JBA NAF Washington, MD 20762-6435

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-04187.

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.