RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04622
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080331

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Motor Transportation Operator, medically separated for “chronic pelvic pain evaluated as endometriosis” and “depressive disorder,” rated 10% each, with a combined disability rating of 20%.   

CI CONTENTION:  “I was not awarded…PTSD despite the fact of showing all of the signs.”  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 - 20080307	VARD - 20080929	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pelvic Pain…	7699-7629	10%	Pelvic Inflammatory Disease/ Endometriosis	7614	10%	20080715	
Depressive Disorder	9434	10%	Depressive Disorder	9433	10%	STR	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Pelvic Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI reported pelvic pain which started on the right side in 2004 and sometimes radiated to the left thereby involving the entire pelvis.  On 30 August 2006, she underwent a laparoscopy with lysis of adhesions and a left salpingostomy (opening of the fallopian tube).  Pathology findings dated 31 August 2006 showed a fimbriated structure with smooth muscle consistent with a fallopian tube with peritubal fibrosis, and a benign thin walled cyst, but were negative for malignancy.  An abdominal ultrasound on 20 October 2006 revealed no evidence of acute pathology.  On 10 January 2007, the CI underwent a second operative laparoscopy, a right and left salpingectomy, and further lysis of extensive adhesions.  Endometriosis was not identified, and on 11 January 2007, a pathology report indicated fallopian tube adhesions and a thickened wall with focal chronic inflammation, but no evidence of malignancy.   Despite the surgeries, the CI continued to have pelvic pain with any kind of exercise or strenuous activity.  

The 13 November 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of pelvic pain that was crampy in nature and involved the entire pelvis.  Physical examination showed normal external female genitalia, no cervical motion tenderness, and a uterus that was normal in size, shape, and contour, and minimally tender.  The left adnexa was without mass and minimally tender, and while the right adnexa was non-palpable and felt normal, a moderate amount of discomfort was elicited; the bladder area was nontender.  The examiner’s diagnosis was chronic pelvic pain, surgically demonstrated extensive pelvic adhesive disease, and depression (see below).  Recommendations included checking chlamydial  gonococcal antibodies to determine whether a prior infection could explain the pelvic adhesive/tubal disease, utilizing in-vitro fertilization for conception, involving the CI in a pain clinic, continuing mental health (MH) support, and determining whether a third laparoscopy would likely make a significant difference in her symptoms and ability to perform military duties.  

At a VA gynecology visit on 12 June 2008, less than 3 months after separation, the CI indicated that the pelvic pain was not her main issue since it was usually relieved with Phenergan (antihistamine for nausea) and ibuprofen (nonsteroidal anti-inflammatory drug).  Her concern centered on infertility issues as she reported trying to get pregnant since 2005 and attempting a trial of Clomid (clomiphene to treat infertility) and human chorionic gonadotrophin in 2006 for two cycles.  An examination was deferred and the provider noted pelvic pain well-controlled with oral medications, which were to be continued.  The CI was referred to a reproductive endocrinology and infertility specialist.  

At the 15 July 2008 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported chronic pelvic pain described as “crushing and sharp.”  A pelvic examination was abnormal and marked by severe pain, tenderness, vaginal wall spasms, and edema.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pelvic pain 10%, analogously coded 7699-7629 (endometriosis), citing continuous treatment for pain control.  The VA also rated the pelvic pain 10%, coded 7614 (fallopian tube disease, injury, or adhesions of (including pelvic inflammatory disease (PID)), based on the C&P examination, citing symptoms that required continuous treatment.  Members noted that the analogous use of code 7629 requires a “diagnosis of endometriosis…substantiated by laparoscopy,” which was not the case, nor was there pathology to support the diagnosis.  The use of code 7614 was more accurate based on clinical and pathology findings, and does not require the finding of endometriosis; however, a higher rating than 10% stipulates “symptoms not controlled by continuous treatment,” which the CI did not have.  After due deliberation, considering all of 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 chronic pelvic pain.  

Depressive Disorder.  According to the STR and MEB NARSUM, the CI reported feeling depressed at a MH visit on 25 July 2006, after learning weeks earlier that her fallopian tubes were blocked and prevented her from having children.  She had also been seen by the behavioral health clinic in April 2006 for anger issues and was treated with medication and individual therapy.  The CI was initially diagnosed with anxiety due to a medical condition and given a Global Assessment of Functioning (GAF) score of 65 (some mild symptoms).  On, 28 July 2006, she was diagnosed with depression and treated with antidepressant medication.  In November 2006, she began experiencing suicidal ideation and was hospitalized due to feeling overwhelmed by the fertility issue with documentation of poor coping skills during her inpatient care.  Thereafter she was followed in the MH clinic and by a psychiatrist on a regular basis.  

At a psychiatry visit on 13 March 2007, the CI reported her medication was not “working as well as it was,” and the dosage was increased; her GAF score was 60 (moderate symptoms).  While the increased dose initially help with sleep and depressed mood, she remained hopeless about the future related to her infertility and inability to have children.  Another antidepressant, as well as a sleep medication, were added to the treatment regimen.  At a 10 August 2007 MH visit, the CI indicated she was angry because she was not treated before deployment and “just want[ed] to get out of the Army.”  At a 24 August 2007 psychiatry clinic visit, a new sleep medication was prescribed and with discontinuance of one anti-depressant and sleep aid.  At a psychology visit on 27 August 2007, results from psychological (MMPI-2) and personality (MCMI-III) tests were noted to be grossly invalid.  Because of over reporting, the provider felt there was a malingering component to the CI’s depression; the GAF score was 65 (some mild symptoms).  

The 24 August 2007 MEB NARSUM psychiatry examination, 7 months prior to separation, noted complaints of depression related to an inability to have children.  The CI had symptoms of intermittent suicidality, depressed mood, low energy, and hypersomnolence as well as loss of appetite, insomnia, isolation, rumination, and hopelessness about the future.  There were no symptoms of post-traumatic stress disorder documented from a previous deployment.  The mental status examination revealed an appropriately attired woman with good grooming and hygiene.  She was cooperative but became somewhat tearful when she talked about her inability to have children, and “continued to “ruminate and to perseverate on.”  Eye contact was fair, however, she looked down when discussing some of her depressive symptoms.  She presented with psychomotor retardation, but no agitation, and speech was regular in rate, rhythm, and tone.  The CI’s mood was depressed with congruent affect, and her thought process was ruminative regarding pregnancy with “all-or-nothing thinking.”  Her thought content was “devoid of suicidal ideation or homicidal ideation,” but she did have “chronic thoughts of suicidal ideation.”  She denied any auditory or visual hallucinations and her cognition was grossly intact.  Judgment was good, but insight was impaired, and estimated intelligence was average.  The examiner’s Axis I diagnosis was depressive disorder, not otherwise specified, with a marked military/psychiatric degree of impairment noted.  Impairment for social and industrial adaptability was mild, and a GAF score of 50 (serious symptoms) was rendered.  

The commander’s statement on 10 September 2007 indicated the CI’s depressive disorder prevented her from handling any weapons, and affected her ability to work independently since she was prone to psychological “crumble when placed under stressful situations.”  At a MH clinic visit on 24 September 2007, the CI was assessed for her major depression and given a GAF score of 60 (moderate symptoms).  The commander’s statement on 6 March 2008 noted the CI was working 3.5 hours a day on computer tasks, filing, and in/out processing of soldiers; however, she was not working in her primary military specialty.  

There was no VA examination proximate to separation in evidence.  However, a VA MH assessment by a clinical social worker on 25 June 2008, 2 months after separation, noted the CI reported a depressed mood, insomnia and loss of interest.  She also had intrusive thoughts and nightmares about possibly dying while flying in a helicopter with an injured enemy soldier who had a live grenade hidden under him that failed to explode. She responded “yes” to traumatic stress symptoms with a score of 62 out of 80.   A mental status examination revealed appropriate dress, sufficient attention and concentration, impairment for immediate memory, orientation to person, place, time, and situation,  cooperative behavior, clear and coherent speech, a euthymic (normal) mood, appropriate affect, reduced interest, guilt, reduced energy and concentration, decreased appetite, and agitation.  Thought processes and content were relevant, judgment was within normal limits, and insight was good.   The Axis I diagnoses were PTSD and major depressive disorder with a GAF score of 51 (serious symptoms).   At a psychiatry visit the same day, the CI described a full constellation of symptoms consistent with major depression and PTSD.  Her two most troubling symptoms were moodiness and poor sleep.  She was assessed and had symptoms of depression and some irritability.  Wellbutrin (antidepressant) was discontinued and a trial of Lamictal (anticonvulsant/bipolar treatment) was prescribed.  A treatment plan was established on 7 August 2008, and at MH visits on 12 November 2008 and 10 December 2008, the CI continued to re-experience the traumatic event with avoidance of trauma relevant stimuli, emotional numbing, and persistent hyperarousal.  She also reported a significant depressed mood and anhedonia and struggled with infertility.   At a therapy session on 27 February 2009, 11 months after separation, the CI reported sleeping about 2 hours without her sleep medication, but said she was doing well in school, talking to friends on the phone, and watching TV.  She was looking forward to spring break and planned to go on vacation.  Additionally, she had broken up with her boyfriend but reported satisfaction with her status.  However, her GAF scale was 50 (serious symptoms).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the depressive disorder 10%, coded 9434 (major depressive disorder), citing continuous medication required to control symptoms.  The VA also rated the depressive disorder condition 10%, coded 9433 (dysthymic disorder), based on the STR, citing 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 panel considered whether the provisions of VASRD §4.129 (mental disorders due to traumatic stress) were applicable, and agreed that the evidence of the record did not support a traumatic stressor as the cause of the MH since symptoms of PTSD were not present prior to separation.  Although the CI had deployed, there were no traumatic stressors attributed to the onset of her depressive disorder condition, which included symptoms related to her infertility issues as well as the surgical procedures performed to ameliorate pelvic pain and adhesions.   Members had a lengthy, detailed discussion about an appropriate rating for the CI’s MH condition at the time of separation.  The panel majority pointed to the facts that psychological testing results were deemed invalid due to over reporting of symptoms as well as the CI’s desire to get out of the Army.  Furthermore, the panel majority noted that both the PEB and VA assigned a 10% rating and that  criteria were not met to warrant a  higher 30% rating, which requires evidence of  “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks” due to  such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events.”  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 depressive disorder condition.  

BOARD FINDINGS:  In the matter of the chronic pelvic pain and IAW VASRD §4.116, the panel recommends no change in the PEB adjudication.  In the matter of the 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.  

Minority Opinion.  Although the CI had invalid psychological testing results, nevertheless, she had a true and legitimate basis for her depression, which was extensively treated during a hospitalization, through group therapy, and with many psychiatry sessions where multiple medications were prescribed that insufficiently controlled her depressive symptoms as well as her impaired sleep, which resulted in her inability to perform her military specialty and to work independently according to her commander since she was prone to psychologically crumble when placed under stressful situations and she was working only from 0800-1130, Monday through Friday, on computer tasks, filing, and in/out processing of soldiers.  Therefore, she unequivocally met the criteria for a 30% which requires evidence of “Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.”  She clearly had a depressed mood and anxiety as well as chronic sleep impairment along with only limited work capacity.  Furthermore, she was noted to have marked military/psychiatric impairment as well as mild social and industrial adaptability impairment.  Nevertheless, the CI’s condition did not rise to a 50% rating at the time of separation, which requires “Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships,” although the CI did have difficult social relationships, but her major concern was related to infertility.  Therefore, the minority voter recommends modification of the ROP including the Board Findings as follows:

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the depressive condition, coded 9434.  

In the matter of the depressive disorder condition, the panel recommends a disability rating of 30%, coded 9434 IAW VASRD §4.130.  

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	
Chronic Pelvic Pain	7699-7629	10%	
Depressive Disorder	9434	30%	
COMBINED	40%	

AR20190001703, XXXXXXXXXXXXXXXXXXXX

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Dear XXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.