RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2018-00443
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20070503

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Dental Assistant, medically separated for “depressive disorder, not otherwise specified [NOS]” with a disability rating of 10%.   

CI CONTENTION:  “Conditions continue to cause quality of life degradation, making it difficult to find/obtain work/life balance.  Unable to perform certain tasks and have been found unfit for jobs/career choices due to loss of range of motion in wrist, chronic pain, migraines, depression, anxiety.”  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 – 20070208 	VARD - 20080205	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Depressive Disorder, NOS	9499-9433	10%	PTSD with Depressive Symptoms	9411	30%	20071102	
Bilateral Wrist Pain	5215	Cat II	Residuals, Right Wrist Carpectomy	5299-5215	10%	20071102	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Depressive Disorder.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s mental health (MH) disorder presented in August 2004 with symptoms of depressed mood accompanied by poor sleep, anhedonia, decreased ability to concentrate and low energy.  She admitted to a history of restricting food since age 12 with binging and purging behavior.  The CI admitted to sporadic disordered eating behaviors in response to stressors at work or when feeling down and lonely.  She was hospitalized for 3 days in November 2006 after expressing suicidal thoughts.  Post hospitalization, she was referred to inpatient care in December 2006 to treat the eating disorder.  

The 4 January 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of continued symptoms of depression and disordered eating behavior.  The CI was receiving outpatient talk therapy and medication, and planned to attend a support group.  The mental status examination (MSE) was unremarkable with the exception of depressed mood and affect.  The diagnoses of eating disorder NOS and depressive disorder NOS were recorded.  The examiner was silent in regards to the severity of each condition and the impact of each condition on continued military service.

At the 2 November 2007 VA Compensation and Pension (C&P) examination, 6 months after separation, the CI reported insomnia, fatigue, problems with short-term memory, focusing and concentrating.  She had panic symptoms twice a month.  The CI worked a part-time job at a gym, was living with her fiancé who was scheduled to be deployed, and reportedly had very little time to socialize due to her working hours.  She was not in MH treatment but was taking left over anxiety medication twice weekly.  The CI also reported trauma symptoms related to sexual assaults prior to entering the service.  The MSE was unremarkable with the exception of anxious mood.  The examiner assessed PTSD.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the MH disorder 30% analogously coded 9499-9433 (dysthymic disorder), but reduced the rating to 10% after a deduction of 20% “for aggravating/contributing factors” for her eating disorder, citing “symptoms of the eating disorder since age 10 and opines that it existed prior to service [EPTS], making it a non-ratable/non-compensable condition under DoD disability law/policy.  The PEB opined that were it not for the non-ratable/non-compensable condition, social and industrial rating would be best described as mild.”  The VA rated the MH disorder 30%, coded 9411 (PTSD), based on the C&P examination, citing occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.  

Panel members first agreed that the provision of VASRD§ 4.129 for a “mental disorder that developed in service as a result of a highly stressful event” were not applicable.  Next, the panel noted the underpinning for the condition being EPTS, on which the deduction hinges, was overly tenuous.  The NARSUM examination indicated definite social and occupational impairment for the military due to the conditions of depression and eating disorder NOS.  The examiner suggested that the coexistence of an eating disorder and the nature of her MH presentation had led her to the MEB, implying that the eating disorder contributed significantly to the overall MH disability picture.  

The NARSUM noted the self-report of a pre-existing disordered eating behavior; however, the diagnosis of an eating disorder was not recorded in the STR at the time of entry into service.  In fact, no specific eating disorder was diagnosed during the NARSUM.  The NARSUM examiner implicated both conditions as interfering with duty and each causing significant impairment.  Further, even if the eating disorder was in fact EPTS, the process itself of clinically extricating the disability attendant to one diagnosis versus the other in psychiatric cases is overly speculative without a directed opinion from the examiner addressing the degree of contribution from each diagnosis.  No such input from a psychiatric examiner is in evidence; thus the panel could not fairly apportion a deduction even if the competing diagnosis was not in question.  Having concluded that no deduction should be applied, members turned to deliberation of a fair rating (IAW VASRD §4.130) of the overall psychiatric disability in evidence at separation.  

Both the NARSUM and the C&P MSEs were similar.  The CI continued to have symptoms at the time of the NARSUM examination, and that evidence supports the presence of some occupational impairment.  The panel considered the absence of psychiatric hospitalizations and emergency room visits related to MH in the 6 months prior to and after separation.  The C&P examination noted the CI was working part-time, was engaged to marry and was not in MH treatment.  She reported difficulty with sleep, concentration and short-term memory and had anxiety attacks twice a month.  Her symptoms of depression had apparently resolved and her eating disorder evidently no longer met criteria for an eating disorder based on the absence of the diagnosis during the C&P examination.  Therefore, panel members agreed the 30% rating and no higher was warranted.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30%, coded 9499-9433 for the MH disorder.  

Contended PEB Condition:  Bilateral Wrist Pain.  Although the PEB indicated the contended condition was not compensable in that it EPTS and was not permanently aggravated by service.  A review of the service entrance examination was negative for any wrist disability.  The record showed right wrist surgery in September 2006 during active duty.  Although the contended condition was not profiled in the 6 months before separation or specifically implicated in the commander’s statement, the right wrist did fail retention standards.  The duty restrictions on the profile closest to separation did not include the wrists, but it limited the lifting of weight and restricted full use of the right arm.  The orthopedic surgeon stated [about the right wrist] that improvement to the extent that would allow the CI to participate in normal military activities was questionable.  However, the surgeon also noted that it was not possible to predict whether the CI would be able to return to her military duties.  As noted, the commander did not specifically implicate the wrist condition but did note that her duty-related restrictions that included no use of right arm, had not allowed her to utilize her expertise as a dental technician.  The NARSUM noted the CI was able to achieve a full composite fist, had full active extension (dorsiflexion, normal 70) but no hyperextension, and supination of the forearm was painful and limited to 50 degrees (normal 85).  Pronation of the forearm was 60 degrees (normal 80).  Panel members agreed, there was not a preponderance of evidence to support that either wrist condition EPTS, but there was a preponderance of evidence to support that the right wrist condition and not the left, would have caused the CI to be separated from service.  

Panel members considered the disparate examinations and agreed that the post-separation VA examination was more probative in that it was more comprehensive.  The VA examination showed only 5 degrees of dorsiflexion.  Therefore, a rating of 10% under code 5215 is warranted for dorsiflexion less than 15 degrees.  After due deliberation, the panel agreed the preponderance of the evidence with regard to the functional impairment of the right wrist favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5215 and meets the VASRD §4.71a criteria for a 10% rating.  

BOARD FINDINGS:  In the matter of the depressive disorder, the panel recommends a disability rating of 30%, coded 9499-9433 IAW VASRD §4.130.  In the matter of the contended bilateral wrist condition, the panel agrees the right wrist was unfitting and recommends a disability rating of 10%, coded 5215 IAW VASRD §4.71a.  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	
Depressive Disorder, NOS	9499-9433	30%	
Right Wrist Pain	5215	10%	
COMBINED	40%	

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-2018-00443.

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 in accordance with the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay

I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept the recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 90 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married, in such a case, failure to render an election will result in automatic enrollment by law.