RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2013-00150
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20140515
SEPARATION DATE:  20031216

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty P02/E-5 (FC2, Fire Controlman) medically separated for cholinergic urticaria/anaphylaxis and depression.  The two unfitting conditions could not be adequately rehabilitated to meet the physical requirements of her Rating or satisfy physical fitness standards.  She was placed on limited duty [LIMDU] and referred for a Medical Evaluation Board (MEB). The cholinergic urticaria/anaphylaxis and depression conditions, characterized as “cholinergic urticarial/anaphylaxis” and “depression,” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded four other conditions (see rating chart below) for PEB adjudication.  The Informal PEB adjudicated “cholinergic urticarial/anaphylaxis” and “depression” as unfitting, rated 10% and EPTS respectively with application of the VA Schedule for Rating Disabilities (VASRD).  The PEB adjudicated allergic rhinitis; migraine w/o aura; mood disorder and bulimia nervosa (BN) as Category III conditions (those that are not separately unfitting and do not contribute to the unfitting conditions).  The PEB also added menstrual migraines and chronic allergies as Category III conditions.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI writes: “I was being seen at mental health at the VA.  One day I thought I have [sic] the flu.  The next day I went to Riverside Regional Medical Center because that was the closest hospital.  They did a muscle biopsy to check and see if I had polymyositis.  When the neurologist got the test back it was negative.  He said see a Dr. XXX.  Address is 1xx W-- Blvd Ste xx Newport News, VA 23601.  He referred me to a psychiatrist DR XXX Palace, NN, VA 2360 who told me I had serotonin syndrome from the litium and other meds the VA had me on.  I was assigned physical and occupational therapy from the outside to help me learn to walk and get around.  I also have a weekly nurse that comes sees me.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The ratings for the unfitting cholinergic urticarial/anaphylaxis and depression along with the comorbid mental health (MH) conditions of mood disorder and BN are addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Naval Records.

RATING COMPARISON:

Service IPEB – Dated 20030814	VA - (1 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cholinergic Urticaria/Anaphylaxis	7825	10%	Cholinergic Urticaria/Anaphylaxis	7825	10%	20031112	
Depression		EPTS	Major Depression w/OCD/Bulimia Nervosa	9404-9434	50%	20031121	
Bulimia Nervosa	Category III					
Mood disorder	Category III					
Other x 4 (Not in Scope)	Other x 7	20031112	
Combined:  10%	Combined:  80%	
Derived from VA Rating Decision (VARD) dated 20040308 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws. The Board considers DVA evidence proximate to separation in arriving at its recommendations; DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence.  Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

Cholinergic Urticaria/Anaphylaxis.  The narrative summary (NARSUM) noted that the CI had a history of chronic urticaria (hives), associated at times with shortness of breath (SOB), triggered by exercise and treated with high doses of steroids over a long period of time.  The NARSUM also noted that the CI was treated for environmental allergies, which did not seem to play a role in the urticarial/anaphylaxis symptoms.  In October 2002, the CI was referred to allergy clinic and the condition was diagnosed as urticaria/anaphylaxis (cholinergic urticaria) with exacerbations triggered by stress or heat in approximately November 2002, 13 months prior to separation.  An allergy visit on 13 November 2002 indicated the CI continued with hives with exercise despite taking allergy medications.  Pulmonary function testing (PFT) on the same day was normal.  An allergy evaluation on 21 March 2003 noted that the CI was hospitalized five times for reactions and all reactions were treated with steroids; what symptoms and over what time period these reactions occurred was not specified.  A PFT the same day was again normal.  A preventive health assessment on 26 March 2003 noted the CI was taking Prednisone 60 milligrams (mg) daily for exercise induced anaphylaxis.  At the MEB exam performed on 18 April 2003, 8 months prior to separation, the CI reported symptoms of hives, nausea, vomiting and diarrhea brought on by heat or stress.  The MEB NARSUM noted normal lung function testing, but did not include a complete physical examination.  Although a visit for referral to allergy clinic noted “she can’t exercise without airway difficulty,” there was no documented wheezing, decreased oxygenation or any other objective respiratory abnormality in the service treatment record (STR).  An emergency room (ER) visit on 30 July 2003 for hives with nausea and throat tightness noted a normal lung exam without SOB and the discharge sheet indicated “continue current medications of 60 mg daily Prednisone.”  The Joint Disability Evaluation Tracking System (JDETS) on 12 August 2003 noted treatment for chronic urticarial/anaphylaxis with steroids and the condition was not expected to improve.  A note dated 25 August 2003, 4 months prior to separation, indicated the CI was placed on quarters for 24 hours due to an acute episode of hives.  At a visit 3 weeks after the PEB on 8 September 2003, the CI was noted to be tapering off steroids.  The allergist prescribed a non-steroidal anti-inflammatory medication, which was noted by the examiner to be effective in steroid dependent cases of chronic intermittent urticaria (hives) in recent medical literature and if symptoms were not controlled, more aggressive therapies would be considered.  At the next follow-up visit a month later, the CI was noted to be off steroids and currently in remission but the examiner noted “hasn’t gone long enough to be sure it won’t relapse.”  A PFT the same day noted “possible early obstructive pulmonary impairment” with further evaluation recommended.  At the VA Compensation and Pension (C&P) examination, performed a month prior to separation, no skin rashes were present on examination and the diagnosis of “idiopathic [unknown cause] anaphylaxis and urticaria” was noted based upon service treatment records.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated the cholinergic urticarial/anaphylaxis condition as unfitting, rated 10% coded as 7825 (urticaria).  The VA also rated the condition as 7825 at 10% based on the STR, noting that the condition was currently asymptomatic, but was not likely to resolve in the near future.  Later VARDs in 2004 and 2006 did not address the urticarial condition and the 10% rating was continued.  The Board first deliberated whether coding as 7825 or analogous to 6602 (asthma) was the most appropriate coding choice for the CI’s condition.  The Board considered that although difficulty breathing associated with the episodes of hives was reported, there was no documented objective evidence of respiratory impairment in the record and cholinergic urticaria can be accompanied by systemic symptoms and concluded that the most medically appropriate code was 7825.

The Board next deliberated the rating of the urticarial condition.  Although there were only two documented treatment visits for acute symptoms, the Board adjudged that it could be reasonably inferred from the records that the CI experienced at least four symptomatic episodes in the 12 months prior to separation, a threshold requirement for any compensable 7825 rating.  The Board acknowledged that in this case the change in treatment proximate to separation provided additional difficulty in applying the 7825 rating criteria.  The CI was markedly improved following the cessation of steroids (immunosuppressive therapy) and the implementation of an alternative medical therapy.  After the medication change, the CI was without symptoms, not on continuous steroids and at had not required intermittent steroid treatment since the change.  The CI remained asymptomatic at the VA C&P examination a month prior to separation and there was no post-separation evidence in the record that the urticarial condition relapsed or worsened.  Therefore, the Board agreed that the CI’s disability due to the chronic urticarial/anaphylaxis condition at the time of separation most closely met the 7825 criteria for a 10% rating IAW VASRD §4.118, specified as “recurrent episodes” responding to treatment with medications other than steroids and did not meet the next higher evaluation of 30%, which specifies “recurrent debilitating episodes” and requiring “intermittent systemic immunotherapy” for control.  Therefore, after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic urticarial/anaphylaxis condition.

Depression, Mood Disorder and Bulimia Nervosa.  The Board agreed the CI’s MH conditions were intertwined in their clinical presentation and addressed together in all MH notes in the records and accordingly the conditions were discussed together in the deliberation of the depression condition.  A non-MH treatment note in the record indicated that the CI’s urticarial/anaphylaxis symptoms had begun in approximately 1997.  Although there are no notes addressing the urticarial condition in the STR before 2001, the Board inferred that the CI had been treated for the disorder with associated steroid weight gain, leading to problems with mandatory weight standards, which were not in evidence earlier in the CI’s military career.  The earliest pertinent note in the record dated 7 May 2001 indicated that the CI was significantly above Navy weight standards and she was referred to weight management.  A note a week later indicated that the CI requested a referral to plastic surgery for liposuction.  The CI sought help for depression symptoms in October 2002 and requested MH and plastic surgery referrals.  The examiner noted the CI was 65 pounds overweight had taken prescription diet drugs in the past and was seeing a nutritionist for weight loss.  The CI reported irritability, moodiness with crying, loss of interest in activities she used to enjoy, sleep problems and decreased concentration, but denied suicidal/homicidal ideation (SI/HI).  She reported she was going through a marital separation.  The CI was prescribed an anti-depressant, referred to MH and to plastic surgery to discuss gastric bypass surgery.  Despite treatment with an anti-depressant her depression symptoms increased, with SI with a plan and she was hospitalized as an inpatient on 6 November 2002.  She was referred for an evaluation for over the counter stimulant abuse during the hospitalization but was deemed not appropriate for substance abuse treatment, because an apparent “weight and self-esteem issue” was “being addressed by nutrition, command fitness, and outpatient psychology.”  Following discharge, the CI continued to be treated as an outpatient with therapy and psychotropic medication for symptoms of depression and an eating disorder.

The initial outpatient MH evaluation on 2 December 2002 noted that the CI was referred for “treatment of an eating disorder and associated depression.”  At the evaluation the CI reported some improvement with antidepressant medication, but continued with symptoms of depression and noted that she had not binged or purged since her discharge, but was continuing to restrict her food intake to lose weight.  It was noted that the CI was on LIMDU (on 13 November 2002) for her non-MH condition at the time with a noted limitation of no deployment.  The CI reported that she was separated from her husband and was attending college classes with fluctuating grades between A’s and F’s, but that she was able to able to maintain work and family responsibilities despite her depression symptoms.  The examiner noted that despite significant symptoms of depression and eating disorder behaviors, the CI had shown resiliency in the past and had strong desire to remain in the Service.  The Axis I diagnoses were dysthymic disorder and BN, purging type and multiple rule out (r/o) diagnoses of r/o major depression, recurrent, r/o substance induced mood disorder and r/o learning disability.  The examiner recommended that the CI was psychologically fit for duty.  An allergy visit on 21 March 2003 noted that the CI could not meet weight requirements but she had “gotten into no trouble using weight loss methods.”  The allergist wrote a note on the CI’s behalf noting that she “can’t possibly be expected to lose weight while taking steroids.  It’s a miracle she hasn’t gained more.  Her evaluation needs to be redone if she was given low marks because of her weight.”  An allergy visit on 18 April 2003 listed “bulimia problems,” and noted the steroid induced weight gain and the military expectation to meet weight standards.

The MEB NARSUM on 18 April 2003, authored by the allergy specialist, noted the CI “has had extensive treatment with very high doses of steroids over a long period of time.  Because of the steroid dosing, she has had problems with overweight.  This has led to her psychological distress and also to other problems, and she is currently receiving care from psychologists and psychiatrists.”  The NARSUM listed a MH diagnosis of depression, did not exist prior to enlistment (DNEPTE).  The Non-Medical Assessment on 22 April 2003 indicated that the CI was working in her specialty and was missing time for medical appointments, her “only limitation is she cannot be exposed to heat,” but did not specifically mention any MH condition.

The MEB psychiatric addendum examination on 9 May 2003, 7 months prior to separation, noted that since adolescence the CI had a history of periodic depression and binge eating with compensatory behaviors to prevent weight gain, such as fasting, vomiting, and abuse of laxatives and over-the-counter stimulants.  On mental status exam (MSE) the CI reported a nervous mood and was observed to laugh incongruously and be occasionally tearful, but the examination was otherwise normal.  The Axis I diagnoses were mood disorder, not otherwise specified and BN, purging type, both noted as “EPTE” (existed prior to enlistment) and “not service aggravated,” with a Global Assessment of Functioning (GAF) of 51 (moderate symptoms).  The examiner opined that based on her current MH symptoms and their chronic nature, the CI was moderately and sometimes severely impaired for military service.  The JDETS on 13 August 2003 noted steroids were associated with weight problems and psychological distress. 

At the VA C&P exam on 21 November 2011, performed a month prior to separation, the CI reported depression, insomnia, fatigue, anxiety, crying all the time with SI and obsessive-compulsive symptoms of checking if she has locked the car, turned off the stove, etcetera, with obsessive thoughts of accidentally doing something that might kill her daughter.  She also reported bulimic symptoms of vomiting and taking laxatives frequently.  The CI reported that she was separated from her husband due to her MH symptoms.  On MSE the CI had both an anxious and depressed mood and was noted to be shaking throughout the examination.  She was fully oriented without evidence of hallucinations, delusions or cognitive deficits.  The Axis I diagnoses were major depressive disorder, obsessive-compulsive disorder and BN, purging type with a GAF of 48 (50-41-serious symptoms).

The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated three intertwined MH diagnoses as follows: Depression as a Category I, unfitting condition, EPTS; and, mood disorder and BN as Category III, conditions that are not separately unfitting and do not contribute to the unfitting conditions.  Therefore, the PEB provided no disability rating for any MH condition.  The VARD on 8 March 2004 rendered a diagnosis of major depression with obsessive-compulsive disorder/BN, rated 50%, 3 months post separation based upon the VA C&P examination noted above.  The Board opined that the CI had only two distinct MH diagnoses of depression and an eating disorder, and that the depression and the mood disorder diagnoses did not represent different MH conditions, but rather different diagnoses of the same symptoms.  For purposes of disability rating IAW VASRD §4.130 it does not matter which diagnosis, mood disorder or depression, is the most accurate from a psychiatric perspective, as only one MH disability rating can be provided for total occupational and social impairment based on the general rating formula for mental disorders, whereas, a separate disability rating may be provided IAW §4.130 for an unfitting eating disorder. The Board thus concluded that the CI had two potentially ratable MH conditions IAW VA rating guidelines.

The Board’s main charge regarding the sole unfitting MH condition of depression is evaluation of the PEB’s adjudication that the depression was EPTS and not service-aggravated and therefore not ratable.  The Board’s deliberations in this regard included consideration of the PEB adjudication of the closely related BN condition.  The Board agreed that the preponderance of evidence supported that the CI’s depression and BN conditions existed prior to enlistment.  However, a presumption of service aggravation may only be overcome by clear and unmistakable evidence that the natural progression of a pre-existing condition was unaltered by any consequence of military service.  The guidance for conceding service aggravation, applicable to the PEB’s determination and to the Board’s recommendation regarding its fairness, is excerpted below from DoDI 1332.38.

The presumption that a disease is incurred or aggravated in the line of duty may only be overcome by compelling evidence or medical judgment that the disease was clearly neither incurred nor aggravated while serving on active duty or authorized training.  Such medical evidence or judgment must be based upon well-established medical principles, as distinguished from personal medical opinion alone.  E2.1.1 defines accepted medical principles as fundamental deductions, consistent with medical facts that are so reasonable and logical as to create a virtual certainty that they are correct.

The initial MH evaluation indicated that the CI’s depression was associated with her eating disorder and the NARSUM referred to exacerbation of her psychological distress related to steroid aggravated weight problems.  The Board concluded that the CI’s mood symptoms related to BN could not be separated from the depression for rating purposes, but that if the Board consensus recommended the BN to be unfitting, the eating disorder behaviors and physical effects of the BN could be rated separately from the mood symptoms.

The CI had a history of depression and eating disorder behavior of binge eating and compensatory behaviors to prevent weight gain which began in adolescence.  There were limited MH treatment notes in the records before the Board, but the available records support that the two sets of symptoms waxed and waned together.  The CI developed a non-MH condition treated with steroid medications that reportedly caused weight gain and/or inhibited mandatory weight loss to meet Navy physical standards.  The Board noted that during the time that the CI was treated with steroids, she had an exacerbation of depression symptoms leading to an inpatient hospitalization and opined that the steroid treatment, which may have psychiatric side effects, may have contributed to, or exacerbated her MH symptoms directly, and likely aggravated her MH symptoms indirectly due to the associated weight gain.  The CI was noted to have responded with increased bulimia behavior and “psychological distress” over her weight gain, as would reasonably be anticipated in an individual with BN, further exacerbated by the need to meet mandatory military weight standards.  The Board noted that the CI’s psychiatric hospitalization closely followed a marital separation, but also noted that the record supported that the separation was provoked by the CI’s MH symptoms and not the cause of them.  The MEB psychiatrist indicated the CI was moderately impaired due to her MH conditions, with likely exacerbations that could cause marked impairment for military duty.  The Board concluded that the evidence in record supported that the unfitting depression condition was aggravated by the CI’s treatment with steroids for her AD incurred non-MH condition.  Board consensus was that the depression condition, adjudicated by the PEB to be unfitting, was service aggravated and therefore, eligible for disability rating.

The Board next deliberated the rating of the CI’s depression condition.  The evidence in the record supports that the CI was treated with antidepressant medication and therapy and was able to perform her military duties and care for her child despite her persistent depression symptoms.  There was no evidence of lost work time due to the depression condition or “intermittent periods of inability” relative to occupational capacity, which the 30% rating language references.  The Board concluded that the evidence in record supported the 10% rating IAW §4.130, specified as mild or transient symptoms which decrease work efficiency only during periods of significant stress or symptoms controlled by medication, but not the higher evaluation of 30%.  The Board noted that the VA rated the CI’s MH condition at 50%.  However, a 50% rating IAW §4.130 would rely on an inference that the acuity of reported symptoms could reasonably be expected to result in impaired occupational reliability and productivity, without objective confirmation that this was indeed the case.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the depression condition, coded as 9434 (major depressive disorder).

The Board deliberated if there was a preponderance of evidence in the record to support that the BN condition was itself separately unfitting.  The evidence in the records supported that the CI was overweight, despite bulimic behaviors, and therefore did not achieve a disability rating IAW VASRD §4.130 rating criteria for BN, even if recommended as unfitting, which require eating disorder behaviors “even when below expected minimum weight.”  The BN condition was not profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no indication in the records that the eating disorder behaviors of the BN condition, separate from effects on the associated MH condition of depression, impaired the CI’s duty performance.  The Board concluded therefore that this condition could not be recommended for additional disability rating.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the BN condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the cholinergic urticarial/anaphylaxis condition, the Board unanimously recommends a disability rating of 10% coded 7825 IAW VASRD §4.118.  In the matter of the depression condition, the Board unanimously recommends a disability rating of 10%, coded 9434 and in the matter of the BN condition the Board unanimously recommends no change in the PEB fitness adjudication, both IAW VASRD §4.130.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Cholinergic urticarial /anaphylaxis	7825	10%	
Depression	9434	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130412, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
	         COMMANDER, NAVY PERSONNEL COMMAND
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:   (a) DoDI 6040.44
       (b) PDBR ltr dtd 21 Nov 14 ICO XXXXXXXXXXXXXX  
       (c) PDBR ltr dtd 9 Dec 14 ICO XXXXXXXXXXXXXX
       (d) PDBR ltr dtd 9 Dec 14 ICO XXXXXXXXXXXXXX
          
1.  Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (d).

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 40 percent (increased from 10 percent) disability rating effective date of discharge. 
  
     b. XXXXXXXXXXXXXX, former USN: Disability separation with a final disability rating of 10 percent (increased from 0%) effective date of discharge.   

     c. XXXXXXXXXXXXXX, former USN: Disability separation with a final disability rating of 20 percent (increased from 10%) effective date of discharge.

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are completed.

	XXXXXXXXXXXXXX
	Assistant General Counsel
	  (Manpower & Reserve Affairs)