RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX 	CASE:  PD-2013-01205
BRANCH OF SERVICE:  AIR FORCE  	BOARD DATE:  20150714
SEPARATION DATE:  20020409

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Munitions Storage Journeyman) medically separated for major depressive disorder (MDD).  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS).  He was issued a temporary S4 profile and referred for a Medical Evaluation Board (MEB).  The “(MDD) single episode severe with mood congruent psychotic features” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The MEB also identified and forwarded one other condition (schizotypal personality disorder) for PEB adjudication.  The Informal PEB adjudicated the mental health (MH) condition as unfitting, rated 30%, and then deducted 20% citing less aggravating/contributing factors resulting in a final compensable rating of 10%.  This rating cited application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be Category III, not separately unfit and not compensable or ratable.   The CI made no appeals and was medically separated.  

CI CONTENTION:  He was given a higher rating for his MH condition by the VA.  His complete submission is at Exhibit A.

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

IPEB – Dated 20020207 | VA* - (~12 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Major Depressive Disorder | 9434 | 10% | Major Depression | 9434 | 30% | 20030416
Schizotypal Personality Disorder | Cat III | No VA Placement
Other MEB/PEB Conditions x 0 (Not In Scope) | Other x 0 (equals SC, NSC & deferred)
RATING:  10% | RATING:  30%
*Derived from VA Rating Decision (VARD) dated 20030521 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Major Depressive Disorder and Schizotypal Personality Disorder.  The service treatment record (STR) indicated that the CI initially self-reported to MH in spring of 2001.  His diagnosis was “partner relational problems.”  A second diagnosis of adjustment disorder with mixed anxiety and depressed mood was added upon his first MH hospitalization in August 2001.  The STR noted that all MH treatment was discontinued and his case file was “closed” on 1 November 2001.  Approximately 4 weeks later, the CI again self-reported to medical with complaints of suicide/homicide ideations secondary to stressors of family discord specifically referencing “ongoing litigation around a divorce and child custody/support issues.”  He again was hospitalized for psychiatric treatment from 30 November to 14 December 2001, while overseas, and remained in in-patient status upon transfer back to the United States (US).  During his overseas hospitalization, his Global Assessment of Function (GAF) upon admission was assessed at 20 which improved to 65 (between “mild” and “moderate” impairment) on 10 January 2002.  Despite medication and continued counseling, the CI achieved minimal improvement in his overall symptoms and was referred to a MEB.  His MEB was conducted in January 2002. 

The MEB psychiatric narrative summary (NARSUM) dated 15 January 2002, 3 months prior to separation, clearly described the CI’s psychiatric chronology with emphasis on his latest inpatient treatment regime.  His mental status examination (MSE), which was presented in the NARSUM, appeared to be the CI’s condition upon inpatient admission when he returned back to the US on 17 December 2001.  His MEB diagnosis was MDD; single episode, severe with mood congruent psychotic features.  Additionally, the examiner noted that the CI’s condition was in “partial remission.”  His “external precipitating stress” was assessed as “moderate,” specifically noting relational problems and financial issues.  “As of 15 January 2002, [the CI’s] symptoms are fairly well controlled on antidepressant and antipsychotic medication.  He is not considered to be an imminent threat to himself or others.”
         
At the VA Compensation and Pension (C&P) examination of 16 April 2003 (12 months after separation), the CI reported having a lack of energy, motivation, and the inability to find pleasure in activities.  He reported “being better now (after military service) because [he] does not have as much stress.”  He did not endorse associated intense fear, horror, helplessness, or social isolation.  His MSE revealed a depressed mood and a restricted affect.  His insight and attention span were noted to be impaired and his judgment was fair.  His thought process and content were “goal directed.”  The CI’s Axis I diagnosis remained major depression; severe and recurrent.  There was no Axis II diagnosis and his GAF was 52; connoting near “serious” impairment…a decline since released from active service.
   
The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA applied the clinically appropriate code 9434 (MDD) and arrived at different ratings under VASRD §4.130.  The PEB listed the unfitting condition with “definite social and adaptability impairment” with a final 10% rating less contributing factors.  The VA cited moderate occupational and social impairment for a 30% rating without any deductions.  Neither the PEB nor the VA elected to apply VASRD §4.129, with its minimum rating and stipulation for a follow-up evaluation within 6 months, to the CI’s unfitting MH condition.  The first question that came before the Board was whether the CI’s MH condition met the §4.129 definition of “a mental disorder that develops in service as a result of a highly stressful event [that] is severe enough to bring about the Veteran’s release from active military service.”  The Board noted that the CI’s personal and occupational stressors, although considerable, were not at all comparable with §4.129 criterion definition.  All members agreed that the main stressors in this case were directly related to the CI’s family, marriage, financial, and legal concerns; and therefore, the requisite §4.129 link that the condition occurred “as a result of a highly stressful event” was not satisfied.  The Board also considered that the VA did not apply §4.129 to the CI’s initial rating, thereby reflecting their opinion that this threshold was not met as well.  The Board therefore will consider only the VASRD §4.130 impairment present at separation for a single rating recommendation.

The challenge before the Board was to consider the symptoms of the ratable MDD and to avoid subsuming the symptoms of the non-ratable Schizotypal personality disorder.  All members agreed that the 10% threshold was supported by the MEB, and some elements of the 50% threshold were met when considering reduced productivity (inpatient status) and a flattened/restricted affect.  However, neither of these rating criteria was approached when considering the CI’s entire clinical presentation.  Therefore the other challenge before the Board was to evaluate the MDD evidence, not as any single snapshot in time, but rather as a whole.  The Board’s deliberations were centered on arguments for a 30% versus remaining at 10% permanent rating recommendation.  
The vast majority of evidence demonstrated that the CI had a low threshold for stress which led to the emergence of the bizarre behaviors classified under Schizotypal personality disorder which moderately impacted his occupational and social life.  Physiologically and psychologically the CI appeared to perform best when he was removed from highly stressful environments to include AFS duties and family responsibilities.  Probative value (PV) between the pre-separation NARSUM and the post-separation VA examination was also discussed and all members agreed that the NARSUM held greater PV due to the nearest time reference to separation.

The NARSUM clearly indicated that the CI was still on psychiatric inpatient status as of 15 January 2002, which was continuous since November 2001.  Board members considered that this extended stay as an inpatient was synonymous with VASRD criteria of “intermittent periods of inability to perform occupational tasks” (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation); and therefore, is supported at the 30% level.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the MDD 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 MDD condition, the Board unanimously recommends a disability rating of 30%, coded 9434 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation: 

CONDITION | VASRD CODE | RATING
Major Depression Disorder | 9434 | 30%
COMBINED | 30%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130311, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2013-01205.

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 appropriate under 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 their 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 30 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 or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment. 
Sincerely,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings
 
cc:
SAF/MRBR
DFAS-IN

PD-2013-01205