RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01338
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20140327
SEPARATION DATE:  20040412

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSgt/E-5 (3S051/Personnel Journeyman) was medically separated for major depressive disorder (MDD).  The MDD could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards.  She was issued a permanent S4 profile and referred for a Medical Evaluation Board (MEB).  The MDD condition, characterized as “MDD, severe, with psychotic features,” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The MEB also identified and forwarded generalized anxiety disorder (GAD) for PEB adjudication.  The Informal PEB adjudicated “major depressive disorder w/psychotic features” as unfitting, rated 50% with a 40% reduction for a 10% rating with application of the VA Schedule for Rating Disabilities (VASRD).  The PEB identified the personality disorder, not otherwise specified (NOS) as a Category III condition (one that is not separately unfitting and not compensable or ratable).  The PEB also adjudicated tobacco abuse as a Category III condition.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI writes: “Due to PTSD & Bi-Polar diagnoses & increase of migraine headaches & left & final ovary.”

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 rating for the unfitting MDD condition is addressed below and posttraumatic stress disorder (PTSD) and bipolar conditions will be considered in the mental health (MH) condition review.  The migraine headaches and left ovary conditions are not 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 Military Records.

RATING COMPARISON:

Service IPEB – Dated 20040212 | VA - (10 Mos. Post-Separation)*
Condition | Code | Rating | Condition | Code | Rating | Exam
MDD W/PSYCHOTIC FEATURES | 9434 | 10% | Bipolar Disorder | 9432 | NSC |
PERSONALITY DISORDER, NOS | Category III | No VA Entry | - | - | -
TOBACCO ABUSE | Category III | No VA Entry | - | - | -
No Additional MEB/PEB Entries | Other x 0 |
Combined:  10% | Combined:  NSC
Derived from VA Rating Decision (VARD) dated 20050615 (most proximate to date of separation [DOS]).   * The VA identified Bipolar Disorder in an exam of 20050219, but identified it as NSC.

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; and, 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.

MDD w/Psychotic Features.  The narrative summary (NARSUM) notes the CI had a history of an initial psychiatric hospitalization in January 2000 when she was pregnant and experienced irrational thoughts of harming herself that she shared with her mother.  She was treated as an inpatient and an outpatient until July 2000.  In July of 2000, the CI overdosed on a sleep medication due to some personal relational stress and was hospitalized for a week.  According to the NARSUM the CI was seen intermittently for depressive symptoms and there were issues of medication compliance.  She was involved in counseling for 1.5 years and reported that it was helpful.  She was seen in the emergency room for anxiety and treated with oral anti-anxiety medication.  In January 2002, the CI sought care for anxiety, depression and sleep difficulties.  She reported suicidal thoughts (SI) that she would not act on, but that she did selflessly.  In September 2003, the CI experienced increased anxiety and her medications were changed, but her symptoms continued to increase and she requested partial hospitalization.  She participated in an adult psychiatric partial hospitalization program (APPHP) from 17 November 2003 to 9 December 2003.  Notes from the program indicated that the CI reported “worsening” of her symptoms approximately 3 years earlier when she began to have bad anxiety attacks and to cut herself.  She reported that she feels the desire to hurt herself every day; that she was experiencing increased counting behavior; counts by even numbers; and, always sets her clock to odd numbers.  The CI reported that she has episodes of racing thoughts, decreased need for sleep, with increased risk taking, spending and sexual behaviors.  On admission the CI reported worsening depression and anxiety symptoms, auditory hallucinations of people calling her name and anger episodes involving hurting herself, though she denied SI or homicidal ideation (HI).  The Axis I diagnoses were: GAD; MDD (severe, recurrent) and alcohol abuse; consider Bipolar I disorder, most recent episode depressed mood and the Axis II diagnosis was borderline personality disorder (PD).  The examiner noted that the symptoms of possible mania seemed more consistent with the Axis II PD, but the CI responded well to a trial of Lithium (medication), which seemed to improve her mood and anxiety.  The CI’s mental status examination (MSE) at discharge noted a “satisfied” mood without SI, delusions or hallucinations, thought or speech disturbance, cognitive impairment or other abnormalities.  The commander’s statement indicated that when the CI returned to work from the APPHP she experienced an emotional outburst at the customer service counter and was removed from duty on 16 December 2003.  The MEB examiner on 13 January 2004, approximately 3 months prior to separation, noted that the CI’s condition had worsened with acute anxiety and she reported increased auditory hallucinations.  The CI was noted to recently be in therapy up to three times per week.  On the MEB MSE, the CI had a depressed and anxious mood and was angry and tearful at times.  She had normal speech and reported “vague auditory non-command hallucinations.”  Her cognition, judgment and insight were deemed poor, and she reported self-mutilating behavior with anxiety exacerbations, but denied SI or HI.  The diagnoses were the same as previously indicated with a Global Assessment of Functioning (GAF) of 55 (moderate symptoms or moderate difficulty in social, occupational or school functioning)  An emergency room visit for anxiety in April 2004, a couple weeks prior to separation, was a noted in the records.  At the VA Compensation and Pension (C&P) mental disorders examination on 19 February 2005, performed 10 months after separation, the CI reported that a psychiatrist adjusted her medications post-separation and that she was on Lithium (mood stabilizer), antidepressant, antianxiety and sleep medications.  She reported that though her last treatment visit was in October 2004, she had obtained medication refills through the mail.  She had not worked since her separation from the military.  She reported alcohol abuse from 2001 to 2003, but denied current use.  The CI was involved in a relationship and getting married soon for the third time.  The CI reported episodes of mania lasting 2 to 3 weeks followed by depression.  During a manic period she reported having a lot of energy, feeling that she could do anything, insomnia and “being mean to people.”  During the depression period she felt sad, had low motivation and slept excessively.  The CI reported feelings of anxiety, irritability impulsivity, anger and transiently hearing and seeing things.  She reported current depression, but denied current hallucinations or SI/HI.  On MSE the CI was fully oriented, depressed, and tearful, with intact memory, without evidence of hallucinations, SI/HI or paranoia.  Concentration, judgment and insight were deemed fair.  The diagnosis was Axis I: bipolar disorder NOS and alcohol abuse in remission and Axis II: borderline PD with a GAF of 55.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB listed a single Category I condition of MDD with psychotic features and two Category III conditions (not separately unfitting and not compensable or ratable) of PD NOS and tobacco abuse.  The PEB rated the MDD as current disability 50% and subtracted 40% for aggravating and contributing factors, for a final combined compensable disability rating of 10%.  The VARD on 15 June 2005, 14 months post-separation, indicated that the military treatment records could not be located by the service and therefore the VA could not service-connect the VA rendered diagnosis of bipolar disorder NOS.  The Board first unanimously agreed that application of VASRD §4.129 was not appropriate in this case in the absence of a causative highly stressful event.  Both the NARSUM and the VA C&P examinations reported similar MSE and GAF scores.  The NARSUM examination described significant history of symptoms instability that led to psychiatric hospitalizations.  The CI expressed SI, reported auditory and visual hallucinations and engaged in self-mutilation when socially or occupationally stressed.  Sixteen months prior to separation the CI was hospitalized due to symptoms of hearing voices and paranoid ideation; 5 months prior to separation the CI was in an APPHP and 2 weeks prior to separation the CI went to the emergency room for anxiety.  The CI was noted to not fully comply with treatment, which included self-discontinuation of medication at times.  The NARSUM recorded a GAF of 55 (moderate impairment).  Impairment for further military duty was noted as marked and prognosis poor.  The VA C&P examiner provided an Axis I diagnosis of bipolar disorder NOS with a GAF of 55.  As stated above, the CI was challenged in her ability to fully comply with treatment.  However, it was noted she improved with medications, specifically, Lithium, a very potent antidepressant and mood stabilizing medication.  Although she demonstrated improvement with medications, the evidence in the records available suggested that significant symptoms with recurrent exacerbations would likely remain.  The Board noted that the CI contended MH diagnoses of PTSD and bipolar disorder.  The service diagnosed MDD, GAD and PD.  The VA diagnosed bipolar disorder, alcohol abuse in remission and a PD.  The Board noted there is no indication in the records available, before or after separation, that the CI was ever diagnosed with PTSD.  At a very remote VA C&P PTSD examination on 18 April 2013, 9 years after separation, the MH examiner indicated that the CI did not have a diagnosis of PTSD based on Diagnostic and Statistical Manual of Mental Disorders IV criteria.  Regarding the contended bipolar disorder diagnosis the specific MH diagnosis is otherwise a moot issue for the Board.  The diagnosis was MDD with psychotic features and the VA diagnosis was bipolar disorder NOS.  However, only one MH disability rating can be assigned based on total social and occupational functioning and the CI was diagnosed by the service with a serious Axis I MH condition.  The Board agreed that at the time of separation the §4.130 threshold for a 30% rating (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) was exceeded and agreed that the next higher evaluation of 50% (occupational and social impairment with reduced reliability and productivity) was achieved, evidenced by depressed mood with passive SI, without intent, self-mutilating behavior when stressed, transiently abnormal thought content and persistent occupational difficulties.  The Board next reviewed to see if the next higher rating of 70% was achieved, specified as occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood” and agreed that it was not.  The Board noted that at the post-separation VA C&P examination noted above, the CI was improved on her current medications, which included Lithium, with a depressed mood and affect and otherwise normal MSE.  The CI was noted to be involved in a significant relationship and getting married soon, though she was unemployed, the MH examiner provided the opinion that the CI was capable of gainful employment.  Members agreed that the totality of the evidence in the records available supported a separation disability rating of 50%.

The Board next examined whether the reduction in the rating was warranted.  The PEB subtracted 40% from the adjudicated 50% disability rating based on the contributing and aggravating factors of medication non-compliance and a PD.  The psychiatric consultant opined that medical standards for diagnosing a PD require evidence that certain criteria are met, one of which is the criteria that a “pattern of behaviors” began prior to or during early adulthood, and that the “enduring pattern” is not better accounted for by another mental illness.  Available records in evidence (to include the commander’s statement) do not provide sufficient documentation to establish clear evidence that the applicant met any diagnostic criteria for a PD.  Historical data replete with corroborating, collateral information from reliable historians supporting an enduring pattern of behaviors are not in evidence.  No personality testing was in evidence.  The psychiatric addendum implicated two Axis I conditions: MDD (severe, with psychotic features, recurrent), “as manifested by depressed mood, decreased ability to concentrate and make decisions” and GAD and one Axis II condition: borderline PD “as manifested by a pervasive pattern of instability” as contributing to unfitness.  The CI’s performance review in the year prior to separation noted good duty performance and provided no evidence for the basis of a PD interfering with performance.  Diagnostic criteria for any PD require the ability to determine that symptoms described in a PD are not better accounted for by another mental illness.  The Board found no convincing evidence for a pre-existing formally diagnosed PD prior to service and the service entry (Military Entrance Processing Station) physicals from December 1995 had no evidence of any MH disorder or MH symptoms.  As stated above, the CI improved with medications, including an antidepressant and mood stabilizing medication.  Therefore, in this case it is not clear if the CI’s reported symptoms and impaired medication adherence would be present in the absence of a diagnosed mood condition.  Resolving doubt in favor of the CI, the Board concluded that the medication non-compliance should be considered as a consequence of her MH condition and not a deductible contributing or aggravating factor when rating her disability.  Therefore, Board members agreed, there was insufficient evidence to warrant a decrease in the rating since there is not sufficient evidence to support the position of aggravating/contributing factors in this case since the CI was diagnosed with a primary Axis I diagnosis, recorded as severe.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a change in the PEB adjudication for the Category I MDD condition to a permanent disability rating of 50%.

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 50%, 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 recharacterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:

UNFITTING CONDITION | VASRD CODE | RATING
Major Depressive Disorder with Psychotic Features | 9434 | 50%
COMBINED | 50%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130910, 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 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2013-01338.

	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