RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXX BRANCH OF SERVICE: navy

CASE NUMBER: PD0900491 BOARD DATE: 20091104

SEPARATION DATE: 20030708

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SUMMARY OF CASE: This covered individual (CI) was a Musician First Class flute and piccolo player who was medically separated from the Navy in 2003 after more than 10 years of service. The medical basis for the separation was Dystonia.

The CI began having problems playing the piccolo and flute soon after she started in the US Naval Academy Band. She developed major depression and was hospitalized four times for depression and suicidal ideation during the time period of 1997 to 1999. In July 2000 she obtained a neurology consult to determine if an organic etiology for her problem existed. An extensive work-up revealed a diagnosis of embouchure dystonia, a focal task specific musician’s dystonia. Treatment with Seroquel helped her symptoms, but increased doses were required and this led to facial tics so the dose had to be lowered and her symptoms persisted. She had switched to another instrument but her MOS was for flute and piccolo which she could no longer play. After she received the diagnosis of dystonia, she did not have any recurrence of serious depression or suicidal ideation and there were no further hospitalizations for mental illness. She continued psychotherapy to deal with her neurologic condition and she remained on Seroquel. She did not have any further hospitalizations. The CI was undergoing treatment for mental illness when she entered active duty and had received a waiver to enter service. At two previous medical boards (1998 and 2000) completed for mental illness, the Navy had found her fit for duty.

Appropriate therapy failed to alleviate her symptoms and she was referred to the Navy Physical Evaluation Board (PEB). The Informal PEB determined she was unfit for continued Naval service and she was then separated with a 10% disability for Dystonia using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Service and Department of Defense regulations.

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CI CONTENTION: The CI states: “My depression was never taken into consideration when I was medically discharged. The Dystonia and Depression go hand in hand and cannot be viewed separately in this case as my medical records indicate.

In February of 1997 I went to the Mental Health Clinic at the United States Naval Academy because I was a flute player (MU2) in the USNA Band and I was having problems playing my instrument (see Enclosure I, treatment record SF 600 Substitute dated 24 Feb. 97). Specifically, I was unable to form an embouchure (correct mouth position) in order to play my flute at a professional level. Believing that my problem was stress related 1went for a consultation, For the next 3 years, I was a patient of Dr. Wagoner who was my psychiatrist. During this time, my playing problems were attributed to Major Depression (296.32) and Panic D/O without Agoraphobia (300.1) vs. Psychological Condition affecting medical condition (lip spasm)(316.00). For those three years, I developed severe depression as well as an eating D/O, both of which led to 4 inpatient psychiatric hospitalizations as well as 2 partial inpatient psychiatric hospitalizations. During that time j had been prescribed Prozac, Effexor, Buspar, and Klonopin among other medications throughout my treatment (sec Enclosure #2, treatment records SF 600 Substitute dated 10 March 97,24 March 1997,14 October 1997, 11 June 1999, 14 October 1999). Because my playing problem was NOT diagnosed correctly (musician's dystonia), I continued to blame myself for my inability to play the flute. By March of 2000, it was still believed by Dr. Wagoner that my inability to play the flute was due to performance anxiety (see Enclosure 3, letter written by John H. Wagoner, MD, PhD dated March 10, 2000).

Because my playing problems were NOT getting better despite years of psychotherapy and hospitalizations, I basically quit all treatment. In May of 2000, at the advice of my Chief at the Band, I went to see a new clinical psychologist, Dr. Held, at the Mental Health Clinic (see Enclosure 4, treatment record Computer Generated SF600 dated 15 May 2000, 30 May 2000,21 June 2000, and 28 August 2000). She suspected my playing problem was due to a conversion DIO and to rule out a physical problem, recommended that I see a neurologist. I continued to see Dr. Held weekly for therapy even after seeing a neurologist and receiving a correct diagnosis (see Enclosure 5, Computer Generated SF 600 dated July 2001,7 August 2001, 1 October 2001, and ADDENDUM TO MEDICAL BOARD [written 28 February 2003]).

After seeing several neurologists, to include Dr. Frucht, a specialist at the Neurological Institute at Columbia Presbyterian Hospital, I was correctly diagnosed with Musician's Dystonia or Task Specific Focal Dystonia (see Enclosure 6, SF-513 dated 01 August 2001). I have since been discharged from the military due to the dystonia. However, my depression was clearly documented on my discharge physical (see Enclosure 7, SF 93, DO Form 2697, SF 600, SF 2697 [addendum to earlier dated forms]).

From 1997-2000, I was going to the Mental Health Clinic for the sole reason of overcoming my inability to play the flute. Had I been referred to a neurologist at the onset of my difficulties, my life would have been dramatically different. The stress from my treatment on top of the stress from my command basically caused me to be unable to do my job or function at a healthy level. This stress crossed into other areas of my life and eventually contributed to the demise of my marriage (see Enclosure 8, letter dated 10 May 2000 addressed to Captain Locklear, Commandant of Midshipman).

Although I now know that my inability to play the flute is neurological in nature, I still suffer from the depression that was brought on by the incorrect diagnosis and mistreatment by my command. In fact, enclosed is a recent letter from my initial psychiatrist, Dr. W---, stating my "chronic, substantive, persistent, pervasive disability" (see Enclosure 9, letter to the PDBR dated 28 July 2009). Since 2000, I have been taking 150 mg of Quetiapine Fumarate daily to treat the depression that resulted from this mistreatment. My depression was never taken into consideration when I was medically discharged. The Dystonia and Depression go hand in hand and cannot be viewed separately in this case as my medical records clearly indicate.

It was clear prior to my enlistment in the USN that I was a high functioning person who also served in the United States Marine Corps from 1984-1988 and was even meritoriously promoted during that enlistment. It wasn't until my enlistment in the United States Navy that my daily functioning was jeopardized.

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RATING COMPARISON:

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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 PDBR to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. After careful consideration of all available information, the Board unanimously concluded that the CI’s condition is appropriately rated at 10% for 8207 Dystonia as it was rated by the Navy PEB.

The CI’s Dystonia directly caused her inability to perform the duties of her MOS and is therefore unfitting. Various therapies were tried but none enabled her to play the flute and piccolo. The nerve involved is the facial nerve and the condition is rated as moderate incomplete paralysis of the facial nerve. The condition does not meet the severe rating as only playing the flute and piccolo were affected. The CI had no other abnormalities attributable to the facial nerve.

The Board opined that the CI’s mental illness was not an unfitting condition. The CI was receiving treatment for mental illness prior to her enlistment and received a waiver to enlist. Her symptoms became more severe when she was unable to play the flute and piccolo as evidenced by suicide attempts, multiple hospitalizations, and intensive outpatient programs. During the time of these severe symptoms, the CI had two separate medical boards and both times the Navy PEB found her fit for duty. After an organic cause for her inability to play was discovered, her symptoms became much less severe as evidenced by the lack of any further hospitalizations or suicidal ideation. She did require continued medication and psychotherapy. The Navy PEB that determined the CI was unfit secondary to dystonia, did not address the CI’s mental health conditions. However, this Board determined that if the CI had been able to play her instruments, she would have more likely than not been fit for duty despite her mental illness. Therefore Major Depression with Anxiety Disorder is not unfitting and cannot be rated.

The Board also examined Essential Familial Tremor and Temporomandibular Joint Disorder and did not find either of these conditions to be unfitting. Carpal Tunnel Syndrome, Right Hand was rated by the VA but was not mentioned in the Disability Evaluation System (DES) package and could not be considered by the Board.

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RECOMMENDATION: The PDBR therefore recommends that there be no re-characterization of the CI’s disability and separation determination.

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The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20090813, w/atchs.

Exhibit B. Service Treatment Record.

Exhibit C. Department of Veterans' Affairs Treatment Record.

Deputy Director

Physical Disability Board of Review

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL

OF REVIEW BOARDS

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

RECOMMENDATION ICO XXXXX

Ref: (a) DoDI 6040.44

(b) PDBR ltr dtd 10 Nov 09

I have reviewed the subject case pursuant to reference (a) and approve the recommendation of the PDBR contained in reference (b), that Ms. XXXX’s records not be corrected to reflect a change in either her characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board.

Principal Deputy

Assistant Secretary of the Navy

(Manpower & Reserve Affairs)