RECORD OF PROCEEDINGS
                     PHYSICAL DISABILITY BOARD OF REVIEW

NAME:                            BRANCH OF SERVICE:  AIR FORCE
CASE NUMBER:  PD1000117                            SEPARATION  DATE:
20040308
BOARD DATE:  20111018
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SUMMARY OF CASE:  Data extracted  from  the  available  evidence  of  record
reflects that this covered  individual  (CI)  was  an  active  duty  SrA/E-4
(2A651B/Aircraft Mechanic) medically separated from the Air Force  in  2004.
The medical basis for the separation was major  depressive  disorder  (MDD).
She did not respond adequately  to  treatment  and  was  unable  to  perform
within her Air Force specialty.  She was issued a permanent S4  profile  and
underwent a  Medical  Evaluation  Board  (MEB).   MDD,  recurrent,  moderate
without  psychotic  features,  anxiety  disorder,  not  otherwise  specified
(NOS), paranoid personality disorder, post jaw surgery, marital discord  and
occupational problems were forwarded to the Physical Evaluation Board  (PEB)
IAW AFI 48-123.  No other  conditions  appeared  on  the  MEB’s  submission.
Other conditions included in the Disability Evaluation System  (DES)  packet
will be discussed below.   The  Informal  PEB  (IPEB)  adjudicated  the  MDD
associated with anxiety disorder  condition  as  existed  prior  to  service
(EPTS)  without  service  aggravation,  definite   social   and   industrial
adaptability impairment, rated  at  10%,  but  not  secondary  to  the  EPTS
status, with application of the DoDI 1332.39.  Tobacco  abuse  and  paranoid
personality disorder were determined to  be  Category  III  conditions,  not
separately unfitting and compensable.  The CI appealed  to  the  Formal  PEB
(FPEB) which upheld the  IPEB  decision  and  adjudicated  that  the  CI  be
discharged under Other Than Chapter 61, Title 10, United  States  Code.   In
2007, the CI submitted a  rebuttal  to  the  Air  Force  Board  of  Military
Records (AFBCMR) which adjudicated that she was entitled  to  10%  severance
pay for aggravation of the pre-existing condition.  She was  then  medically
separated with a 10% combined disability rating IAW  the  Veteran’s  Affairs
Schedule for Rating Disabilities (VASRD).  The date of  separation  remained
8 March 2004.
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CI CONTENTION:  The CI appended a one-page memorandum  to  the  application,
“Symptomology severity limited ability not only functioning at work but  had
a large impact on family as  well.   The  ‘Disposition  and  Recommendation’
portion of the Medical Evaluation Board dated October 6,  2003  stated:   1.
indications for a decreased  chance  of  long-term  remission;  2.  Need  to
continue  psychotherapy  and  psychotropic  medication;  and  3.  “She  will
continue to follow up at Ramstein Life Skills Clinic since  her  husband  is
active duty.  My contention at the time, and still  is  the  irrelevance  of
that statement AND the  inaccuracy  due  to:  my  husband  and  I  had  been
physically separated since June (4 months prior) AND further  inaccuracy  MY
RANK I had changed rank 15  months  prior  to  that  determination….The  MEB
papers were wrong, the highlighted portion were the  wrong  portions.”   She
elaborates no specific contentions regarding rating or coding  and  mentions
no additionally contended conditions.
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RATING COMPARISON:
* AFBCMR Dated 20080527 increased to 10%    ** VA Increased to 50% from
20080725
|Service FPEB – Dated 20031219    |VA (#Mo. Pre/After  Separation) – All    |
|                                 |Effective Date 20040309                  |
|Condition          |Code         |Rating                                   |
|Post Jaw Surgery   |Not Unfitting|                                         |
|Marital Discord    |Not Unfitting|                                         |
|Occupational       |             |                                         |
|Problems           |             |                                         |
|↓No Additional MEB Entries↓      |Tinnitus                                 |
|Final Combined:  10% NA          |Total Combined:  40% then 60% 20080725   |


ANALYSIS SUMMARY:  It is noted for the record that  the  Board  has  neither
the  jurisdiction  nor  authority  to  scrutinize  or  render  opinions   in
reference to the CI’s statements in the application regarding  medical  care
or suspected DES improprieties in the processing of this case.

Mental  Condition/Major  Depressive  Disorder/Anxiety  Disorder.   The   MEB
narrative summary on 6 October 2003, six months prior to  separation,  noted
the CI first presented for treatment in  the  mental  health  clinic  on  19
February 2002, citing marital difficulties and suicidal ideation.  Over  the
course of the next 20 months, she was treated  successively,  with  multiple
anti-depressant  medications  and  extensive  counseling,  without  adequate
improvement.  Initially, she was thought to have a single episode of a  MDD.
 Subsequently, in June  and  July  2003,  eight  to  nine  months  prior  to
separation, she had recurrent MDD  which  had  psychotic  features  and  was
given an S4 profile,  which  stood  until  separation.   She  had  intrusive
thoughts and paranoid ideation and felt extremely overwhelmed.  She has  not
had any ideas  of  reference  or  auditory/visual  hallucinations.   The  CI
stated that her father subjected her to both emotional and  physical  abuse.
Mental status exam was significant for  tangential  and  disjointed  thought
processes.  Judgment and insight were limited due to her  inability  to  see
her role in interpersonal relationships.  She denied dissociative  episodes.
 She endorsed suicidal ideation, but did not consider it a  viable  solution
and  had  no  suicidal  or  homicidal  plan  or  intent.   Her  profile  was
consistent with someone who  endorsed  bizarre  thoughts.   It  suggested  a
person who is  socially  isolated  with  a  general  sense  of  sadness  and
disharmony, as well as underlying anxiety.  Under assessment, it  was  noted
that the greatest concern was her transient  symptoms  of  thought  blocking
and paranoid thoughts.  The  differential  included  a  MDD  with  psychotic
features, a primary psychotic process such as schizophrenia or  a  regressed
personality disorder.  She was noted to have some features  consistent  with
a paranoid personality disorder.  She was noted to have  moderate  premorbid
disposition from the abuse  by  her  father  and  the  chronic  feelings  of
anxiety and depression  since  age  13.   She  was  diagnosed  with  a  MDD,
moderate without psychotic features and paranoid personality disorder.   She
was receiving Welbutrin, Zoloft, and  Klonopin.   The  psychiatric  examiner
indicated, “The combination of MDD, recurrent, moderate to  severe,  without
psychotic features, anxiety disorder NOS, and paranoid personality  disorder
indicate  decreased  chance  of  long-term  remission.   The  symptoms   are
pervasive and not conducive  to  military  duty.   [CI]  will  need  ongoing
psychotherapy  and  psychotropic  medication”.   Her  global  assessment  of
function (GAF) was 55.  The Board notes  the  CI  completed  a  five-session
course of substance abuse awareness  on  29  November  1999,  starting  four
months after entry on active duty; no formal diagnosis was made.  The  Board
also notes that she was found  disqualified  for  the  Personal  Reliability
Program (PRP) based upon an initial screen on 6 August 1999, less  than  one
month after her enlistment began.   While  the  specific  reasons  were  not
annotated, this determination  is  consistent  with  a  pre-existing  mental
health condition  as  determined  by  the  PEB.   Both  the  IPEB  and  FPEB
adjudicated  the  condition  as  EPTS  and  recommended  separation  without
severance pay.

The VA compensation and pension  (C&P)  exam  was  accomplished  6  December
2006, two years and eight months after separation.  At that time there  were
sleep and eating disturbances, suicidal ideation without a plan, but the  CI
was in a stable “wonderful” second marriage,  working  fulltime  and  was  a
college student.  The VA C&P examiner determined that she had  a  depressive
disorder, NOS, and a panic anxiety disorder without agoraphobia.  A  GAF  of
42 was assigned, consistent with either  serious  symptoms  or  any  serious
impairment in social, occupational, or school functioning.  The VA  decision
rating officer determined that there was no medical  evidence  for  an  EPTS
condition since there were no records of care for this prior  to  enlistment
despite, noting that she gave a history of anxiety and depression since  the
age of 13.  She was initially awarded 30% disability.  On 5 September  2008,
over four years after separation, she was reevaluated  by  the  VA  and  was
found  to  have  recent  worsening  of  symptoms  with  severe  anxiety  and
depression.  Her GAF was  34,  indicative  of  some  impairment  in  reality
testing or communication or major impairment in several areas, such as  work
or school, family relations, judgment, thinking, or  mood.   Her  disability
rating was increased to 50%.  Between the two VA C&P exams,  she  petitioned
the AFBCMR.

The Board also reviewed the AFBCMR medical  officer  review,  dated  27  May
2008.  The Board  noted  the  recommendation  made  by  the  AFBCMR  medical
consultant for the  contributions  of  the  pre-existing  component  of  her
condition, the  presence  of  the  paranoid  personality  disorder  and  the
examiners implication that the CI failed to disclose her psychiatric  issues
prior to enlistment; however,  there  was  no  evidence  whatsoever  in  the
record that the  CI  ever  received  medical  treatment  for  a  psychiatric
condition prior to service entry.  While  the  record  states  that  once  a
clear diagnosis of depression was  made  during  service,  the  CI  admitted
depressive symptoms back to the age of 13; there is  no  evidence  that  she
knew what the symptoms meant at the time of service entry.  The AFBCMR  even
conceded  that  such  symptoms  often  appear  during  adolescence   without
indicating mental illness.  The Board therefore determined that there is  no
evidence that the CI deliberately  withheld  any  information  since  it  is
unclear  that  she  had  a  psychiatric  illness  and  unclear  whether  she
understood at that time that she was mentally  ill,  if  she  in  fact  was.
Most importantly, the Board also determined that it was quite clear  due  to
the CI’s initial excellent performance of her military duties that the  CI’s
condition did deteriorate  during  service,  and  thus  the  presumption  of
soundness is not rebutted because of this evidence of  service  aggravation.
As to a baseline paranoid personality disorder,  the  Board  concluded  that
such a diagnosis does  not  cause  depression  or  anxiety,  which  are  the
reasons for separation, and due to that fact and the service aggravation,  a
deduction is not warranted.  The Board then considered  probative  value  of
the mental examinations.  The VA examinations are  remote  from  separation,
and while the Board considered them they do not  carry  the  same  probative
value as that of the MEB examination which  is  temporally  much  closer  to
separation.

The Board majority, however, did not find that there  was  evidence  in  the
record of the  mental  condition  causing  an  interference  with  the  CI’s
ability to function within her career field.  The minority opinion was  that
the mental condition caused  a  disability  consistent  with  a  50%  rating
(occupational  and  social   impairment   with   reduced   reliability   and
productivity) based upon the MEB  examination  showing  a  GAF  of  55,  the
presence  of  suicidal  ideation,  difficulty  in  adapting   to   stressful
circumstances  (including  work  or  a  work  like  setting),  inability  to
establish and maintain effective relationships, impaired judgment,  impaired
abstract thinking, disturbances of  motivation  and  mood,  depressed  mood,
anxiety, and suspiciousness.

Based upon the medical evidence proximate to separation, with a GAF  of  55,
and the summary of the MEB psychiatric exam  above,  the  Board  deliberated
between ratings of 50% versus 30% versus no recharacterization  of  the  PEB
adjudication of the  mental  condition  at  10%.   After  due  deliberation,
considering all of the  evidence  and  mindful  of  VASRD  §4.3  (reasonable
doubt), the Board, by a simple majority,  recommends  no  recharacterization
of the adjudication by the PEB.

Other PEB Conditions.   The  other  conditions  forwarded  by  the  MEB  and
adjudicated as not unfitting by the  PEB  were  post  jaw  surgery,  marital
discord,  and  occupational   problems.    Paranoid   personality   disorder
(discussed above) and tobacco abuse  were  determined  to  be  Category  III
conditions.  None of these  conditions  were  profiled,  implicated  in  the
commander’s statement or noted as failing  retention  standards.   All  were
reviewed by the action officer and considered by the Board.   There  was  no
indication from the  record  that  any  of  these  conditions  significantly
interfered with satisfactory duty  performance.   All  evidence  considered,
there   is   not   reasonable   doubt   in   the   CI’s   favor   supporting
recharacterization of the PEB fitness adjudication for  any  of  the  stated
conditions.

Remaining Conditions.  Other conditions identified  in  the  DES  file  were
tinnitus, back pain, bilateral shin splints, status post  jaw  surgery,  and
status post cesarean section.  Several additional  non-acute  conditions  or
medical complaints were also documented.   None  of  these  conditions  were
clinically  significant  during  the  MEB  period,  none  carried   attached
profiles, and none were implicated  in  the  commander’s  statement.   These
conditions were reviewed by the action officer and considered by the  Board.
 It was determined that none could be argued as  unfitting  and  subject  to
separation rating.  Additionally, bilateral hearing loss and  a  history  of
hemorrhagic cystitis were noted  in  the  VA  rating  decision  proximal  to
separation, but were not documented in the DES file.   The  Board  does  not
have  the  authority  under  DoDI  6040.44  to  render  fitness  or   rating
recommendations for any conditions not considered by the DES and notes  that
the VA determined both of these to be non-service connected.
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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 Board to the extent they were inconsistent with the VASRD in  effect  at
the time of the adjudication.  In the matter of the  mental  condition,  the
Board  by  a  two  to  one  majority  recommends  no  change  from  the  PEB
adjudication 9434-9413 IAW VASRD §4.130.
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RECOMMENDATION:  The Board therefore recommends that there be no
recharacterization of the CI’s disability and separation determination.

|UNFITTING CONDITION                               |VASRD CODE  |RATING  |
|Major Depressive Disorder/Anxiety Disorder        |9434-9413   |    10% |
|COMBINED    |10%     |


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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20100203, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans' Affairs Treatment Record





                                        President
                                                                    Physical
Disability Board of Review

Minority Opinion:  I respectfully disagree with  the  determination  of  the
Board Majority that the CI’s mental condition  should  be  rated  10%  which
according to the VASRD indicates:  occupational and  social  impairment  due
to mild or transient symptoms which decrease work efficiency and ability  to
perform occupational tasks only during periods  of  significant  stress,  or
symptoms controlled by continuous medication.  Were that the  case,  the  CI
would not have been found unfit for  continuation  in  the  military.   Some
Board members considered that  the  symptoms  were  more  severe  than  that
descriptor, but considered some of the effect to be part of  a  pre-existing
condition and  a  personality  disorder.   However,  there  is  no  evidence
whatsoever in the record that the CI ever received medical treatment  for  a
psychiatric condition prior to service entry.  While the record states  that
once a clear  diagnosis  of  depression  was  made  during  service  the  CI
admitted depressive symptoms back to the age of 13,  there  is  no  evidence
that she knew what the symptoms meant at the time  of  service  entry.   The
AFBCMR even conceded that such  symptoms  often  appear  during  adolescence
without indicating mental  illness.   There  is  no  evidence  that  the  CI
deliberately withheld any information since it is unclear  that  she  had  a
psychiatric illness and unclear whether she understood  at  that  time  that
she was mentally ill, if she in fact  even  were.   Diagnosis  of  a  mental
condition cannot  even  be  reliably  made  before  the  age  of  18.   Most
importantly, the Board also determined that it was quite clear  due  to  the
CI’s initial excellent performance of her  military  duties  that  the  CI’s
condition did deteriorate  during  service,  and  thus  the  presumption  of
soundness is not rebutted because of this evidence of  service  aggravation.
As to a baseline paranoid personality disorder, such a  diagnosis  does  not
cause depression or anxiety, which are the reasons for separation,  and  due
to that fact and the service aggravation,  a  deduction  is  not  warranted.
The minority opinion is  that  the  mental  condition  caused  a  disability
consistent with a  50%  rating  (occupational  and  social  impairment  with
reduced  reliability  and  productivity)  based  upon  the  MEB  examination
showing a GAF of 55,  the  presence  of  suicidal  ideation,  difficulty  in
adapting  to  stressful  circumstances  (including  work  or  a  work   like
setting), inability  to  establish  and  maintain  effective  relationships,
impaired judgment, impaired abstract thinking,  disturbances  of  motivation
and mood, depressed mood, anxiety, and suspiciousness.
SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews MD  20762


      Reference your application submitted under the provisions of DoDI
6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2010-00117.

      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 appropriate.  Accordingly, the Board
recommended no re-characterization or modification of your separation
with severance pay.

      I have carefully reviewed the evidence of record and the
recommendation of the Board.  I concur with that finding and their
conclusion that re-characterization of your separation is not warranted.
Accordingly, I accept their recommendation that your application be denied.

                                        Sincerely,





                                       Director
                                       Air Force Review Boards
                                       Agency

Attachment:
Record of Proceedings