RECORD OF PROCEEDINGS
                     PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXX                 BRANCH OF SERVICE:  marine corps
CASE NUMBER:  PD1001089                 SEPARATION DATE:  20021101
BOARD DATE:  20110819
____________________________________________________________________________
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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  PFC/E-2
(3531,  Motor  Transport  Operator)  medically  separated  for  vocal   cord
dysfunction.  In 2001, the CI developed intermittent  symptoms  of  stridor,
dyspnea and chest cramping associated with feelings of  panic  and  anxiety.
His symptoms were initially attributed to asthma, but  he  had  inconsistent
response to bronchodilator and  steroid  therapy.   The  CI  was  eventually
diagnosed  with  vocal  cord  dysfunction,   exacerbated   by   stress   and
depression.  He  was  treated  with  speech  therapy,  breathing  relaxation
techniques, and intermittent benzodiazepine therapy, but  only  had  partial
improvement  in  his  symptoms.   Psychiatry  recommended  the  addition  of
selective serotonin reuptake inhibitor (SSRI) medication  for  treatment  of
underlying depression and anxiety; however, the CI  declined.   The  CI  did
not  respond  adequately  to  perform  within  his   military   occupational
specialty (MOS) or participate in a physical fitness test.   He  was  placed
on limited duty (LIMDU) and underwent  a  Medical  Evaluation  Board  (MEB).
Asthma, vocal cord dysfunction,  adjustment  disorder  and  depression  were
forwarded to the PEB  as  medically  unacceptable  IAW  SECNAVINST  1850.4E.
Other conditions supported in the Disability Evaluation System (DES)  packet
will be discussed below.  The PEB adjudicated  the  vocal  cord  dysfunction
condition as unfitting,  rated  10%,  with  application  of  the  SECNAVINST
1850.4E.  The CI made no appeals and was  medically  separated  with  a  10%
disability rating.


CI  CONTENTION:   “I  use  asthma  medication  and  I  take  anti-depression
medication.  All disabilities have worsened.”


RATING COMPARISON:

|Service IPEB – Dated 20020819      |VA (4 Mo. after Separation) – All   |
|                                   |Effective 20021102                  |
|Condition        |Code             |Rating                      |Conditi|
|                 |                 |                            |on     |
|Combined:  10%                     |Combined:  10%                      |


ANALYSIS SUMMARY:  The Board acknowledges the  sentiment  expressed  in  the
CI’s application regarding the significant impact that his  service-incurred
conditions have had on his current  earning  ability  and  quality  of  life
reflected  in  his  higher  VA  disability  rating.   However,  the  DES  is
responsible for maintaining a fit and vital fighting force.  While  the  DES
considers all of the service member's medical conditions,  compensation  can
only be offered for those  medical  conditions  that  cut  short  a  service
member's career, and then only to the degree  of  severity  present  at  the
time of final disposition.  However, the VA,  operating  under  a  different
set of laws, is empowered  to  periodically  re-evaluate  veterans  for  the
purpose of adjusting the disability rating should the degree  of  impairment
vary over time, as well as  considering  service  incurred  conditions  that
were not unfitting for continued service.

Vocal Cord Dysfunction.  When  the  CI  first  presented  with  symptoms  of
stridor, dyspnea, chest tightness and cough, he was  given  the  presumptive
diagnosis of asthma.  After his episodes failed to  respond  to  traditional
asthma therapy (bronchodilators and steroids), and when  pulmonary  function
studies yielded inconsistent findings, the diagnosis of asthma, as  a  cause
of his attacks, was called into question.  Subsequent visualization  of  the
upper airway during an episode revealed paradoxical  closure  of  the  vocal
cords, confirming the diagnosis of vocal cord dysfunction  as  the  etiology
of the CI’s symptoms.  During acute episodes, the  CI’s  breathing  problems
improved  with  use  of   benzodiazepines   and   removal   from   stressful
circumstances,  but  did  not   improve   with   bronchodilator   treatment.
Providers  from  multiple  disciplines  (speech  therapy,   mental   health,
emergency medicine and  pulmonology)  noted  that  the  CI  had  significant
anxiety as a component of his vocal cord dysfunction.  Additionally,  speech
pathology commented that “stress related to adjustment to military life  and
depression related to being away from his family…appear  to  be  significant
contributing factors.”  Psychiatry recommended  concomitant  treatment  with
SSRIs for management of the related depression and  anxiety  symptoms,  with
occasional short term use of benzodiazepines for acute exacerbations of  his
vocal cord dysfunction.

At the  time  of  the  NARSUM  exam  (7  February  2002)  nine  months  pre-
separation, the CI complained of “persistent  symptoms  of  dyspnea,  panic,
and anxiety, and is unable to control his breathing through  these  episodes
requiring emergency room therapy.”  The examiner documented  a  normal  lung
exam with 100% room air saturation.  The  CI  had  been  prescribed  inhaled
steroids and, as needed,  bronchodilator  therapy  (albuterol)  for  asthma;
however, he was not on any daily medications  for  vocal  cord  dysfunction.
Pulmonary function studies done at  that  exam  indicated  some  restrictive
lung disease that improved with the use of albuterol.  The examiner,  noting
the CI’s  poor  technique,  concluded  that  the  “patient  has  presumptive
airflow obstruction which appears to be reversible,  although  difficult  to
assess at this  time.”   This  study  additionally  documented  evidence  of
persistent truncation of the inspiratory limb on the flow loop,  “consistent
with his established diagnosis of vocal cord dysfunction.”  Prior  pulmonary
function studies, as annotated above, had yielded inconsistent results  that
were not reproducible and that  were  also  difficult  to  interpret.   Some
tests had normal findings while others  suggested  a  restrictive  component
that worsened with albuterol.  At  the  time  of  the  VA  compensation  and
pension (C&P) exams (four months post-separation, 11  March  2003),  the  CI
was no longer on any medication and he was  noted  to  have  a  normal  lung
exam.  Pulmonary function studies were ordered, but not performed.  The  ear
nose and throat (ENT) C&P examiner noted “an  essentially  normal  laryngeal
exam,” and documented “appropriate abduction  and  adduction  of  the  vocal
cords with phonation and respiration.”  The examiner offered no further  ENT
recommendations, but recommended psychiatric  therapy  to  treat  the  vocal
cord dysfunction.  At the subsequent VA mental health  C&P  exam  (18  March
2003), the CI denied any current complaints  or  psychiatric  symptoms,  and
the psychiatric examiner noted that the CI was  adapting  well  to  civilian
life.  The examiner stated that there was “no psychiatric diagnosis at  this
time,” but surmised that the CI’s prior mental  health  symptoms  were  most
consistent with adjustment disorder with mixed features.

The non-medical assessment noted the significant occupational impact of  the
CI’s episodes, commenting that  “[CI]  has  no  control  over  the  time  or
severity of his  attacks”  and  adding  that  the  CI’s  “medical  condition
precludes me from placing this Marine  in  his  MOS  as  a  safety  risk  to
himself and to others on the  road.”   The  assessment  additionally  opined
that, “without close proximity to knowledgeable medical personnel,  [CI]  is
non-deployable and not able to be  left  unsupervised  in  case  of  another
attack.”  The LIMDU specified, “unable to perform  strenuous  activity.   No
PT, no working in harsh conditions, no USMC PTT; no field exercises.”

The PEB and VA coding and rating schema were not comparable.  The PEB  coded
the vocal cord dysfunction condition analogous to  bronchial  asthma,  6699-
6602 and rated at 10%.  They listed asthma and anxiety disorder  as  related
category II conditions that contributed to the unfitting condition.  The  VA
C&P exam noted no laryngeal pathology, thus the VA did not  code  the  vocal
cord dysfunction as a separate  condition.   They  combined  this  condition
with the mental health condition, and  diagnosed  adjustment  disorder  with
mixed features and laryngeal dystonia, coded 9440 and  rated  at  10%.   The
Board considered all of the  evidence,  and  concluded  that  the  unfitting
condition of vocal cord dysfunction was according to the  service  treatment
record a manifestation of an adjustment disorder.  This was later  confirmed
by the resolution of symptoms upon return to civilian  life.   The  lack  of
response of the condition to treatment  for  asthma  was  evidence  for  the
Board to conclude that rating the condition analogous to asthma was not  the
best fit under VASRD coding.  The Board has  the  advantage  of  information
post-separation to further support the diagnosis made by the  service.   The
Board considered the  following  codes  as  preferable  since  they  address
laryngeal dysfunction rather than reversible bronchial  obstruction:   6599-
6516 laryngitis, chronic for which the CI would  receive  a  rating  of  0%,
6599-6519 aphonia complete organic which  directs  rating  under  6516  when
aphonia is incomplete again 0%,  or  6599-6520  under  which  the  CI  would
receive a maximum rating of 10%.  All  evidence  considered,  there  is  not
reasonable doubt in the CI’s  favor  supporting  a  change  from  the  PEB’s
rating decision for the vocal cord dysfunction condition.

Other PEB Conditions.  The PEB adjudged asthma as a  category  II  condition
that contributed to the unfitting vocal cord dysfunction condition.  The  CI
was given  the  presumptive  diagnosis  of  asthma  when  he  developed  the
unfitting  attacks  of  stridor,  shortness  of  breath  and   chest   pain.
Subsequent evaluation discounted asthma as the  etiology  of  the  unfitting
episodes,  and  confirmed  the  presence  of  vocal  cord  dysfunction.   As
discussed  previously,  the  CI’s  unfitting  attacks  did  not  respond  to
treatment for asthma, underscoring the conclusion that asthma  was  not  the
etiology of the episodes.  Service treatment records during the  MEB  period
document that the CI’s asthma, if it was present  at  all,  was  under  good
control and there was no evidence of additional impairment  attributable  to
the asthma condition.  Any limitations  due  to  respiratory  symptoms  were
already considered in the rating for the unfitting  vocal  cord  dysfunction
condition.  All evidence considered, there is not reasonable  doubt  in  the
CI’s favor supporting recharacterization of  the  PEB  fitness  adjudication
for the asthma condition.

The  PEB  adjudged  anxiety  disorder  as  a  category  II  condition   that
contributed to the unfitting vocal cord  dysfunction.   Depressive  disorder
was adjudged  as  category  III,  not  separately  unfitting  and  does  not
contribute  to  the  unfitting  condition.   The  CI  was  noted   to   have
significant anxiety as a component of his vocal cord  dysfunction,  and  his
vocal cord dysfunction episodes  resolved  with  anxiolytic  medication  and
removal from  stressful  circumstances.   After  psychiatric  evaluation  at
Tripler  Army  Medical  Center  in  December  2001,  the  CI  was  initially
diagnosed with adjustment disorder with depressed mood.   At  that  time  he
endorsed symptoms of “worry depression,” insomnia and  feeling  overwhelmed.
The CI noted  acute  stressors  which  seemed  to  trigger  his  vocal  cord
dysfunction attacks, including a recent summary court martial, the death  of
his daughter, and the deaths of a number of his  friends.   He  was  treated
with a course of biofeedback sessions  with  a  resultant  decrease  in  his
episodes of vocal cord  dysfunction.   Additionally,  he  was  referred  for
individual psychotherapy  for  anger  management  and  depressed  mood.   By
February 2002, the CI was noted to  have  persistent  mood  disturbance  and
somatic symptoms  which  were  exacerbated  by  anxiety.   He  continued  to
display a depressed mood and he endorsed  symptoms  of  nightmares,  worries
about death, feeling stressed, weight loss  and  occasional  alcohol  binges
with blackouts.  At that time, the CI was diagnosed with  anxiety  disorder,
not otherwise specified (NOS), depressive disorder NOS, and passive  traits.
 It was recommended that he  begin  therapy  with  SSRIs;  however,  the  CI
declined.  Despite his significant mental health concerns, the  CI’s  mental
health conditions did not result in any duty limitations.   The  psychiatric
examiner determined that the CI was  “psychologically  fit  for  duty,”  but
asserted  that  the  CI’s  continued  somatic  concerns  as  well   as   his
“personality  style  and  dispositional   anxiety   coupled   with   passive
personality traits” made him ill-suited for military service.

At the time of the VA C&P psychiatric exam four months post-separation,  the
CI endorsed no mental health complaints.  He had not been on any  medication
or received any treatment since leaving the service.  The CI was doing  well
occupationally and socially, and he reported that he  had  stopped  drinking
alcohol.  The examiner noted that the  CI  was  adapting  well  to  civilian
life, and concluded that that there was no  psychiatric  diagnosis  at  that
time.  The examiner opined that the CI’s prior history was  most  consistent
with adjustment disorder with mixed features.   He  additionally  noted  the
diagnosis of alcohol abuse  in  partial  remission  and  assessed  a  global
assessment of functioning (GAF) of 68.

The CI’s mental health conditions did not result in duty  limitations,  were
not implicated in the  non-medical  assessment  and  resolved  rapidly  upon
separation from service.  All evidence considered, there is  not  reasonable
doubt in the CI’s favor supporting recharacterization  of  the  PEB  fitness
adjudication for the anxiety disorder and depressive disorder conditions.

IAW DoDI1332.38 E5, the conditions of  alcohol  abuse,  adjustment  disorder
and passive traits do not constitute physical  disabilities.   All  evidence
considered, there is not reasonable  doubt  in  the  CI’s  favor  supporting
recharacterization  of  the  PEB  fitness  adjudication  for   these   three
conditions.


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.  As  discussed  above,  PEB  reliance  on  the
SECNAVINST 1850.4E for rating  the  vocal  cord  dysfunction  condition  was
operant in this case and the  condition  was  adjudicated  independently  of
that policy regulation by the Board.   In  the  matter  of  the  vocal  cord
dysfunction condition and IAW VASRD §4.97, the Board unanimously  recommends
no change in the PEB adjudication.  In the matter  of  the  asthma,  anxiety
disorder  and  depressive  disorder  conditions,   the   Board   unanimously
recommends no recharacterization of the PEB adjudications as not  separately
unfitting.   The  Board  unanimously  agrees  that  there  were   no   other
conditions eligible for Board consideration which could  be  recommended  as
additionally unfitting for rating at separation.


RECOMMENDATION:   The  Board  therefore  recommends   that   there   be   no
recharacterization of the CI’s disability and separation determination.


|UNFITTING CONDITION                               |VASRD CODE  |RATING  |
|Vocal Cord Dysfunction                            |6699-6602   |10%     |
|COMBINED    |10%     |







The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20100916, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.





                                        President
                                                                    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, FORMER USMC, XXX XX XXXX

Ref:   (a) DoDI 6040.44
          (b) PDBR ltr dtd 6 Sep 11

      I have reviewed the subject case pursuant to reference (a) and, for
the reasons set forth in reference (b), approve the recommendation of the
Physical Disability Board of Review Mr. XXXX’s records not be corrected to
reflect a change in either his characterization of separation or in the
disability rating previously assigned by the Department of the Navy’s
Physical Evaluation Board.




                                        Assistant General Counsel
                                          (Manpower & Reserve Affairs)