RECORD OF PROCEEDINGS
                     PHYSICAL DISABILITY BOARD OF REVIEW

NAME:       BRANCH OF SERVICE:  NAVY
CASE NUMBER:  PD1100255      SEPARATION DATE:  20030321
BOARD DATE:  20120130


SUMMARY OF CASE:  Data extracted  from  the  available  evidence  of  record
reflects that this covered  individual  (CI)  was  an  active  duty  FC3/E-4
(1119,  Aegis  Radar  System  Technician),  medically  separated  for  major
depression, recurrent with psychotic features.  The  CI  developed  symptoms
of anxiety, depression and paranoid delusions in  2002.   He  was  diagnosed
with major depression with psychotic features.   The  symptoms  of  paranoia
improved with the use of anti-psychotic medication, however  his  depressive
symptoms did not improve adequately to perform within his  rating.   He  was
placed on limited duty (LIMDU) and  underwent  a  Medical  Evaluation  Board
(MEB).   Major  depressive  disorder,  recurrent  with  psychotic  features;
dysthymia and avoidant personality disorder were forwarded to  the  Physical
Evaluation Board (PEB) as medically  unacceptable  IAW  SECNAVINST  1850.4E.
No other conditions appeared on  the  MEB’s  submission.   Other  conditions
included in the Disability Evaluation System (DES) packet will be  discussed
below.  The PEB adjudicated the major depression (recurrent  with  psychotic
features) condition as unfitting,  rated  10%;  additionally  the  dysthymia
condition  was  adjudged  Category  II  (contributing   to   the   unfitting
condition) and the avoidant personality disorder was  adjudged  Category  IV
(condition  which  does  not  constitute  a   physical   disability);   with
application of the SECNAVINST 1850.4E.  The CI  made  no  appeals,  and  was
medically separated with a 10% combined disability rating.


CI CONTENTION:  He elaborates no specific contentions  regarding  rating  or
coding and mentions no additionally contended conditions.


RATING COMPARISON:

|Service IPEB – Dated 20030121  |VA (2 Mos. After Separation) – All      |
|                               |Effective 20030322                      |
|Condition       |Code          |Rating                                  |
|Avoidant        |Cat IV        |No VA Entry                             |
|Personality D/O |              |                                        |
|↓No Additional MEB/PEB Entries↓|Obstructive Sleep Apnea         |6847   |
|Combined:  10%                 |Combined:  100%                         |


*Initial VARD rated 9434 at 10% (combined 60%) effective 20030322;  VARD  of
20061006 increased 9434 to 30%, effective 20060517 (combined 70%); and  VARD
of 20080326 (de novo review by DRO [decision review  officer])  noted  error
at time of initial rating and increased 9434  to  100%,  effective  20030322
(as charted).


ANALYSIS SUMMARY:

Major Depression, Recurrent with Psychotic Features Condition.  In  February
2002, 13 months prior to separation, the CI  presented  with  complaints  of
anxiety and panic attacks triggered by large groups of people.   Psychiatric
evaluation also documented feelings of depression, hypersomnia,  low  energy
and poor self-esteem.   The  CI  was  diagnosed  with  agoraphobia  (without
history of panic disorder) and dysthymic  disorder.   There  was  no  formal
Axis II diagnosis, but the CI was noted to have  schizoid  traits.   He  was
placed on LIMDU and treatment was initiated with anti-depressant  medication
(Paxil) and counseling, with  the  expectation  that  he  would  improve  to
return to full duty.  In July 2002, eight months prior  to  separation,  the
CI developed paranoid delusions prompting referral  to  the  National  Naval
Medical Center (NNMC).  Evaluation at the NNMC revealed  paranoid  ideation,
disorganized thoughts,  ideas  of  reference  and  cognitive  dulling.   The
examiner noted the CI’s preoccupation  with  thoughts  of  people  following
him.    The   CI   denied   suicidal   ideation,   homicidal   ideation   or
hallucinations.  The Axis I diagnosis was rule out  schizophrenic  disorder,
with an Axis II diagnosis of  schizoid  personality  disorder.   The  Global
Assessment of Functioning  (GAF)  was  assessed  at  55,  in  the  range  of
moderate symptoms.  Treatment was begun with  the  antipsychotic  medication
risperidone and the CI was referred for MEB.

At  the  MEB  narrative  summary  exam,  seven  months  pre-separation,  the
examiner documented the CI’s history of paranoid  delusions  with  depressed
mood, increased sleep, decreased energy and  difficulty  concentrating.   It
was noted that the CI’s paranoid thoughts had responded well  to  treatment,
however, the examiner commented, “to date he has not  shown  a  response  to
treatment for the depression.”  Mental status exam  documented  a  depressed
mood with restricted  affect.   Thought  processes  were  logical  and  goal
directed  and  the  CI  denied  suicidal   ideation,   homicidal   ideation,
hallucinations or delusions.  The CI was noted to have  “good  insight  into
the delusional nature of previous beliefs.”   The  examiner  concluded  that
“because  of  member’s   personality   disorder   and   difficulty   forming
relationships with new people, he is at very  high  risk  of  recurrence  of
these symptoms in the military environment.”   The  Axis  I  diagnoses  were
major depression, recurrent with psychotic  features,  and  dysthymia.   The
impairment  for  social  and  industrial  adaptability  due  to  the   major
depression was assessed as severe; while impairment  due  to  dysthymia  was
assessed as moderate.   The  Axis  II  diagnosis  was  avoidant  personality
disorder and the overall GAF was assigned at 60, in the  range  of  moderate
impairment.  The non-medical assessment  commented  that  the  CI  had  been
assigned specific tasks designed to limit his  personal  one-on-one  contact
with clients and added that the  CI’s  “mental  condition  and  paranoia  is
considered incompatible with his LIMDU assignment.”   As  the  CI  underwent
treatment and therapy during the MEB period, the Axis I diagnoses varied  to
include  major  depressive  disorder  with  psychotic   features   (+/-   in
remission), schizoaffective disorder (depressive type) and  dysthymia.   The
assigned GAFs during the MEB period ranged from 59 – 60,  in  the  range  of
mild to moderate  impairment.   The  service  treatment  record  (STR)  also
documented  a  recurrence  of  paranoid  thoughts  requiring  a   medication
increase, less than two months prior to separation with comment  of  “he  is
stressed in anticipation of MEB coming  back”  and  likely  related  to  the
increased stresses of the DES process.

At the VA C&P exam, two months after separation,  the  CI  endorsed  similar
symptoms  of  depression,  anxiety  spells  and  excessive  sleeping.    The
examiner commented that the CI was taking  significant  medications  without
supervision  and  noted  that  “when  asked  about  impaired   thinking   or
communication, he described a medication  haze.”   The  CI  denied  auditory
hallucinations, suicidal ideation or homicidal ideation.  The  examiner  did
not comment on paranoid thoughts or delusions and did  not  comment  on  the
CI’s affect.  Additionally, the examiner did not comment on the CI’s  social
interactions or occupational status.  There was no irrelevant, illogical  or
obscure speech.  The Axis I diagnosis was major  depression  with  psychotic
features in partial remission with unsupervised medication and the  Axis  II
diagnosis was personality traits, unspecified.  The GAF was assessed at  70,
in the range of mild impairment.

The VA initially assigned a rating of 10% on the basis of  this  evaluation.
The narrative accompanying this rating decision, however, described  that  a
50% rating had been awarded.  This discrepancy was  initially  addressed  in
the 23 February 2004 VA rating decision (VARD) which  re-affirmed  that  the
CI’s rating for psychiatric disability was 10%.  After a  de  novo  decision
review officer (DRO) examination of the case and review  of  post-separation
VA treatment records, the 26 March 2008 VARD increased the  rating  to  100%
effective from the day after discharge from service, noting that  “an  error
was made on the original decision on your claim.”  This award decision  also
noted that the CI had not worked since leaving  the  service  and  concluded
that his “delusional symptoms have met the requirements for the 100  percent
evaluation since … discharge from service.”   Post-separation  treatment  VA
treatment records, covering the period July  2003–February  2008,  indicated
gradual post-separation decline in the CI’s  condition  which  began  around
2005.  Clinic notes from 2003 thru 2004 revealed a  fairly  stable  clinical
course with the CI continuing to endorse  moderate  symptoms  of  isolation,
depression, anxiety and paranoia.  At time of formal psychiatric  evaluation
in September 2003, six months after  separation,  the  CI  reported  feeling
alone, depressed and anxious; and he continued  to  feel  that  people  were
following him.  His GAF was assessed at 55 (MEB  GAF–60,  C&P  GAF–70).   In
January  2006,  (~33  months  post-separation)   the   CI   presented   with
significant decline in his condition.  He had  stopped  his  medication  and
begun isolating himself in his  room  six  months  prior  due  to  paranoia,
hearing  voices,  and  increasing  anxiety.    He   was   hospitalized   for
stabilization with the diagnosis of schizophrenia, paranoid type.

The Board directs its attention to its  rating  recommendations  based  upon
the evidence just described.  It was first adjudged that this case  did  not
meet the requirements for application of a retroactive Temporary  Disability
Retired List  rating  IAW  VASRD  §4.129.   The  psychiatric  condition  was
adjudged to not be a result of a “highly stressful event” (as  per  §4.129).
The  Board  next  considered  the  additional  mental  health  diagnoses  of
dysthymia and schizoaffective disorders  as  both  were  listed  as  Axis  I
diagnoses proximate to separation.  As discussed  previously,  the  specific
diagnosis for the CI’s unfitting mental health condition  varied  throughout
the MEB period.  Regardless of the  specific  mental  health  diagnosis  IAW
VASRD §4.126, evaluation of disability from  mental  disorders,  all  mental
health symptoms will be rated under VASRD IAW §4.130 and the General  Rating
Formula for Mental Disorders.  The  disqualifying  PEB  diagnosis  of  major
depression,   recurrent   with   psychotic    features,    was    considered
administratively final.

All Board members agreed that the §4.130 criteria  for  the  100%  threshold
was not  approached,  at  the  time  of  separation.   The  MEB  exam  would
independently rate at 30%–70%, while  the  initial  VA  C&P  exam  would  be
independently rated at 30%.  The  Board  adjudged  that  the  less-detailed,
almost checklist format of the VA C&P exam rendered it  of  lower  probative
value.  The Board acknowledged that the VA conferred a 100%  rating  on  the
basis of their exam; however, IAW VA-specific  rules  (on  effective  date),
the VA considered  additional  post-separation  worsening  in  their  rating
determination.  The Board  did  not  adjudge  that  the  CI’s  condition  at
separation reflected total “occupational and social impairment.”  The  Board
considered the CI’s mood disturbance,  anxiety  and  difficulty  in  forming
relationships, as well as the MEB’s  conclusion  of  severe  impairment  for
social and industrial adaptability; and concluded that there was  sufficient
evidence that the CI’s condition resulted in  definite  reduced  reliability
and productivity.   Additionally,  impairment  due  to  the  CI’s  recurrent
symptoms of paranoid delusions  and  isolation  along  with  his  difficulty
adapting to stressful circumstances were well documented  in  the  STRs  and
the post-separation VA clinic treatment notes.   The  Board  considered  the
additional  impact  of  the  CI’s  impaired  perception   of   reality   and
deliberated  concerning  the   70%   ratings,   “occupational   and   social
impairment, with deficiencies in most areas.”  The preponderant  discussions
focused on the level of occupational and social impairment  and  if  it  was
constant or occasional.  The major  depressions,  recurrent  with  psychotic
features; and dysthymia conditions at the time of separation  were  adjudged
to best reflect occupational and social impairment with occasional  decrease
in  work  efficiency  and  intermittent  periods  of  inability  to  perform
occupational tasks.  After due deliberation,  considering  the  totality  of
the evidence and  mindful  of  VASRD  §4.3  (reasonable  doubt),  the  Board
majority recommends 30% as the  fair  and  equitable  permanent  rating  for
major depression, recurrent with psychotic features, and dysthymia, in  this
case.

Other PEB Conditions.  The  other  conditions  forwarded  by  the  MEB  were
dysthymia and avoidant personality disorder.  Dysthymia was  adjudged  as  a
Category II condition that  contributes  to  the  unfitting  condition.   As
discussed above, any impairment due to this condition was considered in  the
overall rating recommendation for the  unfitting  mental  health  condition.
The Board,  therefore,  adjudged  that  the  dysthymia  condition  would  be
included as part of the unfitting mental health condition rating IAW  §4.126
(evaluation  of  disability  from  mental  disorders).   The  condition   of
avoidant personality disorder does not constitute a physical disability  IAW
DoDI 1332.38, Enclosure 5,  which  corresponds  with  the  PEB  Category  IV
determination.  All evidence considered, the  dysthymia  condition  was  not
separately ratable and there is not  reasonable  doubt  in  the  CI’s  favor
supporting recharacterization of the PEB Category IV  adjudication  for  the
avoidant personality disorder condition.

Remaining Conditions.  Several additional non-acute  conditions  or  medical
complaints  were  also  documented.    None   of   these   conditions   were
significantly clinically or occupationally active  during  the  MEB  period,
none carried attached duty limitations, and none was implicated in the  non-
medical assessment.  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  obstructive
sleep apnea was noted in  the  VARD  proximal  to  separation  but  was  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.  The Board therefore has no reasonable basis  for
recommending any additional unfitting conditions for separation rating.


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  DoDI
1332.39 for rating major depression (recurrent with psychotic features)  was
operant in this case and the  condition  was  adjudicated  independently  of
that instruction by the Board.   In  the  matter  of  the  major  depression
(recurrent with psychotic features) condition and the  dysthymia  condition,
the Board in a 2:1 vote recommends a permanent service disability rating  of
30% coded 9434  IAW  VASRD  §4.130.   The  single  voter  for  dissent  (who
recommended no recharacterization of the  PEB  adjudication)  submitted  the
addended minority opinion.   In  the  matter  of  the  avoidant  personality
disorder condition, the Board unanimously recommends no change from the  PEB
adjudication as Category IV.  In the matter of any other medical  conditions
eligible for Board consideration,  the  Board  unanimously  agrees  that  it
cannot recommend any findings of unfit for additional rating at separation.


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 his prior medical separation:

|UNFITTING CONDITION                                |VASRD CODE |RATING |
|Major Depression, Recurrent w/ Psychotic Features, |9434       |30%    |
|& Dysthymia                                        |           |       |
|COMBINED   |30%    |

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 2010403, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record





                 President
                 Physical Disability Board of Review
MINORITY OPINION:

The minority voter agrees with the majority that the  psychiatric  condition
did not meet the criteria for application of VASRD  §4.129;  and,  therefore
only the MEB and proximate  VA  psychiatric  evaluations  are  significantly
probative.  Based on the  MEB  exam,  in  this  voter’s  opinion,  the  CI’s
psychiatric  impairment  would  be  best  characterized  as   mild.      The
psychiatric symptoms had responded very  favorably  to  a  course  of  anti-
psychotic medication (risperidone); there was  no  indication  of  psychotic
thought process during the testing; and, the CI was compliant  with  ongoing
treatment.   The assigned GAF of 60  was  indicative  of  mild  to  moderate
impairment.

The Commander’s Non Medical Assessment (NMA) was  written  in  October  2002
and reflects a period of observation before  initiation  of  treatment  with
risperidone as mentioned above.   The  facts  documented  by  the  Commander
cover events from 10  April  thru  12  July  2002.   In  July,  the  CI  was
transferred from the Commander’s unit  (branch  legal  service  office)  for
further  psychiatric  evaluation  and  treatment  which   carried   him   to
separation.  Treatment with risperidone did not start until  mid-July  2002,
and the CI promptly reported subjective benefit.  The NARSUM  confirmed  the
improvement, stating that the CI  experienced  a  rapid  resolution  of  his
paranoia after risperidone was started at  a  1  mg  dose.   In  mid-October
2002, the dosage was increased to 2 mg  and  numerous  subsequent  treatment
notes documented a consistent GAF of 59.  In mid-February  2003  (one  month
pre-separation), the dosage was increased  to  4  mg  because  of  intrusive
paranoid  ideation;  and,  the  resolution  of  this  residual  symptom  was
documented  following  this  titration  of  the  anti-psychotic.   The   GAF
recorded at a session on 24 February 2003 was 60;  and,  ranged  from  59-65
(mild to moderate range) throughout the remaining period up  to  separation.
The Commander would not have been able to observe  the  CI’s  symptoms  with
the benefit of  this  improvement  brought  by  the  medication.   The  duty
limitations and impairments due to the  CI’s  psychiatric  condition,  taken
from the NMA (as elaborated in this record),  were  thus  not  significantly
probative as rating criteria at separation.   The  acuity  of  symptoms  and
occupational impairment reflected in the NMA are  not  corroborated  by  the
MEB  psychiatric  evaluation  and  outpatient  record  more   proximate   to
separation.  The Commander himself in  the  NMA  stated  that  if  the  CI’s
condition stabilized, he would be  a  welcome  addition  and  asset  to  any
command; and, would recommend  retention  on  active  duty  in  a  Permanent
Limited Duty status.

The VA Compensation and Pension exam was a valid and  ratable  exam  done  2
months  post-separation.   It  corroborates  the   psychiatric   improvement
effected by the pre-separation treatment as discussed above.   The  examiner
assigned a GAF of 70 (in the range of mild to slight impairment);  and,  the
VA conferred a §4.130 rating of 10% based on this  evaluation.     One  year
later in February 2004,  a  subsequent  VA  rating  decision  clarified  the
previous decision, and verified the 10% rating based on the  same  May  2003
exam.   It was not until October 2006 that the VA increased  the  rating  to
30% based on an exam done August 2006 (3½  years  after  separation),  after
the CI  had  been  hospitalized  twice  (in  2006)  and  showed  clear  post
separation worsening.    The CI did not  achieve  a  100%  VA  rating  until
2008, based again on progression of disease and an exam from September  2007
(4½ years remote from separation); at which time his diagnosis  was  changed
to schizoaffective disorder, his GAF was lowered to 45, and he  was  labeled
as “seriously mentally ill.”  The VA’s decision to  apply  the  100%  rating
retroactive to separation was  therefore  completely  unsupportable  by  the
evidence cited in its own rating decisions; and, in  this  voter’s  opinion,
was erroneous and unreasonable.  Thus the VA’s retroactive  rating  and  all
VA developments and evidence after  its  initial  examination  proximate  to
separation hold little  or  no  probative  value  relative  to  the  Board’s
mission  to  recommend  a  fair  separation  rating  for   the   psychiatric
condition.   That  (initial)  examination   and   the   pre-separation   MEB
examination are consistent with a 10% rating  IAW  VASRD  §4.130;  a  rating
affirmed and re-affirmed by the VA itself based on the probative evidence.

RECOMMENDATION:

The   minority   voter   recommends   therefore,   that    there    be    no
recharacterization of the CI’s disability and separation  determination,  as
follows:

|UNFITTING CONDITION                             |VASRD CODE  |RATING  |
|Major Depression, Recurrent With Psychotic      |9434        |10%     |
|Features                                        |            |        |
|COMBINED    |10%     |



MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
                                             BOARDS

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATION


Ref:   (a) DoDI 6040.44
          (b) PDBR ltr dtd 22 Feb 12

         I have reviewed the subject case pursuant to reference (a) and non-
concur with the recommendation of the PDBR as set forth in reference (b).
I have considered all available evidence and find the disability rating
award by the Physical Evaluation Board (PEB) accurately reflected the
degree of xxxxxx impairment at the time of his discharge and is in
accordance with regulations.  Therefore, xxxxx records will 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 PEB.




      Principal Deputy
      Assistant Secretary of the Navy
        (Manpower & Reserve Affairs)