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AF | PDBR | CY2012 | PD2012 01695
Original file (PD2012 01695.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: xx          CASE NUMBER: PD12 0 1695
BRANCH OF SERVICE: NAVY          BOARD DATE: 2013 0814
Separation Date: 20030525


SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty HN/E-3 ( Hospital man ) medically separated for irritable bowel syndrome (IB S ). The CI was diagnosed with IB S in July 2001. Despite medication, two endoscopies, a colonoscopy, an upper gastrointestinal ( U GI ) series, e sophagogastroduodenoscopy ( EGD ) , and g astroenterology evaluations, the CI failed to meet the physical requirements of his Rating. He was placed on a 6 - month limited duty (LIMDU) and referr ed for a Medical Evaluation Board (MEB). The MEB forwarded “esophageal reflux, nonulcerative d yspepsia (NUD) , IB S , generalized anxiety disorder , and social p hobia ” to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E . The PEB adjudicated the IB S ( v isceral h yperalgesia) condition as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The PEB adjudicated g eneral a nxiety d isorder as a Category II condition “Conditions that contribute to the unfitting c onditions ; ” g astroesophageal r eflux d isease (GERD) and NUD as a Category III condition “Conditions that are not separately unfitting and do not contribu te to the unfitting conditions” and s ocial p hobia as a Category IV conditio n “Conditions which do not co nstitute a physical disability . ” The CI made no appeals , and was medically separated.


CI CONTENTION : “At time of separation, the Navy authorized 10% for a combination of Gastro-esophageal Reflux Disease (GERD), Tinnitus and social phobia whereas the VA upgraded my disability to 60% for GERD/ Ac id Reflux, Tinnitus and PTSD.”


 SCOPE OF REVIEW : The Board wishes to clarify that the scope of its re view as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e . ( 2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB . ” The ratings for unfitting conditions will be reviewed in all cases. The unfitting IB S condition requested for consideration and the Category II condition , generalized anxiety disorder meet the criteria prescribed in DoDI 6040.44 for Board purview, and are accordingly addressed below. The requested GERD, NUD, and social phobia conditions, which were determined to be not unfitting by the PEB, are likewise addressed below. Any condition or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for futur e consideration by the Board f or Correction of Naval Records.



RATING COMPARISON :

Service IPEB – Dated 20030421
 VA - (2 ½ Mos. Pre/Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
IBS (Visceral Hyperalgesia)
 7319 10% IBS with GERD 7346-7319 10% 20030808
GERD
Category III
Non Ulcerative Dyspepsia
Category III No VA Entry
GAD
 Category II GAD and Social Phobia* 9400 30% 20030806
Social Phobia
Category IV
No Additional MEB/PEB Entries
 Other x 1 20030808
Combined: 10%
 Combined: 40%
Derived from VA Rating Decision (VARD) dated 20030827 ( most proximate to date of separation [DOS]).
* On the 20090128 VARD, his Generalized Anxiety Disorder and Social Phobia was retitled as PTSD, Depressive Disorder, Obsessive Compulsive Disorder, Panic Disorder effective 20081008 based upon a 20081203 C&P. The code remained as 9400 and the award increased to 50%.


 ANALYSIS SUMMARY : The Board notes the current VA ratings listed by the CI for all of his service connected conditions, but must emphasize that its recommendations are premised on severity at the time of separation. The VA ratings which it considers in that regard are those rendered most proximate to separation. 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.

IBS ( Visceral Hyperalgesia) Condition . The CI ’s UGI distress symptoms started in July 2001 with severe epigastric discomfort , dyspepsia, reflux symptoms, significant crampy abdominal pain with abnormal pattern to his bowel movements. The CI was referred to UGI for symptoms of chronic intermittent right middle, upper quadrant abdominal pain, and sharp pains after meals and started on a proton pump inhibitor ( PPI) medication (Prilosec) . The CI was evaluated by UGI who noted nausea, diarrhea, constipation and crampy abdominal pain. T he CI was diagnosed with IB S and started on an anti-spasmodic /anticholinergic medication (Bentyl). In October 2001, there was some improvement in symptoms, however, the CI continued with reflux, spasm , and one loose stool per day. A colonoscopy was normal . A n EGD showed a mildly irregular zline without erosive changes at the gastro esophageal junction. The CI was seen in both November and December 2001 for persistent IBS symptoms and daily loose stools with cramping and urgency. The CI was continued on all medications with a dosage decrease in the additional PPI (Aciphex). The g astroenterologist in a memo to the c areer c ounselor documented that the CI suffered from IBS and NUD which was difficult to control due to various issues including workplace stress and opined that based on the CI’s condition, he would do poorly i f assigned to Sea Duty. In January 2002 , the CI was placed on an 8- month LIMDU for IBS/NUD. The CI underwent a second EGD which demonstrated evidence of non-erosive gastritis. An abdominal ultrasound demonstrated mild hepatomegaly and a contracted gallbladder. The CI continued with persistent IBS symptoms with increased stools, reflux , and rectal bleeding. A urea breath test for heli c obacter pylori was negative. The CI noted that on a typical day he had two loose stools which only resolved with Imodium . The CI was seen in the emergency room for acute abdominal cramping pain with physical findings of mild epigastric tenderness and mild right upper quadrant pain and was treated with a UGI medication preparation. The CI was seen in follow up the next day with symptoms of burning sensation, abdominal pain and constipation. He was seen in follow up by UGI however there was no improvement in symptoms and the examiner opined that there was a worsening of the IBS. A small bowel follow through series ordered by UGI for crampy abdominal pain and tenderness of the right lower quadrant was normal. The MEB n arrative s ummary (NARSUM) exam approximately 4 months prior to separation documented continued significant difficulties NUD symptoms, intermittent crampy abdominal pain with intermittent loose bowels with waxing and waning constipation, dyspepsia and pyrosis . The examiner documented that the CI had done poorly over the year prior to the MEB exam with notable worsening under periods of significant stress. The examiner opined that the CI was limited by his significant symptoms and incapacitation during times of stress. The VA Compensation and Pension (C&P) exam approximately 2 months after separation noted that the CI had occasional nausea and upset stomach, a weight gain of 20 pounds, difficulty with swallowing both liquids and solids for 18 months, constant diarrhea alternating with constipation and abdominal cramps mostly in the lower abdomen and occasionally at the right upper quadrant which occurred m ore than 2/3 of the year. The examiner noted that the functional impairment was that the CI had to stop whatever he was doing to go the bathroom whenever he had diarrhea and this condition occurred 2 to 3 times per month. There were abdominal exam findings of mild tenderness in the right upper and lower quadrants. The examiner diagnosed IBS with diarrhea during periods of stress. A repeat UGI series demonstrated minimal esophagitis. A repeat EGD was normal.

The Board directs attenti on to its rating recommendation based on the above evidence . The PEB coded the IBS ( v isceral h yperalgesia) condition as 7319 i rritable colon syndrome rated at 10% m oderate; frequent episodes of bowel disturbance with abdominal distress . The VA coded the IBS with GERD as 7346 h iatal h ernia with 7319 i rritable colon syndrome condition rated at 10%. There is ample documentation in the service treatment record that the CI had chronic persistent abdominal pain, cramping , and diarrheal stools which were refractory to medication. The g astroenterologist documented that the CI suffered from IBS and NUD which was difficult to control. The MEB examiner documented that there w ere significant difficulties ; NUD symptoms, intermittent crampy abdominal pain with intermittent loose bowels with waxing and waning constipation, dyspepsia ( indigestion) and pyrosis ( heartburn). The C&P examiner noted constant diarrhea , alternating with constipation , and abdominal cramps which occurred more than 2/3 of the year. The Board reviewed the criteria for a 10% rating ( m oderate; frequent episodes of bowel disturbance with abdominal distress) versus a 30% rating (s evere; diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress rating). The Board adjudged that the evidence clearly exceeded the 10% rating and was closer to the 30% rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the IBD (Vis ceral Hyperalgesia) condition.

Generalized Anxiety Disorder C ondition. Although the CI had a history of shyness, difficulty connecting with others, and anxiety, he was never diagnosed with a mental illness and was deemed qualified for enlistment. In September 2001 the CI was screened by e mergency p sychiatry service for endorsing symptoms of excessive worry, restlessness, being easily fatigued, difficulty with concentrating, irritability, muscle tension, difficulty falling asleep or staying asleep, hesitancy, anxiety in social and performance situations, and panic attacks. These symptoms were present daily and never abated despite medications and intense therapy. During recruit training at Great Lakes, the CI exhibited regular episodes of excessive worry, tearfulness, difficulty concentrating, insomnia, and irritability. These symptoms interfered with his concentration for hospital corpsman training. The CI’s emotional difficulties continued when he was transferred to field medicine training at Camp Pendleton, and later when he was transferred to a Pediatrics Clinic at Naval Medical Center San Diego . He was d ropped from the field medicine training program (the CI infers an inability to cope with the stress of training), and was subsequently transferred to the pediatrics clinic. There h e reported incapacitating fear that he would cause harm to his pediatric patients by dropping them or inadvertently injuring them through clumsiness. The CI continued with symptoms of panic and indicated that his anxiety precipitated reac tive depressed mood of several d ays duration associate d with feelings of guilt and shame. These symptoms continued despite a referral to an anxiety psycho education group and stress management techniques along with psychopharmacologic treatment. Presumably, after his work in the Pediatrics Clinic, he was transferred to preventative medicine training ; however he was dismissed from the training program after several weeks due to increased anxiety and difficulty maintaining academic performance. Following that assignment, he was transferred to sick call, where he endorsed sustained difficulty with excessive worry, irritability, tearfulness and feelings of inadequacy. In January 2002, the treating p sychiatrist ( p sych r esident ) sent a memo to the e nlisted d etailer which documented that medication and supportive therapy for the treatment of generalized anxiety disorder had started in September 2001. The p sychiatrist opined that the CI had shown significant improvement during that time; however he needed more time to complete a 10 session course of group therapy. In August 2002 , the CI called for a mental health consultation with symptoms of worsening short – t erm anxiety and insomnia in the context of workplace stressors. The CI endorsed worsening irritability, restlessness, tearfulness, insomnia, and an inability to control the worry. The CI was advised to restart an antidepressant (Trazedone) for insomnia. The CI was seen in s tress m anagement for ongoing anxiety and insomnia. The CI had a restricted affect and hyper vigilance, and the examiner recommended biofeedback and stress group therapy. A p ersonality a ssessment i nventory t est was administered to the CI and he demonstrated passive aggressive traits, difficulty with anger control and a moderate depressed mood. The MEB NAR SUM exam documented that the symptoms of irritability, restlessness, tearfulness, insomnia, and an inability to control the worry continued. The mental status exam (MSE) showed a mildly anxious and mildly constricted affect. He endorsed losing his temper and occasionally fantasizing about hitting others but contained this impulsive desire. The examiner diagnosed Axis I: generalized a nxi ety d isorder and s ocial p hobia and a ssigned a Global Assessment of Functioning (GAF) of 61-70 with some difficulty in occupational or school functioning , but generally functioning pretty well, has some meaningful interpersonal relationships. The VA p sychiatric C&P exam approximately 2 months after separation noted that the CI continued to endorse feelings of anxiety, worry, difficulty falling asleep and staying asleep , panic and easily being frustrated. The MSE indicated a euthymic mood and affect. The examiner diagnosed Axis I: g eneralized a nxiety d isorder , manifested by daily occurrences of excessive worry, being easily fatigued, impaired concentration, irritability, muscle tension, and sleep d ifficulties. The GAF was 65.

The Board’s main charge is to assess the fairness of the PEB’s determination that generalized anxiety disorder was related to the unfitting condition, Category II. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The generalized anxiety disorder was an integral part of the CI’s inability to perform his military duty. Despite medical and psychiatric treatment, the CI continued to experience occupational and social functional impairment as a result of generalized anxiety disorder. After due deliberation, the Board consensus was that the preponderance of the evidence with regard to the functional impairment of generalized anxiety disorder condition favors its recommendation as an additionally unfitting condition for disability rating.

 The Board directs its attention to the question of applicability of §4.129, m ental disorders to traumatic stress, and the rating recommendation based on the evidence just described. The Board could not identify any discreet “highly stressful event” and it determined that §4.129 did not apply.

The Board directs attention to its rating recommendation based on the above evidence. The PEB coded the generalized anxiety disorder condition as a Category II condition “ Conditions that contribute to the unfitting conditions. ” In the original VARD ( 21 August 2003 ), t he VA coded the generalized anxiety disorder and s ocial p hobia conditio n as 9400 generalized anxiety disorder and rated at 30%. The VARD 28 changed the coding to posttraumatic stress disorder and increased the rating to 50% based on military sexual trauma. There is documentation that despite psychotropic medications and intense therapy, the CI’s symptoms continued. The MEB examiner noted chronic symptoms of irritability, restlessness, tearfulness, insomnia, and an inability to control the worry. The C&P examiner documented feelings of anxiety, worry, difficulty falling asleep and staying asleep , panic, and easily being frustrated . The Board adjudged that the VA examination was closer to separation and therefore had higher probative value. The Board review e d the 10% criteria versus the 30% criteria. The Board adjudged that the evidence clearly exceeded the 10% criteria and was closer to the 30% criteria. The Board determined that the evidence presented did not approach the 50% criteria. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the generalized anxiety disorder condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that GERD, NUD, and social phobia were not unfitting. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The GERD and social phobia were not referred for limited duty. Although NUD was referred for limited duty, its symptomatology was incorporated into the IBS diagnosis and functional impact. GERD, NUD, and social phobia were not implicated in the commander’s statement and were not judged to fail retention standards. All were reviewed by the action officer and considered by the Board. There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the GERD, NUD, and social phobia conditions and therefore no additional disability ratings are recommended.

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 IBD ( v isceral h yperalgesia) condition, the Board unanimously recommends a disability rating of 30 %, coded 7319 IAW VASRD §4. 114. In the matter of generalized anxiety disorder condition, the Board by a vote of 2:1 agrees that it was unfitting and by a vote of 2:1 recommends a disability rating of 30%, coded 9400 IAW VASRD §4.130. The single voter for dissent, who recommended that the generalized anxiety disorder was not separately unfitting, did not elect to submit a minority opinion. In the matter of the contended GERD, NUD, and social phobia conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting. 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 his prior medical separation:
UNFITTING CONDITION
 VASRD CODE RATING
IBD (Visceral Hyperalgesia)
7319 3 0%
G eneralized Anxiety Disorder
9400 3 0%
COMBINED
 5 0%
invalid font number 31502


The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 2 120718 , w/atchs
Exhib it B. Service Treatment Record
Exhibit C. Department of Veterans ’ Affairs Treatment Record





xx
President
Physical Disability Board of Review


MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATION


Ref: (a) DoDI 6040.44
(b) PDBR ltr dtd 5 Nov 13

I have reviewed subject case pursuant to reference (a) and concur, in part, with the recommendation of the Physical Disability Board of Review as set forth in reference (b). I found sufficient evidence to warrant an increase in the disability rating previously awarded Mr. xx. Therefore, his records will be corrected to reflect a change in his combined disability rating from 10 percent to 40 percent with placement on the Permanent Disability Retired List effective the date of his discharge.



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

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