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AF | PDBR | CY2012 | PD2012 01782
Original file (PD2012 01782.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD1201782
BRANCH OF SERVICE: AIR FORCE     BOARD DATE: 20130418
DATE OF PLACEMENT ON TDRL: 20010905
Date of Permanent SEPARATION: 20030216


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSgt/E-5 (2S071/Supply Management Craftsman) medically separated for major depressive disorder (MDD). In 1998, she was originally diagnosed with adjustment disorder and began experiencing symptoms of depression in 1999. She was hospitalized briefly, in 1999 and then again in 2001, for suicidal ideation. The MDD condition could not be adequately rehabilitated to meet the mental requirements of her Air Force Specialty. She was issued a temporary E2/S4 profile and referred for a Medical Evaluation Board (MEB). The mental health conditions, characterized as MDD and adjustment disorder, were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123 and no other conditions were submitted by the MEB. The PEB adjudicated the MDD condition as unfitting, rated 30% referencing the Department of Defense Instruction (DoDI) 1332.39 and Veterans Affairs Schedule for Rating Disabilities (VASRD). The condition was determined to not yet be stabilized and the CI was placed on the Temporary Disability Retired List (TDRL) with ratings as reflected in the chart below. At the first TDRL examination, the CI was determined stable and the IPEB adjudicated the MDD condition as unfitting, rated 10%, referencing the Department of Defense Instruction (DoDI) 1332.39 and VASRD. The CI made no appeals and was medically separated.


CI CONTENTION: The CI elaborated no specific contention in her application.


SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting MDD condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.


 RATING COMPARISON :

Final Service PEB - 20030102
 VA (11 Mos. Prior to Adjudication Date) - Effective 20010906
On TDRL - 20010905
 Code Rating Condition Code Rating Exam
Condition
 TDRL Sep.
Major Depressive Disorder w/ Psychotic Features 9434 30% 10% Major Depressive Disorder 9434 70% 20020318
Adjustment Disorder Not Unfitting No Corresponding VA Entry
No Additional MEB/PEB Entries.
 Other x 3 20020318
Combined: 30% → 10%
 Combined: 80%


ANALYSIS SUMMARY:

Major Depressive Disorder Condition. The psychiatric narrative summary (NARSUM), 21 March 2001, at TDRL entry notes that the CI had a history of depressive symptoms of depressed mood, insomnia, and decreased energy for approximately 2 years and her symptoms were mostly unchanged. The CI was hospitalized, in February 2001, for depression because she called work and indicated she was suicidal and wanted to meet in a parking lot. When met, she was behaving inappropriately and was hospitalized. During hospitalization, she was thought to be delusional. She was put on medications and released, but re-hospitalized within weeks for recurrent suicidal ideation. Prior to these hospitalizations, the service treatment records indicates multiple mental health visits for problems with work and coworkers with a hospitalization in 1999. At the MEB psychiatric exam, 21 March 2001, approximately 2 years prior to permanent separation and just a month post two hospitalizations, the CI reported that she heard her dead brother’s voice that occasionally told her to hurt herself or that others were trying to get her. Medication changes had lessened the voice. She reported seeing his face once. The CI reported occasional anxiety and the only stressor noted was loneliness since a friend had left work. She denied suicidal thoughts or excessive energy. The CI reported a good relationship with her husband of 14 years and her 11 year old daughter and said she loved the Air Force. The MEB physical exam noted that the CI appeared severely depressed with poor eye contact. She was slow with a constricted affect. Her speech was subdued, but otherwise normal. Thought process was normal but the examiner noted that she gave inaccurate information. Insight was diminished, but judgment and cognition were normal, and there was no evidence of hallucinations, delusion, suicidal or homicidal thoughts during the evaluation. The diagnosis was AXIS 1 – MDD, single, severe with psychotic features (a possible alternative diagnosis of schizophrenia was noted); AXIS IV stressor was moderate, occupational and health; AXIS 5 – Global Assessment of Functioning (GAF) was estimated 40 (GAF- 31-40 - some impairment in reality testing or communication or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood). The CI’s impairment for military duty was considered marked and for civilian functioning, definite. The examiner stated that the CI was responding to treatment, but her prognosis was unsure; that he did not expect she could recover in the military; and the chance of recurrence of severe symptoms was high. The CI was referred to the MEB and the PEB placed her on TDRL for the unfitting MDD at 30% because the condition had not yet stabilized. At the VA Compensation and Pension (C&P) exam, 18 March 2002, approximately 6 months post TDRL entry and 11 months prior to permanent separation, the CI reported not working since her separation in 2001. She reported sadness, restlessness, decreased interest, and concentration, and visual hallucinations of her brother. The VA mental status exam (MSE) stated she had a depressed mood, flat affect, and was having sleep problems. She was fully oriented, memory was okay, there were no suicidal or homicidal ideas, and hygiene was adequate. The diagnosis was the same as at the MEB exam with the C&P examiner noting “GAF of 45 - “indicating major symptoms of depression along with evidence of impairment of reality with visual hallucinations and problems with sleep and concentration, which would interfere with her ability to be gainfully employed.” At the TDRL re-evaluation
20 December 2002, approximately 2 months prior to permanent separation, the CI reported some benefit from medication changes but she continued with depression, sleep problems and hearing and seeing her dead brother at times. She described her moods as every two or 3 days going from baseline to low and coming back up again. At the low points, she had decreased energy, interest, and concentration with insomnia. She reported “background suicidal thinking” but no plans. She had gained approximately sixty pounds. She said that occasionally her brother’s voice tells her to hurt herself or that she is bad. The CI reported delusional thoughts of being watched and ideas of reference such as an invisible person took down the visor in her car. She admitted panic attacks several times per week lasting ten to fifteen minutes that she self-managed.

She reported working twenty hours per week at a job, as well as good relationships at home and socially. The MEB psychiatry MSE revealed the CI was depressed, but with improved interaction than at the prior evaluation evidenced by better eye contact and more engaging conversation; thoughts, insight, judgment, and cognition were improved or normal; there was no evidence of hallucinations, delusion, or suicidal/homicidal ideations during the evaluation, but hallucinations, delusions, and suicidal ideation were reported to be ongoing by history. The AXIS 1 diagnosis was again MDD, severe, with psychotic features, chronic (a possible alternative diagnosis of schizoaffective disorder with a bipolar component was mentioned). The GAF was 40. The examiner commented that the CI was “relatively stable,” but that her psychotic symptoms were not in complete remission and that she remained impaired for military service.

The Board directs attention to its rating recommendation based on the above evidence. The Board unanimously agreed that § 4.129 was not applicable in this case. At TDRL entry, the PEB, 21 May 2001, adjudicated the CI’s MDD as unfitting and coded as 9434 (MDD) at 30%. The Board agreed that CI’s MDD exceeded the §4.130 threshold for a 30% rating ( occupati onal and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily) . The deliberation settled therefore on evidence for a 50% (occupational and social impairment with reduced reliability and productivity) versus a 70% (occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood) rating at TDRL entry. At the time of TDRL entry, the CI was approximately a month post two hospitalizations for major depression with psychotic features. She was improving on medications, family relationships remained intact, but severe depressive and psychotic symptoms remained. The Board opined that the evidence in the TDRL entry MEB/psychiatric NARSUM of severe depressed mood with constricted affect, decreased energy, concentration, and insight and reduced, but persistent, suicidal thoughts and hallucinations supported a 70% rating at TDRL entry. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 70% for the MDD condition, at TDRL entry. At the conclusion of TDRL, the PEB, 2 January 2003, adjudicated the MDD as unfitting and rated as 9434 at 10% (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). The VA Rating Decision (VARD), 29 August 2002, rated as 9434 at 70%. The VARD, 17 April 2004, increased the rating to 100% (total occupational and social impairment) with an effective date of 4 November 2003, citing a vocational rehabilitation report and the C&P exam of
18 March 2002. At the time of TDRL separation (permanent separation), the Board unanimously agreed that the 30% rating criteria were exceeded and the deliberation focused on a permanent disability rating of 50% or 70%. The Board opined that the evidence in the record supported that the CI had a depressive disorder with persistent, but intermittent psychotic features improved with treatment from the time of TDRL entry. At the TDRL re-evaluation was when the CI indicated that family and social relationships remained intact. The examiner noted improved interactions, thought processes and insight compared with the prior evaluation, despite the reported history of continued psychotic symptoms. The examiner thought that the CI was stable, but that her psychotic symptoms were “not in complete remission.” He opined that she may achieve some additional improvement with continued therapy and medication adjustments. Therefore, the Board adjudged that the “fair and equitable” rating of the CI’s MDD at the time of permanent separation most nearly met the 50% rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a permanent disability rating of 50% for the MDD condition at permanent separation.


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 MDD condition, the Board unanimously recommends a disability rating of 70%, at TDRL entry and a permanent disability rating of 50% at permanent separation coded 9434 IAW VASRD §4.130. 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 her prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
TDRL PERMANENT
Major Depressive Disorder w/ Psychotic Features 9434 70% 50%
COMBINED 70% 50%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120928, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record





         XXXXXXXXXXXXXXXXXXXX, DAF
         Director of Operations
         Physical Disability Board of Review


 SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews MD 20762
Dear XXXXXXXXXXXXXXXXXXXX :
         Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2012-01782.
         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 not appropriate under the guidelines of the Veterans Administration Schedule for Rating Disabilities. Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.
         I have carefully reviewed the evidence of record and the recommendation of the Board. I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly. The office responsible for making the correction will inform you when your records have been changed.
         As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP). Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election. If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

                                                               Sincerely,



XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency
Attachment:
Record of Proceedings

cc:
SAF/MRBR
DFAS-IN



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