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AF | PDBR | CY2012 | PD2012 01903

Original file (PD2012 01903.rtf) Auto-classification: Approved

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX CASE: PD1201903
BRANCH OF SERVICE: AIR FORCE BOARD DATE: 20130509

SEPARATION DATE: 20020129

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SRA/E-4 (2A752/ Nondestructive Inspection) medically separated for Major Depressive Disorder (MDD). In August of 2000 she was referred to the family advocacy program for persistent depressive symptoms and experienced several panic attacks for which she was seen in the Emergency Room. The MDD condition could not be adequately rehabilitated to meet the mental requirements of her Air Force Specialty (AFS). She was issued a temporary S4 profile and referred for a Medical Evaluation Board (MEB). Major depressive disorder and depersonalization disorder, were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123 and no other conditions were submitted by the MEB. The informal PEB adjudicated the MDD associated with depersonalization disorder as unfitting, rated 10%, referencing the Department of Defense Instruction (DoDI) 1332.39 and Veteran’s Affairs Schedule for Rating Disabilities (VASRD). Obesity was added as a category III condition, not separately unfitting and therefore not compensable. The CI made no appeals, and was medically separated with A 10% disability rating.

CI CONTENTION: “The member suffers from multiple psychiatric illnesses that were not properly treated. A proper treatment plan for illnesses were implemented only weeks upon separation when she then began receiving Social Security Disability Benefits and a DVA rating of 70% Individual Unemployable for depression alone. Member is now rated at 90% Individual Unemployable, permanent and totally disabled. Member also suffers from illnesses due to fibromyalgia but was discharged too soon for a diagnosis to be rendered. Due to her current status her DVA rating is 40% for fibromyalgia and she receives special pay for housebound status.”

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 Service rating for the unfitting MDD associated with depersonalization disorder condition is addressed below. The requested fibromyalgia and other psychiatric conditions mentioned in the application were not identified by the PEB, and thus are not within the DoDI 6040.44 defined purview of the Board. The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that the Military Disability Evaluation System has neither the role nor the authority to compensate service 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 Veteran Affairs, operating under a different set of laws. The Board considers VA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12 month interval for special consideration to post-separation evidence. Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation. 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 Air Force Board for Correction of Military Records.

RATING COMPARISON :

Service IPEB – Dated 20011211	VA - (2 ½ Mos. Post-Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
MDD a/w Depersonalization Disorder	9434	10%	Depression	9434	70%	20020410
Obesity	CAT III	No Corresponding VA Entry
No Additional MEB/PEB Entries	Other x 10	20020410
Combined: 10%	Combined: 80%

Derived from VA Rating Decision (VA RD ) dated 200 20926 ( most proximate to date of separation [ DOS ] ).

ANALYSIS SUMMARY:

MDD Condition. The narrative summary (NARSUM) notes that upon referral to the mental health clinic in August 2000, the CI described over a year of depressed mood as well as problems concentrating. Her second marriage had failed and she was feeling hopeless and guilty regarding her inability to care for her children adequately. She described anxiety symptoms and an occasional accompanying feeling that the surrounding environment was “not real.” She received weekly individual therapy and was placed on psychotropic medication.

At the MEB exam, the CI reported that the medication had decreased the frequency and intensity of the episodes of feeling “not real.” Depression, too was somewhat improved but she continued to experience increased irritability, sleep problems and anxiety. Mental status examination documented depressed mood. Affect was full ranging with tearfulness appropriate to content. There were no psychotic features noted. The CI admitted to thoughts about suicide prior to starting treatment, but there was no mention of suicidal ideation at the time of the examination. Insight was felt to be good and judgment was fair. The examiner noted that her condition remained severe and that she was easily overwhelmed by the easiest task. It was noted that that almost a year after starting treatment, while there had been some symptom improvement, she had persistent symptoms of depression, poor coping skills and a tendency to decompensate when placed in stressful situations. Prognosis was felt to be poor in terms of her being able to function on active duty. Degree of impairment for social and industrial adaptability was described as “definite” due to major depressive disorder and “considerable” due to depersonalization disorder. Global Assessment of Functioning (GAF) was rated at 40 (lowest in the year) to 61 (highest in the year) which span the range from major impairment (very serious symptoms) to mild-moderate symptoms. The examiners assessment was that “her mental illness remains severe, … she has persistent symptoms even with the change to a low stress working environment. … prognosis is poor for full recovery.” Axis I diagnoses were Major depressive disorder, severe; and Depersonalization disorder. Axis IV (Psychosocial and Environmental Problems) was stated as “None.”

At the VA Compensation and Pension (C&P) exam performed 2 1/2 months after separation, the CI reported that anxiety attacks and feelings of depersonalization had become worse since her discharge and were occurring at a rate of about once every two weeks. Mental status exam mentions that the CI appeared very “needy” and preoccupied. Thinking was goal directed and without obvious psychotic symptoms. She appeared overwhelmed, indecisive and dependent. Affect was bland, flat, and restricted. Anxiety and irritability were noted. Mood was depressed with low energy, feelings of helplessness and worthlessness and she described guilt particularly with respect to her children. Insight was felt to be “fair at best” and judgment was “medicolegally intact.” The examiner described her as highly overdependent, having very poor coping skills, and to be functioning very poorly on her own. A GAF score of 40 was assigned (major impairment range) citing “major impairment on work, family relationships and socialization.”

Subsequent VA records indicated sustained mental health rating at 70% including a mental health exam 9 years post-separation with a GAF of 48, additional diagnosis of fibromyalgia, and VA granting of individual unemployability.

The Board directs attention to its rating recommendation based on the above evidence. Both the PEB and the VA coded the condition at 9434 (major depressive disorder). VASRD §4.129 was adjudged as not being applicable as there was insufficient evidence of a highly stressful event that led to the CI’s mental health disorder or medical discharge. The PEB, while acknowledging that the CI’s medical condition prevented her from reasonably performing her duties, remarked that “a great deal (but not all) of member’s stressors are situational in nature (performance and weight management program failures) and will resolve upon separation. The Board opines her social and industrial adaptability impairment rating for on-going issues is best described as mild.” This conceptualization resulted in a rating of 10%.

The VA, noting that the C&P examiner felt that she suffered from major impairment with respect to work, family relationships and socialization, rated the condition at 70% indicating that a higher 100% rating would have required total occupational and social impairment. The Board noted that the VA C&P exam assigned a GAF score of 40 which connotes “major impairment in several areas, such as work or school, family relations, judgment, thinking or mood.” Although the GAF score assigned in the MEB exam mentions both 40 (lowest in the year) and 61 (highest in the year), the provider’s statement that the CI had not made much progress and that her symptoms had persisted even with the change to a low stress working environment appeared to imply a GAF score at the lower end of that range at the time of the MEB exam. The GAF assignment, symptom description and clinical course argue against the PEB’s characterization of the severity as mild or transient, and it is clear that symptoms were not completely controlled on medication. The Board placed the greatest probative value on the pre-separation service exam for rating. The Board focused on the CI’s persistent symptoms and occupational impairment and deliberated if the CI’s condition at separation was closer to the 50% rating criteria, or more nearly approached the 70% criteria-level. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 50% for the major depressive disorder condition.

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 the MDD condition was operant in this case and the condition was adjudicated independently of that instruction by the Board. In the matter of the major depressive disorder condition, the Board unanimously recommends a disability rating of 50% 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
MDD Associated with Depersonalization Disorder	9434	50%
COMBINED	50%

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20121107, 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-2012-01903.

         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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AF | PDBR | CY2012 | PD2012 01903

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