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AF | PDBR | CY2013 | PD-2013-01064

Original file (PD-2013-01064.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXX CASE: PD-2013-01064
BRANCH OF SERVICE: AIR FORCE BOARD DATE: 20150107

DATE OF ENTRY ONTO TDRL: 20050219

DATE OF EXIT FROM TDRL: 20060702

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve 1Lt/0-2 (92T1/Student Navigator) medically separated for major depressive disorder (MDD). The condition could not be adequately rehabilitated to meet the requirements of his Air Force Specialty. He was issued a permanent S4 profile and referred for a Medical Evaluation Board (MEB). MDD was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123, and the MEB also identified and forwarded one other condition (sub-clinical hypothyroidism) for PEB adjudication. The Informal PEB (IPEB) adjudicated “major depressive disorder, severe without psychosis, single episode, existed prior to service (EPTS) without service aggravation, social and industrial adaptability impairment mild” and “hypothyroidism as EPTS,” Category II conditions, conditions that can be unfitting but are not currently compensable or ratable. The PEB also recommended discharge under provisions other than Chapter 61, Title 10, United States Code. The CI appealed to the Formal PEB (FPEB), which adjudicated “major depressive disorder, severe without psychosis, single episode, social and industrial adaptability impairment mild” as unfitting rated at 30%, with application of the VA Schedule for Rating Disabilities (VASRD), with t he hypothyroidism again adjudicated to be C ategory II , placing the CI on Temporary Disability Retired List (TDRL). Approximately 13 months later at the TDRL re-evaluation, the IPEB adjudicated the MDD condition as unfitting, rated 10%. The CI made no appeals and was medically separated.

CI CONTENTION: “I have suffered continuous symptoms and receive continuous treatment for both Major Depressive Disorder and Hypothyroidism since before being separated. The Department of Veterans Affairs recently finally adjudicated me 30% service-connected disabled for the Depression and has deemed my Hypothyroidism service-connected. While I have initially received a 0% rating for the Hypothyroidism, that is being appealed, as I am required to take medication daily for the rest of my life to treat the disease.”

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. The requested hypothyroidism condition is 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 future consideration by the Board for Correction of Military Records.

RATING COMPARISON :

Final Service IPEB – 20060515	VA Rating Decision* - 20080708
TDRL Entry – 20050218	Code	Rating	Condition	Code	Rating Proximate
Condition		TDRL Entry	TDRL Exit			TDRL Entry	TDRL Exit
Major Depressive Disorder	9434	30%	10%	Depression	9434	NA	NSC**
Hypothyroidism	Category II	NA	Hypothyroidism	7903	NA	NSC**
Other x 0 (Not in Scope)	Other x 0
Combined: 30% → 10%

* Most proximate to TDRL entry

** Subsequent VARD dated 20130428 rated 9434 at 30%, and 7900 at 0%, both effective 20110921

ANALYSIS SUMMARY: The Board must emphasize that 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, operating under a different set of laws. The Board considers VA evidence within 12 months of separation only to the extent that it reasonably reflects the disability at the time of separation. The Board also acknowledges the CI’s implied contention for a rating of the hypothyroidism condition which was determined to be not unfitting by the PEB. Disability compensation may only be offered for those conditions that cut short the member’s career. Should the Board judge that this contested condition was most likely incompatible with military service, a Service disability rating IAW the VASRD, based on the degree of disability evidenced at separation, will be recommended.

Major Depressive Disorder Condition. Review of the service treatment record (STR) showed the CI experienced several months of low mood and problems with concentration, forgetfulness, low interest, anxiety and sleep difficulty that led to a 3-day psychiatric hospitalization in March 2004. Stressors included his wife’s recent diagnosis of depression and his recent arrival at a new duty station. After hospital discharge, the CI was followed closely by mental health (MH) providers for counseling and medication management of depression. Other treatment included pet therapy and biofeedback. The diagnosis and medication treatment resulted in removal from duties associated with flying. An escalation of subjective stress and anxiety occurred in the context of a special duty tasking, but symptoms returned to more normal levels when the tasking was removed.

Psychological testing on 7 April 2004 (10 months prior to entry on TDRL) indicated good psychological health, but with more of a vulnerability to periods of depression than the average person. In June 2004, a medication for sleep was self-discontinued because the CI felt like he no longer needed it. On 4 June 2004, an internal medicine evaluation concluded that recently detected mild thyroid laboratory abnormalities were not significant enough to cause suicidal ideation or depression. However, on 24 June 2004, an endocrinologist indicated that subtle hypothyroidism “may and could possibly have a significant clinical effect on … his mental well-being.” But later on 22 July 2004, the endocrinologist reported that the thyroid abnormalities were not significant enough to cause severe depression. Review of the STR found no diagnosis of depression due to a general medical condition (e.g. hypothyroidism) rendered by a psychiatrist. The commander’s statement on 8 July 2004 (7 months prior to entry on TDRL) reported that the CI was “working as a casual student,” but no details about his performance in that capacity were provided. A reference to the special duty tasking (point of contact duties for a change-of-command ceremony) confirmed an inability to complete those duties due to increase in symptoms.

The psychiatric narrative summary (NARSUM) on 27 July 2004 reported a chief complaint of “still having depressed mood and thoughts of suicide, but not as severe.” Details of current occupational and social functioning were not provided. Mental status exam (MSE) showed a dysphoric affect and mood, but was otherwise unremarkable. Orientation, judgment, speech and tested memory were normal. Panic attacks and current thoughts of harm were denied. An Axis I diagnosis of MDD was rendered and an assigned Global Assessment of Functioning (GAF) was 70 (connoting mild symptoms or impairment). Social and industrial impairment was considered to be mild. The examiner concluded that mental symptoms were not due to a general medical condition. On 30 July 2004, the NARSUM examiner reported that review of MH records found a prior episode of depression while in Officer Training. However, in a Letter of Exception for the IPEB, the CI indicated the “episode” was not during Officer Training, but afterwards and that it was never diagnosed or treated as clinical depression.

A psychiatric second opinion on 5 August 2004 (6 months prior to entry on TDRL) noted that the CI denied all symptoms of depression. A diagnosis of depressive disorder, not otherwise specified (NOS) was rendered and an assigned GAF was 75-80 (transient symptoms, no more than slight impairment). The FPEB document on 13 December 2004 indicated that in October 2004, with his doctor’s consent, the CI tapered off his psychotropic medication which resulted in a relapse of depressive symptoms in November 2004. An outpatient psychiatric visit on 26 January 2006 (5 months prior to removal from TDRL) reported that the CI was “doing well in Law School and believes his grades…will reflect this. He continues to maintain a stable relationship.” He endorsed drinking more alcohol than normal, but was making attempts to cut down. He identified no stressors that prompted more drinking.

The TDRL re-evaluation NARSUM psychiatrist on 30 March 2006 (3 months prior to removal from TDRL) reported that the CI was diagnosed with generalized anxiety disorder (GAD) in January 2006, and that anxiety symptoms were controlled with medication. He had also been counseled many times about alcohol use. The CI’s current symptoms were anxiety, poor concentration, constant worry and periodic sleep difficulty. However, he was “managing both attending law school and working as a legal assistant at a local law firm without much difficulty.” He also maintained a “regular social life.” MSE was normal except for a mildly anxious affect and mood that was “not as good.” The Axis I diagnoses were MDD (recurrent, moderate, in partial remission) and GAD. Alcohol use disorder was a “rule out” diagnosis. The current GAF was 65 (mild symptoms or impairment). At a MH visit in May 2006, the CI was noted to have some difficulty concentrating for prolonged periods and some trouble with sleep in the context of going through final exams. He was now exercising and consuming little alcohol. By June 2006 he was “doing well and is leaving for London for school.” The only VA exams in evidence were performed in 2013.

The Board directed its attention to its rating recommendation based on the above evidence. Because the VA exams in evidence were years after removal from TDRL, they held no probative value in the Board’s deliberations. It is noted that the disability associated with all psychiatric conditions, regardless of the diagnosis, is subsumed under a single rating using the same criteria IAW VASRD §4.130. Therefore the addition of anxiety disorder by the TDRL re-evaluation NARSUM does not affect the disability rating assigned by the PEB or the recommendation from the Board. The Board next considered whether the provisions of VASRD §4.129 were applicable for the unfitting MH condition. Regardless of final PEB diagnosis, §4.129 does not specify a diagnosis of PTSD, rather it states “mental disorder due to a highly stressful event,” and its application is not restricted to PTSD. Members agreed that the requisite §4.129 link that the condition occurred “as a result of” in-service stressors was not adequately satisfied; and therefore concluded that application of §4.129 was not appropriate in this case.

Regarding the rating at the time of entry on TDRL, Board members considered if there was evidence to support a rating higher than the 30% assigned by the PEB. The §4.130 criteria for the 30% rating are “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.” The next higher 50% rating requires “occupational and social impairment with reduced reliability and productivity.” The Board considered that since the initial hospitalization, there were no subsequent hospitalizations or emergency room visits for psychiatric reasons. Although suicidal ideation had been present, the NARSUM examiner noted no current evidence of thoughts of harm. While there was one 30% threshold symptom (depressed mood) at the NARSUM exam, there were no 50% threshold symptoms such as flattened affect, panic attacks or impaired judgment. Board members agreed that the NARSUM’s assessment of mild social and industrial impairment and the subsequent evaluation by a psychiatrist for a second opinion reflecting absence of all symptoms of depression were not consistent with a 50% rating. The Board also concluded that any possible, though unlikely, contribution of thyroid disease to MH symptoms was appropriately subsumed under the rating for MDD.

As regards to the permanent rating recommendation, the Board considered if a rating higher than the PEB’s 10% was warranted. The 10% rating specifies “occupational and social impairment due to mild or transient symptoms which decrease work efficiency … only during periods of significant stress, or; symptoms controlled by continuous medication.” Board members noted that one or possibly two 30% threshold symptoms were present, but that occupational and social functioning was described as being quite good. The Board concluded that the “occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks” stipulation of the 30% rating was not met and that the condition was most accurately described by the 10% rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the MDD condition.

Contended PEB Condition. The Board’s main charge is to assess the fairness of the PEB’s determination that hypothyroidism was not unfitting. The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. While hospitalized for depression, laboratory evaluation revealed possible mild hypothyroidism. Subsequent assessment by an endocrinologist found ultrasound and laboratory evidence suggestive of chronic thyroiditis (thyroid inflammation). However, except for a possible connection to depression (as previously elaborated), the endocrinologist found no symptoms or physical examination findings of thyroid disease. A low dose of thyroid replacement hormone was prescribed. The NARSUM examiner indicated that standards were met with regard to endocrine conditions. The hypothyroid condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards. This condition was reviewed and considered by the Board. There was no performance based evidence from the record that hypothyroidism significantly interfered with satisfactory duty performance. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the hypothyroidism condition and so no additional disability rating is 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. In the matter of the MDD condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended hypothyroidism condition, the Board unanimously recommends no change from the PEB determination as not unfitting. There were no other conditions within the Board’s scope of review for consideration.

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

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130725, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record

XXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAF/MRB

Dear XXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2013-01064.

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 appropriate. Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board. I concur with that finding and their conclusion that re-characterization of your separation is not warranted. Accordingly, I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:

Record of Proceedings

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AF | PDBR | CY2013 | PD-2013-01064

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