DEPARTMENT OF THE NAVY

BOARD FOR CORRECTION OF NAVAL RECORD

S

2 NAVY ANNE

X

WASHINGTON DC 20370-510

0

JRE
Docket No: 4548-00
21 September 2001

This is in reference to your application for correction of your naval record pursuant to the
provisions of title 10 of the United States Code, section 1552.

A three-member panel of the Board for Correction of Naval Records, sitting in executive
session, considered your application on 30 August 2001.
Your allegations of error and
injustice were reviewed in accordance with administrative regulations and procedures
applicable to the proceedings of this Board.
consisted of your application, together with all material submitted in support thereof, your
naval record and applicable statutes, regulations and policies.

Documentary material considered by the Board

 

.

After careful and conscientious consideration of the entire record, the Board found that the
evidence submitted was insufficient to establish the existence of probable material error or
injustice. In this connection, the Board substantially concurred with the rationale of the
hearing panel of the Physical Evaluation Board which considered your case on 11 May 1999,
a copy of which is attached; however, it accepts the determination of the Director, Naval
Council of Personnel Boards that your back condition was unfitting and ratable at 10%. It
was not persuaded that you should have been retired by reason of physical disability, vice
discharged with entitlement to disability severance pay.
been denied. The names and votes of the members of the panel will be furnished upon
request.

Accordingly, your application has

It is regretted that the circumstances of your case are such that favorable action cannot be
taken. You are entitled to have the Board reconsider its decision upon submission of new
and material evidence or other matter not previously considered by the Board. In this
regard, it is important to keep in mind that a presumption of regularity attaches to all official

records. Consequently, when applying for a correction of an official naval record, the
burden is on the applicant to demonstrate the existence of probable material error or
injustice.

Sincerely,

W. DEAN PFEIFFER
Executive Director

Enclosure

SAN DIEGO FORMAL PEB RATIONALE

A medical board was held at Naval Hospital, Pensacola, Florida
on 25 August 1998 with diagnoses of:

1.
2.

Chronic Low Back Pain  
Chronic Daily Headache Combination of Analgesic Rebound Headache
and Migraine (30781)

With Right Sciatica Etiology Unknown (7242)

The informal Physical Evaluation Board found the member fit for duty on
04 December 1999.

This member appeared before the formal PEB on 11 May 1999 requesting to
be found unfit for duty under VA Codes  
disorder/depression) at  
pain) at 10%
the alternative,

the member requested EPTS (dysthymic disorder).

disability and placed on the TDRL. In

lo%, 8100 (migraines) at  

9433/9434  (dysthymic

for a total of 30%

lo%, and 5295 (low back

Accepted documentary evidence consisted of:

Exhibit A  
Exhibit B  
Exhibit C  
Exhibit D  
Exhibit E  

- PEB Case File
- Additional Medical Information
- Performance Evaluations
- PRT Folder
- Ltr from GYSGT McCoy dated 06 May 99

The member's medical board was dictated 25 August 1998 and reports
diagnoses of chronic low back pain of unknown etiology and chronic daily
headaches.
clarify the diagnoses and also add a new diagnosis of major depression.
The member arrived at the formal board with a cane and riding in a
wheelchair, though there is no substantiation in the medical board of any
necessity for the wheelchair or the cane.

In addition, the member has multiple addenda which modify and

The member requested  
the.additional  diagnosis of "major depression" or alternatively for a
putative diagnosis of dysthymic disorder EPTS.
will be addressed seriatum.

ratin.gs  for her low back pain, headaches, and for

These various complaints

The first issue is the member's chronic daily headaches which she
testified have been going on since she had her child in 1993. An
addendum on the headaches was written 2 October 1998 which noted that the
patient has a constant right retro-orbital pain that waxes and wanes in
severity, but is
that the member has no history of a visual aura prior to or during the
headaches.
the evaluating neurologist felt that the
patient's complaint was consistent with a combination of analgesic
rebound headache and migraine headache without aura.
neurologist did not make a specific diagnosis of migraine headaches.

"generally not incapacitating."

Based on this,

However, the

The addendum also notes

Enclosure (1)

1

,

.

As noted by

  diagnosis of migraine

that in itself is not synonymous with disability

the member's headaches are "generally not

Even stipulating arguendo that the member has a
headaches
the evaluating physician,
incapacitating and she is able to continue working through the pain." The
member testified the last time she saw a physician for her headaches was
in March 1998.
she takes daily.
duties adequately as reflected by her outstanding performance
evaluations.
class petty officer in December 1998 in spite of her complaints.
there is no evidence that the headaches can be considered
separately unfitting condition.

the member was just promoted to first
Thus,
in-any  way a

She has never taken anything stronger than Tylenol, which

Moreover, the member has continued to perform her

In addition to that,

 

The member has undergone two  

rheumatology and orthopedics, without

EMG's, all of which have been normal.

The medical board work-up
MRI's, CAT
The member has

The next issue is the member's low back pain.
has been extensive and normal.
scan, X-rays, and 
been evaluated by neurology,
finding any etiology for her complaint.
she saw a civilian orthopod in Atlanta.
the member's complaints.
ANA, and rheumatoid factor,
or negative as appropriate.
without any relief of her pain.
strength that is  
muscle wasting.
and with a normal range of motion.
form of a Standard Form 600 entry of 15 Decembe-r 1998 notes that the
member went to see her physician after receiving her fit for duty
finding.
proportion to physical findings,
normal.

The member also testified that
No one has found any reason for
The member has had a CBC, bone panel, HLAB-27,
all of which have been within normal limits
The member has had two epidural injections

5/5 in all muscle groups without evidence of atrophy or
The reflexes have been normal without evidence of spasm
Additional medical evidence in the

The reported diagnosis is low back pain with pain out of

The physical examination has noted

but the physical findings are all

The member arrived at the formal board in a wheelchair claiming that she
cannot walk for extended periods without pain, but there is no evidence
in the record that the member has been prescribed a wheelchair as a
necessary treatment for her complaints.
the member's complaints and symptomatology are grossly out of proportion
to any physical findings.
the Navy, the member said that she would visit a doctor.
has visited many doctors to no avail.
member has any underlying organic pathology.
evidence that this is a separately unfitting condition.

When asked what she would do if she got out of
However, she

There is no evidence that the

Thus, we have a situation where

there is no

Therefore,

The member's final complaints are psychiatric.
addendum which was dictated on 11 December 1998 and was in response to a
visit by the member to her psychiatrist after she got the fit for duty
finding.
The addendum makes a diagnosis of major depressive disorder
mild, but there is nothing in the write-up which would support such a

First, the member has an

Enclosure (1)

2

 

per-i&d.

The

The

for

.

was never medicated,

and never hospitalized.

However, she never received any treatment

1993/94, there is no
The member reported
she went home and drank a

she suffered an eight month period of "depressed mood, anhedonia,

the evaluating psychiatrist notes that the member
but after the break-up with the father of her

Apart from the "relational breakup" in  

continued to perform well above standards during this

her performance evaluations for that period indicate that

diagnosis.
evidence that the member has ever been depressed.
that after she got her fit for duty finding,
fifth of rum and sat awake all night ruminating about her situation.
Under marital history,
has never been married,
child,
hopelessness, and confusion."
beyond counseling,
Furthermore,
she
mental status examination for this addendum in December 1998 notes that
the member demonstrated no psychomotor retardation, her speech was
normal, and there is no mention of neurovegetative symptoms and the
member denied suicidal ideation.
mood was depressed, angry and tearful,
report that could be construed as abnormal.
is no way to substantiate a diagnosis of major depressive disorder.
member would be more reasonably diagnosed as suffering from a phase of
life problem or perhaps at most an adjustment disorder with depressed
mood.
her psychiatrist once a month.
was written, the member was just promoted to first class petty officer
because of her outstanding performance.
the same period show that she continued to perform very well.

The member testified that she is on no medication and only sees

Apart from a mention that the member's

there is absolutely nothing in the

Furthermore, at the time this addendum

Her performance evaluations  

Based on these data, there

Apart from the member's  

However, there were no data offered to substantiate this

The member's counsel asked for a possible rating as EPTS dysthymic
disorder.
diagnosis either.
was unpleasant because her father was physically and mentally abusive,
there were no data to suggest that the member had ever suffered any
psychiatric disorder based on this abusive childhood.
member testified that she graduated from high school a year early because
of her outstanding performance.
The member showed a burn on her right
hand and forearm from being scalded as a baby, but she could not remember
the episode and did not assert that this had been done to her
intentionally by her father.

a.ssertion  that her childhood

In fact, the

In sum, we have a member who has a long history of superb performance and
has most recently been promoted to first class petty officer in spite of
the fact that she is approximately fifty pounds overweight.
has extremely dramatic complaints without any objective substantiating
data.
The member is currently a single parent who is facing orders to
sea duty if she is found fit for duty.
and received an accelerated reenlistment bonus.
She has campaigned
vigorously to be found unfit for continued naval service based on some
sort of a disability,
but there are no substantiating data to warrant
such a finding.

Therefore, after careful consideration of all relevant

She has also recently reenlisted

The member

.

Enclosure (1)

3

medical evidence,
naval service.

the formal board finds the member fit for continued

._.-

Enclosure (1)

4