RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXX	CASE:  PD-2013-01452
BRANCH OF SERVICE:  Army  	BOARD DATE:  20140919
SEPARATION DATE:  20040726

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve 0-3 (General Transportation) medically separated for a bipolar disorder condition.  The condition could not be adequately rehabilitated to meet the occupational requirements of his Military Occupational Specialty (MOS).  He was issued a permanent S3 profile and referred for a Medical Evaluation Board (MEB).  The bipolar disorder condition, characterized as “bipolar NOS [not otherwise specified],” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  Additionally, narcissistic and schizotypal traits as medically unacceptable and alcohol dependence were submitted by the MEB.  The Informal PEB adjudicated “bipolar disorder with underlying narcissistic and schizotypal traits” as unfitting, rated at 0%.  The PEB determined the alcohol dependence, narcissistic and schizotypal traits were not separately unfitting and not rated.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Quadruple open heart surgery, medical stress (sp) disorder”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

Service  IPEB – Dated 20040528	VA*	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder	9432	0%	Bipolar Disorder	9432	0%	20051206	
Other x 0 (In Scope)	Other x 18		
Combined:  0%	Combined:  60%	
*Derived from VA Rating Decision (VARD) dated 20071018 (most proximate to date of separation in evidence).

ANALYSIS SUMMARY:  

Bipolar Disorder Condition.  The CI was admitted to a psychiatric inpatient hospital unit for bipolar disorder and alcohol dependence on 10 October 2003.  Symptoms of posttraumatic stress disorder were not present and although the CI had deployed to Iraq, there were no traumatic stressors attributed to the onset of his mental condition.  Identified stressors included recent difficulties with his health (underwent gall bladder surgery), marital stressors and alcohol dependence.  Alcohol dependence had been a problem for the CI for many years extending into his late teens and he had previously undergone an inpatient treatment program in approximately 1985 (according to Addiction Medicine Services consult 15 October 2003).  The hospital discharge narrative summary (NARSUM) dated on 28 October 2003, recorded excellent response to treatment including medication and listed final Axis I diagnoses of bipolar disorder NOS, most recent episode manic and alcohol dependence.  Narcissistic and schizotypal traits were also noted on Axis II of the psychiatric diagnosis.  The psychiatrist noted the CI was at risk for recurrence of the bipolar disorder in the setting of a highly stressful military environment and was not suited for continued military service.  Although the psychiatrist assigned a global assessment of 75 (denoting transient symptoms with slight impairment), he stated that civilian occupational impairment was estimated as mild to moderate at the time of hospital discharge.

The MEB psychiatry NARSUM dated 7 May 2004 stated the CI’s bipolar disorder had remained in continuous remission since discharge from the hospital in October 2003 on medication treatment.  At the time of the MEB NARSUM, the mental status examination was normal including mood, affect, thought processes, insight, judgment and cognitive functions (memory, concentration).  There was no suicidal thinking.  The psychiatrist determined that the CI remained in complete remission on medication and had no social or industrial impairment.  Alcohol dependence was indicated as in remission.  The psychiatrist assigned the CI a Global Assessment of Function score of 90, (absent or minimal symptoms, good functioning in all areas).  The MEB psychiatrist did note his condition was at risk for recurrence under highly stressful conditions.  The military pharmacy medication record reflected prescriptions for the psychiatric medication up to the time of the MEB in May 2004.  The medical hold commander’s comments signed 20 May 2004 noted the CI’s S3 physical profile and stated that the CI was not working in his primary military occupational service but was working in the administrative section of the military traffic management center with satisfactory duty performance.

The VA examinations dated 30 August 2004 and 2 September 2004 (a month post-separation), indicated the CI was not taking any medications on a regular basis.  The first VA mental health Compensation and Pension (C&P) examination available in the file was performed on 6 December 2005 (15 months after separation).  At the time of this examination, the CI reported some episodes of decreased sleep and increased goal directed activity without functional impairment.  The CI was not taking medications.  He denied depression, PTSD symptoms (nightmares, etc.), suicidal thoughts, or alcohol use.  The CI stated he did not directly witness traumatic events while deployed.  The mental status examination was normal.  The examiner noted the insomnia and increased goal directed activity were consistent with bipolar disorder but that the CI was functioning “relatively well” and recommended resumption of treatment.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated a 0% rating for the “bipolar disorder with underlying narcissistic and schizotypal traits” (coded 9432) noting the CI was in full remission without any social or industrial impairment.  The PEB noted that alcohol dependence and personality traits were not separately unfitting and therefore not rated.  The VA rated the bipolar condition (9432) at 0% likely based on good functioning off of medication at the time of the VA C&P examination.  All Board members agreed that the evidence of the record did not support a traumatic stressor as the cause of the mental condition for which application of VASRD §4.129 would be appropriate.  Based on the MEB NARSUM proximate to separation, there was no social and occupational impairment which supported a 10% rating or higher.  The MEB NARSUM and STRs prior to separation reflected ongoing medication treatment supporting a 10% rating for symptoms controlled by continuous medication.  The Board discussed that fact that the post-separation VA C&P examinations indicated the CI had stopped taking medication but noted the presence of mild symptoms and concluded the 10% rating was supported at the time of separation based on the evidence of the STRs.  The Board noted the PEB indicated that the alcohol dependence in remission and the narcissistic and schizotypal traits were not separately unfitting or rated.  Alcohol dependence (as a primary condition not due to mental illness) and personality traits are not disabilities which are subject to rating but may form the basis for administrative separation when they interfere with duty (DoDI 1332.38 Enclosure 5).  In the CI’s case, the alcohol dependence was in remission and the personality traits, which are long standing characteristics, had never interfered with performance of duty.  Regardless, the VASRD §4.130 rating was based on the overall social and occupational impairment without any deduction for the alcohol dependence in remission or the Axis II traits.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) the Board recommends a disability rating of 10% for the bipolar 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.  In the matter of the bipolar disorder condition, the Board unanimously recommends a disability rating of 10%, coded 9432 IAW VASRD §4.130 mental disorders.  In the matter of the alcohol dependence and narcissistic and schizotypal traits, the Board unanimously recommends no change from the PEB determinations as not separately unfitting or ratable.  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, effective as of the date of his prior medical separation.

UNFITTING CONDITION	VASRD CODE	RATING	
Bipolar Disorder	9432	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130813, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

			

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXX, AR20150008368 (PD201301452)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						

CF: 
(  ) DoD PDBR
(  ) DVA