RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX 	CASE:  PD-2014-01649
BRANCH OF SERVICE:  NAVY  	                        SEPARATION DATE:  20080515

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, Snap II Supply & Financial Management Storekeeper, medically separated for “bipolar disorder and “posttraumatic stress disorder” with a disability rating of 10%.  

CI CONTENTION:  

“Veteran has difficulty in work environment…” The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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:    

SERVICEPEB - 20080130	VARD - 20081107	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder	9432	10%	Bipolar Disorder with Psychotic Features and Anxiety Disorder (Also Claimed as PTSD)	9413-9432	70%	20080612	
PTSD	Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Bipolar Disorder Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bipolar condition began in February 2004 after his father and sister were killed in an accident in July 2005.  He presented for psychiatric treatment in August 2005 with report of depression with crying, anger, insomnia and poor appetite for several weeks.  He struck objects, had decreased concentration and interest, and “blackouts,” periods of consciousness associated with 3-4 minutes of not being aware of his actions.  He also had “spurts of energy and nightly panic attacks.  He denied suicidal thoughts but had homicidal thoughts to kill the person who caused the deaths of his father and sister.  He was diagnosed with major depression disorder.  In September 2005 he was diagnosed with PTSD after he developed nightmares and intrusive recollections of his father’s physical abuse.  He had brief auditory hallucinations of his father threatening to come after him.  He was placed on 4 hours of work per day because his symptoms were disabling.  Symptoms of hypomania (racing thoughts, anxiety, anger, pacing, and decreased sleep) appeared in October 2005.  In October 2006 he was treated with medication which helped decrease his anger, racing thoughts and hypomania.  Psychotherapy helped him grieve the deaths of his family members.  

His last visit to mental health in March 2007, performed one year prior to separation, documented significant depressive symptoms and significant PTSD symptoms stemming from his father’s physical abuse of him as well as the death of his father and sister in the accident.  He still had insomnia, irritability and became very upset regarding the physical abuse and deaths.  Medications included a mood stabilizer, an anti-depressive, two anti-anxiolytics, and a sleep aid.  Significant symptoms of depression and PTSD remained.  He was attending college, had a good grade average, was married and had a child.  Mental status examination (MSE) showed a sad, anxious and restricted affect appropriate to ideation.  Diagnoses of bipolar disorder and PTSD were rendered.  The second commander’s statement noted the CI’s condition required 8-16 hours away from his current duties.  The CI noted the medication had a negative effect on his overall work performance.  

At the VA Compensation and Pension (C&P) examination performed a month after separation, the CI reported he had been working for the past 3 weeks and had not resumed psychiatric care since discharge.  However, he was looking for mental health treatment in their community.  He said his job was “ok” without providing much detail.  His wife assisted with the interview.  He never returned to full duty during the service and spent over 2 years on limited duty until his discharge.  He reported racing thoughts, difficulty sleeping, anger outbursts, irritability and mood swings.  His wife reported he had visual hallucinations, spent impulsively, was tearful and aggressive, pushing her and putting holes in the wall.  Function in daily activities was limited because of his confusion for periods of time e.g. leaving the shower with soap on, fallings and staying awake during daytime.  He had difficulties performing activities of daily living (ADLs).  He had no friends but helped take care of the children.  He was taking a medication to treat mood instability and seizures, a medication to treat psychosis, a medication for sleep/anxiety and a medication for his daytime sleeping disorder.  MSE showed he was extremely anxious, had restricted affect, had mumbled speech, provided limited information, had impaired thought process and ability to communicate.  He denied suicidal ideation.  He had cognitive difficulties and insight and judgment were poor to fair.  Medications helped the auditory and visual hallucinations which were not present on interview.  Diagnoses of bipolar disorder with psychotic features and anxiety disorder were rendered with a Global Assessment of Functioning (GAF) score of 43 (serious symptoms, impairment.)  The examiner noted that his presentation made it highly surprising he could manage in any work environment and it was highly likely future employment would be affected by his mental issues.  He did not appear competent to handle his benefits and his wife was managing their finances. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 9432 code (bipolar disorder) and subsumed PTSD as a related Category II condition under the unfitting bipolar condition.  The VA also assigned a 70% rating using an analogous 9413-9432 code (anxiety disorder-bipolar disorder) based on the VA C&P examination a month after separation, citing the evidence of record and the results of the recent VA examination.  The 70% rating connotes occupational and social impairment with deficiencies in most areas.  Application of VASRD §4.129 is considered by the Board for all cases of Service connected psychiatric conditions resulting in separation; but, all members agreed that the ‘highly stressful event’ requisite for §4.129 was not satisfied in this case.  Disability associated with any psychiatric condition, regardless of the diagnosis or multiple diagnoses, is subsumed under a single rating using the same criteria IAW VASRD §4.130 general rating formula for MH conditions.  

The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication,” for a 30% rating is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks,” while criteria for a 50% rating requires “occupational and social impairment with reduced reliability and productivity.”  The Board noted the C&P examination was much more proximal to the time of separation and therefore of greater probative value.  The Board noted that he was never able to return to full duty while in the Service.  His wife assisted with the interview, he was unable to perform ADLs and was unable to handle his benefits.  His wife was handling finances.  The examiner was very surprised the CI was reportedly working for 3 weeks in an unknown capacity but opined that his mental issues would impair his ability to work.  He was helping with the children but not doing much else and had no friends.  He continued to report symptoms of depression and psychosis despite taking several medications to manage his mood instability, psychosis, and sleep problems.  He demonstrated multiple impairments on the MSE.  The Board agreed that he met criteria for a 50% rating, noting decreased reliability and productivity due to his ongoing psychosis and bipolar symptoms.  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 bipolar condition.  

BOARD FINDINGS:  In the matter of the bipolar condition, the Board recommends a disability rating of 50%, coded 9234 IAW VASRD §4.130.  In the matter of the contended PTSD condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  There were no other conditions within the Board’s scope of review for consideration.

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Bipolar Disorder 	9432	50%	
RATING	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140416, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 21 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX 
	(c) PDBR ltr dtd 03 May 16 ICO XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 24 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 17 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 15 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 13 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 13 Apr 16 ICO XXXXXXXXXXXXXXXXXXXX
	(k) PDBR ltr dtd 15 Apr 16 ICO XXXXXXXXXXXXXXXXXXXX
	(l) PDBR ltr dtd 22 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (l) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 50 percent disability rating (increased from 10 percent) effect date of discharge. 

     b. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effect date of discharge. 
 
     c. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
     
     d. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge.

     e. XXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 40 percent disability rating (increased from 10 percent) effect date of discharge. 
 
     f. XXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge. 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

     g. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge.

     h. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge.

     i. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge.

     j. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 40 percent disability rating (increased from 20 percent) effect date of discharge.

     k. XXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge.

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.

	XXXXXXXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)