RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01926
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150205
SEPARATION DATE:  20061222

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Information Technology Technician) medically separated for bipolar disorder.  This condition could not be adequately rehabilitated to meet the requirements of her Air Force Specialty.  She was issued an S4 profile and referred for a Medical Evaluation Board (MEB).  The “bipolar II disorder” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The Informal PEB adjudicated “bipolar II disorder…mild” as unfitting, rated 10%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The PEB also listed “hypothyroidism” as Category II, (Can be unfitting, but not currently compensable or ratable).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions”

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:

PEB – Dated 20061016	VA* - (~3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar II Disorder…Mild	9432	10%	Bipolar, Not Otherwise Specified	9432	30%	20070404	
Hypothyroidism	Cat II	Hypothyroidism	7903	10%		
Other x 0 (Not in Scope)	Other x 3	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20070522 (most proximate to date of separation (DOS)).

ANALYSIS SUMMARY:

Bipolar Disorder.  The narrative summary (NARSUM) notes the CI had been seen by behavioral health (BH) a few times in 2004 for insomnia and test related anxiety.  Her First Sergeant referred her to BH in July 2004 when she was depressed, drinking heavily, and called him.  She was referred for early substance abuse intervention and no further treatment was recommended following an education class.  Notes in the service treatment record (STR) indicated the CI was involved in counseling with the chaplain for adjustment issues and was referred again to BH in February 2005.  At the initial BH evaluation on 2 February 2005 the CI reported a depressed mood, sleeping more than usual and not feeling rested, loss of interest and pleasure in activities, decreased concentration and memory, and increased weight.  She reported recent suicidal ideation (SI) but denied she would ever harm herself.  The CI additionally reported that for a few days at a time she would not need sleep and would feel rested, associated with high energy and either a good mood or irritability.  She denied any problems with duty performance or recreational activities due to the mental health symptoms (hypomania or depression).  The CI reported less intense mood swings beginning in high school, but had never sought treatment.  The mental status examination (MSE) noted a depressed mood and affect, recent SI (without intent), but no current SI, and an otherwise normal examination.  The Axis I diagnosis was Bipolar II disorder with a Global Assessment of Functioning (GAF) of 51 (on the cusp of moderate to severe impairment ranges).  The CI was started on antidepressant medication by her primary care physician and initially her symptoms improved, but when they returned, medication more targeted to bipolar disorder was added by a psychiatrist and adjusted, with good control of symptoms.  Notes in the STR indicated that once stabilized on medication, the CI reported doing well.  The psychiatrist recommended against deploying her because she could decompensate, but recommended that the CI be allowed to complete her enlistment.  BH notes from March to October 2006 indicated the CI’s condition remained stable with GAF in the mild to minimal impairment ranges.  During this time the CI reported some depression symptoms associated with stress related to estranged family members and anxiety reported at times related to expectations of change.  The commander’s statement noted that the CI had been unable to pass fitness tests due to medication related weight gain and that the “high stress of our military lifestyle is becoming too much for her to handle.”  An enlisted performance review for the period May 2005 to May 2006 indicated the CI’s performance was excellent or exceptional in all categories except for an average rating for meeting Air Force standards [weight and fitness].

At the MEB examination on 18 September 2006, 3 months prior to separation, the CI was noted to be stable on medications and weekly therapy, with occasional passive SI.  On MSE the CI reported fluctuations of mood (“depressed” or “happy”), energy levels, sleep, and concentration, with racing thoughts at times, but no major difficulties completing her job duties.  The examiner noted passive SI, but no suicide attempts and there was no evidence of delusions or hallucinations.  The Axis I diagnosis was Bipolar II disorder, most recent episode depressed with a GAF of 75 (slight, if any, impairment range).

At the VA Compensation and Pension (C&P) examination on 4 April 2007, 3 months after separation, the CI reported being treated for bipolar II disorder since 2005 with psychotropic medications which were helpful, but she still had symptoms.  Anxiety related to test taking and driving in unfamiliar areas with panic type symptoms was noted.  The history noted the CI got along well with most of her family including her father, step-mother and a brother, and she kept in touch on a regular basis with three or four friends.  The MSE noted the CI was lethargic with a depressed mood but normal affect, with normal thought, without cognitive deficits, SI, or psychotic features.  The examiner indicated the CI had panic attacks.  The CI was unemployed and reported difficulty job hunting due to depressive symptoms.  The Axis I diagnosis was bipolar disorder, not otherwise specified, with a GAF of 53 (moderate impairment range).
The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the bipolar II disorder 10%, coded 9432 (bipolar disorder) and the VA rated it 30%, also coded 9432.  The Board agreed that based upon rating criteria for mental health disability due to occupational and social impairment IAW VASRD §4.130 there was no evidence in record of “decreased reliability and productivity” to support a 50% rating and deliberations therefore settled upon a 30% rating, characterized as “occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily)” versus a 10% rating characterized by “mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.”  The evidence in record indicated the CI was well controlled on medications with some continued symptoms that did not impact her ability to perform her duties.  The C&P examiner noted the presence of panic attacks associated with test taking and driving.  However, although anxiety symptoms related to test taking or anticipation of change were noted, there were no panic attacks reported in the STR.  Members debated whether the persistence of cyclic bipolar II symptoms despite treatment was more consistent with the 30% rating than the 10% rating.  However, despite any ongoing symptoms, the CI’s performance evaluations to May 2006 were excellent and mental health notes from May to October 2006 indicated the CI remained stable on her medications, without episodes of significant decompensation.  The C&P, just 3 months after separation indicated the CI was unemployed but job hunting, despite her symptoms and she reported good family relationships and regular socializing with friends.  The Board concluded that the functional disability due to the bipolar disorder at the time of separation was more consistent with the 10% rating IAW §4.130.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the bipolar II condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the hypothyroidism condition 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.

Hypothyroidism Condition.  The NARSUM notes that the CI had side effects related to her psychotropic medications which overlapped with signs and symptoms of thyroid disease, including weight gain.  A note in the STR on 10 February 2006 indicated that blood work indicated an abnormal Prolactin level (pituitary hormone) related to the medication and a mildly abnormal thyroid test.  Physical examination did not indicate any gross enlargement or abnormality of the thyroid.  The CI’s medication was changed to address the prolactin level and she was prescribed thyroid medication.  Thyroid medication dosage adjustments were made and the CI indicated in June 2006 that she was feeling more energetic with thyroid blood work in November 2006 reflecting adequate thyroid hormone replacement levels.

The hypothyroidism condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  There was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended hypothyroid condition and so no additional disability ratings are 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the Bipolar II disorder condition and IAW VASRD §4.130 the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended hypothyroid 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 20140502, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

				
XXXXXXXXXXXXXXXXXXXX
President
DoD 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-2014-01926.

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,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR