RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02024
BRANCH OF SERVICE:  Army	BOARD DATE:  20150327
DATE OF PLACEMENT ONTO TDRL:  20060101 
DATE OF REMOVAL FROM TDRL:  20070626 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (Unit Supply Specialist) medically separated for a bipolar disorder.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent S3 profile and referred for a Medical Evaluation Board (MEB).  The “Bipolar 1 disorder” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “bipolar disorder, type 1” as unfitting, rated 30%.  The CI made no appeals and was placed on Temporary Disability Retired List (TDRL).  Approximately 21 months later, the PEB adjudicated the bipolar disorder condition as stable, but still unfitting, and rated it 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made an appeal but later withdrew his request 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 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:  

Final PEB – 20070511	VA Rating Decision1 - 20060425	
TDRL Placement – 20060101	Code	Rating	Condition	Code	Rating
Proximate	
Condition		TDRL
Placement	TDRL Removal			TDRL2
Placement	TDRL3 Removal	
Bipolar Disorder, Type I	9432	30%	10%	Bipolar I Disorder	9432	30%	30%	
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 2	
RATING:  30% → 10%	RATING:  30%	
1. Most proximate to TDRL Placement.  2. Rating derived from C&P exam dated 20060223, ~2 mos. post-TDRL placement. 
3. Rating derived from C&P exam dated 20090723, ~25 mos. post-TDRL removal. 

ANALYSIS SUMMARY:  

Bipolar Disorder, Type I.  The CI was administered an Article 15 on 28 April 2005 for the use of marijuana on/about 17 February and 18 March 2005.  He was reduced in rank, given additional duties, and approved for “Chapter 14 (AR 635-200)” discharge.  Subsequent records indicate that his substance abuse had started at age 18, 3 years earlier (26 April 2012 admission note), and that the use on active duty was deliberate in an attempt to be discharged rather than being redeployed (clinic notes on 26 November 2012 and 31 January 2014).  The day of the discharge approval, he was referred to mental health (MH) by his commander and chaplain for a history of depression which was actually improving at the time of the visit, 20 May 2005.  He was noted to have circumstantial speech (take the “long way” to their point, but eventually they get there).  The CI was scheduled a follow up 3 days later on 23 May 2005, but was brought to the emergency room by military police on 22 May 2005 for “weird behavior” and was admitted to the psychiatric ward.  The CI was a poor historian and the history was obtained from other sources who noted that the CI began bizarre behavior 5 days earlier.  He had pressured speech, auditory hallucinations, and racing thoughts.  He was diagnosed with bipolar disorder I with psychotic features and started on medications.  He stabilized and was discharged on 1 June 2005, but his unit did not continue his medications and he was readmitted, for a week, on 21 June 2005 for re-stabilization after symptom recurrence.  

The narrative summary (NARSUM) was accomplished on 29 June 2005, while the CI was still admitted.  The CI reported that he had been deployed from August 2003 to February 2004 and again from September to October 2004.  His girlfriend had recently given birth to their child and he also had financial problems.  At the time of the examination, stable on medications, he was cooperative and polite and no longer a management problem.  His mental status examination (MSE) was essentially normal.  The CI was next seen on 6 July 2005 in MH and reported sadness due to separation from his family, but denied hallucinations or manic symptoms.  He reported some daytime sedation from his medications.  On examination, his mood was depressed and affect constricted, but otherwise unremarkable.  He was thought to have bipolar disorder I in remission.  He was seen again 2 days later with similar findings and diagnosis.  It was thought that the CI was more likely to “remain in remission and do well at home with family.”  The CI was granted convalescent leave from 9-31 July.  He was seen in psychiatry on his return on 1 August 2005 and reported that he felt “moving kinda fast” and a decreased need for sleep (5 hours).  His family noted that he spoke fast.  The MSE showed a depressed mood and constricted affect, but was otherwise unremarkable.  The diagnosis remained mixed bipolar disorder I in remission.  The last MH visit prior to TDRL placement was on 22 August 2005.  The CI reported resolution of his symptoms of “decreased sleep” and “moving kinda fast” and was ready get things done.  His medications had been increased at his last visit.  He denied talking fast and felt less tired than before.  The MSE examination was again unremarkable other than the constricted affect.  The depressed mood had resolved.  The diagnosis was unchanged and he remained in remission.  The CI was placed on TDRL effective 1 January 2006.  
The first visit in the VA system was on 16 February 2006 and for establishment of care.  He denied MH symptoms and his examination was unremarkable other than a flat affect.  At the VA Compensation and Pension (C&P) exam performed on 24 February 2006, 2 months after separation, the CI reported decreased motivation to help out around the house and for personal grooming.  His sister managed his finances.  He stated that he has less interest in pleasurable activities, but had seven friends.  He and his girlfriend argued over little things, but otherwise he denied getting into arguments.  He endorsed some paranoia in crowds.  He stated that he was not working and that his mental condition impaired his ability to work.  He also reported that he had been hospitalized three times, most recently in August 2005, for the MH condition.  The Board noted that this is not consistent with the records.  He endorsed a history of nightmares and flashbacks related to his deployments.  However, on the post deployment assessments dated 18 March 2004 and 26 October 2004, he did not desire MH counseling.  The initial deployment was the more problematic.  The second deployment to Afghanistan was less so.  The CI stated “There was nothing really that happened in Afghanistan.  That was pretty much of a slow run.”  On examination, his affect was solemn.  He reported some loss of interest in pleasurable activities, detachment, and decreased ability to recall traumatic events.  He was thought to have both post-traumatic stress disorder (PTSD) and bipolar disorder in partial remission and was assigned a Global Assessment of Function (GAF) of 65 consistent with some mild symptoms or impairment.  

The CI was next seen by a psychiatrist a month later on 21 March 2006 and noted to have a subdued and flat affect.  He was given the single MH diagnosis of mixed bipolar disorder with a GAF of 50 (upper limit for serious symptoms or impairment).  He was thought to be over-medicated though.  At a follow up appointment on 4 May 2006, 4 months after TDRL placement, he again appeared overmedicated but did not want a reduction.  When seen on 29 August 2006, 8 months after TDRL placement, he was working and enjoyed his job.  He was assigned a GAF of 60, moderate symptoms or impairment, and his medication dosage was reduced.  

The TDRL removal NARSUM was dated 10 April 2007, 15 months after TDRL placement.  Although the CI was late for his appointment, he was cooperative, dressed appropriately, and had intact grooming.  His MSE examination was normal and he denied hallucinations and delusions.  Suicidal and homicidal ideation was absent.  Cognition, insight, and judgment were intact.  The diagnosis remained bipolar disorder I manifested by a single manic episode.  The second VA C&P for MH conditions was accomplished on 23 July 2009; over 2 years after TDRL removal and well outside the normal 12 month window assigned a high probative value for rating purposes.  However, it noted that he had been working at his current occupation for over a year and stated “I love my job.”  He was married and had a good relationship with his wife and step children.  He socialized and would socialize more if not for financial limitations.  He was talkative with pressured speech, but otherwise the MSE was unremarkable.  This is consistent with the TDRL removal NARSUM.  
The Board directed its attention to its rating recommendation based on the above evidence.  The Board first considered if the condition was secondary to a traumatic event and the provisions of VASRD §4.129 were applicable.  Substance abuse can trigger the onset of symptoms, be used to self-medicate the symptoms, and has a high incidence among persons with bipolar illness for not completely clear reasons.  The CI reported that he deliberately used marijuana in order to be discharged and not be re-deployed because he did not want to go back to war.  The onset of symptoms was months after his return from theater, but in the context of his non-judicial punishment with attendant loss of rank and pay, a new child, and financial difficulties.  The Board did note that the VA subsequently retroactively applied VASRD §4.129 on the 3 June 2011 VARD citing the comment by the PEB at TDRL placement citing the “recent deployment to Afghanistan, birth of a child, and geographic family separation.”  The latter two are typical stresses in military life for someone his age.  The CI himself discounted significant stress from the deployment at the VA C&P shortly after TDRL placement.  The Board determined that the evidence does not support the application of VASRD §4.129.  

The Board first considered the rating IAW VASRD §4.130 at TDRL placement.  The four MH examinations which were proximate to separation were all written by the same psychiatrist.  These consistently noted that the CI was in remission.  The VA C&P examination was accomplished by a clinical psychologist and relied on information provided by the CI which is not consistent with the evidence in the record.  The Board considered the evidence and all members agreed that the §4.130 criteria for a rating higher than 30% were not met at the time of separation.  The Board then considered the permanent rating at TDRL removal.  The CI had an unremarkable examination and was doing well on medications without a relapse.  The VA C&P 2 years after TDRL removal indicated that the CI had done well as he was married with step children, had been working over a year, and enjoyed socialization.  The description for a 30% rating is “Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal).”  That for a 10% rating is “Occupational and social impairment due to 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 Board determined that the 10% rating better fit the disability in evidence at separation and a higher rating is not supported.  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 disorder I condition at either TDRL placement and removal.  

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 disorder I condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  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 20140505, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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 XXXXXXXXXXXXXXX, AR20150013705 (PD201402024)

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 and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     XXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA