RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02392
BRANCH OF SERVICE:  Army 	BOARD DATE:  20150519
SEPARATION DATE:  20040706

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E-4 (Carpentry and Masonry Specialist) medically separated for bipolar I disorder.  The bipolar disorder could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty. He was issued a permanent S3 profile and referred for a Medical Evaluation Board (MEB).  The “bipolar type I disorder w/psychotic features” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (migraine headaches) for PEB adjudication.  The Informal PEB (IPEB) adjudicated “bipolar I disorder” as unfitting, rated 10%, with application of AR 635-40.  The migraine headaches condition was not addressed by the PEB.   During the process, the case was returned for informal Reconsideration reflecting that the recommendation of 10A/C (combat related) during the IPEB proceedings did not appear warranted; however, no rating change was made.  The CI made no appeals and was medically separated.

CI CONTENTION: “Please consider all conditions.  Bipolar disorder and social anxiety problems.” 

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: 

Recon IPEB – Dated 20040426	VA* - (~18 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar I Disorder	9432	10%	Bipolar Disorder	9432	10%	20060110	
Headaches	Not addressed  by the PEB	No VA Placement	
Other x 0 (Not In Scope)	Other x 0 	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20060410 (most proximate to date of separation (DOS)).  
ANALYSIS SUMMARY:

Bipolar I Disorder.  According to the narrative summary (NARSUM) evaluation, the CI acknowledged onset of depression at age 17.  There was no prior history of psychiatric hospitalization, psychosis or mania, and depression symptoms were stable since February 2003 on antidepressant medication.  After being deployed to Iraq for 9 months, the CI experienced a 2-week history of increased energy, auditory hallucinations and delusions in the context of a chronic stressful environment.  He was hospitalized on 4 January 2004 with a diagnosis of psychosis and treated with multiple psychotropic medications.  Psychotic symptoms resolved but some hypomanic symptoms (less severe forms of mania) persisted upon return to CONUS.

The NARSUM mental status exam performed on 27 January 2004 (5 months prior to separation) showed a normal appearance and speech.  Mood was “upbeat” and affect displayed a hypomanic tendency.  The recent psychotic thinking was acknowledged, but there were no current psychotic symptoms, and no suicidal or homicidal ideations.  Insight and judgment were good; and abstract thinking and short and long-term memory was intact.  The examiner rendered a diagnosis of bipolar I disorder (with psychotic features) that was improved, but persistent hypomanic symptoms required medication adjustment.  A current Global Assessment of Functioning (GAF) score of 55 was assigned, connoting moderate symptoms or impairment.  The highest GAF during the previous year was 75 (no more than slight impairment).

A VA mental health outpatient note on 7 February 2005 (7 months after separation) reported the CI was working 21 hours per week and taking 12 semester credit hours at a community college.  His GPA was 3.6.  He was taking two psychotropic medications regularly, and reported mildly diminished mood and some anxiety regarding thoughts that people were judging him.  There were no symptoms of mania or psychosis, and appetite, sleep and energy were “good.”  

At a follow-up visit on 18 May 2005 (10 months after separation) the CI reported he recently completed a semester, but had dropped six semester hours of classes in the past year because a “full academic load was too much.”  He planned to continue classes and work full-time.  He denied mania or depression, although depression was subsequently noted to be “1” on a 1-10 scale. He reported good appetite, energy and sleep.  He noted some anxiety daily before work, concerned that people were judging him.  Mental status exam showed a normal appearance, speech and thought processes.  Memory and judgment were intact.  The examiner opined that the CI was “doing fairly well on current meds” but could benefit from some medication adjustments.  The assigned GAF score was 55.

At the VA Compensation and Pension (C&P) exam performed on 10 January 2006 (18 months after separation), the CI reported that he was taking antidepressant medication for much of the time he was in the military.  His psychotic and manic symptoms developed while deployed in the context of increasing pressure and sleep deprivation, but no specific traumatic events were described.  The examiner referred to outpatient treatment notes from a different provider who noted the CI to be both anxious and depressed, and that documented a GAF score of 45 (serious symptoms or impairment) in July 2004 (i.e. at the time of separation).  The CI currently lived with his parents and was a full-time student at a community college where he had dropped some classes but completed others with good grades.  He did not have a job.  He hung out with friends, went to bars once per week and worked out at the gym three or four times per week.  He took a trip to Colorado with his father to visit relatives, and attended a family wedding in Florida.  He endorsed good quality sleep and denied psychotic or delusional thoughts.  Although his thoughts could seem to race when under stress, he did not have full-blown manic symptoms.  Suicidal thoughts previously occurred, but not recently.  Mental status exam noted normal speech and appearance with some mild anxiety present.  Memory was intact and there was no indication of delusions or hallucinations.  The examiner rendered a diagnosis of bipolar I disorder and assigned a GAF of 54. 

The Board directed attention to its rating recommendation based on the above evidence.  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.  Under the 9432 code (bipolar disorder), the PEB and the VA assigned a 10% rating, but the Board considered if a higher was warranted at the time of separation.  It was agreed that the 50% rating (occupational and social impairment with reduced reliability and productivity) was not described by the evidence and deliberation settled on arguments between a 10% and 30% rating.  The §4.130 criteria 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).  A 30% rating required (occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks).

The Board considered that the NARSUM exam reported no current threshold symptoms of a 30% rating and a GAF score that reflected moderate symptoms or impairment, but in the context of a recent hospitalization for serious psychotic symptoms.  While possibly one or two 30% threshold symptoms (depression, anxiety) were reported in post-separation VA notes and by the C&P examiner, these were very mild or situational.  Board members debated the relevance of a reported GAF score near the time of separation suggesting serious symptoms or impairment, and noted the CI’s apparently successful college performance and relatively intact social functioning during the months after separation.  On balance, the Board majority concluded that there was not adequate reasonable doubt favoring the next higher 30% rating, and agreed that at the time of separation the condition more nearly approximated the criteria for the 10% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bipolar disorder condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that migraine headaches were 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.  At the MEB exam the CI reported a history of “reoccurring migraines” which were noted to be “not limiting.”  The profiling section of the DD Form 2808 listed a diagnosis of migraine headache, profiled P1.  The NARSUM evaluation reported a history of episodic “stress headaches” associated with vision changes, nausea and vomiting.  There were no treatment notes for headaches in the available clinical record.

The migraine headaches condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  This condition was reviewed and considered by the Board.  There was no performance based evidence from the record that it 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 condition and so no additional disability rating 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.  As discussed above, PEB reliance on AR 635-40 for rating bipolar disorder was operant in this case and the condition was adjudicated independently of that regulation by this Board.  In the matter of the bipolar I disorder condition and IAW VASRD §4.130, by a majority vote, the Board recommends no change in the PEB adjudication.  In the matter of the contended migraine headaches 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.

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 20140520, 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 XXXXXXXXXXXXXXXXXX, AR20160000280 (PD201402392)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA