RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02543
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20150327
SEPARATION DATE:  20060930

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E-5 (Aviation Electronics Technician) medically separated for bipolar disorder.  The condition could not be adequately rehabilitated to meet the requirements of his Rating, so he was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The “major depressive disorder, single episode, severe, specified as with psychotic behavior” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. No other conditions were submitted by the MEB.  The Informal PEB adjudicated “bipolar I disorder” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  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 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:

IPEB – Dated 20060713	VA* - (~6 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar I Disorder	9432	10%	Bipolar Disorder	9432	10%	20070327	
Other x 0 	Other x 5	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20070531 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Bipolar Disorder.  In a note dated 11 December 2001 the CI reported having experienced increasing depressive symptoms over the prior few weeks marked by2-to-3 hours sleep per night, reduced appetite, low energy, suicidal ideation, minor impairment of short-term memory depressed mood, and perceptual abnormalities such as hearing loud noises he believed others did not and experiencing his own voice as external.  The diagnosis of a depressive disorder was made and the CI was placed on an S-1 profile and referred for counseling, therapy, and medication.  His Global Assessment of Functioning (GAF) score ranged from 65 (mild symptoms) to 75 (transient symptoms) at that time.  On 20 March 2006, the CI was evaluated for increased symptoms of paranoia and periods of “black outs,” feeling restless, emotional lability, anxiety, depression, irrational fears, and feeling emotionally rejected.  He had a history of bipolar diagnosis and was previously on Paxil (paroxetine) and Zoloft (sertraline) for depressive symptoms.  As a result of significant anxiety, depression and paranoid symptoms, he was admitted to the hospital for several days.  He was discharged on Effexor XR (venlafaxine hydrochloride) for depression and anxiety and Geodon (ziprasidone) for manic symptoms; and outpatient therapy was continued to treat the bipolar disorder with a depressed mood.  His GAF during and post discharge was 41-50 (serious symptoms).

The CI was placed on LIMDU on 6 April 2006 with a start date of 24 March 2006 for the bipolar disorder with limitations of no weapons carrying, no overnight duties, and no deployments or transfer.  Additionally, he was assigned an alternate duty assignment.  The MEB narrative summary (NARSUM) dated 22 May 2006 noted the CI experienced occupational problems, depressed mood and poor functioning prior to a hospital admission in March 2006 where he was diagnosed and treated for bipolar I disorder with psychotic features.  On the Report of Medical History dated 24 May 2006 for the MEB examination, the CI noted anxiety and the examiner commented “R/O anxiety/mood disorder.”  At the MEB physical examination the CI’s psychiatric status was not determined, but his history of a bipolar disorder was noted.  He had an emergency room visit on 30 April 2006.  Thereafter, he complied with the hospital discharge medication treatment plan to which Buspar (buspirone) for anxiety was added along with intensive outpatient treatment.  At the NARSUM examination the CI was cooperative, mildly depressed, anxious, and had an appropriate, but decreased range of affect.  His thought was coherent, logical, goal-directed, and without any psychotic features.  He actively planned for the future and denied suicidal or homicidal ideation.  His GAF was 55-65 (moderate to mild symptoms).  The non-medical assessment dated 19 June 2006 indicated the CI’s “medical condition is not conducive to the billet he is assigned and has caused a noticeable decline in his work performance.  Although once a competent technician, his present condition hinders his performance and limits his abilities.”  In a Report of Medical Assessment dated 2 August 2006 the CI reported he was taking the Effexor, and Buspar as well as Remeron (mirtazapine), an antidepressant, and Seroquel (quetiapine), an atypical anti-psychotic medication, for the bipolar disorder.

At the VA Compensation and Pension (C&P) examination dated 27 March 2007, performed 6 months after separation, the CI reported details of being told inappropriate jokes and not stopping the individual.  That lead to his being charged under the UCMJ and awaiting a Captain’s Mast.  Apparently, he also threw his command chief against the wall prior to the hospitalization for the bipolar disorder in March 2006, although he did not remember the details.  Earlier in his Navy career, the CI served in the Middle East in 1999 and again in 2000-2002, worked on aircraft, and flew in a KC-10 tanker over the combat zone.  However, there was no direct combat where he was located.  After separation on 30 September 2006, he took medication until about November 2006 when it ran out; however, he did attend some outpatient group sessions at a Vet Center.  His depression and anxiety appeared to be mild most of the time with some worsening, but no readily apparent exacerbations even without medication.  The depression occurred “a couple of times a week” with some reported hypomanic episodes also occurring.  The examiner noted the CI’s affect was serious and his mood was anxious and depressed, but his symptoms appeared to be mild and intermittent.  The CI often had 2-to-3 hours of sleep a night and usually had 4-to-6.  He also had occasional panic attacks and suicidal thoughts.  Short term memory was mildly impaired.  Although he had testing suggestive of moderate depression and significant anxiety, the examiner opined the CI’s clinical presentation suggested somewhat lesser symptoms.  The diagnosis of bipolar I disorder (unspecified) was supported by the his mental health history; however, the examiner noted the CI’s presentation at the examination was less clear for that diagnosis, but it appeared “appropriate to attribute the anxiety and depressive symptoms . . . as being related to the same disorder.”  No other mental disorders were found; and substance abuse did not play any role in the CI’s condition.  His GAF was 64 (mild symptoms) related to anxiety and depression with some mild difficulty in social function and slight impairment in occupational functioning.  He was able to work full-time and do a good job even without medication, although he had more problems with increased stress or if he felt others were evaluating him or his actions.  More than 8 months after separation the CI was followed by a VA social work provider for anxiety beginning 19 June 2007.  Screening tests were negative for PTSD and positive for depression.  Psychiatric evaluation on 3 August 2007 revealed a history of an overdose in 2000 on ephedrine and that the CI was treated with several medications while in the service, but he went “cold turkey” due to not being able to pay for his medications after separation and came to be “in a depressed state where the whole world is on top of me.”  However, he worked as a technician and had a GAF of 65; and his Effexor medication was resumed.  At a follow-up on 4 September 2007, the CI noted some improvement in depressive symptoms and mood stability; and medication dose was increased.   Adding Buspar was considered for the CI’s anxiety, but its use was deferred pending determination of possible interactions with other medication.

The Board directed its attention to its rating recommendation based on the above evidence.  The Board first deliberated whether VASRD §4.129 (for any “mental disorder that develops in service as a result of a highly stressful event”) is applicable to this case.  All members agreed that the bipolar disorder was not related to a highly stressful event.  The VA examination indicated that although the CI was both in and flew over a combat zone, there was no exposure to combat or any traumatic event; and the service treatment record did not support any highly stressful event, although the CI faced a potential Captain’s Mast.  Therefore, the Board determined that the bipolar disorder was independent of any significant highly stressful event; and, VASRD §4.129 is not applicable in this case.  The Board turned to deliberation of a fair rating recommendation at the time of separation; this derived from criteria of VASRD §4.130 and based on the disability evidenced in the service record at the time of separation.  The PEB assigned a 10% rating using code 9432 for bipolar I disorder, while the VA likewise used code 9432 for the bipolar disorder and assigned a 10% rating, which is based upon “[o]ccupational 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.”  However, the Board sought a route for a higher rating at 30%, which requires: 

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), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).

The Board noted the CI had GAF scores of 55-65 (moderate to mild symptoms) during the NARSUM examination, 64 (mild symptoms) at the VA C&P examination, and 65 (mild symptoms) at a VA clinic several months later.  However, he did note stress when under pressure and did report a depressed mood, anxiety, panic attacks, sleep impairment, and mild memory loss.  Additionally, he took multiple medications prior to separation, although he went for a period of time after separation with any severe exacerbations and was able to maintain employment.  The Board discussed and carefully considered whether the CI’s condition at the time of separation warranted a 30% rating since he did have both symptoms and was taking many prescribed medications to achieve a GAF score in the moderate to mild range, albeit he could not perform the duties of his Military Occupational Specialty.  However, the Board noted that the CI was working upon separation, had satisfactory social interactions with family and friends, and was again on medication.  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 of the bipolar I 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.  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 l 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 20140429, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 29 Sep 15

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN