RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02998
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080819

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Combat Medic, medically separated for “bipolar disorder, type II,” with a disability rating of 10%.

CI CONTENTION:  The CI requests consideration of all conditions.  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 based upon a 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:  

SERVICE PEB – 20080530	VARD - 20081208	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder, Type II	9434	10%	PTSD w/Bipolar II Disorder, Hypomania And Depression	9432-9411	50%	20081023	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Bipolar Disorder, Type II.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) psychiatric narrative summary (NARSUM), the CI’s bipolar II condition began in 2005 during his first deployment to Iraq as a combat medic from February 2004-February 2005.  He witnessed persons killed, wounded, or dead, engaged in direct combat where he discharged his weapon, and felt he was in great danger of being killed.  He developed nightmares and flashbacks and was treated by a psychiatrist in Iraq.  He had worsening problems while deployed to Katrina in 2005 and reported to a psychiatrist that he was having vivid flashbacks of events in Iraq and was treated with anti-depression medication.  He then developed symptoms of bipolar illness and began to experiment in 2006 with ecstasy and crystal meth.  He was hospitalized for 10 days for his substance abuse as well as extreme mood swings and suicidal ideation.  Hypomania symptoms were noted to be possibly related to the anti-depression medication, which was discontinued.  Medications were changed and he was treated as an outpatient from 2006-2007.  Symptoms improved significantly as he received individual and group therapy and medications were changed again.  Prior to deployment to Iraq in October 2007 he discontinued his medications since they made him drowsy.  He was medically evacuated and again reported traumatic exposures on the Post-Deployment Health Assessment in January 2008.  He reported nightmares, avoidance, hypervigilance, and detachment.  Hypomania symptoms returned and he had verbal altercations with other officers.  A diagnosis of bipolar disorder was rendered although the STR referenced a previous diagnosis of posttraumatic stress disorder (PTSD).  He had no history of psychiatric illness prior to deployment to Iraq.  He was taking two psychotropic medications.  Mental status examination (MSE) was unremarkable.  Diagnosis of bipolar II was rendered.  The examiner noted his mental illness impacts his work, his ability to sustain a marriage and his ability to refrain from impulsive actions.  STRs from May 2008 noted that he was taking one anti-depression medication because the other medications made him groggy.  He had a flashback of an incident that occurred in Iraq and had to leave his work in the emergency room.  He did not follow-up with mental health because he did not feel they were “doing anything.” 

At the VA Compensation and Pension (C&P) mental disorders examination performed 2 months after separation, the CI reported nightmares and intrusive thoughts several times weekly, hypervigilance and avoiding combat themed movies and Iraq-related news.  He drove down the middle of the road to avoid explosive devices.  He denied the use of drugs.  After separation he worked swing shifts with a 40-hour week.  He also volunteered as a resuscitation instructor and was involved in fund raising activities.  He was taking two mood stabilizing medications.  He lived with his parents, had no social activities or relationships and interacted with few people outside of fellow workers and worked constantly.  MSE showed he was very talkative, and anxious when discussing Iraq.  He reported an overdose of medication in August 2008 which he did not report but denied current suicidal ideation.  He reported he was in a hypomanic episode for the past two weeks and was struggling against being down and trying to maintain his performance on his job.  Diagnoses of bipolar disorder and PTSD were rendered with a Global Assessment of Functioning (GAF) score of 55 (moderate symptoms, impairment.)  The examiner noted that the PTSD appeared to be a major sustainer and stressor of his bipolar disorder.  

The October 2009 VA C&P examination provided historical content.  The CI reported after discharge he worked from October-November 2008 and from January to June 2009 as an emergency medical technician.  The work was difficult due to the close environment which would trigger intrusive thoughts and anxiety.  He had not worked since June and had limited activities of daily living.  He stayed around the house, watched TV and tried to read.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the bipolar II condition 10% coded 9432 (bipolar disorder), citing mild/transient symptoms controlled by continuous medication.  The VA rated the bipolar II condition 50% coded 9432-9411 (PTSD with bipolar disorder), based on the VA C&P examination 2 months after separation, citing reduced reliability and productivity.  

The Board first considered if application of VASRD §4.129 with a 6 month (50% minimum) period on the TDRL was indicated in this case (per Board directive from DOD.)  Members agreed that the provisions of VASRD §4.129 were applicable in this case due to the traumatic combat experiences.  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 Panel then considered if there was evidence for a §4.130 rating higher than the §4.129 minimum mandated 50% at time of TDRL placement.  The Panel agreed that the §4.130 criteria for a rating higher than 50% were not met near the time of separation, and therefore the minimum 50% initial TDRL rating is applicable at the time of TDRL placement.  

The most proximate source of comprehensive evidence on which to base the permanent rating is the VA C&P examination dated October 2008, performed two months post-separation.  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 CI reported he was working in emergency medical services and volunteering.  However, he reported that despite taking significant doses of two psychotropic medications, he was struggling with symptoms of hypomania, trying to keep his job, anxiety and depression, social isolation, and constant need to engage in goal-directed activity.  The 2009 C&P examination noted he was unable to maintain employment.  The Board agreed the CI fulfilled criteria for a 30% disability rating.  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 6-months of constructive TDRL and a 30% permanent rating thereafter for the bipolar condition.

BOARD FINDINGS:  In the matter of the bipolar disorder condition, the Board unanimously recommends a disability rating of 50%, coded 9432 IAW VASRD §4.129 for 6 months from the time of discharge consistent with a constructive period of TDRL and then a permanent separation rating of 30% IAW VASRD §4.130. 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; a 6-month period on TDRL with a disability rating of 50% (IAW §4.129) and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, with a rating of 30%, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Bipolar Disorder	9432	50%	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140516, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXX, AR20160013315 (PD201402998)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to  constructively place the individual on the Temporary Disability Retired List (TDRL) at 
50% disability for six months effective the date of the individual’s original medical separation for disability with severance pay and then following this six month period re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30%.

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of temporary disability effective the date of the original medical separation for disability with severance pay.

b.  Providing orders showing that the individual was retired with permanent disability effective the day following the six month TDRL period.

c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, provide 50% retired pay for the constructive temporary disability retired six month period effective the date of the individual’s original medical separation and then payment of permanent disability retired pay at 30% effective the day following the constructive six month TDRL period.  

d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA