RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03006
BRANCH OF SERVICE:  NAVY	SEPARATION DATE:  20020401

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Information Systems Support Technician, medically separated for “bipolar I disorder with psychotic features,” with a disability rating of 10%.

CI CONTENTION: “Please consider 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 - 20011210	VARD – 20030417 and 20030723	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar I Disorder	9432	10%	Bipolar Disorder Type I	9432	10%	20030205	
Mechanical Low Back Pain	Cat III	DDD, Lumbar Spine	5293-5292	20%	20030528	
[Bilateral] Patella Femoral Syndrome		Right Knee Osteoarthritis 	5003-5260	10%		
		Left Knee Osteoarthritis	5003-5260	10%		
Borderline Personality Disorder	Cat IV	Borderline Personality Disorder	9499-9435	NSC	20030205	
		PTSD	9411	Denied		
Alcohol Dependence		No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Bipolar Disorder (Subsuming the Category IV Conditions).  The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented a history of childhood abuse and depression (one suicidal gesture at age 16).  The CI’s first contact with nental health (MH) providers was in July 1998 (4 months after entry), as a command referral for “issues with anger.”  He related a history that his girlfriend was raped by his best friend in the months preceding enlistment and he drank heavily since then.  This resulted in Axis I diagnoses of post-traumatic stress disorder (PTSD) and alcohol dependency, and an Axis II diagnosis of borderline personality disorder.  The next MH entry in the available STR was a referral for “substance abuse and anger.”  The mental status examination (MSE) was normal and the axis diagnoses remained the same, although the PTSD was characterized as “probable” and existing prior to service (EPTS).  The psychiatrist at that time recommended consideration of administrative separation, but there was no STR evidence of a command response.  There were few MH entries in the available STR for the following 2 years, and those reflected ongoing alcohol treatment indicating there were two relapses.  In May 2001 (11 months before separation) the CI was command referred to psychiatry for “bizarre behavior” in the context of a drinking binge.  He reported cyclical depression and anxiety with a recent hypomanic episode (spending spree), and was admitted for psychiatric stabilization (4-day stay).  The Axis I diagnoses at discharge were “bipolar I disorder” and alcohol dependence (EPTS) with Axis II borderline personality disorder (“antisocial features”); and, the CI was referred for an MEB.  Those diagnoses were corroborated by neuropsychological testing (cognitive testing was normal).  The follow-up outpatient entries from the interval to separation reflected a stable, improving course; documenting compliance with medications (Zyprexa, Lithium) and psychotherapy (weekly); and, abstinence from alcohol.

The MEB psychiatric NARSUM in September 2001 (7 months before separation) corroborated the above evidence and documented an interim recurrence of “distractibility and racing thoughts” that was currently responding to medication adjustment.  The MSE recorded an “anxious” mood with a “full ranging and congruent” affect.  The examiner noted difficulty with concentration and “some paranoia;” but, there was no suicidal ideation, delusional or hallucinatory content, speech disturbance, objective cognitive impairment, or other abnormality.  The Axis I and II diagnoses were identical to those above (same psychiatrist), and constituted the MEB submissions to the Physical Evaluation Board (PEB).  The NARSUM stated that the CI “can perform the duties of his rating on shore ... [although he] ... continues to be unsuitable for sea duty;” but, opined that “impairment for civilian employment is moderate to severe.”  The commander’s non-medical assessment (NMA) stated the CI was “performing above average” in his rating, and did not note any behavioral issues or cognitive impairment.

A NARSUM addendum by the same psychiatrist was submitted in January 2002 (2 months before separation), stating it was “presented to assist the patient in his rebuttal” of the PEB’s 10% determination.  It documented continued compliance with treatment and alcohol abstinence; and, opined, “Despite mild to moderate improvement ... over the past seven months, the patient continues to experience recurrent manic and depressive symptoms ... impairment for social and industrial adaptability is severe in that he will require a work environment that is stable, routine, and unlikely to induce significant stress.”  The PEB’s decision memorandum was dated the day after the addendum, and there was no record of formal acknowledgement of the opinions expressed in the psychiatric addendum.  

At the VA Compensation and Pension (C&P) general examination dated 07 February 2003 (10 months after separation) documented continued maintenance on the above medications but no active psychotherapy.  The CI endorsed “some slight mood swings, but nothing of concern” and denied depression or any manic (or hypomanic) episodes.  The CI was employed in his field (telecommunications specialist) and “feels that he is functioning well in the workplace.”  He was recently married and there was no documentation of any domestic strife or social impairment.  The MSE recorded a “euthymic” mood but “slightly restricted and anxious” affect, and was otherwise normal.  The Axis I diagnoses were “bipolar disorder, Type 1,” PTSD “in partial remission,” and alcohol dependence “in full remission,” with an Axis II diagnosis of borderline personality disorder “by history.”  The Global Assessment of Functioning (GAF) assignment was 65-75 (mild to slight impairment).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB conferred a 10% rating under code 9432 (bipolar disorder) without reference to DoD or Service criteria.  The PEB additionally listed alcohol dependence and borderline personality disorder as Category IV (not constituting a ratable physical disability).  The VA’s 10% rating under the same code was based on the above post-separation C&P evidence and quoted the VASRD §4.130 10% criteria, “occupational and social impairment due to mild or transient symptoms which decrease work efficiency … only during periods of significant stress, or; symptoms controlled by continuous medication.”  Members agreed that the Category IV conditions were not subject to rating as specified by DoDI 1332.38 (Enclosure 5); although, the contribution of these conditions to the overall psychiatric impairment rated under criteria of §4.130 was impossible to quantify as a formal deduction.  Members also agreed that the provisions of VASRD §4.129 for any “mental disorder that develops in service as a result of a highly stressful event” were not applicable to this case (primarily organic diagnosis with no distinct service stressor).   

The Board then turned to deliberation of a fair rating recommendation under criteria of §4.130 at the time of separation.  Members first agreed the reasonably intact functioning evidenced at separation would not support the §4.130 criteria for a 50% rating (“occupational and social impairment with reduced reliability and productivity”, and exampling acute features not in evidence).  Deliberations thus settled on recommendations for a 10% rating (as above) vs. a 30% rating (“occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks”).  Members carefully considered the MEB psychiatrist’s opinion as expressed in the addendum; but, agreed that it was not borne out by the objective evidence documented by the post-separation C&P psychiatrist.  That indicated that the CI made a rapid and successful transition to civilian employment; and, there was no suggestion this required any workplace accommodation as predicted in the addendum.  The C&P evidence reflected relatively unimpeded social and occupational functioning, and the resulting 10% rating by the VA was well grounded in the applicable §4.130 criteria.   The objective evidence at the time of separation (clinical entries in the STR, the NARSUM functional assessment, and the commander’s NMA) was better aligned with the §4.130 criteria for a 10% rating than with those for 30%.  It was also relevant that the CI’s overall MH impairment was correlated with his success at managing the (unratable) alcohol dependency.  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 disorder.  

Contended PEB Conditions:  Mechanical Low Back Pain and [Bilateral] Patellofemoral Syndrome.  The CI experienced an atraumatic onset of bilateral knee pain in September 2000 which was associated with mild degenerative changes and no ligamental, meniscal, or other structural pathology (non-surgical).  This resulted in a period of limited duty (LIMDU) from which he was removed and returned to duty in May 2001 (11 months before separation).  Outpatient STR clinical entries confirmed a normal gait, normal to near-normal range of motion (ROM), and the absence of instability or impingement.  The CI suffered a strain injury to his back in August 2001 (11 months before separation) and was subsequently diagnosed (MRI) with mild multi-level degenerative disc disease (T12-S1, no herniation or neural impingement).  This was managed conservatively (no surgical indications) and did not result in LIMDU.  Outpatient STR clinical entries documented normal neurological findings and an improving course with no indication of significant ROM limitation or incapacitation.  

An orthopedic addendum to the NARSUM in September 2001 (7 months before separation) opined the knee condition was “chronic ... [and] ... not activity limiting,” was amendable to continued conservative management, and the CI was orthopedically cleared for a psychiatric PEB.  The commander’s NMA (4 days before the orthopedic addendum) referenced only the knee condition and conveyed an understanding that the CI was still on LIMDU, although this had expired several months earlier (see above).  A general C&P examination contemporary with the above psychiatric C&P (10 months after separation) corroborated full employment status; noted “occasional” treatment of knee pain with anti-inflammatories; and, stated “currently his back is pretty stable.”   The physical examination (and that from an earlier orthopedic C&P) recorded normal gait and neurological findings, without significant abnormalities of the knees or lumbar spine (flexion 65 degrees for VA 20% rating).  

The Board’s main charge was to assess the fairness of the PEB’s determination that the bilateral knee and lumbar spine conditions were not unfitting (Category IV).  Although the knee condition was non-specifically implicated in the commander’s NMA, there was ample contemporary and subsequent evidence that no significant limitation of duties was imposed by the condition at the time of separation.  Members agreed that there was no performance-based evidence indicating that the knee or back conditions interfered with duty requirements to an extent that would have prohibited further military service.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded there was insufficient cause to recommend a change in the PEB fitness determinations for the bilateral knee and lumbar spine conditions; thus, neither was eligible for rating.  

BOARD FINDINGS:  In the matter of the bipolar disorder and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended bilateral knee and lumbar spine conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  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 20140514, 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 20 Oct 16

      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:

		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN