RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03095
BRANCH OF SERVICE:  AIR FORCE  		separation DATE:  20160114

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Security Forces) medically separated for Bipolar II disorder, rated 10%.

CI CONTENTION:  “Consider all conditions.”  The Applicant’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 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 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:    

SERVICE PEB - 20040503	VARD - 20121101	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder II	9432	10%	Bipolar Disorder	NSC	---	20041005	
Personality Disorder	Cat III	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS: ---	

ANALYSIS SUMMARY:   

Bipolar Disorder II Condition.   Service treatment records indicated the CI was first seen in Mental Health (MH) in December 2003 secondary to multiple personal stressors.  She was diagnosed with occupational problems and uncomplicated bereavement, and was determined to be of low risk for harm to self or others.  Treatment records fall silent until April 2004.  The narrative summary (NARSUM) was accomplished approximately 2 weeks prior to separation.  The NARSUM noted that the CI was admitted to inpatient psychiatry on 9 April 2004.  She reportedly had become combative and required transport to the local emergency room.  While in the ER she required physical restraints. Whenever she was released from restraints, she would act out suicidal behaviors and was subsequently admitted to the inpatient unit.  She admitted to auditory hallucinations and reportedly felt the devil was speaking with her.  She also demonstrated delusions of persecution.  She was discharged a week later with the diagnoses of psychosis, not otherwise specified and depression, not otherwise specified, and was discharged on Effexor (antidepressant) and Zyprexa (antipsychotic) medications.   The mental status examination (MSE) at the NARSUM recorded increase in psychomotor activity, with abnormal affect documented as “irritable, anxious and dysphoric, full range, labile and somewhat inappropriate at times.”  Her insight and judgment were felt to be historically poor, and cognitive functioning was intact.  The Axis I diagnosis of Bipolar II disorder severe with psychotic features, chronic, in partial remission, was recorded with a Global Assessment of Functioning (GAF) score of 55 (moderate impairment or moderate symptoms).  An Axis II diagnosis of personality disorder, not otherwise specified was also recorded.  The physician recommended permanent Personal Reliability Program decertification which meant she would no longer be eligible to work in her primary AFS.  An addendum to the NARSUM noted that the CI was hospitalized on the day of the NARSUM after experiencing “some minor conflict at her work location.”  The CI reportedly took an overdose of her prescribed medications in a suicide attempt.  During the hospitalization, the antidepressant medication was discontinued; however, she was continued on the antipsychotic medication and another mood stabilizing medication was added (Depakote, 1500mg daily).  The psychiatrist wrote, “At this time, the treating psychiatrist (by record is the same psychiatrist who prepared the NARSUM and addendum) is looking into possible transfer to a state facility for long term care.”

At the VA Compensation and Pension (C&P) exam, 5 months post-separation, the CI reported that since leaving the service she lived briefly with her father who was physically abusive and this caused her to move out.  She had lived in her car for a couple of weeks but when she enrolled in a community college she was given housing.  She was not doing well in school and noted that she had been out of her medications for the past 3 months.  Since she had been out of medications, she had a problem keeping her mood stable.  MSE was unremarkable, and a GAF of 60 (cusp of mild and moderate) was documented.  The examiner wrote, “The examiner opines that her current psychiatric problems are more likely than not unrelated and not caused by her brief military service in the Air Force.”

The Board directed its attention to the rating recommendation based on the evidence just described.  The PEB rated the condition of Bipolar II disorder at 30% coded 9432 with a 20% deduction for contributing/aggravating factors.  The personality disorder was adjudicated as a Category III condition (not separately unfitting and not compensable or ratable).  The VA did not service-connect the condition of Bipolar disorder and the VARD noted that the preponderance of evidence showed the condition existed prior to service.  The Board first noted there was no specific, highly stressful service related event to invoke §4.129 for a mental disorder due to traumatic stress.  The Board next considered the rating deduction.  The Board next noted that IAW DoDI 1332.38, enclosure 5, the personality disorder which was found to be not separately unfitting is not a condition that constitutes a physical disability and therefore is not eligible for service disability rating and the Bipolar disorder was the sole MH condition eligible for disability rating.  However, MH disability rating is based on total social and occupational functioning.  The PEB’s AF Form 356 did not offer a rationale for this determination; however, the Board surmised that the deduction likely reflects the personality disorder diagnosis. All members agreed that the PEB’s deduction could not be upheld for the following reasons.  First, the contribution from a diagnosis of personality disorder, on which the PEB deduction hinges, is very tenuous.  Although the psychiatrist diagnosed personality disorder, there was no documentation to support that the CI’s behavioral issues were not the by- product of the primary Bipolar diagnosis.  In fact, the psychiatrist recorded “suicidal gestures” as one of the manifestations of the Bipolar condition.  There were no symptoms or behaviors directly attributable to the personality disorder.  Lastly, the process of clinically extricating the disability attributed to one diagnosis versus the other in cases involving psychiatric disorders is overly speculative without a directed opinion from the examiner addressing the degree of contribution from each diagnosis.  DoDI 1332.38 specifically requires PEBs and MEBs apportion out the non-compensable portion of a mental health disability if ascertainable.  No such input from a psychiatrist was provided; thus the Board could not fairly apportion a deduction even if the competing diagnosis were not in question.  All Board members agreed, there is sufficient evidence to support a disturbance in mood in which a personality disorder may have contributed negatively; however, there was insufficient evidence to support the notion that in the absence of a personality disorder, her Bipolar disorder would have had no or minimal impact on occupational functioning.  All members agreed that the PEB’s deduction could not be upheld for application to the Board’s recommendation.  The Board next proceeded with the rating recommendation IAW VARSD 4.130. The 30% rating is for “Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.”  All Board members agreed this rating was approached.  The higher rating of 50% requires evidence of “Occupational and social impairment with reduced reliability and productivity.  The NARSUM, 2 weeks prior to separation, documented a MSE that showed increase in psychomotor activity, abnormal affect, and poor judgment.  Military duty impairment was noted to be marked.  The psychiatrist noted that her condition was in partial remission; however, on that same day she made a suicide attempt and was again hospitalized.  The same psychiatrist wrote in an addendum one week before separation, “At this time, the treating psychiatrist is looking into possible transfer to a state facility for long term care.” After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board recommends a 50% disability rating (no deduction) for the Bipolar II disorder.

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 II condition, the Board unanimously recommends a disability rating of 50%, coded 9432 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Bipolar Disorder II 	9432	50%	
RATING	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140619, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-03095.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

Attachment:
Record of Proceedings 

cc:
SAF/MRBR 
DFAS-IN