RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03168
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20100218

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Linguist, medically separated for “bipolar disorder”  with a disability rating of 10%.

CI CONTENTION:  The CI requests the Board 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 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:  

SERVICE PEB - 20091106	VARD - 20100908	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder	9432	10%	Bipolar Disorder with PTSD
	9432-9411
	50%
	20100701
	
Post-Traumatic Stress Disorder in Partial Remission	Cat III					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Bipolar Disorder.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bipolar condition began on or about February 2004 after she was reportedly raped in the military by a male acquaintance.  Although she reported a depression “off and on” and self-mutilation when feeling distressed during her teen years, there was no medical documentation of diagnosis and treatment of any mental disorder until after the rape.  
She sought psychiatric treatment for the first time in the military after 6 years of service, and the STR supported a diagnosis of PTSD and remission of symptoms after several months of treatment.  However, she continued to receive trials of anti-depression medications between 2004 and 2008.  She reported that she had been able to perform her duties without incident until the rape.  Stabilization with medications was extremely difficult due to consistent and recurring problems with side effects.  

The CI had reported during a psychiatric visit in April 2008 that the most significant stressor in her life was that her husband had reported he was leaving.  In July 2008 she was removed from her duties due to concerns that her disorder impaired her judgment and reliability as related to classified materials.  This was a permanent duty restriction.  In August 2008, she reported auditory and visual hallucinations of 2 weeks.  She was hospitalized on an in-patient psychiatric unit for 6 days and symptoms abated with psychotropic medication.  The September 2008 NARSUM examination was conducted the next day during a follow-up visit.  She reported hypomanic symptoms of mood swings, irritability and racing thoughts and side effects of her medication.  Diagnoses of bipolar disorder, existing prior to service (EPTS) and PTSD in remission and medically acceptable were rendered.  

The CI disagreed with several findings in the NARSUM examination and submitted a statement in which she associated the onset of hypomanic symptoms, including a marked decreased need of sleep, with the anti-depression medication.  She attributed the onset of her first “true depression” to the 2004 rape, and to post-partum depressive episodes.  She noted that she did not receive a diagnosis of bipolar disorder until after the rape, the anti-depression medications, and post-partum depression.  She denied the bipolar illness was EPTS, given the lack of diagnosis and treatment prior to entering the military.  The November 2008 addendum noted the NARSUM diagnoses were upheld and no changes were made.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated May 2009, 9 months prior to separation, the CI reported a 2-week in-patient psychiatric hospitalization and a 1 week in-patient psychiatric hospitalization without documenting the dates.  The CI was being treated for bipolar disorder with a mood stabilizer and counseling.  

At the 2009 NARSUM examination, the CI reported mild mood changes with brief hypomanic symptoms (decreased sleep, high energy level) and depressive symptoms daily lasting from 20 minutes to the whole day.  Her only continuous symptom was mild distractibility.  She had nightly nightmares and hypervigilance.  She was being treated with light therapy and yoga and did not wish to resume medication, due to side effects, unless necessary.  Her supervisor noted she was working outside her occupational specialty due to suspension of her security clearance due to her psychiatric illness.  She performed routine administrative tasks and interacted with others without problems.  Mental status examination (MSE) was essentially normal.  She was clinically and functionally stable but had a higher risk for recurrence.  Diagnoses of bipolar disorder in partial remission and PTSD in partial remission were rendered.  The PTSD was noted to be medically acceptable.  Occupational and social impairment with reduced reliability and productivity precluded her working in her MOS at the time.  

At the VA Compensation and Pension (C&P) examination for PTSD in July 2010, performed 4 months after separation, the CI stated that she reported the 2004 rape to the military and civilian authorities and named the man.  She had been raped pre-military when she was 18.  The first hospitalization occurred immediately after the first rape and the second hospitalization occurred due to symptoms of bipolar disorder at a military facility.  She reported she was raped again in November 2008 by an assailant from the Navy with whom she fought but does not recall the event.  She did not report this assault because nothing happened after she reported the first rape.  
Current symptoms included irritability, minor depression that lasted a day, goal oriented behaviors, restlessness and racing thoughts.  She also reported PTSD symptoms, including dissociative events.  She stated she had lost 4 weeks from work in the past year due to flashbacks.  

Social interactions were unpredictable due to her mood.  She had no infractions other than two counseling letters for being late.  She was attending college on a work study program in pursuit of a degree.  Work included two jobs teaching at the gym twice a week and working at the Veteran’s Resource Center.  She spent time with her children three nights a week and weekends and was physically active outdoors.  MSE was essentially unremarkable.  Diagnoses of PTSD and bipolar I were rendered and Global Assessment of Functioning (GAF) score of 60 (moderate bordering on mild symptoms, impairment.)  

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating under the 9432 code (bipolar disorder) citing report that the condition was in partial remission.  The PEB adjudicated the PTSD condition as not separately unfitting and not contributing to the unfitting condition, thereby receiving the Category III designation.  

The VA assigned a 50% rating using an analogous 9432-9411 code (bipolar disorder with PTSD) based on the VA C&P examination 4 months after separation, citing sleep impairment, concentration difficulty and dysphoric mood with a comprehensive disability picture that showed moderate impairment.  Application of VASRD §4.129 is considered by the Board for all cases of service connected psychiatric conditions resulting in separation; but, members agreed that the “highly stressful event” requisite for §4.129 was not satisfied in this case.  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.  Members deliberated whether a rating higher than 10% was appropriate at 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.”  

According to the 2009 NARSUM, the CI reported symptoms of hypomania and PTSD and had accepted non-medicine therapies since she had many side effects with medication.  She was reportedly stable clinically and functionally.  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 condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that PTSD was not unfitting.  The PEB determined the PTSD condition was in partial remission and therefore assigned it as Category III not separately unfitting.  The PTSD was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.   There was no performance-based evidence from the record that the PTSD significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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  PTSD and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the bipolar condition and IAW VASRD §4.124, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended PTSD condition, the Board unanimously recommends no change from the PEB determination 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 2 July 2014, with attachments
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 6 Jul 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:

		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC

						  	XXXXXXXXXXXXXXXXXXXX
	     				  		Assistant General Counsel
						  	(Manpower & Reserve Affairs)