RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03259
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050917

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Guard on temporary tour of duty E-5, Human Resources Specialist, medically separated for Bipolar disorder, rated 10%.

CI CONTENTION:  “Please consider all conditions”

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 condition 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 Admin IPEB – Dated 20050804	VA* - (~6 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder	9432	10%	Bipolar Disorder	9432	30%	20060327	
Recurrent Genital Herpes	Not Unfitting	Genital Herpes	7820-7806	10%	20060314	
Osteoarthritis Knees	Not Unfitting	Patellofemoral Syndrome Left Knee	5099-5014	10%	20060314	
		Patellofemoral Syndrome Right Knee	5099-5014	10%	20060314	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0	
RATING: 10%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20060428 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:

Bipolar Disorder.  The narrative summary (NARSUM) noted that he reported childhood history of depression; however, was never seen for depression until March 2003.  The CI took an antidepressant medication (Paxil) for 5 months in 2003.  His depression was somewhat responsive to the combination of medication and talk therapy; however, his condition deteriorated after his divorce and subsequent separation from his girlfriend.  He was also having a great deal of stress at work.  In December 2003, the CI became suicidal and planned to shoot himself with his revolver.  He presented to the emergency room (ER) and was subsequently hospitalized for one week (31 Dec-6 Jan 04) with the diagnosis of major depression, recurrent (MDD).  His condition stabilized with outpatient treatment and he was able to work as long as 20 hours a day for several weeks.  He again developed increased symptoms of depression and was deemed non-deployable by his psychiatrist.  He continued his participation in mental health treatment.  In January 2005, he was diagnosed with bipolar disorder and started on a different antidepressant (Wellbutrin) and an antipsychotic medication for mood stabilization (Seroquel).  The psychiatrist initially documented the CI’s condition had impacted his ability to perform his duties, stating, “He is not likely retainable in the military because he will require chronic treatment with mood stabilizers.”  However, this statement was later modified in January 2005.  The psychiatrist wrote, “Patient has always been able to do his duty in the military without medications…there is no reason to believe that he will not be able to do his duty in the future, with or without medications.”  The commander’s statement noted observations of the CI suggested significant impairment in his ability to perform his duties.  The commander noted that the CI began having problems with bouts of depression beginning in December 2003.  While mobilized (Jul-Sep 2004) he missed many days of work, often 3-4 days a week due to his condition.  When he showed up to work, he was unfocused, anxious and restless.  The commander stated, “Although he often worked very long hours and under a heavy workload, his performance was less than adequate, this had negative effects on his section’s overall performance…”  It was noted that in late September 2004, the CI advised the commander that he was seriously contemplating suicide; he was admitted to medical hold facility.  The commander’s statement reflected observations made from September 2003-September 2004, prior to the Bipolar disorder diagnosis.  The NARSUM accomplished on 23 March 2005 did not record a mental status examination (MSE).  A Global Assessment of Functioning (GAF) score of 55 (moderate) was documented.  It was noted that his condition was stable on medications and that he was not currently suicidal, but had been in the past.  

The VA Compensation and Pension (C&P) exam was conducted approximately 6 months post-separation.  The examiner noted the CI had remained in outpatient treatment and was taking two anticonvulsant medications for mood stability.  The CI worked at a helpdesk answering phones, did not like this job, and this job represented a 47% pay cut from the pay he received in the Service.  He had been married for 2 years.  His mood symptoms fluctuated often from being very depressed with no energy to days of feeling very motivated with lots of energy.  He had fleeting thoughts of suicide.  His sleep was fair to poor depending on his mood state.  At times he felt hopeless.  He had a temper, but had no legal involvement.  MSE recorded dysphoric mood and mildly constricted affect, and no evidence of psychosis or a formal thought disorder.  The examiner recorded a GAF score of 45 (serious symptoms or serious impairment).

The Board directed its attention to its rating recommendation, based on the evidence just described.  The PEB assigned a 10% rating, rated as mild industrial impairment, requiring ongoing medication.  The VA granted a 30% rating under the same code, 9432 (Bipolar disorder).  The Board first unanimously agreed that VASRD §4.129 was not applicable in the absence of a highly stressful causative event.  The higher rating of 30% requires evidence of “Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.”  The Board undertook a review of the evidence and noted that the CI had no psychiatric hospitalizations in the 18 months before separation and no visits to the emergency room for acute care.  He initially presented with anger, irritability, and expressed suicidal ideations.  Although he continued to express suicidal thoughts, he remained safe, and reportedly continued to work, but with considerable impairment.  However, information regarding occupational functioning in the 9 months before separation was absent.  The NARSUM noted he had been complaint with his medication, his response had been good and that medication must be continued.  His treating psychiatrist wrote in January 2005 that the CI could function well with or without medication.  That evaluation was accomplished on 19 January 2005 and at the time the CI had a normal MSE, was sleeping well, did not have suicidal or homicidal ideations, and was considered stable with follow-up planned for 6 months or as needed.  However, clinic treatment entry dated 20 April 2005 noted the CI presented to the clinic with suicidal ideation and plans to use his gun.  He was not admitted to the hospital.  He noted that he had started school and was feeling more stressed.  In June 2005, he was seen by his treating psychiatrist who noted that his mood had been very good and he had been sleeping well without medication.  Follow-up was expected in 3 months.  In October 2005 (one month post separation), the CI is seen in follow-up with his psychiatrist who noted that his mood “has sagged the last month associated with the stress of working and going to school.”  One month later in follow-up, the psychiatrist wrote, “Patient’s mood has been quite good.”  He had maintained his employment and was sleeping about 6 hours at most and often tired during the day.  The Board noted that in the following months his condition took on a cyclical pattern of mood stability, mood instability, good sleep, poor sleep, and worsening anxiety which did stabilize after the C&P exam.  There was significant difficulty in adjusting his medication to control his symptoms. He underwent multiple medication changes and adjustment without any noted sustained benefit. The C&P mental exam documented work history and noted that he was working and did not have any apparent issues on the job, except he did not like it and was not making the money he once had made while in the service.  He reported chronic sleep impairment, achieving approximately 4-5 hours with medication, he had mood swings, a quick temper, but no report of violence, no panic attacks, impairment in judgment, or noted difficulty in establishing or maintaining relationships due to his mental health condition. In the months following the C&P exam, there is a pattern of symptom stability and significant improvement. He obtains employment that he enjoys, he now works 12 hours at work 5 days or nights per week and his work shift changes from days during the week to nights on the weekend so he can spend time with his family. He has continued with school, and the 1 September 2006 visit with his therapist noted he was doing better overall with life, stable on his medication and “things are good in his relationship.” The 13 September 2006 entry recorded “Vet was very up for this session”, his job status was now full time with benefits and he noted he had been frustrated with his work situation and hours but now feels he can settle in and focus on school and family.  The 10% disability rating is for “Occupational 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; best reflects his condition at separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends no change in the PEB adjudication for the condition Bipolar I disorder.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that recurrent genital herpes and osteoarthritis of knees were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  These contended conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation 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 the contended recurrent genital herpes and osteoarthritis of knees conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the Bipolar Disorder condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended recurrent genital herpes and osteoarthritis of knees 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 2014-03259, 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
for XXXXXXXXXXXXXXXXXXXXXXX AR20160004426 (PD201403259)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review
(DoD PDBR) recommendation and record of proceedings pertaining to the subject
individual. Under the authority of Title 10, United States Code, section 1554a, I accept
the Board's recommendation and hereby deny the individual's application.
This decision is final. The individual concerned, counsel (if any), and any Members of
Congress who have shown interest in this application have been notified of this decision
by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF:
( ) DoD PDBR
( ) DVA