RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03322
BRANCH OF SERVICE:  MARINE CORPS		SEPARATION DATE:  20050615

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Motor Vehicle Operator, medically separated for “bipolar I disorder” 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 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 - Dated 20050419	VARD - 20060919	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar I Disorder	9432	10%	Bipolar I with Psychotic Features	9432	50%	20060815	
Borderline Personality Traits	Cat IV					
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:

Bipolar I Disorder.  According to service treatment records (STR), the CI was referred to the behavioral health clinic in January 2004 due to his report of depression and suicidal ideation.  Over the Christmas holidays he had developed thoughts of shooting himself with his gun while standing duty.  He had experienced a sad, irritable mood since late adolescence and had suicidal ideation in times of adversity.  After the clinic evaluation, he received a diagnosis of dysthymic disorder and borderline personality traits.  He was treated with an anti-depression medication and symptoms resolved.  Shortly after he deployed to Iraq for a 7 month tour where he discontinued the medicine without a return of symptoms.  After redeployment, on or about 10 January 2005, he developed symptoms of mania, including euphoria, decreased sleep, racing thoughts, increased goal-directed activity, and impulsivity.  Due to bizarre behavior, excessive talk, disorganization and delusional ranting, he was taken to the emergency room 14 January 2005 where he was admitted into the inpatient psychiatric unit.  He remained for 9 days and was diagnosed with bipolar I disorder and treated with an anti-convulsion, mood-stabilizing agent.  On 2 February 2005, 4 months before separation, he was readmitted to the hospital with a return of psychotic symptoms.  The medical staff attempted to find the right balance of medication to mood-stabilizing; however, the CI’s condition was not stabilized.  The CI accepted this imbalance believing he did not have a bipolar disorder.  His condition could not be successfully treated to meet his military specialty and he was referred to a Medical Evaluation Board (MEB).  The MEB forwarded “bipolar affective disorder, manic, severe, specified as with psychotic behavior” to the Physical Evaluation Board (PEB) for adjudication.

At the MEB psychiatric narrative summary (NARSUM), also in February 2005, the CI noted he regularly experienced feelings of emptiness and boredom and identity disturbance.  The mental status exam noted rapid but not pressured speech and elevated mood.  He was taking an anti-convulsion and mood-stabilizing medication 3 times per day.  An Axis I diagnosis of bipolar I and Axis II note of borderline personality traits were rendered with a Global Assessment of Functioning (GAF) score of 60 (moderate symptoms, impairment).

The MEB NARSUM addendum documented a psychiatric admission on 21 March 2005, 3 months before separation, noting this was his third hospitalization in the past 2 months for symptoms consistent with mania: pressured speech, irritability, delusions of grandeur, decreased sleep, increased energy and impulsivity.  He reported he had been unable to tolerate various medications due to their serious side effects.  The mental status exam revealed slightly tangential thoughts, slightly grandiose thought content, poor judgment and poor insight.  He denied suicidal ideation.  A diagnosis of bipolar I disorder with psychotic features was rendered with a GAF score of 40 (impairment in reality testing, impairment in most areas.)  The examiner opined the degree of industrial, military and civilian impairment was severe.  He initially resisted medication but later agreed.  Mania resolved to hypomania but he would not take the medication on weekends and mania returned.  He remained on the inpatient unit and was noncompliant with treatment.  No commander’s statement was in evidence.

At the August 2006 VA Compensation and Pension (C&P) examination in August 2006, 14 months after separation, the CI reported trouble sleeping for 1 year due to panic attacks, auditory hallucinations, depression, social withdrawal, mood swings lasting 4-6 weeks, thoughts of killing that can last up to 4 weeks, and mania that included unusual spending behavior.  He had not received psychotherapy within the past year but was taking Prolixin (anti-psychotic medication) twice daily for the past 6 months and medication to counter side effects.  His last psychiatric hospitalization occurred in January 2006, 6 months after separation.  Since separation he worked in lawn care for 1 month and was a machinist for 2 weeks.  His relationships with his supervisors and co-workers was good.  The stress of work resulted in a suicidal ideation and hospitalization.  He reported writing a “hot check” which he paid back.  He was currently working in lawn care for a month and had an “ok” relationship with his supervisor and co-workers.  The mental status examination revealed he had auditory hallucinations which were transient and sometimes of a command nature, telling him to kill himself.  He had delusions which were intermittent, including one that somebody was after him all the time.  There was no acute psychosis evident.  A diagnosis of bipolar disorder I was rendered with a GAF score of 65 (mild symptoms, impairment.)   The examiner noted he was “not” mentally capable of managing benefit payments due to the stress of managing funds.  He was able to perform activities of daily living and could understand commands.  He had a fiancé though he had difficulty in establishing other relationships.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a rating of 10% for the mental health condition after performing a 20% deduction for non-compliance coded 9432 (bipolar disorder).  The VA assigned a 50% rating also coded 9432 without a noncompliance deduction.
The Board first determined that the CI’s mental health condition was not caused by a specific, highly stressful event to invoke §4.129 for a mental disorder due to traumatic stress.  The Board next considered the PEB’s noncompliance rating deduction.  The CI reported he was unable to tolerate various [anti-convulsion and mood-stabilizing] medications due to their serious side effects during his psychiatric hospitalization in March 2005, 3 months before separation.  The Board conceded even though he was non-compliant the CI continued to accept and utilize these medications, despite multiple medication trials, the unpleasant medication side effects, and his difficulty in accepting the bipolar diagnosis.  Additionally, the board also agreed that the mania components of the CI’s bipolar diagnosis at least in part could have reasonably attributable to the CI’s non-compliance.  IAW DoDI 1332.38, the Board determined the CI’s non-compliance was “reasonable” as the CI’s mental health condition was not “stable” and the PEB’s 20% rating deduction was “not consistent with medical facts.”  After due deliberation, the Board determined a non-compliance dedication was not applicable.

The Board next proceeded with the rating recommendation.  The Board noted the CI had undergone 3 hospitalizations within 6 months of separation.  Psychosis, mania and suicidal ideation were frequent recurring symptoms.  The MEB NARSUM addendum was completed 3 months prior to separation which indicated the CI that was never fully stabilized even while taking medication.  He had a functional score of 40, denoting serious symptoms and impairment.  The C&P examination, although beyond the period of probative value, did provide valuable historical data.  Post- separation, the CI had only been able to work intermittently up to 1 and a half months before becoming stressed and suicidal.  The Board agreed that the CI’s condition met criteria of a 70% rating at the time of separation.  After due deliberation, and in consideration of all the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 70% for the bipolar I condition coded 9434.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that borderline personality traits were not unfitting.  The Board agreed with the PEB designation of borderline personality traits as Category IV, is a condition that does not constitute a physical disability.  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 borderline personality traits condition and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the bipolar I condition, the Board recommends a disability rating of 70%, coded IAW VASRD §4.130.  In the matter of the contended borderline personality traits condition, the Board 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 single voter for dissent recommended re-characterization but at a lower rating and did not elect to submit a minority opinion.  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 the prior medical separation:

CONDITION	VASRD CODE	RATING	
Bipolar Disorder	9434	70%	
COMBINED	70%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140701, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 15 Apr 16 ICO XXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 23 May 16 ICO XXXXXXXXXXXXXXXXXX  
	(d) PDBR ltr dtd 27 May 16 ICO XXXXXXXXXXXXXXXXXX 
	(e) PDBR ltr dtd 23 May 16 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 23 May 16 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 09 May 16 ICO XXXXXXXXXXXXXXXXXX 
	(g) PDBR ltr dtd 27 May 16 ICO XXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 22 Jan 16 ICO XXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXXXXX 
	(i) PDBR ltr dtd 14 Apr 16 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (i) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Temporary Disability Retired List for six months with a 50 percent disability rating effective date of discharge followed by transfer to the Permanent Disability Retired List with a final rating of 30 percent (increased from 10 percent).

     b. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Temporary Disability Retired List for six months with a 50 percent disability rating effective date of discharge followed by transfer to the Permanent Disability Retired List with a final rating of 30 percent (increased from 10 percent).

     e. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 40 percent disability rating (increased from 10 percent) effect date of discharge. 

     f. XXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effect date of discharge.

     g. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     h. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge. 
     
     i. XXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 70 percent disability rating (increased from 10 percent) effect date of discharge.
 
     j. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effect date of discharge.       

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.

	XXXXXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)