RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03434
BRANCH OF SERVICE: Army 	SEPARATION DATE:  20070329

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Infantryman, medically separated for posttraumatic stress disorder (PTSD) with bipolar I disorder, rated at 10%. 

CI CONTENTION:  The CI contends for all of his 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 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:  

IPEB - Dated 20070201	VA* - (~4 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD comorbid with Bipolar Disorder	9411	10%	PTSD with Bipolar Disorder, mixed and Anxiety Disorder NOS	9432-9411	50%	20061205	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 9	
RATING:  10%	COMBINED RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20070424 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

PTSD comorbid with Bipolar I Disorder.  Service treatment records (STRs) noted the CI deployed to Iraq in 2003-2004 and again from 2005-2006.  He had many combat exposures during both deployments and sustained an injury to his back during the first deployment.  After his first deployment he was seen for about 15 counseling sessions in 2003.  His problems included insomnia, nightmares, guilt feelings and depressed mood.  He reported he saw more horror and death during the second deployment and sustained a concussion and loss of consciousness (LOC) for about 30 minutes after his vehicle was hit.  The narrative summary (NARSUM), dated September 2006, noted he was treated for acute PTSD in Iraq in October 2005.   The Compensation and Pension (C&P) examination, dated December 2006, noted he saw a counselor and a psychiatrist in Iraq and was diagnosed with major depression and treated with medicine for sleep and depression.  After his return he continued to hear news of combat trauma to friends and other Soldiers, resulting in a deepening depression.  The CI reported that when he was young, he was diagnosed as having attention deficit disorder (ADD) and placed on Ritalin and Adderall.  

The NARSUM examination, performed 6 months before separation, documented the CI was admitted to a psychiatric hospital in May 2006 for 3 days.  Symptoms included depression, irritability, suicidal thoughts, nightmares and distressing memories of deployment.  He described mood instability and racing thoughts. He had recently married but his wife was threatening to leave.  Diagnoses of bipolar disorder and PTSD were rendered and he was discharged with medicine for depression and mood instability.  Despite intensive outpatient treatment and medications, he was again hospitalized in a psychiatric hospital from 27 July to 7 August due to worsening depression.  Medications were changed and there was partial improvement.  Individual and marital therapy continued and he was referred for a Medical Evaluation Board (MEB).  The NARSUM examiner noted two checklist assessments for PTSD were consistent with a PTSD diagnosis.  At the mental status examination (MSE), the CI reported a mood that changed from depressed to irritable to inappropriately elevated.  There were no delusions or hallucinations and he denied suicidal or homicidal thoughts.  Diagnoses of bipolar I disorder and PTSD was rendered.  The examiner noted marked impairment for military duty and that he displayed signs of mental illness on examination.  He received an S3 profile.  The commander’s statement indicated he was physically incapable of performing his duties because of PTSD and bipolar disorder.  

At the C&P examination performed 3 months before separation, the CI noted he had flashbacks nearly every night and would become angry, irritated and impulsive.  He also had severe mood swings, at times feeling happy and at other times feeling depressed, withdrawn and frustrated.  He had mild to moderate symptoms of obsessive/compulsive disorder and a fear of spiders.  Occasionally, he had anxiety with shaking and trembling with palpitations and excessive sweating.  He endorsed symptoms of PTSD and had trouble falling asleep.  He did not like to go to the mall or restaurants.  He was taking two medications for depression and one medication for sleep.  His wife was pregnant but was asking for a divorce and wanted an abortion.  He wanted to find a job that did not require association with a lot of people.  He wanted to be a police officer but did not think he could do that job.  MSE indicated an anxious mood, a constricted affect, fair attention, concentration and forgetfulness.  He had anxiety attacks but no evidence of panic attacks.  Judgment and memory were intact.  He had suicidal ideation and plans in the previous 4 months but none that were current.  Diagnoses of PTSD, bipolar disorder, and anxiety disorder, not otherwise specified (NOS) were rendered with a Global Assessment of Functioning (GAF) score of 60 (moderate bordering on mild impairment, symptoms).  The VARD assigned a 50% disability rating for PTSD with bipolar disorder and anxiety disorder.

The Board directed attention to its rating recommendation based on the above evidence.  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.  The Board first considered if application of VASRD §4.129 with a 6 month (50% minimum) period on the TDRL was indicated in this case.  Board members agreed that the provisions of VASRD §4.129 were applicable in this case due to the combat experiences.  The Board then considered if there was evidence for a §4.130 rating higher than the §4.129 minimum mandated 50% at time of TDRL entry.  The Board agreed that the §4.130 criteria for a rating higher than 50% were not met near at time of separation, and therefore the minimum 50% initial TDRL rating is applicable.
The most proximate source of comprehensive evidence on which to base the permanent rating recommendation in this case is the VA C&P examination performed 3 months before separation and the follow-up treatment notes up to 4 days post-separation.  There was no relevant VA outpatient or civilian provider evidence providing psychiatric details during the 6-month interval.  The C&P evaluation nevertheless serves as a useful reference point and retains relevant probative value.  The C&P examination noted he had no difficulty performing activities of daily living (ADL), and with help, he would be able to maintain effective social relationship with his wife, and could be able to find a job in the near future.  The psychiatry follow-up treatment note dated January 2007 noted the CI showed some increased anxiety related to transition and moving but was generally stable.  MSE showed mild depression and anxiety and no suicidal/homicidal ideation or impaired thinking.  He was taking two medications for depression, one medication for mood stability and one medication for sleep.  On 19 March 2007, the therapist noted the CI appeared happy and attended the session with his wife and baby.  They were looking for a home to purchase and the CI had secured employment.  He denied depression or safety concerns and felt his mood had improved. He completed paperwork for follow up at the VA.  The Board agreed the CI’s condition reflected the assigned disability rating of 10%, connoting mild or transient symptoms that were controlled with continuous medication.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 50% for 6-months of constructive TDRL and a 10% permanent rating thereafter for the PTSD comorbid with bipolar I condition.

BOARD FINDINGS:  In the matter of the PTSD comorbid with bipolar I condition, the Board unanimously recommends a disability rating of 50%, coded 9411 IAW VASRD §4.129 for 6 months and then a permanent separation rating of 10% 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, effective as of the date of his prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
 PTSD comorbid with Bipolar I Condition	9411	50%	10%	
RATING	50%	10%	

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20140723, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB												

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 XXXXXXXXXX, AR20160008018 (PD201403434)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to  constructively place the individual on the Temporary Disability Retired List (TDRL) at 
50% disability for six months effective the date of the individual’s original medical separation for disability with severance pay and then following this six month period no recharacterization of the individual’s separation or modification of the permanent disability rating of 10%.

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum as follows:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of temporary disability effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was separated with a permanent combined rating of 10% effective the day following the six month TDRL period with no recharacterization of the individual’s separation.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will provide 50% retired pay for the constructive temporary disability retired six month period effective the date of the individual’s original medical separation and adjusting severance pay as necessary to account for the additional TDRL time in service.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA