RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03452
BRANCH OF SERVICE: AIR FORCE 	SEPARATION DATE:  20091127

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Airfield Systems Journeyman, medically separated for bipolar disorder associated with anxiety disorder, rated at 10%.

CI CONTENTION:  The CI requests review of all of her conditions. Her 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 - 20090818	VARD - 20100611	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder, NOS, Associated w/Anxiety Disorder	9432	10%	Bipolar Disorder, Type I, with Depressed Mood, Panic
Disorder, and Agoraphobia (Also claimed as Generalized
Anxiety Disorder, PTSD  and Depression)	9432	50%	20100611	
PTSD	Category II					
Borderline Personality Disorder	CAT III	Borderline Personality Disorder	Not Service Connected	
Alcohol Abuse	CAT III	No VA Entry	
RATING:  10%	RATING:  70%	

ANALYSIS SUMMARY:  

Bipolar Disorder, NOS, Associated W/Anxiety Disorder.  The narrative summary (NARSUM) noted the CI was first evaluated in mental health (MH) in May 2008 while enrolled in the Alcohol and Drug Abuse Prevention and Treatment (ADAPT) program for alcohol abuse, but did not receive MH treatment.  In August 2008, she was referred to MH for treatment after an overnight stay in a local hospital’s behavioral health unit that focused on alcohol consumption.  At that time she reportedly denied significant mood symptoms; however, on 2 September 2008 she returned to MH and noted she had mood swings “for a very long time,” and felt she was “just used to them”.  It is not clear if the CI was assessed with a psychiatric diagnosis at this point.  Treatment records fall silent until March 2009.  On 4 March 2009, the CI underwent an initial civilian psychiatric evaluation that documented the CI’s report of difficulties with mood, anger, panic attacks, self-mutilation, and history of excessive alcohol use.  That evaluation noted that the CI had a 2-day psychiatric hospital admission in August 2008 (recorded as overnight admission in the NARSUM) after presenting acutely intoxicated with alcohol and suicidal ideation (not recorded as suicidal ideation in the NARSUM).  The examiner recorded that the CI began MH treatment in November 2008 that consisted of weekly counseling, and since then she had taken Paxil (antidepressant, Risperdal (anti-psychotic, mood stabilizer), and Seroquel (anti-psychotic, mood stabilizer) as needed for panic attacks.  These medications were started during the February 2009 inpatient admission that occurred in the context of self-mutilation behaviors (cutting arms and legs with a razor blade).  It was noted that the CI had difficulties with recurrent depressive episodes and mood swings since her teenage years.  She had panic attacks since age 6, and a history of childhood sexual abuse (age 5 and 6) by a female teenage babysitter.  While in college at the age of 18, she was referred to MH on two occasions for alcohol intoxication.  She indicated she had not received formal MH treatment or been diagnosed with an MH condition prior to the military.  She noted a history of trauma related symptoms as the result of the childhood molestation, and endorsed symptoms consistent with a bipolar diathesis.  The mental status examination (MSE) noted absence of suicidal or homicidal ideation, absence of acute distress, and absence of psychotic symptoms.  The CI’s affect demonstrated mild anxiety, she was mildly inattentive at times, and her judgment was opined to be “slightly decreased.”  The diagnoses of posttraumatic stress disorder (PTSD), bipolar disorder not otherwise specified (NOS), panic disorder with agoraphobia, and alcohol dependence (self-report remission since August 2008) were recorded on Axis I, and borderline personality traits was noted on Axis II.  A Global Assessment of Functioning (GAF) score of 55-60 (moderate) was assessed.  At the NARSUM on 2 June 2009, the CI reported a history of irritability, crying spells, persistent sad mood, fatigue and lack of interest, hopelessness and helplessness.  She also had frequent insomnia and worried constantly.  All of her symptoms have been present since her teenage years, and she thought that it was “normal.”  Her depressive moods alternated with brief periods of elevated mood associated with increased energy and productivity.  These periods described as hypomania are followed by severe depression.  In addition to difficult mood symptoms she had a history of self-harm behaviors, impulsivity, and relational difficulties opined to be consistent with a diagnosis of borderline personality disorder, which was noted as affecting her job performance.  There are also symptoms of chronic anxiety consistent with the diagnosis of generalized anxiety; she worried all the time.  Some of her anxiety symptoms are characteristic of PTSD; however, the psychiatrist noted it is unclear how much this affects her current presentation.  The CI was also a second year student working on a degree in atmospheric science while working as an intern at a local television station.  It was noted that she participated in therapy that focused on managing her depressive and anxiety symptoms.  The examiner recorded that the CI had not been suicidal, but had engaged in risky behaviors.  The NARSUM examiner noted the CI had seen multiple providers and the record reflected discrepancies in the reporting of panic symptoms, childhood history and pattern of alcohol use.  For example, her treating psychiatrist had diagnosed alcohol dependence, while information shared by the CI and alcohol treatment providers indicated a pattern of abuse and not dependence.  She reportedly denied or minimized the contribution of childhood sexual abuse to various providers and reportedly told hospital staff that she had a “great” childhood.  The CI also has reported panic disorder symptoms to her psychiatrist, while describing generalized anxiety and obsessive compulsive type symptoms to her therapist (the author of the NARSUM).  Her current symptoms were mood instability, frequent crying spells, insomnia, feelings of hopelessness about her future and guilt (irrational).  It was noted that therapy had improved many of these symptoms; however, she continued to cut herself, albeit less frequent.  MSE was performed on 12 May 2009 by her social work therapist, and at that time documented that the CI was restless, had an anxious mood and affect, ruminated about fears of germs, failure, physical appearance and aging.  Judgment was assessed as fair and there was no evidence of psychosis.  Suicidal and homicidal ideations were absent.  The MH diagnoses listed were bipolar disorder NOS, generalized anxiety disorder (GAD), PTSD by history, alcohol abuse, in remission and borderline personality disorder.  The condition of PTSD by history was opined to have caused minimal degree of impairment for military service and mild for civilian, social and industrial adaptability.  A GAF of 54 (moderate) was recorded.  

The VA Compensation and Pension (C&P) mental examination was accomplished approximately 7 months after separation.  The CI acknowledged a history of two psychiatric hospitalization and alcohol abuse.  She indicated she has remained in treatment since separation and noted that her VA psychiatrist has diagnosed her with bipolar disorder and borderline personality disorder.  Since her discharge, she had panic attacks at work which she also reportedly had while working in the Air Force.  She worked part-time as a bartender and was a full-time college student, receiving A’s and one B and was on the Dean’s List.  The CI reported chronic suicidal ideation with plan but no intent, and sleep difficulty requiring treatment with three different medications.  She continued to have mood swings, felt mildly and chronically depressed, and continued to engage in self-mutilation behaviors, last episode a week after an argument with her boyfriend.  There had been no additional hospitalizations or recorded visits to the emergency room related to MH concerns.  The examiner noted the CI had never deployed to a combat zone, or overseas, and her history was absent of service related traumatic events including personal assaults.  She noted that she has “somewhat better control” of her symptoms since leaving the service.  The MSE recorded affect was tense and slightly restricted; she appeared sad but not tearful.  The remainder of the MSE was unremarkable.  She has panic attacks that lasted from 5 minutes up to an hour, and had on average, two a week.  They often occurred when driving to work or school and she had to pull off the road.  She reported she had missed 4 days from school due to her inability to get out of bed secondary to depressive symptoms.  The examiner assessed a GAF of 50 (borderline serious to moderate), noted this score reflected her conditions of bipolar disorder, currently depressed with suicidal ideation, panic disorder and borderline and obsessive-compulsive personality disorders.  Alcohol abuse remained in remission.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition of bipolar disorder NOS associated with anxiety disorder, coded 9432 (bipolar disorder) at 10%.  The VA, using the same code, granted a disability rating of 50% for the condition of bipolar disorder Type I.  First, the Board noted there was no specific, highly stressful service related event to invoke §4.129 for a mental disorder due to traumatic stress.  All Board members agreed the provisions of §4.129 were not applicable.  The Board noted the PEB’s determination to not include a separately unfitting characterization of the anxiety disorder.  The Board agreed the diagnosis code 9432, bipolar disorder, was the best fit for the CI’s condition since the service treatment records (STR) reflect treatment was focused on mood disorder with overlapping anxiety; therefore, it was appropriate to combine the two conditions. The Board next considered the Category II PTSD condition and agreed, although the condition was diagnosed the treatment record did not focus on her PTSD, and there was no evidence that her treatment consisted of modalities specific for PTSD.  Therefore, all Board members agreed there was not a preponderance of evidence to support a separately unfitting PTSD condition.  Regardless of diagnosis, VARSD §4.130 rates conditions based on symptoms, and therefore, all symptoms related to mental health are considered in the rating scheme.  The Board proceeded to rate under §4.130 and compared the NARSUM opinion of the CI’s employability and work function, the C&P examination 7 months after separation, and the commander’s statement of duty performance.  The Board considered the 50% rating criteria for “reduced reliability and productivity due to such symptoms as: flattened affect; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory  impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.  The Board carefully reviewed the record in evidence and noted that many of the symptoms recorded in the C&P examination were not present in the NARSUM.  At the time of separation, there was no recorded evidence of panic attacks occurring on a weekly basis and no report of chronic suicidal thinking.  The commander’s statement dated 4 June 2009 (5 months before separation) indicated that her MH condition had significantly impacted her ability to perform her duties, and that senior staff “stays alert to any irrational behavior due to previous self-destructive behavior.  “She is now unreliable for duty and not fit for deployment.”  However, it was noted that anxiety and mood symptoms also impacted her work, but appeared to have had less of an impact than the behavioral symptoms (self-destructive-cutting) that are more reflective of the personality disorder.  The Board noted that the CI’s symptoms had not required visits to the ER, or hospitalization in the 9 months before separation, and there was no evidence of impairment in judgment.  After separation there was no report of symptoms requiring hospitalization. Although the CI endorsed significantly more symptoms at the C&P examination such as chronic suicidal thoughts and panic attacks 1-2 times a week, the CI was able to continue college as a junior with one B and the rest A’s and placed on the Dean’s list, while working part-time.  She reported she had missed 4 days from attending classes due to depressive symptoms and in the past month she had to leave work due to a panic attack.  After considerable deliberation, members concluded the 50% level of disability is not supported.  Deliberations focused on the 30% versus 10% rating levels.  The 30% rating requires evidence of “Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks”.  The NARSUM exam, the CS and the C&P exam, all provided sufficient evidence to support the 30% rating criteria.  Board members agreed that her symptoms were not mild or transient, and although medication was noted to have improved some of her symptoms there were significant mood and anxiety symptoms that were not adequately controlled by the continuous use of medication and or therapy.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), and the application of §4.130, the Board recommends a disability rating of 30% for the bipolar disorder NOS condition.  

Contended Conditions.  The personality disorder is not a physical disability for rating purposes in accordance with DoDI 1332.38 E2.1.25, and the condition of alcohol abuse, in remission is also not considered a physical disability for rating purposes in accordance with DODI 1332.38.E5.1.2.1.  Additionally, the Board noted the alcohol abuse condition was in full remission.  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 any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the bipolar disorder NOS, associated with anxiety disorder condition, the Board unanimously recommends a disability rating of 30%, coded 9432 IAW VASRD §4.130.  In the matter of the contended borderline personality disorder and alcohol abuse 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 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 NOS, associated with Anxiety Disorder	9432	30%	
RATING	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140712, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-03452.

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 XXXXXXXX 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,