RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03520
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20050913

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E3, Fireman, medically separated for “bipolar I disorder” with a disability rating of 20%.

CI CONTENTION:  The CI continues to struggle with mental illness on disability severance pay.  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 based upon a 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 - 20050603	VARD - 20060329	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar One Disorder	9432	20%	Bipolar Disorder	9432	30%	20060117	
Personality Disorder, NOS	Cat IV	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Bipolar Disorder.  According to service treatment records (STR) and the mental health (MH) Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bipolar disorder began in December 2004.  The CI’s commander had referred him to psychiatry in approximately January 2005 because the CI’s behavior had become “bizarre and unusual” for him in the previous few days.  The CI was hospitalized on 1 January 2005 as a psychiatric inpatient.  The CI’s wife reported that in December 2004, the CI had become unpredictable and erratic when he expressed interest in investing money, going back to college, and gaining legal custody of two adolescent friends of the family all at once.  The CI had not been previously on psychotropic medications and had no psychiatric hospitalizations.  The MH MEB NARSUM dated 24 January 2005 noted that on the day of hospital admission, the CI had become “enraged with his wife” and while in the car, struck her and told her to get out of the car.  The CI claimed he realized his behavior and called the police because he was fearful of what he might do.  Also within a few days he had struck another service member, which the CI’s leading Chief Petty Officer claimed was completely out of character for him.  The CI had not been in combat.  The CI denied symptoms or a history of anxiety, post-traumatic stress disorder, depression or mania.  He denied a history of alcohol abuse or illicit drug use.  On the admission mental status examination (MSE) the CI was initially friendly and cooperative, but became progressively dramatic and irritable.  He was not aggressive.  He maintained good eye contact.  His memory was intact.  His speech was pressured and loud.  His mood was expansive with a labile affect.  Thought processes were circumstantial and content was thought to be remarkable for “ideas of persecution.”  The CI thought members of his command were “out to get” him and the examiner thought it bordered on paranoid.  A neurological evaluation, including brain MRI was negative.  The Axis I diagnosis was bipolar I disorder, most recent episode manic, with psychotic features and the Global Assessment of Functioning (GAF) assignment was 65, which is in the mild impairment range on this scale.  

Psychological testing dated 21 January 2005 (during the hospitalization) the CI reported having been diagnosed with bipolar I disorder, with mood swings from “neutral to angry.”  The CI reported a chaotic childhood and that he was a gang member in adolescence involved with drug dealing and had been exposed to multiple highly stressful events.  The MH examiner indicated the CI had not had any previous disciplinary problems and his command spoke highly of him.  The evaluation including standardized psychological testing resulted in diagnostic considerations on Axis I of rule out bipolar I disorder, with psychotic features and an Axis II diagnosis of personality disorder not otherwise specified (NOS), with schizotypal (social anxiety, difficulty establishing and maintaining social connections to others, eccentric or odd) and antisocial features.  During hospitalization the CI was titrated on antipsychotic and mood stabilizing medications and attended individual and group therapy.  He was eating and sleeping well.  His mood stabilized and he denied SI/HI.  Serial MSE noted improved mood without delusions, but he was judged to have minimal insight into his condition.  The CI’s privileges were advanced during his hospital stay and he was working around the MH facility without issues.  He was making plans for the future and actively participating in his discharge planning.  At the time of discharge the CI was not psychotic and denied SI/HI and he entered a residential treatment program (RTP). 

Psychiatry notes from late January 2005 to early February 2005 indicated the CI was doing well on medications but he continued to believe that he did not have an illness, rather it was a “weakness.”  At a MH visit on 14 February 2005, the CI reported he had stopped his medications in an effort to determine if he had an illness.  On February 17, the CI became agitated, was observed to be pacing in the RTF, worrying about upcoming issues, and he was provoking a physical altercation with another RTP patient.  When the psychiatrist evaluated him that night, he had racing thoughts, pressured speech, and was agitated and he refused to sit down.  When he offered admission to inpatient care, he refused and requested to be brought to jail.  On his way to inpatient he punched a wall, breaking it.  He also rushed another patient threatening homicide.  He was placed in restraints and medicated.  Medications were re-initiated and “symptoms of mania quickly resolved.”  MH notes from mid-March to mid-May 2005 noted the CI was again stable without any issues noted.  At the final psych visit in record dated 6 June 2006, the CI was still in the RTP and reported that he was compliant with his medications, but was having trouble getting up in the morning and performing his duties and getting to work, but denied any symptoms of mania; the examiner questioned whether the CI was getting depressed.  

At the VA Compensation and Pension (C&P) examination on 17 January 2006, 4 months after separation, the CI reported that he was in the process of a divorce.  The CI had two jobs since military separation; he had been laid off from one job, but remained employed part time at the other since October 2005.  He reported difficulty adjusting to work and getting along with others in general.  He was out of his psychotropic medications and he was not interested in taking medications or being in therapy.  The CI reported that he was in control of his “racing thoughts, suspiciousness, and grandiose thinking” which he rated as “mild to moderate” in intensity.  The VA examiner advised the CI that he should be in treatment.  The CI indicated he would consider it if his symptoms worsened.  The MSE noted a full affect and a mildly anxious and depressed mood.  Thought processes were noted to be coherent, but at times tangential and circumstantial.  He was alert, cooperative, and oriented in all spheres.  He denied SI/HI, delusions, or hallucinations.  The CI reported that fellow employees considered him “hyperactive” and “energetic.”  The CI reported no problems taking care of himself.  He denied substance abuse history or treatment.  The Axis I diagnosis was bipolar I disorder, most recent episode hypomanic, with a GAF assignment of 60, which is in the moderate impairment range on this scale.  The VA examiner determined the CI was competent to manage his own affairs.

Outpatient VA MH notes indicated that 8 months after military separation the CI decompensated and was admitted voluntarily.  The CI reported he had been feeling paranoid and was not sleeping well.  He got into a physical altercation with his cousin and the police were called who took him to the hospital.  The hospital admission note indicated the CI wanted to go back on his medication for bipolar disorder.  He denied manic or depressive episodes.  He reported he was at the same part time job noted above and also had obtained a second job.  A drug screen was negative.  The MSE noted that the CI’s “judgment seems to be impaired,” but the exam was otherwise normal.  His mood was “neutral” and his affect was appropriate.  He was cooperative and he appeared comfortable.  There was no SI, evidence of delusions or hallucinations (or other symptoms suggestive of psychosis), speech disturbance, or cognitive impairment.  The Axis I diagnosis was bipolar disorder by history, rule out Intermittent Explosive Disorder and the GAF assignment was 40, which is associated with significant impairment in several areas or some impairment in reality testing or speech on this scale.  During hospitalization the CI was restarted on medications to stabilize his mood and sleep medications.  During hospitalization he was not disruptive, there was no evidence of mania, hypomania, or psychotic symptoms.  He denied SI/HI.  He requested to be discharged on 31 May and the examiner noted he was not demanding about the request.  He was discharged and his GF picked him up.  At the time of discharge the CI was considered competent and employable.  

On 7 June 2006, approximately a week after discharge, the CI’s GF called the psychiatrist and reported the CI was in “crisis.”  He was not sleeping and was behaving erratically.  He had hit someone (outside of the family) and had been threatening to family.  He was transferred to the hospital where he was previously admitted with partial commitment papers.  On admission his MSE was normal.  The CI requested to be discharged as soon as possible for his job, but he was admitted due to signs of decompensation of his bipolar disorder for medication adjustment.  There were no issues during hospitalization and the CI responded well to treatment.  The CI was discharged on 13 June 2006 at his request so that he could continue working.  Discharge diagnoses were schizoaffective disorder, bipolar type/intermittent explosive disorder.  The GAF assignment was 60, which is in the moderate range of impairment on this scale.  Discharge medications included medication for mood stabilization and antipsychotic medications.  The examiner indicated that the CI was not a threat to himself or others, had no signs of psychosis and he was considered stable and employable.  The CI was discharged on antipsychotic and mood stabilizing medications.  Outpatient VA MH notes indicated that between June 2006 and July 2007 (9 to 22 months after separation), refused to take some of his medications, but continued working.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 30% rating under the 9432 code (Bipolar disorder) applied a 10% ratings reduction for non-compliance.  The PEB also adjudicated personality disorder, not otherwise specified as a Category IV condition (a condition which does not constitute a physical disability).  The VA rated the Bipolar disorder 30%, based on the C&P examination 4 months after separation.  
The Board noted there was no traumatic event causing the unfitting mental health condition and concluded that application of VASRD §4.129 was not appropriate in this case.  DODI 6040.44 defines a 12-month period after separation for special consideration of VA evidence in the Board’s rating recommendation.  The PEB provided a 30% rating as noted above, and deducted 10% for non-compliance.  Although the PEB made a rating deduction for treatment non-compliance with psychiatric treatment, which was DoD practice at the time, the Board considered its rating recommendation based solely on the impairment and the guidelines of the applicable VASRD diagnostic codes.  Additionally, IAW DoDI 6040.44, the Board may not recommend a lower combined rating than that of the PEB and therefore the Board considered that no less than a 30% rating as adjudicated by the PEB before the deduction was appropriate, but reviewed to see if the next higher 50% rating was supported.  There was evidence of frequent psychiatric hospitalizations (before and after separation), with recurrent episodes of severe mood disturbance, impaired impulse control, impaired judgment and difficulty establishing and maintaining relationships, that required psychotropic medications for maintenance.  Although the CI’s ability to work for periods of time argued for a 30% rating, specified as “occupational and social impairment with “occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal),” the severity of the recurrent bipolar disorder exacerbations and the cyclic nature of bipolar disorder supported the 50% rating, specified as “occupational and social impairment with reduced reliability and productivity.”  After deliberations, all Board members agreed that the CI’s condition at the time of separation supported the next higher 50% rating and that although during exacerbations, the CI manifested some symptoms typical of the 70% rating, following separation the CI was living independently and was able to maintain some employment, albeit interrupted by two brief hospitalizations.  Board consensus was that these factors argued against the higher 70% rating and it was concluded that a 50% rating was appropriate.  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 the bipolar I disorder, coded 9432.  

Contended PEB Conditions:  Personality Disorder, NOS.  The Board’s main charge is to assess the fairness of the PEB’s determination that the personality disorder, NOS was not unfitting.  The personality disorder is a condition not constituting a physical disability, IAW DoDI 1332.38 and is not separately eligible for disability rating.  Therefore, the Board has no basis for recommending it as unfitting.  Additionally, all social and occupational impairment is subsumed in the Board’s single VASRD 4.130 rating recommendation for the bipolar disorder.  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 the contended personality disorder and so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the bipolar disorder, the Board unanimously recommends a disability rating of 50%, coded 9432 IAW VASRD §4.130.  In the matter of the contended personality disorder NOS, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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; 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	PERMANENT RATING	
Bipolar Disorder	9432	50%	
The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140717, 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 19 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX   
	(c) PDBR ltr dtd 20 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 26 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 19 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 16 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 29 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 20 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX

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. former USN: Retroactive placement on the Permanent Disability Retired List with a 40 percent disability rating (increased from 20 percent) effective date of discharge.  

     b. former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effective date of discharge.  

     c. former USN: Entitlement to disability severance pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.  

     c. former USN: Entitlement to disability severance pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     d. former USN: Entitlement to disability severance pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     e. former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effective date of discharge.  

     f. former USN: Retroactive placement on the Permanent Disability Retired List with a 50 percent disability rating (increased from 20 percent) effective 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.