RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-03565
BRANCH OF SERVICE:  AIR FORCE                                                     	
DATE OF PLACEMENT ONTO TDRL:  20021227       DATE OF REMOVAL FROM TDRL:  20040618

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E-5, Ground Radio Technician, medically separated from the Temporary Disability Retired List (TDRL) for “bipolar I disorder associated with post-traumatic stress disorder [PTSD],” with a disability rating of 10%.

CI CONTENTION:  His condition continues to worsen and negatively impact his daily activities.  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 – 20021227/20040618	VARD - 20030715	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Bipolar I Disorder associated with PTSD	9432	30%	10%	Bipolar Affective Disorder with PTSD	9411	30%	30%	
COMBINED RATING:  30% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Bipolar I Disorder associated with PTSD Condition.  The treatment record indicated that the CI initially sought mental health care while stationed in Europe, complaining mainly of disturbed sexual function.  Later, back in the US, he had episodes of auditory hallucination, hearing vague voices at work, although no one was really there.  He again sought mental health care in November 2001 and was assessed with bipolar disorder, manic type and began medication treatment.  In January 2002 he reported episodes of flashbacks (dissociative episodes), and nightmares related to Kosovo.  The CI indicated the voices he heard turned to be those of combatants from Kosovo area shouting at each other.  PTSD was eventually added to his diagnosis of bipolar disorder.  Although his manic symptoms had somewhat stabilized with medication, (Neurontin--is not a mood stabilizer, and certainly not used for mania) he continued to report disturbed sleep secondary to nightmares.  His sleep and nightmares improved with Klonopin (anxiolytic).  

On 27 August 2002, the CI had a 3-day psychiatric inpatient admission due to a manic episode.  The admitting psychiatrist noted that the CI had a long history of mood swings with irritability.  He currently had gone several nights without sleep, had psychomotor agitation (pacing), his irritability increased and he spent money recklessly.  He was not suicidal or homicidal on admission, but his mental status examination (MSE) noted his mood was euphoric; speech was pressured and thought were tangential at times.  He reportedly alluded to some paranoia.  His concentration was poor as demonstrated by his inability to perform serial 7’s.  It was noted that the CI experienced episodes of flashbacks during the admission.  The CI noted that these were more common during his manic episodes and relates to the traumatic events he witnessed while stationed in Kosovo.  He was discharged in stable condition with several medications to include Zyprexa (antipsychotic), Klonopin, and Neurontin.  The psychiatrist diagnosed bipolar I disorder, manic, moderate with rapid cycling and PTSD as a second diagnosis.  A Global Assessment of Functioning (GAF) score of 50 (serious symptoms or impairment) was assessed.  

The narrative summary (NARSUM) dated 11 October 2001 suggested that the CI had received a prior Medical Evaluation Board determination that was not in evidence.  It was noted that the CI was currently functioning well with his medications and had maintained regular monthly follow-up with his social worker until 25 March 2002.  Treatment was terminated at that time because he was functioning well.  In late April 2002 he presented to mental health as a walk-in due to report of flashbacks.  He was identified as being in a hypomanic state, and was under increased emotional stress because the commander was delaying a decision about re-enlistment/extension.  He was also exposed to what he identified as a traumatic trigger (walking by the firing range).  The CI returned to monthly follow-up with the social worker in May and in June he experienced an increase in stressors with the birth of his first child.  He settled into a normal routine in July but experienced manic episode and PTSD symptoms which prompted the August 2002 admission noted above.  The NARSUM examiner noted that the CI denied he had any interpersonal or occupational problems during the course of his treatment and he had also denied a history of self-harm of harm to others.  The examiner noted that he was compliant with medication, had good insight and judgment; however a formal MSE was not in evidence.

At the TDRL removal exam, March 2004, the CI indicated that he had received ongoing medication refills by telephone and had been fairly stable since TDRL placement.  He had no further hospitalizations and his last appointment with the psychiatrist was in April 2003.  His medications had not changed; however, he noted that he had experienced 2 periods of mania lasting a few days, but his medication regimen had kept him stable without the need for additional intervention.  He had a trigger for each episode.  The episode in February 2003 was triggered by the death of his sister and in July 2003 his manic episode was triggered by flashbacks on the anniversary of his trauma.  The CI has lived with his father, 2-year old son and wife since TDRL placement.  His relationship with his father was described as good because his father also suffers from PTSD.  

He also enjoyed a good relationship with wife and noted that she was supportive.  He did not work during TDRL but was a full-time college student working on an Associates’ degree and teaching certificate earning A and B grades.  He described his social interactions as good; he had many friends.  The MSE was normal.  The psychiatrist documented bipolar I disorder, rapid cycling, recurrent, chronic, moderate, in complete remission, on psychotropic medications.  The diagnosis of PTSD was also recorded as mild, in remission, on psychotropic medications.  A GAF of 75 (connotes if symptoms are present they are transient and expectable reactions to psychosocial stressors) was assessed.  The examiner noted that the CI remained unqualified for worldwide service and that he required ongoing psychiatric care.

The Board directed attention to its rating recommendation, based on the evidence.  The PEB assigned a 30% rating at TDRL placement.  The Board first unanimously agreed that VASRD §4.129 was not applicable in this case.  The predominant presentation and disability of this CI related to his bipolar condition, not to PTSD.  The Board found no evidence of a traumatic stressor related to the onset of bipolar symptoms.  There was no evidence in the treatment record to support a finding that his PTSD symptoms would have been present in the absence of the bipolar condition.  The record furthermore suggested his PTSD symptoms were the by-product of his bipolar condition, occurring only in the context of hypomanic-manic episodes.  The Board next proceeded to the 4.130 rating.  All members agreed that at the time of placement of the TDRL, the VASRD §4.130 threshold for a 30% rating was met.  A higher rating of 50% requires Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.  The NARSUM noted that the CI’s condition had improved with the changes in his medications.  He required further stabilization and was placed on the TDRL.  Although a formal MSE was not in evidence, the examiner indicated he had no problems with judgment, and was not psychotic.  It was noted that his condition had not affected his occupation.  The commander’s statement (CS) documented, “His current condition has not hindered his abilities to accomplish any of his primary duties.”  The CS also noted although his profile prevented worldwide deployment and he could not travel outside CONUS area, the recommendation was to retain him.  All Board members agreed the CI’s condition at TDRL placement did not exceed the 30% disability level.   After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bipolar associated with PTSD condition at TDRL placement.

The Board next directed attention to the permanent rating recommendation based on the evidence described.  The PEB rated the condition at 10%, noting that his condition was in remission.  The TDRL examiner noted the CI indicated that he had received ongoing medication refills by telephone and had been fairly stable since TDRL placement.  He had no further hospitalizations and his last appointment with the psychiatrist was in April 2003.  His medications had not changed, and despite his report of manic episodes, visits to the emergency room or inpatient treatment was not required; his medication stabilized him.  He reported good supportive relationships with his father and wife.  Although he had not worked during TDRL, he was a full-time college student working on an Associates’ degree and teaching certificate earning A and B grades.  The psychiatrist opined that his condition was in full remission and assigned a GAF of 75 and his MSE was normal.  He described his social interactions as good and stated he had many friends.  All Board members agreed that his condition best reflected the 10% disability rating for symptoms that are mild and controlled by continuous medication.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bipolar associated with PTSD condition at TDRL removal.

BOARD FINDINGS:  In the matter of the bipolar I disorder associated with PTSD condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication at TDRL placement and at permanent separation.  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 20140726, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-03565.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings