RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03656
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080430

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E2, Transportation Management Coordinator, medically separated for “bipolar II disorder,” with a disability rating of 10%.

CI CONTENTION:  The CI requests the Board 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 - 20080310	VARD - 20080724	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar II Disorder	9432	10%	Bipolar Disorder	9432	30%	20080318	
Right Knee	Not Unfitting	Right Knee Retro Patellar Pain Syndrome	5260	0%	20080317	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Bipolar II Disorder.    According to service treatment records (STR) and the Medical Evaluation Board (MEB) psychiatric narrative summary (NARSUM), the CI had not presented to mental health (MH) prior to his 1 April 2007 psychiatric hospitalization.  The psychiatric NARSUM indicated that the CI was admitted after reporting suicidal ideations.  He also noted a history of impulsive behaviors and indicated that he believed he had developed bipolar disorder based on his family history.  The hospital discharge summary dated 4 April 2007 noted that at the time of admission he reported symptoms of depression, including problems with sleep, focusing, depressed mood, decreased energy, increased anger and distractibility.  The CI also described a history of elevated mood accompanied by a decreased need for sleep and excessive spending of money (hypomania).  During the admission interview, the CI reported a 1-month history of daily suicidal thoughts.  He denied a past history of depression prior to entering the Army, and reportedly stated, “I was happy back home in Ohio.”  He also reportedly stated several times that he wanted to be discharged from the Army, after 9 months of service and no foreign deployments.  He reported periods of mood swings where he felt hyper for about an hour accompanied by excessive energy and restlessness and anger, followed by a depressed state. The CI’s fiancé of 2 months noted that he had unexplained violent outbursts which he would have no recall of.  He denied violence towards the fiancé.  The CI denied past psychiatric history of hospitalization, medication or counseling.  The CI was started on antidepressant and mood stabilizing medications and his condition improved significantly.  However, he indicated that he felt his symptoms would resolve if he were allowed to return to his family.  It was noted that he had consistently endorsed feeling overwhelmed at the thought of returning to the base, and he had consistently associated continued service with hopelessness.  His mental status examination (MSE) at discharge noted that he was pleasant, made good eye contact, smiled appropriately, had no psychotic symptoms, and no impairment in thinking or judgment.  He stated he felt “fine.”  The diagnosis of bipolar disorder, type II was recorded with a Global Assessment of Functioning (GAF) score of 50-55 (moderate symptoms/impairment), compared to an admission GAF of 35 (some impairment in reality testing or communication).  The CI was discharged to outpatient care.  At his first outpatient medication evaluation on 23 April 2007, the CI reportedly complained that his antidepressant medication was not working.  He thought he needed an increase in dosage because he still had “a lot of mood swings.”  The examiner noted his reported symptoms were vague and that he was not a good historian.  His MSE was normal.  The CI reported that he had received a refill for his mood stabilizer medication (Depakote) off post; however, the examiner indicated the refill was not reflected “in the computer list.”  The CI participated in group and individual therapy with a psychologist.  At the 30 May 2007 session, the CI reported he was doing well and that the group treatment “was helping him tremendously.”  He noted he had a plan for employment when he left active duty, and stated he felt less depressed and had not had any symptoms of mania.  

The psychiatric NARSUM was completed on 13 June 2007, 9 months before separation.  The CI reported occasional auditory hallucination, using his own name.  The MSE was unremarkable and the CI noted he had no further suicidal ideations since April 2007.  His judgment was considered “good.”  The psychiatrist opined that the CI had a good response to his medications and that treatment notes from early June indicated he had stabilized with medication; however, continued with problems of adapting to the demands of the military.  At that time he was taking an antidepressant (Celexa) and Depakote for mood stability.  On 19 June 2007, his treating psychiatrist assessed him with bipolar disorder II and personality disorder (avoidant/dependent/passive-aggressive/schizotypal features). He was prescribed Geodon for mood stability and both Celexa and Depakote were discontinued.  The psychiatrist wrote, “SM would like medication to make his problems go away, has difficulty forming a treatment alliance.”  In July 2007, the CI was seen for domestic violence against his wife.  The CI noted in his 30 July 2007 visit with his psychiatrist, that the emergency room (ER) personnel had called the police after his wife presented to the ER with a friend for a stomach problem.  The CI reportedly stated, “They thought it was from me.”  He noted that his new medication (Geodon) “works good” except for morning sleepiness.  He denied hearing voices.  His dose was reduced to address daytime sleepiness.  On 8 August 2007, the CI noted he was no longer suicidal, his only medication was Geodon, and his overall condition had stabilized.  He also noted that his sleep problems had improved with the medication.  The 17 August 2007 social work entry noted the CI’s wife reported the CI had raised his hand to her as if he was going to hit her and that he had hit her in the past and they were involved with family advocacy because of his aggression.  Family advocacy entry dated 21 November 2007, (3 months after the wife revealed domestic abuse) noted the CI was an active participate in marital therapy and shared that things had been going well.   He noted that he and spouse had fewer arguments, which were frequently associated with wife’s lack of interest in sexual relations.  Psychiatry entry dated 26 November 2007 noted the CI’s mood as “quite stable on minimal mood-stabilizing medication.” At the time he was taking only one psychotropic medication given at bedtime.  His diagnoses remained bipolar disorder and personality disorder.  At the 8 February 2008 visit with a new psychiatrist, the CI stated he was “feeling much better; I do not have mood swings now.”  He reportedly stated he had mood swings at least once a week prior to the military and daily after joining the military.  He noted he had some sleep disturbance and that there was a newborn in the home.  It appeared he was prescribed a different mood stabilizer in January 2008 (Lamictal).  On 31 January 2008, the CI noted he was not sleeping well; however, he reportedly was not willing or did not want to take sleep medication.  He returned to psychiatry on 20 February stating that his mood swings had increased; however, his MSE was normal.  

At the VA Compensation and Pension (C&P) mental examination in March 2008, performed a little over a month before separation, the CI reported that he was seeking employment at the plasma center and felt positive about leaving the military.  He noted that his relationship with wife and 6-week old daughter was “good.”  He reported he was hospitalized for 5 days in April 2007 secondary to suicidal ideation with a plan to drown or smother himself (inconsistent with admission record).  The CI reported that his current medication was helpful in making him feel more relaxed, and that his talk therapy helped him develop effective coping strategies and relaxation techniques.  The CI also noted that he was charged with domestic violence in 2007 because, “I wasn’t taking my medicine.  I just lost it.”  He indicated that he engaged in social activities with his wife and friends “multiple times a week” and had no difficulties with any activities of daily living.  His sleep was poor and he took daytime naps.  He was not taking medication for sleep, and had refused sleep medication in the past.  The CI described his moods as up and down, “depending on what’s going on around me.”  He said his moods changed quickly.  He had symptoms of depression that lasted about 30 minutes.  His “manic” symptoms lasted for an hour to all day.  He indicated that he was more stable with his medication.  MSE recorded depressed affect with an anxious and depressed mood; all other aspects of the examination were normal.  The examiner opined that his symptoms were intermittent and recorded a GAF of 63 (mild).

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating under the 9432 code (bipolar disorder), citing “symptoms that decrease ability to perform occupational tasks only during periods of significant stress.”  The VA assigned a 30% rating using the 9432 code based on the VA C&P examination a month before separation, citing symptoms that were “moderately impacting his functioning” due to sleep impairment and mood disorder.  All Board members first agreed that the preponderance of evidence did not support the application of §4.129.  The Board next considered the rating recommendation.  The higher rating of 30% requires evidence of “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks” due to  such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events.  The NARSUM examiner noted that the CI’s symptoms had significantly improved and he was responding well to medication.  At the time of the NARSUM, his MSE was essentially normal. His judgment was not impaired.  The NARSUM was 9 months before separation.  Treatment entries following the NARSUM up to 2 months before separation demonstrated his bipolar symptoms had stabilized with medication, although he continued to report transient mood swings precipitated by relationship issues, financial problems or stressor of being in the military.  In the 6 months before separation, his MSEs were normal and his psychiatrist considered his condition stable with medication.  The CI also indicated his condition was stable in the majority of treatment records post hospitalization.  The Board noted the last two treatment entries 8 February and 20 February recorded normal MSE.  His medication was still being titrated in February and he indicated he was still having mood swings. However, the C&P examination a month before separation noted the CI reported that his moods were up and down, “depending on what’s going on around me” and that his medication provided mood stability. The commander’s statement dated 15 January 2008, noted that the CI worked well with others, and was capable of working independently.  It was stated that he had been a good Soldier in the WTU, his performance was satisfactory and he had presented few problems to the chain of command.  The Board considered the absence of psychiatric hospitalization in the 12 months before separation, absence of visits to the ER related to psychiatric symptoms, absence of panic attacks, no issues with memory, and the evidence of mood stability, the NARSUM, commander’s statement and the VA C&P examination.  All Board members agreed, the record sufficiently documented that the CI’s mood was stable in the absence of interpersonal and occupational stressors, and that his symptoms were more reflective of the 10% disability level for “occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress.”  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 II condition.   

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the right knee condition was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The service treatment records noted the CI reported right knee pain in May 2007 that was aggravated with running and improved with rest.  Radiographs of the right knee in July 2007 were normal.  The last treatment entry for right knee was dated 18 July 2007 documenting full range of motion in the left knee, no evidence of tenderness to palpation and no signs of inflammation or instability.  The right knee was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.   There was no performance based evidence from the record that the right knee condition significantly interfered with satisfactory duty performance.  After due deliberation, and 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 right knee condition and so no additional disability rating is recommended.

BOARD FINDINGS: In the matter of the Bipolar II Disorder condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right knee condition, the Board unanimously 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 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 20140731, 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 XXXXXXXXXXXXXXXXXX, AR20160007116 (PD201403656)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA