RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-04040
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090710

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Infantryman, medically separated for “bipolar disorder” with a disability rating of 10%. 

CI CONTENTION:  The CI requests the Board to 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 - 20090629	VARD - 20091016	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder	9432	10%	Bipolar Disorder, Cognitive Disorder due to TBI, and Alcohol Dependence	9432	100%	20090615	
Chronic Intermittent Right Wrist Pain	Not Unfitting	Right Wrist Fracture	5215 	NSC	20090610	
Hypertension	Not Unfitting	Hypertension	7101	0%	20090610	
Bilateral Knee Pain	Not Unfitting	Left Knee Degenerative  Arthritis	5003	10%	20090610	
Bilateral Ankle Pain	Not Unfitting	Left Ankle Degenerative  Arthritis	5014	10%	20090610	
		Right Ankle Degenerative  Arthritis	5014	10%	20090610	
Palpitations	Not Unfitting	Cardiac Condition	7099-7000	NSC	20090610	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:  

Bipolar Disorder.  The service treatment records demonstrated that the CI first encounter with mental health (MH) occurred in December 2007, at which time he was not diagnosed, but had reported feeling angry.  The CI noted that he did not know why he had angry feelings, but that overall he was doing well and was looking forward to going on leave.  He denied suicidal and homicidal ideations.  The narrative summary (NARSUM) was conducted in March 2009, 4 months before separation.  The examiner documented the CI’s reported history of having stress related to adjusting to the rules and regulations of the service and stress associated with a difficult divorce.  He began having mood swings and temperament issues.  He had conflict with his command after returning from deployment to Iraq in April 2008.  Treatment records were silent from December 2007 until October 2008.  The CI was hospitalized for 8 days in late October 2008 after expressing homicidal ideations towards someone in his cadre.  He was started on medication and discharged to outpatient care.  Less than 2 weeks later, he was hospitalized again for homicidal ideations reportedly aggravated by alcohol use.  The CI underwent a Fit-for-Duty evaluation in December 2008.  He was found fit; however, it was felt that he would function better in a different Military Occupational Specialty (MOS).  However, his command favored him returning to his old MOS.  At the time of the evaluation, the CI was taking an antidepressant and medications to treat anxiety symptoms.  He continued to have unstable mood symptoms that worsened in February 2009.  The worsening of his mood symptoms led to the initiation of mood stabilizing medication for the condition diagnosed as bipolar disorder.  Due to the recurrent nature of bipolar disorder and the need for blood monitoring for Depakote, it was noted that he could not deploy to a combat zone or have a successful military career.  The mental status examination (MSE) was unremarkable, and suicidal or homicidal ideation was absent.  The psychiatrist opined that his occupational level of disability was mild or transient with decrease work efficiency and ability to perform occupational tasks at times of significant stress, requiring continuous medication for his condition.  However, the examiner stated the CI’s condition had improved with treatment “But is not yet stable although his short-term prognosis is favorable.”  Although the NARSUM did not record a diagnosis of alcohol abuse or dependence, treatment entry dated 5 March 2009 documented that CI had a diagnosis of alcohol dependence and had been in treatment for both conditions (bipolar and alcohol), including a recent inpatient admission for detoxification and rehabilitation.  Treatment entry dated 23 February 2009, recorded the CI was discharged from the hospital on 22 February.  However, the admission date was not recorded, and there were no other entries that documented admission date or length of stay.  That entry also recorded the CI reported the hospitalization was beneficial and that he felt optimistic.  He denied depressed mood, and suicidal or homicidal ideation.  

The VA Compensation and Pension (C&P) mental examination was accomplished 1 month before separation.  The CI noted that he had continued to abuse alcohol, and he was much less social but admitted to multiple sexual encounters with women.  The examiner noted he was not a reliable historian, “not forthcoming with information and was at times not appearing to be honest.”  The CI reported ongoing mood symptoms, stated he had impaired impulse control, and constant headaches.  MSE recorded that his thought processes were impaired “as he has confusion and has difficulty understanding directions”; however, he was fully oriented, had appropriate behavior, his judgment was not impaired and his abstract thinking was normal.  He reportedly had homicidal ideation.  The psychologist diagnosed bipolar disorder, cognitive disorder not otherwise specified (NOS) secondary to traumatic brain injury (TBI), and alcohol dependence, and noted the symptoms of the conditions overlapped and could not be differentiated.  The General C&P examination recorded the CI’s report of having been physically attacked in 2008 where he was struck with pipes.  The CI reportedly stated he was diagnosed with closed skull fracture of orbital roof; closed skull fracture of orbital rim zygomatic arch; and TBI.  He stated that he had lost consciousness for greater than 24 hours.  There was no documentation of this event or of a TBI diagnosis in the service treatment record, and his profile primarily related to MH restrictions with the exception of no Army physical fitness test (APFT) push-ups (likely secondary to wrist pain).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition of bipolar disorder at 10%, coded 9432 (Bipolar disorder).  The VA assigned a rating of 100% for combined conditions of bipolar disorder, cognitive disorder due to TBI and alcohol dependence, coded 9432.  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, and mild memory loss (such as forgetting names, directions, recent events.  The NARSUM examiner noted that the CI’s symptoms had significantly improved, but had not stabilized.  At the time of the NARSUM, his MSE was essentially normal.  His intellect was judged to be average, and the psychiatrist noted that he used complex concepts and vocabulary during the examination.  His judgment was not impaired.  The examiner noted mild impairment due to his condition.  The commander’s statement (14 weeks before separation) documented that the CI had been AWOL for 2 days, twice in 2008; however, he presented to work every day.  He had no difficulty communicating with others, he related civilly to supervisors and other workers, he maintained his appearance, he remember locations, work-like procedures and instructions, and maintained an acceptable level of attention and concentration to carry out instructions and complete tasks in a timely manner.  The care specialist recorded the CI “makes simple decisions but usually not complex or unfamiliar decisions.”  The care specialist also noted that the CI had no behavioral or psychological symptoms which interfered with the workplace, and that the CI was unable to perform duties in his MOS due to “Him requiring definitive care for bipolar” and because he could not meet the physical demands of the service, retaining him was not recommended.  The Board noted the last treatment entry dated 27 March 2009 recorded the CI reported “No symptoms” during his visit with his alcohol treatment counselor.  The C&P examination, a month before separation recorded an array of symptoms not documented anywhere else in the treatment record, such as memory problems, problems with thinking, impulse control issues, constant symptoms of withdrawal, and social isolation, and constant violent thoughts, symptoms reflective of TBI.  The CI reported a 32-day hospitalization from February to March 2009, which was not supported by the service treatment record, but the record did document hospitalization at some point in February with discharge on 24 February for alcohol treatment.  The C&P examiner also stated that the CI was not a reliable historian.  All Board members agreed, the C&P examination demonstrated great disparity between its findings and the preponderance of evidence in the service treatment record.  Therefore, that examination lacked probative value, and thus, was of limited benefit in the Board’s proceedings.  The Board considered the three hospitalizations, the NARSUM examiner’s opinion that symptom stability had not been achieved, but had significantly improved, and the care specialist opinion that the CI’s MH symptoms had not interfered with his duties.  The Board additionally considered the absence of hospitalization beyond February 2009.  Although, the NARSUM examiner opined that his condition had not yet stabilized, the examiner also opined good short-term prognosis, and noted that his condition had caused occupational impairment that was mild or transient.  The Board undertook a careful review of the record in evidence, and noted in the 5 months before separation, there were no hospitalizations, no visits to the emergency room, no evidence of memory loss, no panic attacks, and no report of chronic sleep impairment, and no clinical evidence of depressed mood.  He had minimal participation in MH treatment.  The MH encounter dated 16 March 2009 stated the CI was doing well and had a bright affect and the CI stated he was ready to get on with his life.  The last treatment entry dated 27 March 2009 documented “No symptoms”. The medication profile demonstrated his last filled prescription for 30 day supply of Depakote was in May 2009 with no refills.  Board members concluded, at the time of separation his bipolar condition had stabilized, and there were no documented symptoms in the service treatment record in the 5 months before separation with the exception of the C&P examination.  
The Board acknowledged the C&P examination, however, the examiner’s assessment was that the CI was not a reliable historian, thus, the Board considered the exam findings were not probative.  The Board found no evidence in the service treatment record consistent with the findings of the C&P examination. There was no evidence in the NARSUM, care specialist, or the service treatment record, of impaired thought processes, confusion or difficulty in understanding directions.  The Board also acknowledged the CI had anger issues; however, there was no evidence of a legal history, nor was there any demonstrated impulse control issue.  After considerable discussion, all Board members agreed the CI’s condition at the time of separation; best reflected the 10% criteria for symptoms 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 condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the chronic intermittent right wrist pain, hypertension, intermittent bilateral knee pain, intermittent bilateral ankle pain, and “palpitations with negative Holter monitoring and stress testing” conditions were not unfitting.  The chronic intermittent right wrist pain condition was profiled U2; however, the only related physical restriction was APFT push-ups.  He was able to move with a fighting load for at least 2 miles, construct a fighting position, and participate in upper body weight training.  Radiographs of the right wrist in June 2009 were normal, and examination of the wrist during the MEB was negative for pain and there were no signs of nerve compression.  There was no evidence from the record that this condition required treatment, and this condition was not judged to fail retention standard.  The conditions of hypertension, intermittent bilateral knee pain, intermittent bilateral ankle pain, and palpitations with negative Holter monitoring and stress testing were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  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 condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended chronic intermittent right wrist pain, hypertension, intermittent bilateral knee pain, intermittent bilateral ankle pain, and palpitations with negative Holter monitoring and stress testing 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 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 with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

28 JUL 2016

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 AR20160009461 (PD201404040)

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