RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04058
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20030620

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Information Management Apprentice, medically separated for “bipolar disorder,” with a disability rating of 10%.

CI CONTENTION:  “I was given 10% for my MEB and the VA rated me 30% for my bipolar condition.”  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 - 20030606	VARD - 20030916	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder	9432	10%	Bipolar Disorder	9432	20%	20030820	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bipolar Disorder.  According to the service treatment records (STR) and the mental health (MH) Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was initially treated with an antidepressant medication in October 2002, after reporting depressive symptoms (decreased sleep, depressed mood) at the primary care clinic.  Her symptoms responded well to the medication.  The CI was also followed by the life skill center for the diagnosis of adjustment disorder with rule out of depression.  The CI had reported feelings of increased guilt about giving up her three boys for adoption.  From October 2002 to mid-April 2003, she remained stable with treatment and her condition was considered mild; however, on 15 April 2003, she was admitted to the psychiatry inpatient unit due to safety concerns.  Prior to admission, the CI had presented to the outpatient clinic as a walk-in with the report that her mood stabilizing medication had caused severe drowsiness and violent nightmares.  She was unable to contract for safety.  Post-hospitalization, the CI demonstrated good stability; however, she was referred to the MEB.

The NARSUM was accomplished while the CI was in inpatient treatment on 17 April 2003.  At the time of admission, the CI reported she had recently experienced new symptoms.  In the week prior, she developed mood swings with persistently elevated mood and decreased need for sleep.  She had increased energy and other symptoms suggestive of bipolar disorder.  The CI also noted that beginning in October 2002 she had depressive symptoms associated with family stressors.  She also reported chronic feelings of emptiness, interpersonal relationship problems, poor self-esteem, issues with abandonment and difficulty controlling anger.

On the second day of admission, she requested to be discharged.  She was discharged on the fourth day.  At discharge, she noted some improvement in her condition and that she no longer had nightmares and was able to contract for safety.  Her medications had changed and included mood stabilizer, antidepressant and anti-anxiety medicine.  The mental status examination (MSE) was unremarkable and although the psychiatrist stated her insight and judgment was limited, there was no indication that her thinking was impaired.  The diagnoses of bipolar type II disorder and borderline personality disorder was recorded with a Global Assessment of Functioning (GAF) score of 70 for mild symptoms.

On 1 May 2003, the CI was re-admitted to the inpatient unit after she reportedly attempted suicide by ingesting pills.  On the nursing admit note dated 2 May, the CI stated “I don’t want to be a burden to my husband and having to wait for a long time for my MEB.”  She also expressed frustration in not being able to perform the work duties she had done in the past.  During hospitalization, the CI actively participated in treatment.  She noted improved insight and acknowledged she had a large support group.  She was happy to be going home.  Her medications were changed, and the anti-anxiety medication that she used to overdose was discontinued.  Her GAF score at discharge was in the mild range.

Post hospitalization, treatment records indicated that she achieved stability, but had occasional family related stressful issues which she was able to manage on her own.  The CI discontinued her medications within 3 weeks of discharge.  Treatment entry notes dated 30 May 2003 noted that she had continued to do well off all medication and inquired about changing her diagnoses.  She denied having any problems with severe mood swings and erratic behavior until beginning medication in October 2002.  However, she reportedly described a pattern of unstable relationships and a childhood history, opined by the psychologist, consistent with personality disorder.  The psychologist noted that her MSE was normal, she had good judgment and her GAF score was in the mild range.  Mental health notes dated 2 weeks before separation noted the CI’s treatment providers agreed that the CI generally functioned well, but had a pattern of mood instability that was compromised during crisis situations.

At the VA Compensation and Pension (C&P) examination, 2 months post separation, the CI reported she had been hospitalized “several times” and that her most recent hospitalization occurred in “early June 2003” just before she was discharged from the service (not consistent with the treatment record).  She was not employed but noted that she had a good supportive husband.  She had two prior marriages.  There was no indication that the CI was taking any psychotropic medications or was in any form of mental health treatment.  The MSE was unremarkable.  The examiner diagnosed bipolar II disorder and assessed a GAF score in the moderate range.  The only stressor recorded was “unemployment.”

The Board directed attention to its recommendations based on the above evidence.  The PEB rated the condition at 30%, coded 9432 with a 20% deduction for contributing/aggravating factors.  The personality disorder was adjudicated as a CAT III condition (not separately unfitting and not compensable or ratable).  The VA used the same code to rate the condition at 30%.  The Board first noted there was no specific highly stressful service related event to invoke §4.129 for a mental disorder due to traumatic stress.  The Board next considered the rating deduction.   The Board noted that IAW DoDI 1332.38, enclosure 5, the personality disorder which was found to be not separately unfitting is not a condition that constitutes a physical disability and therefore is not eligible for service disability rating and the mood disorder was the sole mental health condition eligible for disability rating.  The mental health disability rating is based on total social and occupational functioning.  The PEB’s AF Form 356 did not state rationale for the deduction; however, it is not uncommon to encounter PEB deductions based on diagnoses of personality disorders as contributing or aggravating factors of the primary Axis I diagnosis.

All members agreed that the PEB’s deduction could not be upheld for the following reasons.  First of all, the contribution from a diagnosis of personality disorder, on which the PEB deduction likely hinges, is very tenuous.  Although the psychiatrist diagnosed personality disorder, there was no documentation to support that the CI’s behavioral issues were not the by- product of the primary mood disorder diagnosis.  Although there were symptoms and behaviors that likely reflected personality influences, there was insufficient evidence that any of the behaviors or symptoms were directly attributable to the personality disorder.  Lastly, the process of clinically extricating the disability attributed to one diagnosis versus the other in cases involving psychiatric disorders is overly speculative without a directed opinion from the examiner addressing the degree of contribution from each diagnosis.  No such input from a psychiatrist was provided; thus the Board could not fairly apportion a deduction even if the competing diagnosis were not in question.  All Board members agreed, there is sufficient evidence to support a disturbance in mood in which a personality disorder may have contributed negatively; however, there was insufficient evidence to support the notion that in the absence of a personality disorder, her mood disorder would have had no impact on occupational functioning.  All members agreed that the PEB’s deduction could not be upheld for application to the Board’s recommendation.  

The Board next proceeded with the rating recommendation IAW VARSD 4.130.  The 30% rating is for “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.”  The Board considered the Commander’s Statement dated 2 months before separation, stating the CI’s duty performance had deteriorated as a result of her bipolar diagnosis.  The Commander also stated that she was unable to satisfy her basic duty requirements and that her stress level and emotional distress “elevates frequently” to the point that she becomes non-functional.  The Board also considered her treatment team’s assessment that she functioned well until she was faced with a crisis situation.  Treatment records after the second hospital admission demonstrated she was stable in the 6 weeks before separation.  Her family crisis continued and she managed to remain stable off medications.  At the time of the C&P examination, there had been no significant change in her symptoms and she was stable and had no hospitalizations or recorded visits to the emergency room.  She was not employed, but she was just discharged from the service.  There was no indication that she was in any form of treatment.  The CI had denied having any mental health symptoms at her last mental health appointment, 3 weeks before separation.  After careful deliberations, the Board agreed, the overall totality of the CI’s disability more accurately reflects the 10% description, “occupational and social impairment due to mild or transient symptoms which decrease work efficiency only during periods of significant stress, or; symptoms controlled by continuous medication”, at separation.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board recommends a 10% disability rating (no deduction) for the bipolar disorder condition.

BOARD FINDINGS:  In the matter of the Bipolar Disorder condition and IAW VASRD §4.130, the Board recommends no change in the PEB adjudication.  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 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

Dear 

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-04058.

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