RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX                                           CASE:  PD-2015-00016
BRANCH OF SERVICE:  Army                                                                  separation date:  20070504

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Infantry, medically separated for a bipolar I disorder condition rated at 10%.  

CI CONTENTION:  His conditions continue to worsen and negatively impact his daily activities.  His 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:  

IPEB - Dated 20070223	VA* - (~3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar I Disorder	9432	10%	Bipolar Disorder	9432	10%	*STR	
Osteoarthritis of Lumbar Spine	Meets Retention	Osteoarthritis Lumbar Spine	5010	10%	20070822	
Other Conditions x 0 (Not In Scope)	Other x 4 	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20071030 (most proximate to date of separation [DOS]).  *CI failed to report to PSTD Exam 20070911.

ANALYSIS SUMMARY: 

Bipolar I Disorder Condition.  The CI first presented to mental health for a command-directed evaluation due to concerns about his anger and possibly harming others in August 2004.  At the time, the CI reported he was overwhelmed emotionally with multiple stressors.  He was angry over a car accident that had occurred 3 months prior which left him with injuries.  He had intense anger toward the NCO who also allegedly made fun of him on occasions.  Other concurrent stressors were a divorce, learning his stepfather might have cancer, and financial difficulties.  In addition to the above, the CI also recently lost his squad, all of whom were leaving the unit.  The psychologist diagnosed adjustment disorder and occupational problems, and referred the CI to outpatient follow-up in 3 days.  However, 2 days later, he was escorted to mental health (MH) after stating he wanted to kill his wife.  He was evaluated by the psychiatrist and diagnosed with adjustment disorder and partner relational problems, and was referred to anger management classes.  He did not present to follow-up until 23 September 2004, once again command-directed.  He reportedly trashed his room and the hallway of the barracks the night before, causing considerable damage.  He was intoxicated at the time.  The CI again reported occupational issues and sleep problem, and was assessed with alcohol misuse and intoxication, occupational problems and sleep disorder.  Ambien was prescribed and again he was referred to anger management classes.  The CI attended his first anger management class in November 2004.  In late February 2005, He reported increased suicidal and homicidal thoughts, and had become increasingly verbal and hostile with persons in his command with which he had conflicts.  For this reason, he underwent a third command-directed MH evaluation and was assessed with adjustment disorder with mixed disturbance in emotions and conduct, and occupational problems.  The psychiatrist recommended continuing anger management and possible rehabilitation transfer to a different unit.  It was also noted that if transfer was not possible, an administrative separation might be warranted.  

The narrative summary (NARSUM) noted that the CI participated in anger management classes from November 2004 through April 2005.  He had good participation in class and frequently brought up concerns about feeling he was picked on or harassed by an NCO in his unit.  It was noted that no further acts of aggression or inappropriate alcohol use was recorded after the above cited incidents.  The CI was also referred for psychological testing and that evaluation assessed the same diagnoses as above and additionally documented a personality disorder.  The NARSUM noted the CI’s last anger management class was on 27 April 2005 and at that time he reportedly stated that things were going very well.  He reported significant improvement in support from his command.  The CI then deployed.  He next presented to MH in-theater on 18 August 2006, for complaints of suicidal and homicidal ideation, which had worsened over the previous several months.  He had plans to commit suicide after killing his chain of command.  His initial evaluation was completed with a diagnosis of chronic PTSD with psychotic features and antisocial personality disorder.  The next day he was evaluated by a psychiatrist who assessed major depression and after two follow-up visits, recommendation was made to evacuate him to the restoration program in Baghdad.  He arrived at the program in late August and the psychiatrist there diagnosed him with “possible bipolar disorder with psychotic features.”  Due to worsening symptoms, he was evacuated to Germany where he could receive a higher level of care.  He spent 3 days in the hospital (12-15 September 2006) and underwent psychological evaluation.  The psychologist diagnosed personality disorder and recommended separation based on that diagnosis.  After arriving in the U.S., he was started on medication for depression, and prescribed medication for sleep.  Over the next month, his condition improved significantly.  He spoke without bitterness and anger and the psychiatrist felt that he might not require an administrative separation if he continued to demonstrate improvement.  

At the NARSUM dated 30 November 2006, the CI noted that he had become increasingly depressed towards the end of his stay in Iraq and had begun to hear voices.  These voices were critical of him and told him things that he should have done.  Things began to improve in October.  He began feeling essentially normal by late October.  He felt increasingly friendly, outgoing, and had improved social interactions with others.  He felt calm and relaxed.  It was noted that because of his dramatic improvement in mood and affect, after initiation of lithium, his diagnosis was revised to bipolar I disorder.  Instead of an administrative separation, he was placed on permanent profile and recommended to undergo an MEB.  A formal mental status examination was not recorded at the time of the NARSUM; however, the examiner noted “over the subsequent two months,” his condition had remained stable.  He had not demonstrated irritability, anger or hostility and he showed no signs of mania or depression.  There were no psychotic symptoms and no thoughts of suicide or homicide.  The diagnosis of bipolar disorder I, most recent episode depressed, was assessed, and a Global Assessment of Functioning (GAF) score of 65 was recorded, which denotes mild symptoms and or mild impairment.  It was recommended that he continue with his medication since his response to treatment had been good and his prognosis for continued stability was noted as good.  The CI was non-attendant to the VA Compensation and Pension (C&P) mental evaluation.  

The Board directed its attention to its rating recommendation, based on the evidence just described.  The PEB assigned a 10% rating, rated as mild industrial impairment.  The VA used the service treatment record and assigned a 10% rating under the same code, 9432 (bipolar disorder).  The Board first unanimously agreed that VASRD §4.129 was not applicable in the absence of a highly stressful causative event.  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.”  The Board undertook a review of the evidence and noted that the CI had no psychiatric hospitalizations in the 8 months before separation and no visits to the emergency room for acute care.  He initially presented with anger, irritability, and aggression, and had made suicidal and homicidal threats.  His condition notably improved in the 6 months before separation and by his own report he began to feel essentially normal about 6-7 months before separation.  He attributed his improvement to the change in medication.  The NARSUM noted he had been compliant with his medication, his response had been good and that medication must be continued.  His prognosis was good for continued stability. The 10% disability rating is 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, or; symptoms controlled by continuous medication; better reflects the CI’s condition at separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board unanimously recommends no change in the PEB adjudication for the bipolar I disorder condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that osteoarthritis of the lumbar spine was not unfitting.  The lumbar spine condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  The condition was reviewed and considered by the Board.  There was no performance based evidence from the record that the back condition 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  osteoarthritis of the lumbar spine and so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the bipolar disorder condition and IAW VASRD §4.30, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended osteoarthritis of the lumbar spine 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 20141216, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXX AR20160011863 (PD201500016)

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