RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00066
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080125

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Information Systems Operations Analyst, medically separated for “bipolar disorder” with a disability rating of 10%.   

CI CONTENTION:  The CI requests that all conditions be considered.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20071218	VARD - 20080620	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder	9432	10%	Bipolar Disorder, Mixed; with Post-Traumatic Stress Disorder…	9432-9411	50%	20080317	
PTSD	Not Unfitting					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Bipolar Disorder Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bipolar disorder condition began in October 2007 after taking an anti-depression medication.  A primary care provider referred the CI to Behavioral Health when she reported nightmares, early awakening, decreased sleep and daytime fatigue that began after her deployment.  She also reported depression, irritability and avoidance symptoms.  Psychological testing was consistent with PTSD.  The CI reported the nightmares were related to exposures while deployed to Kuwait.  She received medication to treat the symptoms, and in October 2007 she reported depression with anxiety for which she also received medication (Celexa).  At a November 2007 appointment the CI showed considerable motor restlessness and reported inability to sleep, great energy, racing thoughts and an increase in goal-directed activities.  She reported similar symptoms had previously occurred when she took another anti-depression medication to stop smoking.  The examiner noted symptoms were consistent with hypomania and ordered a mood stabilizer and anti-anxiety medications.  The MEB forwarded “bipolar disorder” for PEB adjudication.  

The MEB NARSUM examination on 3 December 2007, 2 months prior to separation, noted the CI’s previous mental symptoms were absent and that she was stabilized with the medications.    Current medications included an anti-anxiety medication as needed, an anti-convulsion medication daily, and birth control pills.  Mental status examination (MSE) dated 26 November 2007 showed no evidence of hypomania or anxiety.  Diagnoses of bipolar disorder, not otherwise specified (NOS) and PTSD were rendered with a Global Assessment of Functioning (GAF) score of 55 (moderate symptoms, impairment.)  The examiner noted significant improvement with positive stabilization.  Bipolar illness was the focus for unsuitability for further service.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 11 December 2007, 2 months prior to separation, the CI reported trouble sleeping, anxiety or panic attacks, and depression.  

At the 17 March 2008 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported paranoia, racing thoughts, significant sleep problems despite sleep medication, episodes of anxiety, excess energy, loud and pressured speech, excessive spending, inability to focus.  She continued with psychotropic medication and reported no periods of remission.  She also described combat exposures and subsequent symptoms of PTSD, though the examiner noted an overlap with symptoms of bipolar disorder i.e. sleep disturbance, irritability and poor concentration.  The CI also endorsed intrusive thoughts and avoidance.  Her dreams were no longer related to military experiences and had diminished significantly.  She had separated from her fiancé and had a roommate who had two children.  She was working for an Internet company and things were going well on the job.  She enjoyed everything and liked to fix things.  At the MSE, the CI displayed slightly rapid and slight pressured speech, mild disorganized thought pattern, and at times difficulty in expressing her concerns.  Diagnoses of bipolar disorder and PTSD were rendered with a GAF score of 55 (moderate symptoms, impairment.)  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bipolar condition 10%, coded 9432 (bipolar disorder), citing symptoms controlled by continuous medication.  The VA rated the bipolar disorder with PTSD condition 50% coded 9432-9411 (bipolar disorder - PTSD), based on the C&P examination 2 months after separation, citing reduced reliability and productivity.  Application of VASRD §4.129 is considered by the panel for all cases of service-connected psychiatric conditions resulting in separation.  All members agreed that the ‘highly stressful event’ requisite for §4.129 was not satisfied for the bipolar disorder.  The panel then considered if there was evidence for a §4.130 rating higher than the 10% assigned by the PEB.  

The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication” and for a 30% rating is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.”  The NARSUM exam noted mental health symptoms were absent and there had been significant improvement with mood stabilization.  The C&P examination 2 months after separation noted the CI remained mildly symptomatic and was still taking medication.  However, she was living with a roommate who had children and was working and things were going well on the job.  The members agreed she did not meet criteria for a 30% disability rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bipolar condition.  

Posttraumatic Stress Disorder.  The panel’s main charge is to assess the fairness of the PEB’s determination that PTSD was not unfitting.  The CI reported no combat exposures, no exposures to wounded, killed or dead, no feelings of being in grave danger or being killed, and no anxiety/depression symptoms on her Post-Deployment Health Assessments in 2006.  She did, though, later report increasing issues with depression, not sleeping, increased anxiety and agitation off and on since April 2006.  The CI later cited exposures to small arms fire, explosive devices and mortar rounds while deployed.  She first reported symptoms in July 2007 and was eventually treated with medication for PTSD.  The examiner noted the hypomania portion of the bipolar disorder was induced by the introduction of medication to target depressive symptoms associated with PTSD.  The CI did receive a P3 profile for both PTSD and bipolar disorder, both conditions were implicated in the commander’s statement, and both were judged to fail retention standards.  The PEB noted, though, that the CI did not meet DSM criteria for PTSD.  The panel noted that while the CI reported exposure to explosions and attacks, her primary problems appeared to be sleep disturbance and nightmares, which eventually subsided.  She also reported depression with anxiety and other symptoms of mood instability.  There was no evidence of Criteria C symptoms of distancing in relationships or numbing, detached feelings.   

There was no performance-based evidence that PTSD significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended PTSD, so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the bipolar disorder and IAW VASRD §4.130, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended PTSD, the panel unanimously agrees that it cannot recommend it for additional disability rating.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141112, 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

10 Apr 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170004769 (PD-2015-00066)

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