RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00071
BRANCH OF SERVICE:  Army	
DATE OF PLACEMENT ONTO TDRL:  20000826 
DATE OF REMOVAL FROM TDRL:  20020206 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3, Wheeled Vehicle Mechanic, medically separated from the Temporary Disability Retired List (TDRL) for a bipolar I disorder condition, with a disability rating of 10% and the CI was medically separated.

CI CONTENTION:   “Please consider all conditions.”  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 

Final PEB – 20020109	VA Rating Decision1 - 20020625	
TDRL Placement – 20020206	Code	Rating	Condition	Code	Rating
Proximate	
Condition		TDRL
Placement	TDRL Removal			TDRL2
Placement	TDRL3 Removal	
Bipolar Disorder I	9432	30%	10%	Bipolar Disorder II	9432	30%	30%	
Other x 0 (Not in Scope)	Other x 0	
RATING:  30% → 10%	RATING:  30%	
1. Most proximate to TDRL Placement
2. Rating derived from C&P examination dated 20020605, ~22 mos. post-TDRL placement 
3. Rating derived from C&P examination dated 20020605, ~4 mos. post-TDRL removal 

ANALYSIS SUMMARY:  

Bipolar Disorder.   The records documented that the CI suffered an emotional event while serving in Germany in October 1999.  There were several incidents that led to his subsequent hospitalizations that included an initial 1 week of inpatient at Landsthul, followed by a transfer to WRAMC where he remained until the narrative summary (NARSUM) was accomplished.  The NARSUM noted that prior to the onset of symptoms, he had been described as being “obedient and zealous”; however, 3 months prior to his hospital admission, he displayed symptoms of depression.  His symptoms eventually led to mood instability suggestive of hypomania.  Prior to the October 1999 admission, he became irritable, made several threatening remarks toward NCOs in his unit, and displayed bizarre behaviors (walking 2 miles away from training site during an exercise to the barracks where he stole bottles of liquor from the barracks placing them in a soda machine).  While hospitalized in Germany, the CI was noted to be irritable and intrusive, and had symptoms suggestive of a bipolar condition.  At discharge he was diagnosed with bipolar affective disorder, manic, and he was admitted to the psychiatry inpatient unit at WRAMC.  At the NARSUM (21 December 1999), approximately 8 months before TDRL placement, the examiner noted although the CI denied psychiatric symptoms, he was observed to display an elevated and irritable mood, grandiosity, pressured speech, flight of ideas, psychomotor agitation, and distractibility.  He was treated with an anticonvulsant medication (Depakote) and anti-anxiety medications.  During the third week of hospitalization, he demonstrated aggressive behaviors that escalated to the extent that he had to be restrained.  It was noted that he was compliant with his medication; in fact, his Depakote was discontinued due to elevated liver function tests.  Treatment with lithium was initiated while Depakote was gradually tapered.  At the time of discharge on 27 December 1999, his mental status examination (MSE) documented mildly pressured speech, some psychomotor agitation, and grossly intact cognition, no evidence of psychosis, suicidal ideations or homicidal ideations.  His affect was normal, and he reported that his mood was “great.”  The diagnosis of bipolar I disorder, manic, moderate, was recorded and the Global Assessment of Functioning (GAF) score assessed on admission was 54 (moderate).  There were several VA clinic notes that were considered by the PEB for rating at TDRL removal.  Treatment records demonstrated that the CI participated in psychotherapy with the VA on a regular basis.  The record notes the CI began his TDRL treatment in January 2001 and was not having any symptom nor was he taking any psychotropic medication.  Psychiatry clinic entry dated 5 June 2001 indicated the CI was not having any mental health symptoms and the plan was to “continue to monitor and observe.”  The CI was instructed to call the clinic if he has signs or symptoms of either depression or mania.  Clinic entry dated 3 August 2001, 6 months before TDRL removal, documented that the CI has not had any signs or symptoms of bipolar disease since separation.  His MSE was normal.  He reportedly stated that he is sleeping well, has a good mood, and he and mom noted he was back to his baseline.  The CI was seeking employment; however, had recently lost his job at Costco where he was on probation status.  The CI was told he was a good worker but tended to talk too much to the customers.  At the VA Compensation and Pension (C&P) mental examination dated 5 June 2002, approximately 6 months post permanent separation, the CI indicated he had no additional psychiatric hospitalizations, and his last episode of hypomania was in May 2001 (not consistent with the VA treatment records as noted above).  He was employed and noted the job was going well and had recently took a certified nurse assistant (CNA) course with the hopes of becoming a CNA.  He was living on his own with three roommates, and enjoyed rollerblading and mountain climbing.  His MSE was normal, and symptoms of a mood disorder were not documented, although the examiner opined a GAF of 60 (moderate) for bipolar II.

The Board directed its attention to its rating recommendation, based on the evidence.  The Board first unanimously agreed that VASRD §4.129 was not applicable in the absence of a highly stressful causative event, but that placement on TDRL for stabilization was appropriate.  The CI continued to have symptoms and was still in need of further stabilization.  All members agreed that at the time of the TDRL placement, the VASRD §4.130 threshold for a 30% rating was met.  A higher rating of 50% requires “Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; this rating was not approached.  The Board noted although the NARSUM was accomplished while the CI was on the inpatient unit, there was no history of suicidal ideation, no visits to the emergency room, no hospitalizations in the 8 months prior to TDRL placement, and no legal issues.  Additionally, the record recorded absence of panic attacks and no documented evidence of impairment in thinking or judgment in the 8 months prior to TDRL placement.  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 condition bipolar I disorder at TDRL placement.

The Board next directed attention to the permanent rating recommendation based on the evidence described.  The PEB rated the condition 10% under code 9432, citing the CI has continued in treatment with the VA and his medications have been discontinued for several months.  The PEB considered his condition was stable for rating and his condition was mild. The VA granted 30% code 9432 (bipolar II) for the condition diagnosed as bipolar II.  The Board members agreed the VASRD §4.130 threshold for a 10% rating was met due the need for continued monitoring of his condition.  The higher rating of 30% requires occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), 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 Board noted the CI was essentially asymptomatic, which was noted in every available treatment record and he was not taking medication.  Normal MSEs were documented in all of the VA treatment notes as well as the C&P examination.  At the time of the C&P examination he was working and demonstrated minimal to no impairment in occupational or social functioning as the result of a mental health condition.  Board members agreed that the 10% rating more accurately reflected the CI’s condition at the time of separation.  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 permanent adjudication for the bipolar I condition.

BOARD FINDINGS:  In the matter of the bipolar I condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB’s TDRL and permanent separation 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 20150115, 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 AR20160013854  (PD201500071)

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