RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00209
BRANCH OF SERVICE:  Navy 	
DATE PLACED ON TDRL:  20011031	
DATE REMOVED FROM TDRL:  20070319

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Surgical Technician, medically separated from the Temporary Disability Retired List (TDRL) (if applicable) for “bipolar I disorder,” with a disability rating of 0%.

CI CONTENTION:  The CI contends for a higher rating (100% VA rating) and also sleep apnea which was not adjudicated by the service.  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 – 20010723/20061215	VARD - 20021218	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Bipolar I Disorder	9432	30%	0%	Bipolar I Disorder	9432	0%	10%	
COMBINED RATING:  30% → 0%	COMBINED RATING OF ALL VA CONDITIONS:  20%/60%	

ANALYSIS SUMMARY:  

Bipolar I Disorder.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) mental health (MH) narrative summary (NARSUM), the CI was in good health until 4 April 2001 when he displayed symptoms of hypomania and confusion.  He left a tattoo parlor began driving around town, but became increasingly confused and ended up many miles away from his destination.  He wound up at a truck stop and locked himself out of his car.  The CI called the police and they found him disorganized, and transported him to the local hospital.  At the hospital, he reported he was unable to focus or concentrate due to racing thoughts, and was disoriented, easily agitated, and had other symptoms significant for bipolar mania.  He was admitted to the hospital, underwent MRI and laboratory studies, including urine drug screen, all of which were normal.  The CI reported he worked two jobs recently and was concerned about the relationship between his wife and his mother as recent stressors.  He denied any recent history of suicidal (SI) or homicidal (HI) ideation; however, noted he had one episode of SI 18 months prior without any attempts.  He was started on antipsychotic medication and later transferred to the Naval Hospital for continued treatment.

Despite psychotropic medication and hospitalization, the CI’s condition could not be rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred to an MEB.  The MEB forwarded “bipolar I disorder, single manic episode, severe with mood congruent” to the Physical Evaluation Board (PEB) for adjudication.

The MEB NARSUM was performed while the CI was on the inpatient unit (30 April 2001), 3 months before TDRL placement.  His mental status examination (MSE) was notable for his being tearful at times, irritable, labile mood and affect, magical thinking, grandiosity, poor attention, poor insight and poor judgment.  Treatment with medication improved his mood and sleep.  The CI was discharged to outpatient care with the diagnosis of bipolar I disorder with psychotic features and a Global Assessment of Functioning (GAF) score of 55 for moderate symptoms and or impairment.  His condition at the time of discharge indicated he did not meet retention criteria; however, the examiner indicated his judgment was intact.  He noted that the CI had an adequate understanding of his illness and could be expected to seek professional assistance “if his symptoms recur.”  The examiner suggested that the CI’s condition was stable; however, treatment had not restored him to a duty status.

The Board first considered its rating recommendation at the time of placement on TDRL.  The PEB rated the bipolar disorder at 30%, coded 9432 (bipolar disorder), and placed the CI on the TDRL List.  The VA rated the bipolar disorder 0%, coded 9432, based on the CI’s STR and absence of examination.  The higher rating of 50% is not warranted unless there is reduced reliability and productivity due to symptoms such as flattened affect, disturbance in thinking or judgment, disturbance in cognition secondary to the MH condition, and difficulty in establishing and maintaining effective relationships at work and socially.  The non-medical assessment (NMA) dated 1 month prior to TDRL placement made no mention of MH symptoms interfering with duty performance.  The psychiatric consultation dated 2 months prior to separation, recommended he return to duty.  The psychiatrist noted that his judgment was intact and he had no significant bipolar symptoms and no evidence of psychosis.  After due deliberation, in consideration of all 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 disorder at TDRL placement.

A VA Compensation and Pension examination was not performed until April 2003, more than 3 years prior to TDRL removal and nearly 2 years after TDRL placement.  That examination noted he was stable on medication and had no intervening hospitalizations, or symptoms of mania.  The CI stated he had done well, his marriage was good and he was working as an operation room technician and was doing well on the job.  He reportedly stated he is completely “fine” when he takes his medication.  The VA assigned a 10% rating based on this examination.

At the TDRL examination performed in November 2006, 1 month prior to separation, the examiner noted there had been a prior TDRL examination that was not available for review, and that the CI had not presented with any documentation.  The CI reported since his last evaluation, he has had no further manic episodes and no symptoms of depression.  He reported no issues with sleep, mood, appetite, energy or concentration, and denied symptoms of bipolar disorder.  He noted he had moved several times and had not had medication for at least the past 5 months, due to the multiple moves.  The CI reported he had worked two jobs after TDRL placement but had lost both of them as the result of his wife’s health and him having to leave work in order to take care of her.  He then moved to another state and worked for 6 months as a surgical tech and was currently working in yet another state and doing well.  The MSE noted the CI had periods of time when his thoughts were tangential and he was fidgety, otherwise his MSE was unremarkable.  A GAF score in the mild range was recorded.  

The Board next considered its recommendation for permanent disability rating at the time of removal from the TDRL.  The PEB rated the bipolar condition at 10%, coded 9432, citing the CI was employed full-time and attending college, and removed the CI from the TDRL List.   The Board considered the evidence and noted the CI had no hospitalizations in the 5 years prior to TDRL removal and was not treated in the ER.  He reported absence of mood symptoms at the VA examination in 2003 as well as at the TDRL removal examination.  There was no report of domestic violence or legal history.  He was able to work full-time jobs and remained stable without medication for a significant period of time.  Although the TDRL examiner noted the condition of bipolar disorder carried a high risk of relapse if untreated, the CI was faced with significant stressors (having to leave jobs due to the need to care for his wife, financial stressor),but there was no evidence that he decompensated in spite of absence of treatment.

Board members agreed, the record demonstrated, at the time of permanent separation, the CI’s condition was stable, and evidence of a significant mood disorder requiring medication was not present.  Thereupon, 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 disorder, type I condition at TDRL placement and removal.

BOARD FINDINGS:  In the matter of the bipolar disorder, type I 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 20150313, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 14 Nov 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN

						  XXXXXXXXXXXXXXXXXXXXX
	     				  Assistant General Counsel
						  (Manpower & Reserve Affairs)