RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00825
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20050722

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve O3, Civil Engineer Officer, medically separated for “bipolar disorder, single episode, severe” with a disability rating of 0%.

CI CONTENTION:  The CI contends for conditions not identified by either the MEB or PEB.  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 - 20050627	VARD - 20150612	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder, Single Episode, Severe	9432	0%	Bipolar (Fatigue)	9432	30%	20050926	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Bipolar Disorder, Single Episode, Severe.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bipolar disorder condition began in April 2005 after she exhibited unusual behavior witnessed by her command.  She had no prior mental health history and had not presented for a psychiatric evaluation prior to being admitted to the hospital in May 2005.  

On 28 April 2005, the CI presented to the emergency room (ER) accompanied by a co-worker, for possible suicidal or homicidal ideation (SI/HI).  She was assessed with acute anxiety and discharged to home with recommended outpatient follow-up.  On 2 May 2005, she was admitted to the inpatient psychiatry unit and assessed with bipolar disorder, single manic episode, severe.  Post-hospitalization follow-up care was never implemented secondary to the CI’s decision to cancel all of her appointment.  

The NARSUM was written while the CI was inpatient (2 May 2005), approximately 3 months before separation.  It was noted that she was brought to the ER by her command due to bizarre behavior in the workplace.  She had made a statement about being able to “communicate with the POW’s” through a chip in her tooth.  She also had expressed paranoia of delusions.  It was noted that she had presented to the ER on 28 April 2005 and was given a next-day appointment at the clinic and failed to attend.  Instead, she reportedly presented to the JAG office to complain that she had been “kidnapped” to the ER the previous day.  The lawyers reportedly referred her to care.  On the day of admission, she reported to work exhibiting disorganized and agitated behavior that resulted in her being escorted to the MH clinic and subsequently to the ER for admission.  

During the admission, the CI reported multiple stressors; she was going through a divorce, had child custody issues, needed to contact the Naval War College about an upcoming semester, and other things she felt needed to be attended to on the day of admission.  She was resistant to being admitted; however, consented as the other option was an involuntary commitment.  Shortly after admission, she was prescribed an antipsychotic medication and her symptoms of agitation subsided.  Later, Lithium was introduced.  Throughout the hospital course, she refused to authorize the staff to contact family for additional history, or to ascertain the safety of her 4-year-old daughter.  However, she indicated that her daughter was being taken care of by family members.  

The mental status examination (MSE) noted pressured speech, absence of psychotic thinking, elements of grandiosity, “markedly agitated and animated” affect, and impaired judgment.  She denied SI and HI.  Global Assessment of Functioning (GAF) score of 20 was assessed on admission.  The record indicated she spent 9 days in the hospital, and since there were no follow-up care, additional MSE were not in evidence.

At the VA Compensation and Pension (C&P) examination, approximately 2 months after separation, the examiner noted that the CI was not forthcoming with describing the genesis of her condition.  She gave a history that seemed “convoluted,” stated that she was not bipolar but rather, had been overworked and fatigued.  It was noted that she focused on having significant menstrual irregularities and premenstrual syndrome (PMS) and opined them to be the cause of her anxiety.  She denied mood swings, psychosis or suicidality and clear evidence of delusions was not present.  She reported daily anxiety symptoms that she opined had been present since her 2004 activation.  

The CI had continued working as an engineer in her civilian job, and there was no indication that she was currently having work difficulties.  She had not received any outpatient psychiatric treatment, had no additional visits to the ER, and no history of additional hospitalizations.  She was not taking any medications.  She indicated that she was a single parent caring for her daughter and that she related well to others.  The examiner noted the CI had multiple symptoms of anxiety and depression, but mostly anxiety, and that she was “hyper-talkative” and extremely tense and anxious which made it very difficult to evaluate her.  It was noted that she had underwent brain CT and MRIs all of them were normal.  Her primary complaints related to physical symptoms, predominantly fatigue and PMS.

The MSE recorded moderate degree of psychomotor agitation, anxious mood, and evidence of disorganized thought processes, which was noted at times to be not logical or coherent.   Although frank psychosis was not documented she reportedly presented material of delusional content.  Her affect at times was noted to be blunted.  Her judgment was not impaired and there was no evidence of cognitive impairment.  The CI was assessed with bipolar disorder, not otherwise specified and anxiety disorder, not otherwise specified.

The Board directed attention to its recommendations based on the above evidence.  The PEB rated the condition at 10% coded 9432 and deducted 10% for non-compliance providing a final rating of 0%.  The VA initially judged the condition was not service related; however, 9 years later, that decision was reversed with the VARD citing “a clear and unmistakable error exists in Rating Decision dated October 2, 2006, for not granting service connection for bipolar disorder.”  The VA then rated the condition 30%, coded 9432 retroactive to the day following date of separation.

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 DoDI 1332.38, enclosure 4.A1.1.2.10.6, and E4.A1.1.2.11.3 references the need to address member’s non-compliance, including a statement to indicate whether the non-compliance is reasonable.  This was not addressed by the MEB psychiatrist or the PEB.  The NARSUM examiner documented that the CI’s judgment was “marginal” and her insight into her illness was “absent.”  The CI provided a rebuttal letter questioning the “legitimacy” of her diagnosis, and to some extent, her letter denied a mental illness.  Her presentation to the C&P examination was similar to her presentation during the NARSUM examination.  Despite the C&P’s examiner’s medical opinion that she suffered from a mental condition, the CI believed her diagnosis was PMS, and that condition was the cause of her anxiety symptoms.  Her belief was that she did not have bipolar but rather was overworked and fatigued.  Board members concluded, absent the PEB’s or the NARSUM psychiatrist’s statement as to whether her non-compliance was reasonable, there was no evidence that her refusal to take medication was not the product of the bipolar illness, and therefore, a 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 noted that the CI’s condition had caused her to increasingly behave inappropriately during a 5-month period.  She had been disruptive at work, made delusional statements.  Was hospitalized but failed to how at her follow-up MH appointments.

There were no treatment records for consideration at the time of separation with the exception of the NARSUM.  The Board considered the commander's statement and the NARSUM, and Board members agreed the CI’s condition was not mild in the 2 months before separation.  Although she was prescribed medication while inpatient, the psychiatrist noted that her symptoms of agitation had improved; however, did not comment on the status of the delusional symptoms or occupational or social impairment.  Two months after separation, there was no clear indication that she continued to have delusional thoughts or any other MH symptoms interfering with occupational or social functioning.  She was providing care for her 4-year-old child, and noted that she had other positive relationships.  She denied any problems with mood, and was noted to have predominately anxiety symptoms.  She had no legal history, had continued to drive a car, was not seen in the ER, and was not hospitalized for MH condition.  The General C&P examination in September 2005 noted that she was working full-time as an engineer for a business specializing in nuclear weapon security.  There was no indication that her MH condition had continued to impair occupational or social functioning.  Despite absence of treatment, there was no evidence supporting that her condition was not stable at the time of separation.  However, the C&P examination noted that she had significant anxiety symptoms, consistent with the findings in the MSE, and appeared to be present only during periods of significant stress.

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.  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, the Board recommends a disability rating of 10%, coded 9432 IAW VASRD §4.130.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Bipolar Disorder	9432	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150604, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 03 Nov 16 ICO XXXXXXXXXXXXXXXXXX    
	(c) PDBR ltr dtd 21 Oct 16 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 24 Oct 16 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 28 Oct 16 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 21 Oct 16 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 03 Nov 16 ICO XXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 28 Oct 16 ICO XXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 28 Oct 16 ICO XXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 28 Oct 16 ICO XXXXXXXXXXXXXXXXXX
	(k) PDBR ltr dtd 28 Oct 16 ICO XXXXXXXXXXXXXXXXXX
	(l) PDBR ltr dtd 03 Nov 16 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (l) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge. 

     c. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     d. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     e. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     f. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     g. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     h. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     i. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     j. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

     k. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.   

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.

	XXXXXXXXXXXXXXXXXX
	Assistant General Counsel
                                                                                     (Manpower & Reserve Affairs)