RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02190
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20090806

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Aviation Electronic Technician, medically separated for “bipolar disorder NOS” with a disability rating of 0%.  

CI CONTENTION:  “Review all conditions.”  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 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 Panel’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Panel 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 determinations 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 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 - 20090513	No VA rating Decision in Probative Range	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder NOS	9432	0%*		
Eating Disorder NOS	Cat II 		
Concussion without LOC	Cat III		
Borderline PD	Cat III		
Alcohol Abuse	Cat IV		
Cocaine Dependence…	Cat IV		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	
*Rated 10%, but reduced to 0% for EPTS deduction.

ANALYSIS SUMMARY:  

Bipolar Disorder NOS Diagnosis.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a mental health history prior to accession marked by physical and sexual abuse, polysubstance abuse, self-mutilation, and suicide attempts.  This is discussed below as disclosed in clinical encounters.  On the pre-enlistment disclosure form, the CI disclosed marijuana use and a conviction for an alcohol related incident.  There is no history of difficulty completing her initial training.  
Her fitness reports covering from August 2005 through March 2008 showed that her performance was satisfactory in her assignment as a plane captain.  The final fitness report closed out on 15 June 2009, less than 2 months prior to separation.  She was working as a staff assistant in the Chaplain’s office and achieved a score of 3.46/5.0, the highest in evidence.  The evaluator observed that she had excelled in her duties and exercised responsibility and accountability.  Her promotion recommendation was “must promote.”  The commander’s assessment dated 4 August 2009, noted that the CI was not deployable and that she had, on occasion, been debilitated.  

According to the mental health NARSUM prepared on 4 March 2009, the CI initially presented to her primary care provider on 4 January 2008 with symptoms of depression.  She was placed on an anti-depressant.  On follow-up on 3 March 2008, she reported that her symptoms were worsening.  Her medications were adjusted and she was placed on LIMDU.  She was also referred to mental health where she was first evaluated on 11 March 2008.  Additional changes in her medications were required and she was begun in outpatient therapy.  She was also diagnosed with a borderline personality disorder.  She was given a second period of LIMDU at the 12 August 2008 re-evaluation.  

The first mental health record in evidence was dated 17 November 2008 and a re-evaluation.  She was diagnosed with bipolar I disorder at this evaluation and prescribed Lithium.  The CI reported periodic depression since middle school.  It was noted that her stomach had been “pumped” three times in middle school due to an overdose (it was not specified on what she overdosed).  She was not sure when she first had manic symptoms, but noted that the most recent episode had been over the summer and lasted 2-3 months.  It had been manifested by “decreased need for sleep, feeling hyper and invincible, increased spending, hypersexual behavior, and audio hallucinations.”  She was living with her boyfriend who was supportive.  She had been separated from her second husband for 2 ½ years.  He was in jail for drug distribution.  She said she was physically and sexually abused by both her father and step-father.  She brought charges against the latter and he was sent to jail.  She was then forced out of her mother’s home and lived with her boyfriend whom she married at 16.  This relationship ended at 19 after she became involved with drugs and night club dancing.  She then married her second husband, a drug dealer, and was involved with methamphetamine and cocaine over the next year until she joined the US Navy at 20 to “make something of my life.”  She stopped the drug abuse, but continued to abuse alcohol and was drinking 4-5 drinks a night at the time of the interview.  She was advised to stop drinking and enter rehabilitation.  

The next mental health encounter in evidence was dated 2 February 2009.  The CI was in her second period of LIMDU which was to expire on 11 March 2009.  She was working in the chaplains’ office and, as noted above, doing well.  She was on medications, but blood levels were low raising concerns about compliance.  She continued to drink alcohol despite being counseled to stop.  She expected to separate in May and planned to go to school and also to continue her relationship with her boyfriend.  Her mental status examination was remarkable for poor insight and judgement; she was also evasive about her past history of abuse and substance abuse.  It was otherwise normal.  It was recommended that she stop the use of Lithium until she had discontinued alcohol use and rehabilitation was again recommended.  It was noted that hospitalization was not indicated.  

At the MEB mental health NARSUM examination dated 4 March 2009, 5 months prior to separation, the CI had developed a good working relationship with her therapist and had discontinued alcohol use.  She remained in remission from her past substance abuse (which included cocaine, ecstasy, cannabis, and methamphetamine).  She had also abused over the counter stimulants and laxatives for weight control.  It was recorded that she had been taken to counseling as teenager, but did not participate.  
Her symptoms had not interfered with her function (this apparently refers to her duties in the US Navy, but it is not specified) until she presented for treatment one year earlier.  Her mental status examination was normal other than being mildly evasive with reference to her prior abuse and substance abuse as well as showing poor insight and judgement.  The following conditions were noted to have existed prior to service (EPTS), but to have been service aggravated: bipolar disorder NOS (not otherwise specified); eating disorder NOS; and a Borderline Personality Disorder.  Alcohol abuse was determined to be EPTS.  Cocaine abuse was also EPTS, but in sustained full remission.  The DD Form 2808 done that day recorded her weight as 116 pounds and height 62 inches.  

Two weeks after separation, on 25 August 2009, the CI was seen in primary care in the VA.  She denied symptoms of depression on screening.  An alcohol screen was positive at 5 (the score ranges from 0, no use, to 12; 3 is positive in women).  She requested that her medications be refilled and her mental health care be transferred to the VA.  On examination, she was noted to have a full range for her affect, pleasant mood, and intact judgement.  She denied suicidal and homicidal ideation.  Her weight was 114.5 pounds.  

The CI was seen in mental health on 31 August 2009.  She was doing well in school and had no legal issues.  She had stopped smoking.  She had also decreased her alcohol intake and was now not sleeping as well at night.  She noted that her depressive symptoms were worse at night and her manic symptoms tended to be in the summer.  She denied drug abuse since the age of 20.  Her mental status examination was unremarkable.  

The CI was next seen in mental health on 3 December 2009.  She reported that her mood had been stable, but that she was pregnant and had discontinued her medications.  She had quit drinking (alcohol).  She reported that she was in a “good” monogamous relationship with the father of the baby.  Reinitiating treatment with Lithium was discussed if either her symptoms increased in the first trimester of pregnancy or once she was in the second trimester.  

She was next seen on 17 December 2009.  She was in the process of moving in with her boyfriend into the home of his parents.  She enjoyed a good relationship with her boyfriend and his parents and saw this as a positive mood.  She planned to attend school full-time the next semester.  She reported that she was stable off medications, but interested in resuming psychotherapy.  Her mental status examination was unremarkable.  She was seen two weeks later on 29 December 2009.  Her examination remained unremarkable and she was on time for her appointment.  She endorsed some awkwardness about being around her boyfriend’s mother all the time, but did find privacy as needed.  Her relationship remained strong and positive.  She was scheduled to be seen again in 2 weeks, but did not show for that appointment or the one scheduled 2 weeks after it (14 and 28 January 2010, respectively).  

There were no further records in evidence until the VA mental health Compensation and Pension (C&P) evaluation.  It was not accomplished until 13 September 2016, 7 years after separation, and the evaluation is not probative (too remote from separation) other than the information it provided about her status proximate to separation.  It noted that she had been married for about 6 years and had 2 children, ages 2 and 6.  She had not worked since separation from the US Navy.  She had an Associate’s Degree and was working on a Bachelor’s degree in Biology.  She denied any legal history.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bipolar disorder NOS condition 0%, coded 9432 (bipolar disorder), reducing the rating by 10% for the EPTS contribution.  The eating disorder was subsumed under the unfitting bipolar disorder as a related Category II condition.  The medical officer observed that her weight was stable in the examinations proximate to separation (her accession weight was not in evidence) and that there was no evidence recorded indicating complications of an eating disorder.  Further, the recorded weight of 114.5 and 116 pounds is a normal weight for a women who is 62 inches in height.  The evidence does not support a compensable condition even if it were a separately unfitting condition.  Accordingly, no additional rating is recommended for the eating disorder.  At the time of separation, the CI had been working in an alternate duty and had “excelled” as noted by her rater.  She was in a new relationship which was stable and resulted in marriage after separation.  She entered school and successfully obtained an associate’s degree.  Her mental status examinations were essentially normal proximate to separation.  She was on medications.  This supports the 10% rating adjudicated by the PEB.  The Board then considered the EPTS deduction.  While the CI clearly had manifestations of a mental health condition prior to accession, she was able to meet standards for the first few years of her enlistment without mental health care.  This is consistent with a 0% rating at accession (a formal diagnosis, but without occupational or social impairment and not on medications).  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Panel recommends a disability rating of 10% for the bipolar disorder, NOS, condition, coded 9432 without an EPTS deduction.  

Contended PEB Conditions: Concussion without loss of consciousness, borderline personality disorder, alcohol abuse, and cocaine dependence in sustained full remission.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement.  Both the concussion without loss of consciousness and borderline personality disorder conditions were determined to be Category III.  There were no records in evidence showing any duty impairment from complications of the reported concussion nor were there contemporary records for the event.  It was recorded on the MEB NARSUM, but not reported on the MEB DD 2807 done the day prior.  The borderline personality impairment was subsumed under the total impairment for the mental health condition.  In addition, the panel noted that IAW DoDI 1332.38 E.5.1.2.9.2., a personality disorder is not a ratable condition.  The alcohol abuse and substance abuse were determined to be Category IV conditions.  Both predated accession.  The CI stopped drinking shortly after separation (when she became pregnant).  The substance abuse was noted to be in remission prior to accession.  Regardless, neither is ratable IAW DoDI 1332.38 E.5.1.2.9.1.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bipolar disorder, NOS condition, the panel unanimously recommends a disability rating of 10%, coded 9432 IAW VASRD §4.130.  In the matter of the contended concussion without loss of consciousness; borderline personality disorder; alcohol abuse; and cocaine dependence in sustained full remission conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  

The panel 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, NOS	9432	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150607, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 17 Jan 17 ICO XXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 17 Dec 17 ICO XXXXXXXXXXXXXXXXXX   
	(d) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 27 Oct 17 ICO XXXXXXXXXXXXXXXXXX 
	(f) PDBR ltr dtd 31 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 07 Dec 17 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (g) are approved.  The official records of the following individuals are to be corrected as follows:

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

     b. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

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

     d. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 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 USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 
     
2.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

                                  	XXXXXXXXXXXXXXXXXX
                                 	Acting