RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX.	CASE:  PD-2016-00229
BRANCH OF SERVICE:  Coast GuarD 	SEPARATION DATE:  20091209

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Supply, medically separated for “low back pain” and “right knee pain,” with a disability rating of 10%.

CI CONTENTION:  The CI requests review of all conditions.  A 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 - 20091013	VARD - 20100420	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder	9432	10%	Not Service Connected	
Panic Disorder w/o Agoraphobia	Not Unfitting	No VA Entry	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY: 

Bipolar Disorder.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s mental health (MH) condition began in December 2005 and a diagnosis of bipolar I disorder was subsequently made.  Treatment consisted of Depakote (valproic acid), which the CI took erratically.  The diagnosis was changed to cyclothymic disorder and the CI was retained on active duty.  In October 2007 the CI had an anxiety attack marked by chest pain, shortness of breath, dizziness, and nausea.  The CI was admitted since an electrocardiogram show inverted T-waves in leads III, AVF, and V3 to V6.  A myocardial infarction was ruled out with three negative sets of cardiac enzymes. Cardiac evaluation included an angiogram with normal coronary arteries and the discharge diagnosis was atypical chest pain most likely psychogenic and bipolar disorder.  In September 2008 the CI felt stressed and had an anxiety attack at work and was visibly subbing during a medical interview.  The CI underwent inpatient mental health evaluation and treatment from 25 September 2008 to 1 October 2008.  His discharge diagnosis was bipolar disorder mixed with hyperanxious disorder with a Global Assessment of Functioning (GAF) score of 32 (some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood).  Treatment consisted of Ambien (zolpidem, a sedative for treatment of insomnia), Seroquel (quetiapine, an atypical antipsychotic drug used in combination with antidepressants), and Depakote.  The CI attended Intensive Outpatient Therapy (IOP) 5 days a week.  On 22 October 2008 the CI reported a panic attacks (see below), one of which was treated in an Emergency Room with lorazepam (to treat anxiety).  The CI continued to have concerns about returning to work and was advised to take Ativan (lorazepam) as needed for anxiety episodes.  In January 2009 the CI was diagnosed with bipolar II disorder, most recent episode depressed, based on a history of weeks of having high moods and weeks of having low moods.  The CI’s immediate work supervisor was contacted and stated the CI did little to no work from early August until mid-September related to his responsibility for procurement and management of funds for a small boat station despite adequate training for the position.  As a result, he was given a timeline to catch up.  The next day the CI had a panic attack at work, felt unstable, and was sent for inpatient psychiatric care, and had not resumed his duties due to IOP.  Additionally, he was diagnosed with panic disorder without agoraphobia, not in remission (see below).  His GAF score was 60 (moderate symptoms or moderate difficulty in social, occupational, or school functioning) with the highest in the prior year being 65 (some mild symptoms or some difficulty in social, occupational, or school functioning).  The examiner noted the CI’s impairment for further military duty was moderate and impairment for civilian social and industrial adaptability was mild. 

The 16 April 2009 MEB NARSUM examination, 9 months prior to separation, noted complaints of being stressed about returning to work and having been diagnosed with a bipolar II disorder.  The examiner noted the CI remained in IOP, was still taking his prescribed medications, and would likely require continued outpatient psychiatric therapy and medication for many months to years to come.  During the 16 November 2009, MEB examination (recorded on DD Forms 2807-1 and 2808) 1 month prior to separation, the CI reported high anxiety, panic attacks, and bipolar disorder.  The examiner noted the CI was diagnosed with bipolar disorder and cyclothymia without any abnormality on the day of the examination.

At the 16 February 2010 VA Mental Health Consultation, 3 months after separation, the CI reported he was currently “running on a high” and the medications helped him stay “even keeled” to avoid daily mood swings.  Mental status examination revealed the CI to be casually dressed, pleasant and cooperative.  His speech was non-pressured.  He had no tics, tremors, tardive dyskinesia (abnormality or impairment of voluntary movement), or akathisia (agitation, distress, and restless as a side effect of antipsychotic and antidepressant drugs).  His mood was good and affect euthymic.  The CI denied suicidal ideation, homicidal ideation, hallucinations, paranoia, or delusions.  Thought processes were linear without any flight of ideas.  He was alert, fully oriented, and had grossly intact memory, attention and concentration.  Insight and judgment appeared good.  The examiner’s diagnosis was bipolar disorder, unspecified with a history of Type II bipolar disorder and the CI did not appear hypomanic or depressed.   His GAF score was 65.  

The panel directed attention to its rating recommendation based on the above evidence.  The Coast Guard PEB rated the bipolar disorder condition 10%, coded 9432 (bipolar disorder), citing occupational and social impairment due to mild or transient symptoms with decrease in work efficiency and ability to perform occupational tasks only during periods of significant stress.  The VA determined the bipolar disorder condition was not service-connected, coded 9432, based on the failure to report to C&P examinations 5 months after separation.

Members discussed whether the a 30% rating, which 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),” is warranted.  Clearly, the CI had depressed moods, anxiety, and panic attacks as well as chronic sleep impairment for which he took Ambien.  However, it was not clear why the CI had such concerns about returning to work despite receiving IOP.  Therefore, it would speculative to address whether the CI had an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks when in fact he was out of work for such an extended period.  Thus, members determined that the CI’s impairment for occupational and social adaptability was mild as indicated by the consulting psychiatrist while the CI was on active duty.  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 disorder condition.  

Contended Condition:  Panic Disorder without Agoraphobia.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not addressed although referred by the MEB.  There was no profile available for review, while the commander’s statement did indicate the CI stated “he was experiencing a panic attack,” for which he was subsequently admitted for mental health treatment.  The CI had atypical chest pain in October 2007 that after cardiology evaluation was felt to be most likely psychogenic.  The CI experienced a panic attack within a day of receiving counseling and a timeline for completing assigned work.  Upon inpatient discharge on 25 September 2008 the CI was diagnosed with bipolar disorder mixed type with a hyperanxious disorder.  Thereafter he had several panic attacks that were originally treated in an Emergency Room with Lorazepam, which was refilled subsequently.  On 5 January 2009 the CI was diagnosed as having a panic disorder without agoraphobia as manifested by recurrent panic attacks and worry about the ramifications of having panic attacks based on the external precipitation stress of anxiety about work.  At the VA mental health consultation in February 2010 the CI stated he had not had a panic attack since just after discharge in late December 2009. 

There was no performance-based evidence from the record other than the panic disorder that resulted in inpatient treatment that the condition 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 determination not to address the panic disorder without agoraphobia for the contended condition.  For even if were determined to be unfitting or not unfitting, no disability rating is recommended since to do so would evoke VASRD §4.14 (avoidance of pyramiding).  

BOARD FINDINGS:  In the matter of the bipolar disorder condition and IAW VASRD §4.130, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended panic disorder without agoraphobia condition, the panel unanimously recommends no change from the PEB lack of determination of the condition as neither unfitting nor not unfitting.  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 20160419, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXX,

I am the Designated Decision Authority for the Coast Guard on applications submitted to the Department of Defense Physical Disability Board of Review (PDBR).  Under the authority of Title 10, United States Code, section 1554a, I accept the PDBR’s recommendation in your case (Case Number PD-2016-00229) and decline to modify your findings. 

Enclosed for your information are a copy of the PDBR’s recommendation and a copy of the record of proceedings. 

A copy of this decision has also been provided to Coast Guard Enlisted Personnel Management Branch, the PDBR, and the Department of Veterans Affairs. 

If you have any further questions, please contact the Coast Guard Personnel Service Center. 

Sincerely,
	
Rear Admiral, U. S. Coast Guard
Assistant Commandant for Human Resources