RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX.	CASE:  PD-2016-01089
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040905

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Chaplain Assistant, medically separated for “bipolar II disorder” and “migraine headache,” rated 10% and 0%, respectively, with a combined disability rating of 10%.   

CI CONTENTION:  “I request the PDBR 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 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 - 20040527	VARD - 20050302	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar II Disorder	9432	10%	Bipolar Disorder with Anxiety Disorder and Depression	9432	10%	STR	
Migraine Headache	8100	0%	Migraine Headache	8100	30%	STR	
Low Back Pain and Pubic Symphysis Pain	Not Unfitting	DJD Syphysis Pubis	5010	10%	STR	
		Chronic Lower Back Pain	5299-5237	NSC	STR	
Allergic Rhinitis	Not Unfitting	Sinusitis	6599-6510	0%	STR	
		Allergic Rhinitis	6522	0%	STR	
Hemorrhoids	Not Unfitting	Hemorrhoids	7336	0%	STR	
Hypertension	Not unfitting	Hypertension	7101	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Bipolar II Disorder.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s mental health (MH) condition began around 1997 while the CI was being treated for depression at different military facilities with a variety of psychotropic medications.  The bipolar II condition was diagnosed around March 2004.  During the 2 April 2004 MEB MH NARSUM examination, 5 months prior to separation, the complaints of occasional mood swings, anxiety and insomnia were noted.  The CI reportedly began treatment for depression in 1997 and was still taking anti-depressant medication at the time of the NARSUM.  In addition to mood and anxiety symptoms, the CI reported she felt she was not fully accepted by her unit and that the difficulties she had at several units had played a significant role in maintaining her depression and headaches.  She was admitted to the psychiatry inpatient unit in February 2004 due to depressed mood and inability to cope with perceived job related stressors.  The CI indicated she felt, because of her Muslim faith, that she was not treated fairly.  

The CI had a history of cyclic mood swings and symptoms suggestive of hypomania; however, she had not experienced a manic episode, and had no other psychiatric hospitalizations.  Her most recent symptoms were predominately related to depression, manifested by lack of motivation, social withdrawal and passive death wishes without suicidal ideation.  The CI reported medication used to treat her anxiety and insomnia had been partially effective.  The CI also participated in therapy with a psychologist.  The CI divorced her third husband in May 2003 and she had custody of her three children.  

The mental status examination (MSE) was recorded on 1 April 2004, and it noted that she had a dysphoric mood, full affect, and was tense and guarded.  Her thoughts were tangential, but pressured speech was not identified, and evidence of disorganized or psychotic thinking was absent.  There were no other abnormalities recorded.  The examiner noted that during the MSE, the CI reported recurrent feelings of helplessness, hopelessness and uncontrollable anxiety, and noted that she had felt “victimized” throughout her military career.  There was no VA Compensation and Pension (C&P) examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bipolar II disorder 10%, coded 9432 (bipolar disorder), citing that the CI required psychotropic medication and outpatient therapy.  The VA also rated the bipolar II disorder (including anxiety disorder and depression) 10%, coded 9432, (bipolar disorder) based on review of the STR, citing the CI required medication for these conditions.  

The panel considered the single hospitalization 7 months before separation, the commander’s statement (CS) 6 months before separation, the NARSUM 5 months before separation, and the single ER visit 3 weeks after separation (without hospitalization).  The panel noted there were no additional hospitalization and no additional ER visit.  The NARSUM noted stable symptoms, and suicidal or homicidal ideation was not present.  The examiner recommended continued MH treatment, but also opined that response to medication had been partial.  The examiner also noted the presence of moderate stressor related to the CI’s reported work situations.  The CI was assigned to the Unit Ministry as the Team NCO.  The commander stated, “Since being assigned to the unit, she [CI] has not planned or executed any key religious training or religious observance events.  She cannot qualify with a weapon due to her mental state and inability to control her shakiness.”  There was no mention of conflicts with co-workers or supervisor, mood symptoms, panic attacks, or any MH symptoms other than shakiness when handling weapon.  The commander also stated, “If any assigned task requires additional effort, [the CI] fails to take the initiative in order to complete the task.  She cannot and will not complete the basic tasks required to manage her office, such as building an itinerary and coordinating with staff members.”  The commander noted that the CI was unable to deploy to support the unit’s mission “because of her medical condition and refusal to perform her duties.”  A careful review of the STR did not provide the panel with any insight for the cause of the CI’s reported inability to perform her duties due to her MH condition.  As noted above, there were no acute manic episodes, no indication of chronic sleep impairment that interfered with performance, no report of significant loss of work due to mood symptoms, no report of panic attacks or memory loss that interfered with duty performance, and no documented visits to the ER prior to separation.  There was no indication that she had displayed mood or destructive behavioral symptoms that interfered with job performance.  No significant social impairment was documented in the STR, and mood symptoms were stable in the 6 months prior to separation.  Panel members agreed, the 10% rating and no higher was justified for “Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.”  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 II condition.  

Migraine Headache.  According to the STR and the MEB NARSUM, the CI’s migraine headache condition began in 1997.  Several different medications were tried with some improvement.  During the 26 March 2004 MEB examination the CI reported she had severe headaches; however, frequency was not documented.  Physical examination was unremarkable.  The 9 April 2004 MEB addendum examination, 5 months prior to separation, noted the single complaint of headache.  The headache was described as sharp, constant pain, typically at 8/10 severity, and was associated with nausea, photophobia and phonophobia.  MRI of the brain was normal.  Physical examination, including neurological was unremarkable.  The examiner documented “prostrating headaches” 4 times per week, lasting 1 hour on each of those occasions, and prostrating was not defined.  There was no indication that the CI had been receiving headache prevention medication.  The hand-written addendum dated 9 April 2004, documented under impression/plan, “Common migraine which has been prostrating 4 hours/week.”  Noted under the H&P section of this same hand written document, the statement “headaches are prostrating about 4 hours/week.”  The examiner recorded starting prophylaxis treatment.

The STR demonstrated 3 occasions where abortive medication was administered, each being 3 months apart (March, June and September 2004).  On each occasion, the headache resolved with treatment.  There was no mention of time loss from work due to migraines, or that the CI had to leave work secondary to headaches.  There was no mention of the CI needing to rest, alter the work environment during headaches, or being prescribed quarters for her headache condition.  The commander’s statement made no mention of headaches, only referring to the MH condition.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the migraine headache condition 0%, coded 8100 (migraine), citing the CI was on prophylactic and abortive migraine treatment with no evidence of emergency room treatment during last several months.  The VA rated the migraine headache condition 30%, coded 8100, (migraine); based on review of the STR 6 months after separation.

The rating options under 8100 for migraine headaches rely on the frequency of ‘prostrating’ attacks, and VASRD §4.124a does not define ‘prostrating’.  The panel precedence has relied on the English definition of prostrating (extreme exhaustion, or powerlessness, reduced to extreme weakness).  

A 10% rating requires evidence of characteristic prostrating attacks occurring on an average once a month over last several months.  The panel carefully considered the frequency and nature of the CI’s headaches including objective and corroborating subjective evidence.  As noted above, the STR recorded three headaches where the CI sought help.  The headaches occurred 3 months apart from each other.  The panel acknowledged the NARSUM examiner’s statement that the CI had prostrating headaches; however, there was absence of documentation supporting prostrating attacks.  The commander made no mention of the CI having headaches or having to leave work due to headaches.  There was no indication from the commander that she required breaks due to headaches, or had to modify the workplace in order to accommodate her headache condition.  All panel members agreed that the 0 % rating criteria 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), panel members agreed there was insufficient cause to recommend a change in the PEB adjudication for the migraine headache condition.

Contended PEB Conditions:  Low Back Pain and Pubic Symphysis Pain; Allergic Rhinitis; Hemorrhoids; Hypertension.  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, implicated in the commander’s statement or judged to fail retention standards.  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 II disorder condition and IAW VASRD §4.130, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the migraine headache condition and IAW VASRD §4.124a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended low back pain and pubic symphysis pain, allergic rhinitis, hemorrhoids and hypertension conditions; the panel unanimously recommends no change from the PEB determinations as not unfitting.  There are 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 20160915, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170015830, XXXXXXXXXXXXXXXXXX. 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
						      					
Enclosure