RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01508
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040517

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E5, Internal Electrician, medically separated for “bipolar disorder I” with a disability rating of 10%.  

CI CONTENTION:  “The VA rated me at 70% for the same condition.”  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040325	VARD - 20050822	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder I	9432	10%	Bipolar Disorder	9432	70%	20040623	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Bipolar Disorder I.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI developed symptoms of mood instability, anxiety, and suicidal ideation in August 2003, 2-4 months into a deployment to Iraq, with no specific history of traumatic stress which may have caused her symptoms.  At the time of initial evaluation, she was diagnosed as bipolar, started on medication, and medically evacuated from theater.  

The 15 October 2003 MEB NARSUM examination, 7 months prior to separation, noted CI complaints of mood instability for approximately 4 months.  The mental status examination showed her mood was anxious and slightly depressed with congruent affect and minimal psychomotor retardation.  Attention and concentration skills were minimally impaired, and there were no suicidal ideations, delusions, hallucinations or other symptoms suggestive of psychosis, speech disturbance, objective cognitive impairment, or other abnormality.  Global assessment of functioning (GAF) was 57 (in the moderate symptom range).  The psychiatrist documented that the CI continued to have depressive episodes which were moderately well-controlled with medications, and that she was moderately stable and would require weekly psychiatric care.  

The 4 November 2003 commander’s statement noted excellent performance prior to “being diagnosed with bipolar disease O/A 15 September 2003.”  The commander indicated that he did not know if the CI was still deployable, but recommended retention.  

There were 18 psychiatry and behavioral health visits following the NARSUM and prior to separation.  Added history included the CI’s bereavement counseling after her mother’s death in April 2003 (prior to deployment).  Mental health evaluations in November and December 2003 recorded manic and depressive episodes with fluctuating mild to serious GAFs (65 to 43) with the December 2003 GAF being 59 (moderate symptom range).  The behavioral health treatment entry on 16 March 2004 documented that the CI’s anxiety seemed “out of control” and that she needed to continue medication and group therapy.  

The 22 March 2004 memorandum from the CI’s treating military psychiatrist (and NARSUM author) to the Formal PEB, requested and supported revision of the PEB’s “EPTS [existed prior to service] condition without permanent service aggravation” determination.  The psychiatrist stated that the CI’s bipolar disorder had “been difficult to manage” and did not anticipate that she would be able to return to her civilian job due to the requirement for medication changes and weekly monitoring.   She also had frequent, rapid cycling, and despite “close attention to medication changes” her condition continued to be “very unstable” and kept her from regularly performing routine assigned duties.  The provider also noted that when the CI was depressed, she had “minimal energy and very poor concentration and when manic she [was] unable to stay on task and frequently [forgot] to complete assigned responsibilities.”  

At the 23 June 2004 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported having a bipolar disorder, taking chronic medications and working part-time.  The MSE was unremarkable with no suicidal ideation, delusions, evidence of racing thoughts, hallucinations or other symptoms suggestive of psychosis, speech disturbance, objective cognitive impairment, or other abnormality.  Her GAF was 50 (50-41=serious symptom range), and the psychiatrist stated “she has serious impairment in social, occupational and mood functioning.”  

Follow-up evaluations in October, November and December 2004 indicated the CI continued with mental health treatment, symptoms (mood lability, racing thoughts, sleep difficulties), and medication changes.  By the 20 October 2004 VA outpatient psychiatric evaluation, 5 months after separation, the CI had been placed on lithium, had been restricted to part-time work due to lack of focus, and was assessed with a GAF of 55.  By 3 November 2004, she was returned to full work and was assessed with a GAF of 50.  Psychiatric assessment on 8 December 2004 documented continued symptoms with work difficulties and a GAF of 55, and the physician recommended the CI not work night shifts.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bipolar condition 10%, coded 9432 (bipolar disorder), citing medication use, outpatient status, and mild impairment.  The VA rated the bipolar condition 70%, also coded 9432, following a De Novo review of an initial 10% rating, based on the C&P examination and subsequent treatment record, citing consistent appeal with GAFs in the 50’s, constant worsening, and “deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood.”  

The panel first addressed whether the provisions of VASRD of §4.129 (mental disorders due to traumatic stress) were applicable, and determined that the bipolar condition was not due to a “highly stressful event.” In accordance with VASRD §4.126, the panel considered all of the evidence of record that related to occupational and social impairment rather than a single examiner’s assessment of the level of disability at the moment of the examination.  Members agreed that at the time of separation, the §4.130 threshold for a 50% rating (or higher) was not approached.  Therefore the panel discussed whether the impairment more nearly approximated a 10% versus 30% rating.  Social and occupational impairment consistent with a 30% evaluation (occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks…), could be surmised from some of the symptoms reported at the time of the MEB NARSUM and the psychiatrist’s memorandum to the Formal PEB, including mood instability, anxiety, decreased attention and concentration, and sleep impairment.  Although the initial C&P examiner assessed the CI with serious impairment with part-time work, the VA rater indicated her condition was stable and well-controlled on medication.  The STR and subsequent VA treatment records showed worsening mood and symptom instability proximate to separation.  The symptoms were difficult to control with medication, but were generally responsive, challenging to treat, and required poly-pharmacy.  Details of the evaluations and work history supported occupational and social impairment with occasional decrease in work that was not only during periods of significant stress, warranting a 30% rating.  Additional symptoms more remote from separation were adjudged as less probative to rating at separation.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the bipolar condition, coded 9432.  

BOARD FINDINGS:  In the matter of the bipolar disorder I, the panel recommends a disability rating of 30%, coded 9432 IAW VASRD §4.130.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Bipolar Disorder I	9432	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161003, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180010641, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure