DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD DC 20374-5023

From: To:

Director, Secretary of the Navy Council of Review Boards PD-2017-01695 

IN REPLY REFER TO

1850
CORB:003
12 Feb 20

Subj:	PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr of 7 Feb 19

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (bl) to the Department of the Navy for appropriate
·	action.

2.	On 31 January 2020, the Assistant Secretary of the Navy took action in your case by accepting the correct recommendation of the PDBR.	Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Physical Evaluation Board from 10 to 30 percent with assignment to the Permanent Disability Retired List.

3.	The Assistant Secretary's determination, which represents final action in your case by the Department of the Navy, was sent to the office of the Deputy Commandant, Manpower and Reserve Affairs, for correction of your records as stated above.	You will be notified once those changes are complete.

RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX		CASE: PD-2017-01695 BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20080830

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Motor Vehicle Operator, medically separated for “bipolar II disorder” with a disability rating of 10%.

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 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 - 20080616	VARD – 20090304 and 20090429	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar II Disorder	9432	10%	PTSD; Bipolar Disorder	9411-9432	30%	20080915
20090528	
Paraphilia NOS	Cat II	No VA Placement	
Psoriasis	Cat III	Dermatitis	7816	NSC	STR	
History of Tympanic Membrane Rupture	Cat III	Right Ear Rupture	6211	NSC	STR	
History of Tension Headaches	Cat III	Tension Headaches	8199-8100	0%	20080820	
Low Back Pain	Cat III	Spondylolysis L5-S1	5239	0%	20080828	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 40%	

ANALYSIS SUMMARY:

Bipolar II Disorder. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was referred for hospital admission in April 2008 after presenting with thoughts of hanging himself or wrecking a government vehicle with the intent of suicide. He had deployed twice to Iraq, the first time in 2003 and the next in the 2004.   The CI presented with a

history of multiple, progressively worse, episodes of depressive symptoms since returning from Iraq in January 2005. He reported nightmares and other problems of PTSD. At times, he cut himself or spent money in hopes of feeling better.

He reported similar episodes in the past, though not as severe. Upon reflection, he reported episodes of elevated, euphoric or irritable mood lasting 2-7 days with decreased need for sleep, psychomotor agitation, racing thoughts, increased goal directed behavior, mild grandiosity, pressured speech and impulsive behavior. He spent excessive money on pornographic material and attended a 12-step program for this addiction. He reported two previous suicide attempts, one by hanging and the other by overdose when he was 15-years-old which resulted in hospitalization. He obtained a waiver at the time of enlistment and at that time he had no active symptoms and took no medication. The CI had tried a number of medications which were not helpful. At one point, he thought he had been diagnosed with manic-depression. He also admitted to a long history of chronic rejection sensitivity and mild paranoia, but denied a history of nightmares, hyper-arousal or avoidance behaviors. The CI completed requirements for Sergeants Distance Education Program in 2006.

The MEB NARSUM examination was conducted while the CI was at an inpatient psychiatry unit from 3-11 April 2008, 5 months prior to separation. He attributed his worsening symptoms to separation from his wife, indebtedness from his excessive spending and perceived mistreatment at the hands of his command. The examiner noted the CI’s depression was possibly due in part to a chemical imbalance. He also reported weekend alcohol use of three to five drinks per setting. A verbal altercation with his wife by phone complicated his course in the hospital. Medications included Lamictal (bipolar depression), Seroquel (mood stabilizer) and Wellbutrin (anti- depression). He responded well and made plans for the future. He was placed on LIMDU and “not returned to duty” status at the time of hospital discharge. Mental status examination (MSE) showed he was withdrawn with downcast gaze; moderate psychomotor retardation; soft, slow and monotone speech; depressed mood with blunted affect; slow and ruminative thoughts and suicidal ideation with a plan to hang himself. Diagnoses were bipolar II disorder and paraphilia with a Global Assessment of Functioning (GAF) of 35 (major impairment in several areas) at admission and 55 (moderate) at discharge. The degree of civilian performance and industrial impairment was moderate.

The 15 May 2008 Non-Medical Assessment (NMA) noted the CI was physically capable of performing his MOS duties and had completed required duties. However, the command opined this was a temporary respite, and he suffered from insomnia and depression and was unable to handle stress. The 18 August 2008 psychology examination noted the CI reported symptoms beginning in February 2008. Medications included a mood stabilizer, an anti-depressant and a sleep aide.  A PTSD screening test was negative.

At the 15 September 2008 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported extensive combat exposure as a Humvee driver for an infantry unit and suffered a ruptured eardrum as a result of an IED. He had difficulty finding a job due to his bipolar disorder and endorsed symptoms of PTSD. Current medications included two mood stabilizers and a mood-stabilizing anti-psychotic agent. The MSE showed a “stressed” mood but appropriate affect and no suicidal ideation. Diagnoses of bipolar II disorder and PTSD were rendered with a GAF score of 60 (moderate bordering on mild). The psychiatry examiner noted the CI was capable of working as a truck driver despite the bipolar disorder. Diagnoses of bipolar II disorder and PTSD were rendered. The 29 April 2009 C&P (PTSD) examination concluded, based upon the September 2008 examination, the CI met criteria for PTSD due to military trauma. The diagnosis of bipolar disorder was independent of PTSD and he met the criteria for both concurrently.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the mental health (MH) disorder 30%, coded 9432 (bipolar), but then deducted 20% resulting in 10% rating due to existing prior to service (EPTS) determination. The PEB listed “paraphilia NOS” as a related diagnosis (Category II) contributing to the disability in this case. The panel concluded the Category II diagnosis was not a separate condition which could be reasonably justified as separately unfitting; nor would a separate rating be achievable without pyramiding (VASRD §4.14). Disability associated with any psychiatric condition, regardless of the diagnosis or multiple diagnoses, is subsumed under a single rating using the same criteria IAW VASRD §4.130 general rating formula for MH disorders. The VA rated the MH disorder 30%, dual coded 9411-9432 (PTSD-bipolar disorder), based on the VA treatment reports and examination, citing poor memory, occasional nightmares, anxiety and hypervigilance.

The panel agreed the provisions of VASRD §4.129 were not applicable in this case because the requisite ‘highly stressful event’ was not satisfied in this case. Although the CI deployed to a combat zone twice, and the NARSUM reported some nightmares and PTSD symptoms following return from the second deployment in 2005, there were few MH records in evidence to support any mental diagnosis until the psychiatric hospitalization in April 2008. At that time he was diagnosed with bipolar disorder and attributed much of his depression to non-deployment stressors such as separation from his wife, debt and difficulties with his command. The panel noted the CI denied symptoms of PTSD during the psychiatric hospitalization in April 2008. A PTSD screening test was negative in August 2008, the month of separation. The CI did not endorse symptoms of PTSD until the post-separation C&P examination.

The panel considered the 20% EPTS deduction made by the PEB for the bipolar disorder. At the MEPS entrance medical examination in June 1999 and at the NARSUM examination, the CI reported a history of two separate suicide attempts and depression followed by a psychiatric hospitalization after each attempt. He believed he was diagnosed with manic-depression (bipolar disorder). He received a waiver at enlistment and no clinical evidence of a problem was noted. As such he would have a 0% rating for bipolar illness at entry with no deduction appropriate from the overall mental illness rating. According to STR, the CI did not present with symptoms of mental distress until April 2008 after 8 years in the Service. Furthermore, the panel concluded that an accurate degree of contribution was unascertainable.

The panel considered the evidence and determined the PEB deduction of 20% was not supported by the evidence. The panel concluded that a separate deduction could not be ascertained as there was no disability apparent at entry, completion of basic training and two deployments, which included combat exposures, and no history of hospitalizations or emergency room visits in the Service for psychiatric reasons until April 2008. The NARSUM examination documented military, industrial and civilian impairment as moderate. The MEB determined the bipolar disorder was significantly aggravated and the PEB originally assigned a 30% disability rating. The commander noted problems with sleep, depression and inability to tolerate stress. The §4.130 criteria for a 30% rating is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.” The    panel agreed that the
§4.130 criteria for a 30% rating was reasonably satisfied by the evidence. 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 MH disorder, coded 9432.

Contended PEB Conditions: Psoriasis, History of Tympanic Membrane Rupture, History of Tension Headaches and Low Back Pain. The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting. None of the conditions were noted on limited duty forms, implicated in the NMA 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 there was insufficient cause to recommend a change in the PEB fitness

determination for any of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS: In the matter of the MH disorder, 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 II Disorder	9432	30%