RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-03065
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20070507

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Communications Electronics Systems Craftsman, medically separated for “bipolar disorder, not otherwise specified [NOS]” with a disability rating of 10%. 

CI CONTENTION:  In addition to the bipolar disorder, the CI requested review of an additional condition not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20070323	VARD - 20080319	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder, NOS	9432	10%	Bipolar Disorder	9432	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Bipolar Disorder, NOS.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s mental health (MH) disorder began in January 2005.  The CI presented for mood symptoms and was initially diagnosed with attention deficit and hyperactivity disorder, dysthymia and adjustment disorder, but the diagnosis was later changed to mood disorder, NOS.  In October 2005, the CI reported a 1-month period of irritable and labile mood with decreased need for sleep, bursts of increased energy, racing, rapid thoughts and decreased ability to concentrate.  Family and co-workers noticed the change in her behavior.  During psychiatry appointments the CI was noted to have an inappropriate affect with inappropriate giggling and pressured speech.  The CI denied grandiosity or harmful or destructive behavior.  This was followed by a period of loss of interest in pleasure in activities, social withdrawal, decreased appetite and decreased libido that lasted several months.  In February 2006 during a depressed period the CI endorsed suicidal ideation (SI), but denied any recent attempts to hurt herself.  She had a history of a suicide attempt at age 13 with pills, but she was found by family members and had her stomach pumped.  The CI denied a history of alcohol or illicit substance abuse.  The CI reported similar episodes of irritability or euphoria in the past that lasted approximately a month, usually once or twice yearly.  During previous episodes the CI reported impulsive spending, multiple impulsive sexual encounters and reckless driving that resulted in a single vehicle accident when she lost control and hit a statue.  There was a family history of bipolar disorder.  The CI had a history of child abuse by her mother.  The CI had a daughter when she was a young adolescent and the child was given to the father’s parents to raise and was abused in that situation.  Her daughter came to live with her at age 9, but had significant mental health issues and the CI found she could not handle raising her.  The CI sent her daughter to a group home, and subsequently to live with her father and step mother.  The CI reported guilt regarding what happened to her daughter.  In July 2006, a diagnosis of bipolar disorder, NOS, was rendered and the CI was started on medication for mood lability (Depakote) with good response.  An anti-depressant medication (Celexa) was added in October 2006 for depressed mood, also with a good response.  At the time of the MEB, her daughter, who was then a young adolescent, also had been diagnosed with bipolar disorder.  Life Skills Support notes after the CI was on Depakote indicate a stable mood without episodes of mania/hypomania and with the addition of Celexa, the CI’s depressed mood improved, with the CI reporting being “less depressed and irritable” and the mental status examinations noting the CI appeared “mildly depressed,” with an appropriate affect.  The global assessment of functioning (GAF) score at examinations from July to December 2006 was 60 to 65 (moderate to mild impairment).  On her Enlisted Performance Report (EPR) for the period 16 December 2005 through 15 December 2006, the CI received the highest rating in all seven categories.  The rater’s final comment was “[the CI] is a take charge NCO with incredible leadership potential; absolutely promote ahead of peers!”  

The 31 January 2007 MEB NARSUM examination, 3 months prior to separation, noted the CI denied any symptoms of mania, hypomania or depression while on medication.  Current medications included Depakote, Celexa and Trazadone (for sleep).  On mental status examination, the CI was appropriately groomed and cooperative.  Her speech was clear and fluent without evidence of pressured speech.  The CI described her mood as “okay” and her affect was mood congruent.  There was no SI or symptoms suggestive of psychosis, speech disturbance, cognitive impairment or other abnormalities.  The Axis I diagnosis was bipolar disorder, NOS.  There was no diagnosis on Axis II and Axis IV noted parent-child problems, occupational problems, and history of abuse.  The MEB NARSUM examiner indicated the CI did not meet criteria for adult attention deficit and hyperactivity disorder, dysthymia, or adjustment disorder at the time.  The GAF was 70 (mild/slight or transient impairment).  The examiner recommended the CI be retained in the military, noting that “there [was] no evidence of occupational impairment and her mood symptoms minimally interfere with her social functioning.”  

The commander’s statement, dated 23 February 2007, indicated the CI was not fit for unrestricted duty due to the stress of her military duties.  The commander stated the CI was unable to perform specific duties required of supervisors, noting interacting between members “within and outside of flight are difficult because of her tendency to be involved in disagreements (stress related).”  He had seen “plenty of outstanding and professional work” from the CI, but although “capable of performing most in- duties,” he did not recommend deployment. The commander said he would not “expect her to handle the physical and or (sic) stress levels that occur during all deployments.”  There was no VA examination proximate to separation in evidence.

A post-separation outpatient VA social work consult on 30 October 2007, 6 months after separation noted the CI’s medications had been changed while visiting family for several months, and she ran out of them earlier in the month.  The CI was taking a new antidepressant prescribed by her primary care physician.  The CI reported inability to sleep, increased energy, decreased appetite, racing thoughts, distractibility and irritability.  The CI was married and employed but was having trouble getting along with co-workers due to her “strong personality.”  She was planning to go back to school to become a teacher.  The MSE was normal except for tearfulness when discussing childhood abuse.  She denied SI and said she would not commit suicide because she knew what it would do to her husband.  The Axis I diagnoses were bipolar disorder, hypomanic and PTSD due to childhood abuse, with a GAF of 63, which reflects mild impairment.  

The CI was seen by a VA psychiatrist on 26 November 2007, 7 months after separation, with complaints of decreased sleep, interest and energy, feelings of guilt, decreased concentration and feelings of helplessness and hopelessness.  The CI had presented to the emergency room while visiting family due to depression symptoms and was put on Abilify and lorazepam.  She did not like them because of the side effects of feeling like she “was on tranquilizers” and stopped them after a few doses.  The CI reported things had been very hard since separation from the military.  The CI and her husband were both employed at low paying jobs and could not pay their bills.  Recently both of their cars had been repossessed, which increased her depression.  The CI also reported continued symptoms of PTSD due to childhood abuse with nightmares and flashbacks, feelings of detachment, efforts to avoid feelings about her childhood, restricted range of affect and hyperarousal symptoms including sleep problems and difficulty concentrating.  The CI had never been hospitalized for her MH disorder.  The CI did not want to take Depakote again due to excessive weight gain and agreed to a trial of Lamictal (an anticonvulsant medication used for bipolar disorder, starting at a low dose.  The psychiatrist indicated the CI had a history consistent with bipolar II and possibly bipolar I disorder and the GAF assignment was 55 (moderate impairment).  

At a VA psychiatric follow-up visit on 22 January 2008, 9 months after separation, the CI was noted to have subthreshold symptoms of mania.  The MSE showed a mildly elevated mood with neutral affect.  Psychomotor activity was not increased or decreased.  There were no abnormalities of thought or speech present.  Concentration was normal and judgment and insight were intact.  The Axis I diagnoses were bipolar disorder and chronic PTSD with a GAF assignment of 65.  The CI’s Lamictal dose was increased.  

At a VA psychiatric follow-up visit on 17 June 2008, 13 months after separation, the CI reported being euthymic and stable since her last visit.  She also denied any nightmares related to abuse since the last visit.  She had been promoted at work.  The mental status examination was normal.  The Axis I diagnoses were bipolar disorder, most recent episode depressed, currently in full remission, responding very well to medication, chronic PTSD and rule out ADD, although the last was considered unlikely since CI did not have attention problems when her mood was stable and euthymic.  The GAF assignment was 73 (slight impairment).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the MH disorder 10%, coded 9432 (bipolar disorder), citing mild social and industrial impairment.  The VA did not service-connect the MH disorder.  There was evidence to support a 10% rating for “occupational and social impairment due to mild or transient symptoms which decrease work efficiency…only during periods of significant stress, or; symptoms controlled by continuous medication.”  Although the CI was being treated for ongoing MH symptoms in the year before separation, the EPR indicated the CI performed at work not just adequately, but in an exemplary fashion.  At the time of the MEB NARSUM, the CI reported no symptoms and the MSE was normal.  The commander’s statement indicated the CI could perform her duties in an outstanding fashion but had limited difficulty in stress related situations and did not recommend deployment due to the high stress levels associated with all deployments.  Following military separation, the CI experienced loss of continuity of medical care as she moved around and while out of medications she had some recurrent symptoms of hypomania/mania followed by depression, which responded well to restarting appropriate medications.  During this time the CI was under significant stress due to separation from the military and serious family financial hardship.  However, the CI was employed throughout this period and within the year after separation was promoted at work.  The panel consensus was that this was consistent with a 10% rating as elaborated above with symptoms controlled by medication.  Although the criteria of occasional decrease in work efficiency” overlaps the 10% and 30% ratings, there was no evidence of “intermittent periods of inability to perform occupational tasks” associated with the next higher 30% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the MH disorder.  

BOARD FINDINGS:  In the matter of the bipolar disorder, not otherwise specified and IAW VASRD §4.130, the panel majority recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

SAF/MRB

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Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-03065.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.