RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXX	CASE:  PD-2013-02021-2
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051220

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Indirect Fire Infantryman, medically separated for “bipolar I disorder, with psychotic features” with a disability rating of 10%.  This case was originally evaluated by the PDBR, and the panel unanimously agreed the stipulations of §4.129 were not met. The Board did not surmise from the record or PEB ruling in the case that any prerogatives outside the VASRD were exercised. In the matter of the bipolar I disorder with psychotic features condition and IAW VASRD §4.130, the Board unanimously recommended no change in the PEB adjudication.  The CI disagreed with the determination and appealed to the United States District Court of the appropriate jurisdiction. The Court granted the defendants’ joint motion for remand and stay of proceedings. The case was remanded to the Army Review Boards Agency, which referred the case back to the PDBR for reconsideration of the disability rating. The complete case file, to include additional documentation provided by counsel representing the CI, was evaluated by a new PDBR panel comprised of different members. These proceedings reflect a de novo review and analysis confined to the appropriate resolution of the major depression appeal.

ANALYSIS SUMMARY:  

Bipolar I Disorder.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bipolar disorder began in August 2005 after an incident of inappropriate behavior during combat field training, during which he declared he was “the Son of God.”  He had deployed to Iraq as an infantryman from April 2003 to April 2004, and on his March 2004 post-deployment health assessment, he indicated he was not engaged in direct combat and denied seeing anyone wounded or killed.  He answered “yes” to feeling in great danger of being killed, but denied symptoms of depression or traumatic stress.  He earned a combat infantry badge (CIB) during this deployment.  His August 2004 and July 2005 pre-deployment health assessments were void of mental health (MH) issues and indicated eligibility for deployment without limitations.  However, during a National Training Center (NTC) rotation in August 2005, he ran away from his platoon.  He was taken to a psychiatric inpatient ward where he stated “I’m Jesus Christ, the Son of God, in the flesh to save people from darkness.”  After being admitted, he was diagnosed with bipolar I disorder, and started on Zyprexa (atypical anti-psychotic) and lithium (mood stabilizer), which controlled his symptoms. 

At the 19 September 2005 MH MEB NARSUM examination, 3 months prior to separation, mental status examination (MSE) showed appropriate affect and no abnormalities of thought content or processes; the CI also denied homicidal/suicidal ideation.  There were no signs or symptoms of an organic mental impairment, and he was diagnosed with bipolar I disorder, severe, with psychotic features, single manic episode.  During the 27 September 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), the CI reported depression and excessive worry.  

The 22 September 2005 commander’s statement noted the CI was “a superior soldier who consistently produce[d] superb results in everything he undertook.  Before NTC he was clearly one of the top soldiers in the troop if not the squadron.”  However, after the NTC incident, the commander observed the CI had difficulties performing his duties, and despite treatment, he was unable to remain in the military.  The commander confirmed the NTC field training was a simulated combat situation and that he did not think the CI’s condition was exaggerated.  

During the 1 November 2005 MEB NARSUM examination, 2 months before separation, the CI reported “feeling fine.”  He explained that ‘before going to the box (the field training), I was reading my Bible and asking God to open my eyes to everything, to see things clearer…When I was returning from the box…I felt threatened by my command.  I felt that God was answering my prayers, and that now I could see the evil inside of people and I was fearful, and that is why I ran.’  The examiner stated that following hospital discharge, the CI attended outpatient psychotherapy sessions, and that he currently reported no longer being fearful.  He endorsed having strong religious beliefs, but did not think he was ‘Jesus Christ in the flesh.’  He denied ever having suicidal or homicidal thoughts, or any prior MH problems or history of MH treatment.  The examination showed the CI had not worked in his military specialty since August 2005, but did perform minor cleaning details during assignment to rear detachment.  The examiner parenthetically noted an exchange with the CI at the conclusion of the examination, excerpted in full below:

At the end of the visit today, I reviewed with the Soldier what he had reported and reviewed again that this would be what my dictation would reflect. On review, he then stated that, "I want things to remain the same." Once I read back to him his previous information that he had given me in review, which I had earlier verified in detail on initial questioning, he stated that he wants things to "stay the same" and that the report should reflect that, "I have the spirit of Jesus in me and I am Jesus Christ in the flesh." When I asked why he wanted to now change that when he had given me a different story earlier, he went on to state that, "I want things to stay the same" and further stated, "I believe
Jesus Christ in the spirit and Jesus Christ in the flesh are the same thing and they are both in me.”

At the 10 January 2006 VA psychology examination, 1 month after separation, the examiner documented that the CI was currently unemployed and lived with his father.  He reported doing well on his prescriptions, although he had one manic episode in September 2005 after running out of medication.  He wanted to be compliant and control his problem and was still on Zyprexa and lithium.  The psychologist noted the CI was not able to speak about his symptoms except to say that his mood changed quickly and he felt paranoia when he was in the manic phase.  Regarding readjustment difficulties, he reported feeling anxious with uncontrollable worry.  He slept approximately 7 hours per night, but with frequently disrupted sleep and awakenings about every 2 hours.  He also reported some nightmares, loss of appetite, and feelings of sadness and anger.  The military history section stated that during his deployment, the CI was frequently a convoy driver and fired his weapon about 3 times per month and was fired upon about 10 times per month, specifically rocket attacks at night.  Neither he nor any of his friends were injured, and the most “stressful event was working constantly.”  He denied military sexual assault, drug, or alcohol problems.  On MSE, he was well groomed and neatly dressed with euthymic mood and congruent affect as well as normal speech.  However, he was guarded and “seemingly confused at times.”  There was no evidence of disturbance of thinking, reality testing, or memory.  Attention and concentration were variable, with fair insight and good judgment; he denied suicidal or homicidal ideation.  The diagnosis was bipolar I disorder, and “exposure to war” was listed as a contributing factor.  

On the same day, a VA psychiatrist evaluated the CI for medication management and recorded a normal MSE, noting he was “looking to get a job in security.”  While the diagnosis remained bipolar disorder, the provider also documented schizoaffective disorder in the differential diagnoses; medications remained the same.  The psychiatrist saw the CI again on 31 January 2006, and reported no change in symptoms or diagnoses.  The medications remained the same, but with an increase in the lithium dosage.  

During the 15 February 2006 VA Compensation and Pension (C&P) MH examination, 2 months after separation, the examiner noted the CI was employed part-time, but later stated he was “awaiting commencement of his first employment since leaving the Army with a security company.”  He lived with his father and stayed home most of the time, but reported having a couple of friends and getting along “adequately” with others.  When explaining the NTC training episode, he believed he was on a spiritual journey and felt “significantly threatened by his comrades.”  The examiner noted that while the CI’s medications seemed very effective, he had a history of paranoid and grandiose delusional thinking and inappropriate behavior.  His current acute psychiatric symptoms were minimal and appeared to be “in remission, secondary to psychiatric medication management.”  On MSE, the examiner found the CI fully oriented with good hygiene and impulse control, normal rate and flow of speech, and euthymic mood.  There was no thought processes or communication impairment, obsessive or ritualistic behavior, suicidal/homicidal thoughts, memory or sleep impairment, or auditory hallucinations.  He also denied any post-traumatic stress disorder (PTSD) symptoms secondary to his experiences in Iraq.  

On 4 April 2006, the CI presented to the emergency room (ER) and was referred to see a psychiatrist, however, there was no record of a MH visit at that time.  He also asked to see a psychiatrist during another ER visit on 5 May 2006, but was referred to the ER doctor without follow-up of his psychiatric concerns.  At a VA psychiatry appointment on 9 May 2006, the CI reported not taking any medications for several months because he was applying for a security job, but could not get clearance due to his diagnosis.  He wanted his diagnosis changed because he did not feel he had bipolar disorder.  He was still unemployed and living with his father.  On MSE, he was pleasant and friendly, with neutral mood and appropriate affect, and no apparent thought disturbance.  He declined to take medications but agreed to monthly follow-up visits.  

At a VA psychiatric follow-up visit on 23 May 2006, the CI’s father attended with him.  The provider noted the CI had strong family and social support and understood he needed treatment, but his capacity for insight was limited.  His father expressed the hope that his son could apply to the police force in spite of his psychiatric history and requested a letter.  The psychiatrist agreed to a limited letter, stating that the CI “appeared to be symptom free at this time.”  Lithium was again prescribed.  

During a 13 June 2006 VA ER visit,  6 months after separation, the CI stated he felt hopeless and wanted to speak to a psychiatrist. He was triaged as not urgent and scheduled for a psychiatric appointment.  The next day, he was admitted to a civilian hospital for inpatient psychiatric treatment.  The hospital note indicated he had been brought to the ER by the police and emergency medical services after standing on the roof of his car ‘waiting for judgement day’ because ‘I have called it myself.’ The note also documented that he had been non-compliant with his medications since January 2006, despite seeing his VA psychiatrist.  The diagnosis on admission was “Schizoaffective Disorder Bipolar Type VS Bipolar I Disorder, Manic with Psychotic Features.”  The hospital discharge summary indicated the CI was exhibiting grandiose and religious content delusional thinking, and making suicidal and homicidal comments; there was no evidence of alcohol or drug use on testing.  He initially did not believe he had any psychiatric problems or need for treatment.  After being treated with Risperdal (atypical anti-psychotic) for the psychosis and Depakote (anti-convulsant) for the mania, his symptoms receded and he was cooperative and participated in activities.  He had good family support and his father assisted with his care plan.  He was deemed medically stable for discharge on 28 June 2006, and in coordination with his VA psychiatrist, recommended for follow-up in a day hospital program.  

At a VA psychiatry visit on 12 July 2006, the CI explained that his hospitalization occurred after he believed “he had developed a new religion based on Machiavelli’s ‘The Prince’ and that he wished to spread the word.”  His father also attended the appointment and added that the CI was “standing in traffic trying to get the attention of people in the street.”  The provider emphasized the CI’s substantial risk of re-hospitalization if he did not consistently take his medications as prescribed.  Three days later, he was admitted for psychiatric inpatient treatment to yet a third hospital.  A written note from the attending physician recorded complaints of racing thoughts and dysphoria with delusional discussions, which were ‘disorganized…and rather illogical.’  Thought content included ‘occasional paranoia with violent thoughts (of starting WWIII).’  The CI denied any active plans of violence and was discharged to his home on 3 August 2006 with prescriptions for Risperdal and Depakote.  

During a VA psychiatry appointment on 8 August 2006, 8 months after separation, the CI was accompanied by his father, who felt he was doing much better after the recent hospitalizations.   The CI had told his employers he would not be back to work for a while.  The MSE showed a mildly constricted but appropriate and non-labile affect, and no speech or thought disturbance.  The provider commented that the CI looked better than when last seen, but noted that the situation remained “somewhat precarious.”  At an 18 August 2006 follow-up visit, the psychiatrist stated “his father remains appropriately concerned as to him taking his medication.”  The CI was not working, but was thinking about returning to school.  

On 7 September 2006, the CI was admitted to the VA day hospital program, and during intake, the interviewer noted he was “well-groomed, verbal, cooperative, has insight, and appears motivated to address his problems.”  He stated that he wanted to rejoin the military or go to school for a new occupation.  He was living with his father and appeared socially isolated with no active friendships, preferring to stay home to remain calm.  Despite his combat history, he reported his deployment experiences did not bother him and he slept well at night.  He appeared physically well and in good shape, and expressed ambivalence about taking medication.  

A 15 September 2006 day hospital treatment entry noted the CI had an interview for a security job that day.  On 21 September 2006, he reported some tension at home because his father thought he had made some unwise decisions (“getting involved with a girl, giving her his car and then they broke up.”)  On 26 September 2006, the CI said that he had spoken to a Marine recruiter about enlisting and needed a letter stating he was fit for duty.  The interviewer noted his attempt to enlist earlier in the summer, and when the “letter was not worded strongly enough,” the CI became discouraged and this led to his hospitalizations.  The interviewer stated that he appeared “quite happy and enthused” when discussing enlisting in a “sane and stable way.”  On the same day, a note by the CI’s psychiatrist indicated that he came in by himself and was “quite fixed on the idea that I would help him get back in the military, but accepted my recommendation to continue talking about this at Day Hospital…”  The psychiatrist said “he continues to look a little better though the prognosis remains quite guarded.”  On 10 October 2006, the CI again attended his appointment by himself and reported things were going well.  The psychiatrist noted that he “returned to the theme of his plan to return to the military,” thinking he could get his discharge diagnosis erased from his military record.  He also admitted he had not been taking his medications, but “grudgingly agreed” to take them after encouragement.  The provider noted an “extremely guarded” prognosis due to his history and compliance issues.  A  note on 20 October 2006 indicated the CI was feeling stable and still pursuing help to get a positive letter to re-enlist.  

A treatment summary signed by the day hospital program coordinator and the treating VA psychiatrist on 7 November 2006, 11 months after separation, indicated the CI’s need for continued intensive treatment with a potential move to vocational rehabilitation as employment was the eventual goal given his young age.  However, at the time, the providers noted the CI “remains unemployable as a result of his Bi-Polar Disorder.”  

The 3 August 2007 VA C&P examination, though written beyond 12 months post-separation, contained the clearest work summary since military separation and indicated the CI had tried to work mall security on and off, but due to frequent hospitalizations had only worked less than 6 months to that date.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bipolar disorder 10%, coded 9432 (bipolar disorder), citing mild industrial impairment.  The VA also rated the bipolar disorder 10%, coded 9432, based on the 15 February 2006 C&P examination, citing confirmation of bipolar disorder with mild symptoms controlled with medication.  The CI filed a Notice of Disagreement with the VA 10% rating on 8 June 2006 and a de novo review of the evidence was performed by the VA.  The 24 October 2006 VA Rating Decision increased the rating to 30%, effective the day after the date of separation.  

The panel first considered whether the provisions of VASRD §4.129 (mental disorders due to traumatic stress) were applicable.  In his initial 2013 application to the PDBR, the CI contended he was given the wrong diagnosis and was receiving care for PTSD.  Regardless of the specific MH diagnosis, the panel considered whether the application of §4.129 for the MH condition was appropriate based on the evidence of a traumatic stressor leading to separation.  

The CI was awarded a CIB and stated that during his deployment to Iraq he feared for his life. However, the panel noted he consistently denied having PTSD symptoms proximate to separation and did not endorse having PTSD until 2013.  Despite the CI’s predisposition to bipolar disorder, which may have manifested at his age absent any highly stressful event during combat training, the panel found no evidence of a MH disorder on his entrance physical, post-deployment health assessment, or two pre-deployment health assessments, and his commander stated he was “clearly one of the top Soldiers in the troop if not the squadron.”  Panel members noted that the CI went into the “box” (combat training at NTC) prayerful and came out feeling threatened by his command and in a psychotic state of mind.  Therefore, the panel agreed that the stress associated with the NTC training, more likely than not, triggered his bipolar disorder and ultimately led to his medical separation.  Panel members concluded that with consideration of VASRD §4.3 (reasonable doubt), the evidence favors application of VASRD §4.129 in this case, with the requisite link between the service stressor and the MH disorder adequately satisfied.  Therefore, the panel recommends a minimum 50% rating for a retroactive 6‐month period on the Temporary Disability Retired List (TDRL) for the bipolar I disorder.  Panel members agreed the evidence did not support a higher rating than 50% at the time of TDRL placement.  

The panel next considered the CI’s VASRD §4.130 rating at TDRL removal at 6 months post-separation.  Between the date of military separation (20 December 2005) and 6 months after separation (20 June 2005), the CI’s bipolar symptoms were “controlled” on his prescribed psychotropic medication, but as is common in those with either bipolar disorder or schizophrenia, his medication adherence was poor.  Thus, panel members agreed his overall occupational and social functioning was not reflective of a MH disorder controlled by medication, and settled its deliberations on a 30% versus 50% rating at permanent separation.  

The evidence in record shows in the 12 months following military separation, the CI lived with his father and was socially isolated.  Although he initially tried to get a position in security or become a police officer, it was difficult to confirm his employment status from the record, although it appeared he may have worked for short periods.  In the spring of 2006, the CI twice walked into ERs requesting to see a psychiatrist, even though he had an established VA MH provider.  In the second instance, he experienced a psychotic episode the next day, supporting the fact that he was not feeling well when he sought ER care.  By 6 months after separation, the CI was hospitalized for the second time with mania and psychotic symptoms.  He was stabilized, discharged, and then re-admitted 2 weeks later with recurrence of mania and delusions for approximately 3 weeks.  Following this discharge, he entered into a VA day hospital program, which he remained in until the end of 2006.  In the day hospital, he was fully oriented and discussed options for his future, however, his treatment notes indicated that he was “fixed” on the idea that his psychiatrist would help him get back in the military.  The panel thought the CI’s focus on a law enforcement career or return to the military reflected his limited insight into his MH disorder.  He also believed it was not a correct diagnosis and that he did not need medication.  His persistence in pursuing re-enlistment after his second and third hospitalizations further provided strong evidence of this lack of insight.  The CI’s father, who was an involved and caring parent, frequently accompanied him to medical appointments after the re-hospitalizations, and panel members took this as evidence to show the CI was not functioning in a reliable manner.  His father also questioned his judgment in giving away his car to a woman and then breaking up. Panel members noted that this evidence suggested the CI’s behavior demonstrated poor judgment common to bipolar mania/hypomania states even between hospitalizations.  

Thus, the panel agreed that at TDRL removal, and IAW VASRD §4.7 (higher of two evaluations), the CI’s disability was more nearly approximated by the 50% rating rather than the 30% rating for occupational and social impairment with reduced reliability and productivity that was more than occasional.  Panel members did not find evidence for a higher rating than 50% at separation.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129, and a 50% permanent rating at 6 months.  

BOARD FINDINGS:  In the matter of the bipolar I disorder, the panel recommends an initial TDRL rating of 50%, coded 9432,  in retroactive compliance with VASRD §4.129 as DoD directed; and a 50% permanent rating at 6 months IAW VASRD §4.130.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior separation be modified as follows: TDRL at 50% for a period of 6 months following the CI’s prior medical separation (minimum of 50% IAW §4.129) and then a permanent 50% disability retirement as below:

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Bipolar I Disorder 	9432	50%	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131030, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 
Exhibit D.  Documentation Provided by Counsel

AR20220001375, XXXXXXXXXXXX

XXXXXXXXXX

Dear XXXXXXXX:

	On remand from the U.S. District Court for the District of Columbia, the Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and recommended to constructively place you on the Temporary Disability Retired List (TDRL) at 50% disability for six months effective the date of your original medical separation for disability with severance pay and then following this six month period re-characterize your separation as a permanent disability retirement with the combined disability rating of 50%.  I accept the recommendation of the DoD PDBR.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.  

	The constructive TDRL period and the re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing you 50% retired pay for six months from the date of your original medical separation and then 50% disability retired pay effective the date following the constructive six month TDRL period, 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, 1835 Army Boulevard, Bldg. 2000, JBSA, Fort Sam Houston, TX. 78234.

	A copy of this decision has also been provided to the Department of Veterans Affairs Medical Center, 800 Poly Place, Brooklyn, NY 11209.

Sincerely,