RECORD OF PROCEEDINGS
                     PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXX                                 BRANCH  OF  SERVICE:   MARINE
CORPS
CASE NUMBER:  PD20110005                SEPARATION DATE:  20050731
BOARD DATE:  20111129


SUMMARY OF CASE:  Data extracted  from  the  available  evidence  of  record
reflects that this covered individual (CI) was an active duty member, SGT/E-
5 (0621 / Field Radio Operator), medically separated for bipolar I  disorder
and  anxiety  disorder,  not  otherwise  specified  (NOS).   The  CI  sought
treatment for mood swings and depressed mood as early  as  1998.   In  2001,
his symptoms progressed to include anxiety, nightmares,  hypervigilance  and
flashbacks of childhood trauma.  The  CI  was  subsequently  diagnosed  with
posttraumatic  stress  disorder  (related  to  the  childhood  trauma)   and
dysthymia.  After treatment with medication and therapy, he  was  determined
fit for duty and successfully deployed with his  unit.   In  2005,  however,
the CI began to display overt signs of mania with psychotic symptoms and  he
was subsequently diagnosed  with  bipolar  disorder.   Despite  therapy  and
medication, he did not respond adequately to  perform  within  his  military
occupational specialty (MOS).  He was placed on  limited  duty  (LIMDU)  and
underwent a Medical Evaluation  Board  (MEB).   Bipolar  affective  disorder
(manic  severe,  specified  as  with  psychotic  behavior),  anxiety   state
(unspecified) and gender identity disorder were forwarded  to  the  Physical
Evaluation Board (PEB) as medically  unacceptable  IAW  SECNAVINST  1850.4E.
No other conditions appeared on the  MEB’s  submission.   The  condition  of
gender identity disorder is not a ratable condition IAW DoD  and  Department
of Veterans’ Affairs  (VA)  regulations  and  that  condition  will  not  be
discussed further.  Other conditions included in the  Disability  Evaluation
System (DES) packet will  be  discussed  below.   The  Informal  PEB  (IPEB)
adjudicated bipolar I disorder and  anxiety  disorder,  NOS,  as  unfitting,
rated 10% each IAW the SECNAVINST 1850.4E.  The CI made no appeals, and  was
medically separated with a 20% combined disability rating.


CI CONTENTION:  The CI states:  “I  was  medically  separated  from  the  US
Marines July  31,  2005.   I  was  identified  with  20%  disability  rating
resulting  from  borderline  personality  disorder  and  tinnitus.    During
treatment at Raleigh-Durham NC, I was evaluated and received 50%  disability
rating.   Eventually,  following  additional  diagnosis  (sic),   this   50%
disability rating was increased to 70%.  I  am  requesting  a  re-evaluation
through  the  Wounded  Warrior  program  to  reconsider  my   original   20%
disability rating from the Marines.”  He additionally lists some of  his  VA
conditions and ratings as per the rating  chart  below.   A  contention  for
their inclusion in the separation rating is therefore implied.

RATING COMPARISON:

|Service IPEB – Dated 20050525  |VA (2 Mos. Pre-Separation) – All         |
|                               |Effective 20050801                       |
|Condition                      |Code                              |Rating |
|Combined:  20%                 |Combined:  60%*                          |


*Increased 9413-9432 to 50% effective 20051110 from VA notes and VA exam  of
20070907 (combined 70%)


ANALYSIS SUMMARY:

Bipolar Disorder and Anxiety Disorder.  At the time of the  MEB  psychiatric
exam, the CI was on medications for depression, anxiety and manic  symptoms.
 He was experiencing symptoms of his manic phase and revealed  that  he  had
recently been in a depressed phase.  The CI noted that  his  manic  episodes
occurred several times per year, lasting from days to two months at a  time.
 During his manic episodes, the CI noted racing thoughts, flight  of  ideas,
impulsive behavior and extremely reactive mood with  rapid  rage.   He  also
reported going for days with minimal sleep and noted a tendency to  take  on
multiple goal-directed activities which he was too  distracted  to  actually
complete.  During severe episodes, the CI also developed psychotic  symptoms
to include delusions of grandeur, paranoid ideation and ideas of  reference.
 He reported that his manic symptoms often led to  aggressive  behavior  and
had led to the end of his marriage.  The CI additionally  endorsed  episodes
of  depression  with  symptoms  of  sadness,  anhedonia,  increased   sleep,
decreased energy, anxiety, irritability and episodes  of  rage.   On  mental
status exam (MSE), his  mood  was  slightly  euphoric  and  his  affect  was
expansive.  The examiner additionally documented distractibility,  pressured
speech  with  excessive  productions,  flight  of  ideas,   tangential   and
circumferential thought processes, and some signs of inflated  self  esteem.
The CI was not  suicidal  or  homicidal.   The  examiner  commented  on  the
history of severe manic episodes with psychotic symptoms and concluded  that
the CI had a poor prognosis for continued military service  and  a  moderate
prognosis for civilian employment.  The Axis  I  diagnoses  were  bipolar  I
disorder (most  recent  episode  manic,  severe  with  psychotic  features);
anxiety disorder, NOS and gender identity disorder.  The  GAF  was  assigned
at 55, in the range of moderate symptoms.  The non-medical assessment  (NMA)
commented that the “SNM does not respond  well  to  the  stresses  of  field
exercises, deployments, or real world military operations.”  The  PEB  rated
the  bipolar  disorder  condition  and  the  anxiety   disorder   condition,
separately, at 10% each on the basis of this exam.

One month later, at the VA compensation  and  pension  (C&P)  exam,  the  CI
endorsed  feelings  of   sadness,   depression,   sleep   impairment,   poor
concentration, nightmares, intrusive thoughts and appetite disturbance.   He
reported having few friends and limited recreational  or  leisure  pursuits.
On MSE, he was extremely anxious, with a tense mood and appropriate  affect.
 There were no delusions,  flight  of  ideas,  hallucinations  or  ideas  of
reference.  He was not suicidal or homicidal and his  insight  and  judgment
appeared  to  be  adequate.   The  examiner  concluded  “moderately  serious
impairment  in  psychosocial  functioning.”   The  Axis  I  diagnoses   were
attention  deficit  hyperactivity  disorder,  bipolar  disorder  and  gender
identity disorder.  The GAF was assigned at 53 (MEB GAF=55),  in  the  range
of moderate symptoms.  The examiner further noted “three  Axis  I  diagnoses
that mutually aggravate one another.  I cannot ascribe a specific degree  of
impairment of any one independent of the other with  any  medical  certainty
without resorting to speculation.”  The VA assigned a rating of 30%  on  the
basis of this exam.  VA records indicate a decrease  in  global  functioning
from four months post-separation and a VA  exam  26  months  post-separation
indicated  significant  new  symptoms  for  memory   and   thought   process
impairment with a GAF of  48.   This  was  adjudged  to  be  post-separation
worsening of the CI’s condition.

The Board directs its attention to its rating recommendations based  on  the
evidence just described.  It was noted that the PEB’s decision to  rate  the
two unfitting mental health conditions separately was  not  consistent  with
the VASRD.  The CI had some treatment notes indicating a diagnosis  of  post
traumatic stress disorder (“PTSD, dysthymia”) from 2002  through  2004  with
indications of “fit for deployment,” and appeared  to  successfully  deploy.
The condition of PTSD was not  significantly  clinically  or  occupationally
active during the MEB period, and  could  not  be  argued  as  unfitting  or
subject to separation rating.  The CI’s unfitting bipolar disorder  appeared
to be long-standing and the  unfitting  anxiety  disorder  did  not  include
PTSD, but was coupled with  depressive  periods  of  his  bipolar  disorder.
There was not sufficient evidence in the record  supporting  application  of
VASRD §4.129, Mental disorders due to traumatic stress.

Separating the psychiatric impairment due to bipolar disorder from that  due
to anxiety disorder requires undue speculation and is a  moot  exercise  for
practical purposes.  The psychiatric impairment from  both  conditions  must
be combined under a single §4.130 rating since  the  VASRD  does  not  allow
otherwise, except in unique circumstances  (older  8045-9304  codes,  eating
disorders,  etc.)  which  are  not  found  in  this  case.   Deductions  for
excluded, or not unfitting, mental health disorders is not permitted  unless
the symptoms and impairment are  distinctly  apportioned  by  the  examiner.
Such was not the  case  and  the  Board  must  rate  the  total  psychiatric
impairment as if the two Axis I conditions were a  single  unfitting  mental
disorder condition.

The MEB exam and the VA exam were both proximate to time of  separation  and
both carried equal probative value.  The degree of impairment  described  at
both  exams  was  in  the  range  of  moderate  symptoms,  with  both  exams
documenting significant  social  impairment.   Both  exams  also  documented
periods  of  intermittent  occupational   impairment   when   the   CI   was
experiencing symptoms of his manic phase or his depressive phase.   The  30%
description (“occupational and social impairment  with  occasional  decrease
in  work  efficiency  and  intermittent  periods  of  inability  to  perform
occupational tasks”) is a better fit with the  occupational  functioning  in
evidence.  The Board  deliberated  if  the  CI’s  history  of  severe  manic
episodes  with  psychotic  symptoms  supported   the   higher   50%   rating
recommendation.  After due deliberation, considering  the  totality  of  the
evidence and mindful of VASRD §4.3 (reasonable doubt), the Board  recommends
a separation rating of 30% for the bipolar  disorder  and  anxiety  disorder
conditions, coded 9413-9432.

Other PEB Conditions.  Gender identity disorder is a  condition  which  does
not constitute a physical disability  IAW  DoDI  1332.38,  E5,  and  is  not
compensable.  All evidence considered, there is not reasonable doubt in  the
CI’s  favor  supporting  recharacterization   of   the   PEB   Category   IV
adjudication for the gender identity disorder condition.

Other Conditions.  The conditions of  right  knee  chondromalacia,  cervical
spine strain  and  tinnitus  were  noted  in  the  VA  rating  decision  and
documented in the DES file.  None of these  conditions  were  clinically  or
occupationally significant during the MEB period, none were  the  basis  for
limited duty and none were implicated in the  NMA.   These  conditions  were
reviewed by the  action  officer  and  considered  by  the  Board.   It  was
determined that none could be argued as unfitting and subject to  separation
rating.

Remaining Conditions.  Several additional non-acute  conditions  or  medical
complaints were documented in the MEB history and physical.  None  of  these
conditions were clinically or occupationally active during the  MEB  period,
none were the basis for limited duty and none were implicated  in  the  NMA.
These conditions were reviewed by the action officer and considered  by  the
Board.  It was determined  that  none  could  be  argued  as  unfitting  and
subject to separation rating.   The  Board,  therefore,  has  no  reasonable
basis for recommending any additional unfitting  conditions  for  separation
rating.


BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military  Department
regulations or guidelines relied upon by the PEB will not be  considered  by
the Board to the extent they were inconsistent with the VASRD in  effect  at
the  time  of  the  adjudication.   As  discussed  above,  PEB  reliance  on
SECNAVINST 1850.4E for rating the  bipolar  disorder  and  anxiety  disorder
conditions was operant in this case  and  the  conditions  were  adjudicated
independently of that instruction by  the  Board.   In  the  matter  of  the
bipolar disorder and anxiety  disorder  conditions,  the  Board  unanimously
recommends a rating of 30% coded 9413-9432 IAW VASRD §4.130.  In the  matter
of the gender identity disorder condition, the Board unanimously  recommends
no recharacterization  of  the  PEB  adjudication  as  Category  IV  (not  a
disability  and  not  compensable).   In  the  matter  of  the  right   knee
chondromalacia, cervical spine strain and tinnitus conditions or  any  other
medical conditions eligible for Board consideration; the  Board  unanimously
agrees that it cannot recommend any findings of unfit for additional  rating
at separation.


RECOMMENDATION:  The Board recommends that the CI’s prior  determination  be
modified  as  follows  and  that  the  discharge  with  severance   pay   be
recharacterized to reflect permanent disability retirement, effective as  of
the date of his prior medical separation:

|UNFITTING CONDITION                               |VASRD CODE  |RATING  |
|Bipolar I Disorder with Anxiety Disorder          |9413-9432   |30%     |
|COMBINED    |30%     |

____________________________________________________________________________
__

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20101201, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans' Affairs Treatment Record





                                        President
                                                                    Physical
Disability Board of Review

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATION
           ICO XXXXX, FORMER USMC, XXX XX XXXX

Ref:   (a) DoDI 6040.44

1.  I have reviewed the subject case pursuant to reference (a) and direct
the subject member’s official records be corrected to reflect the following
disposition:

   a. Separation from the Naval Service due to physical disability rated at
      30 percent with transfer to the Temporary Disability Retired List
      effective 31 July 2005.

   b. Separation due to disability rated at 10 percent effective 30 January
      2007.

2.  Please ensure all necessary actions are taken to implement this
decision, including the recoupment of previously paid disability separation
pay if warranted, and notification to the subject member once those actions
are completed.




                                    Principal Deputy
                                    Assistant Secretary of the Navy
                                      (Manpower & Reserve Affairs)