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AF | PDBR | CY2013 | PD-2013-01767
Original file (PD-2013-01767.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXX     CASE: PD-2013-01767
BRANCH OF SERVICE: NAVY  BOARD DATE: 20140522
SEPARATION DATE: 20060223


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PO2/E-5 (OS2/Operation Specialist) medically separated for bipolar II disorder. The CI’s mental health (MH) condition could not be adequately rehabilitated to meet the requirements of his rating. He was placed on limited duty and referred for a Medical Evaluation Board (MEB). The MH condition, characterized as “bipolar affective disorder, depressed” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. No other conditions were submitted by the MEB. The Informal PEB adjudicated “bipolar II disorder” as unfitting, rated 10%, with likely application of VA Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “Rating was under rated when discharged.”


SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting bipolar II disorder condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. Regarding the MH condition, the case file was reviewed regarding unfavorable diagnosis change, fitness determination, applicability of VASRD §4.129, and rating (via §4.129 or §4.130 as appropriate) of the MH condition. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Naval Records.


 RATING COMPARISON :

Service IPEB – Dated 20051201
 VA - (8 Days Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Bipolar II Disorder 9432 10% Bipolar Disorder 9432 70% 20060215
No Additional MEB/PEB Entries
 No Other Conditions
Rated: 10%
 Rated: 70%
Derived from VA Rating Decision (VA RD ) dated 200 60408 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Bipolar II Disorder. The CI was reportedly diagnosed with bipolar disorder in 2004 by a civilian physician, but did not follow-up with treatment recommendations. He did not present to a service provider for MH care until 1 September 2005. At that time he complained of worsening depressive symptoms that included thoughts of suicide (i.e. jumping off the ship), as well as some manic episodes. He denied ever taking psychotropic medication and was never hospitalized. The CI was referred to a psychiatrist that day and two psychotropic medications were started. A limited duty board psychiatric summary on 2 September 2005 (6 months prior to separation) reported a 1-year history of decreased concentration, poor decision-making, insomnia, decreased appetite, weight loss, loss of interest, daily sadness, tearfulness and chronic and persistent thoughts of suicide. He also noted episodes of feeling elated, over-spending, racing thoughts and decreased need for sleep. A mental status exam (MSE) reported a depressed mood and affect. There was no current evidence of suicidal or homicidal thoughts; and no reported delusions, hallucinations or racing thoughts. Memory was intact. The Axis I diagnosis was bipolar disorder (depressed) and the CI was considered unable to successfully perform military duties due to his symptoms.

On 2 November 2005 (4 months prior to separation), the narrative summary noted that the CI married for the second time 6 months previously. The CI endorsed current symptoms of depressed mood, poor sleep, low energy and concentration and intermittent suicidal thoughts. He had stopped the psychotropic medication previously prescribed due to side effects. Although his depressive symptoms improved after visiting his wife in late September, those symptoms worsened again after return to his duty location. There were no current manic symptoms. MSE showed normal appearance, hygiene and speech. Mood and affect were slightly depressed. He denied thoughts of harm, or hallucinations or delusions. The Axis I diagnosis was bipolar II disorder; an assigned Global Assessment of Functioning (GAF) was 60, connoting moderate symptoms or impairment. A psychotropic medication was prescribed. The non-medical assessment (NMA) on 9 November 2005 reported that the CI was working in an administrative capacity and although work was frequently missed for evaluation, treatment and recuperation, it indicated that in his present mental condition, the CI had good potential for continued service.

At the VA MH Compensation and Pension (C&P) exam performed a week prior to separation, the CI reported that his depressive symptoms began in 2003, were intermittent, but gradually worsened. The medication he was initially prescribed in September 2005 was helpful for his symptoms of depression and sleep difficulty, but he stated since discontinuing the medications in October, these symptoms worsened. He now reported worsening depression and frequent suicidal thoughts with no plan and some anxiety. He also acknowledged occasionally hearing voices; the last episode was 1-2 weeks previously. He denied recent manic symptoms, but noted that his depressive symptoms were adversely affecting his relationship with his wife. His relationship with his mother and sister was described as “fine.” MSE noted a depressed affect, but appearance, behavior and speech were normal. Frequent suicidal thoughts and occasional auditory hallucinations were noted. He was normally oriented and denied panic attacks, memory impairment or ritualistic behavior. The Axis I diagnosis was bipolar disorder and an assigned GAF was 50 (serious symptoms or impairment). The examiner opined that the CI’s employability was presently poor, and that he needed to resume treatment.

At a VA outpatient primary care visit on 19 April 2006 (2 months after separation), the CI reported that he was on medication for his bipolar disorder “that has kept him stable.” He was currently unemployed, but looking for a job. He denied ever having experienced frightening, horrible or upsetting events that resulted in nightmares, avoidance, hypervigilance or detachment. He also stated that during the prior year, he did not experience sadness, depression or loss of enjoyment for more than 2 weeks; and during the prior year did not feel sad or depressed much of the time. During the previous week he indicated he felt depressed less than one day.

At a C&P exam in November 2007 (21 months after separation) the CI reported that since leaving the military he tried working a couple of different warehouse jobs, “but quit after a couple of weeks because he was not getting along with others…He decided to quit rather than be fired.” He also noted that he got along fairly well with people while he was in the military, but that since leaving the service he socialized primarily with family members.

The Board directed attention to its rating recommendation based on the above evidence. Application of VASRD §4.129 is considered by the Board for all cases of service-connected psychiatric conditions resulting in separation; but, all members agreed that the “highly stressful event” requisite for §4.129 was not satisfied in this case. The Board therefore will consider only the VASRD §4.130 impairment present at separation for a single rating recommendation. The PEB assigned a 10% rating under the 9432 code (bipolar disorder), implying that symptoms were “mild or transient” or were “controlled by continuous medication.” The VA used the same code, but considered that the condition was best characterized as “occupational impairment, with deficiencies in most areas,” and therefore justified a 70% rating. The Board considered if a rating higher than 10% was warranted at the time of separation. 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,” while criteria for a 50% rating requires “occupational and social impairment with reduced reliability and productivity.” While there were three 30% threshold symptoms, there were no 50% threshold symptoms such as flattened affect, panic attacks or memory impairment. Although suicidal ideation (a possible 70% threshold symptom) was reported to be ongoing and intermittent, it was absent during two of the exams, and noted to be passive (i.e. no plan) at the C&P exam. The Board also debated the significance of occasional auditory hallucinations noted by the C&P examiner, but agreed these did not reflect the “persistent” characterization of the possible 100% threshold symptom. Board members considered that GAF scores reflected moderate to serious impairment and that there were no psychiatric hospitalizations or emergency room visits. Although the CI complained of social isolation and adverse effects of his condition on his marriage, his other family relationships were “fine.” Board members also deliberated the significance of the primary care clinic visit two months after separation at which time depressive symptoms were largely absent in the setting of being back on psychotropic medication. The degree of occupational impairment was debated in the context of a NMA conclusion that he displayed good potential, but the CI’s decision to quit working two jobs after separation in order to avoid being fired. Ultimately, the Board concluded that the evidence at hand was most accurately depicted by the “occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks” stipulation of the 30% rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the bipolar disorder condition.


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. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the bipolar disorder condition, the Board unanimously recommends a disability rating of 30%, coded 9432 IAW VASRD §4.130. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board recommends that 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 as of the date of his prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
Bipolar II Disorder 9432 30%
RATED 30%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131023, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




XXXXXXXXXXXXXX
President
Physical Disability Board of Review

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
         
Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref: (a) DoDI 6040.44
(b) PDBR ltr dtd 24 Apr 15 ICO XXXXXXXXXXXXXXX
(c) PDBR ltr dtd 24 Apr 15 ICO XXXXXXXXXXXXXXX
(d) PDBR ltr dtd 8 Jan 15 ICO XXXXXXXXXXXXXXX
(e) PDBR ltr dtd 14 Apr 15 ICO XXXXXXXXXXXXXXX
(f) PDBR ltr dtd 21 Apr 15 ICO XXXXXXXXXXXXXXX
(g) PDBR ltr dtd 7 Apr 15 ICO XXXXXXXXXXXXXXX

1. Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (g).

2. The official records of the following individuals are to be corrected to reflect the stated disposition:

a. XXXXXXXXXXXXXXX, former USMC : Entitlement to disability severance pay with a disability rating of 20 percent (increased from 10 percent) effective date of discharge.

b. XXXXXXXXXXXXXXX, former USN : Entitlement to disability severance pay with a disability rating of 20 percent (increased from 10 percent) effective date of discharge.

c. XXXXXXXXXXXXXXX, former USN : Placement on the Permanent Disability Retired List with a 30 percent disability rating effective date of discharge.

d. XXXXXXXXXXXXXXX, former USN : Placement on the Permanent Disability Retired List with a 30 percent disability rating effective date of discharge.

e. XXXXXXXXXXXXXXX, former USN : Entitlement to disability severance pay with a disability rating of 20 percent (increased from 10 percent) effective date of discharge.

f. XXXXXXXXXXXXXXX, former USN : Placement on the Permanent Disability Retired List with a 30 percent disability rating effective date of discharge.

3. Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are completed.



          XXXXXXXXXXXXXXX
         Assistant General Counsel
(Manpower & Reserve Affairs)

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