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AF | PDBR | CY2013 | PD-2013-02086
Original file (PD-2013-02086.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXX     CASE: PD-2013-02086
BRANCH OF SERVICE: AIR FORCE     BOARD DATE: 20141118
SEPARATION DATE: 20050620


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SRA/E-4 (1C052/Operations Resource Management Journeyman) medically separated for bipolar disorder. The mental health (MH) condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty. The MH condition, characterized as “bipolar disorder II,” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. No other conditions were submitted by the MEB. The Informal PEB adjudicated “bipolar disorder II” as unfitting, rated 10% but not compensable because the condition existed prior to service and was not permanently service aggravated. The remaining conditions were determined to be Category III, not separately unfitting and not compensable or ratable. The CI appealed to the Formal PEB (FPEB) which found the bipolar Disorder II as unfitting, rated at 10%, with application of DODI 1332.39, noting the condition did not exist prior to service. The CI made no further appeals and was medically separated.


CI CONTENTION: “Please consider all conditions.”


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 disorder condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. Any condition 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 Military Records.

IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VA Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation.


RATING COMPARISON :

Service FPEB – Dated 2050502
 VA* - (5 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Bipolar Disorder II 9432 10% Bipolar Disorder 9432 30% 20051110
History of Alcohol Abuse
(Binging Behavior)		 Category III No VA Entry
Obesity (Overweight);
[Tobacco Abuse (MEB)]		 Category III No VA Entry
Other x 0 (Not in Scope)
 Other x 7
Combined: 10%
 Combined: 40%
* Derived from VA Rating Decision (VA RD ) dated 200 60308 (most proximate to date of separation ( DOS ))


ANALYSIS SUMMARY:

Bipolar Disorder. The record indicated that the CI had long periods of depressed mood intermixed with short episodes of elevated mood. She was hospitalized for a suicide attempt (intentional overdose of antidepressant medication [Elavil]). The suicide attempt was following “a two week episode of depression triggered by financial concerns and estrangement from her mother.” She was started on an anti-depressant medication (Lexapro/Escitalopram), and at the time of the narrative summary (NARSUM), 7 months prior to separation, she was “taking Lexapro sporadically and has begun psycho-therapy with a counselor. She has noted minimal improvement in her symptoms thus far.” Her history included episodes of depression since age 14, a suicide attempt (slit wrists) at age 15, report of being raped at age 16, binging and purging, placement on the weight management program and an Article 15 for unauthorized use of a government credit card in 2004. Alcohol history included drinking two to three times a month and she noted “that she has difficulty controlling the amount she drinks and typically drinks to the point she passes out.” The MEB physical exam noted a mental status exam without significant abnormalities and the CI denied suicidal or homicidal ideations. Insight was assessed as poor, with judgment fair. The diagnosis was “Bipolar II disorder, recurrent major depressive episodes with hypomanic episodes. ….” An S4T profile was recommended. Global Assessment of Functioning (GAF) was 65 (in the range of mild symptoms). Social/Industrial impairment was assessed as “mild” with military impairment as “moderate.” The examiner indicated the CI had “a significant predisposition to bipolar disorder given multiple episodes of depression before she entered the service. This patient has poor coping mechanisms and it is unlikely the bipolar 2 disorder will improve in this current environment.”

The commander’s statement, 6 months prior to separation, recommended retention and that her medical condition did not affect her ability to perform her normal military duties. The DD Form 2697, dated the month of separation, noted the CI was taking three psychoactive medications (Lexapro/Escitalopram, Abilify/Aripiprazole, and Depakote/Valproic acid). As noted above, the FPEB indicated the mental health (MH) condition was service incurred and compensable at 10% and indicated “Bipolar disorder II, Mild Social and Industrial Adaptability Impairment.”

At the VA Compensation and Pension exam performed 5 months after separation, the CI reported difficulty falling asleep, a significant suicidal ideation the month prior (went to get a knife and husband interceded), depressive episodes, feelings of hopelessness, nervous habits and overspending (manic episodes). She had begun working the prior month as a call facilitator for nurse advice, with “no current impairment in occupational functioning.” The CI started VA treatment a month prior and was on two psychoactive medications (Celexa and Depakote). The diagnosis was bipolar disorder, most recent episode depressed and the GAF was 63 (in the range of mild symptoms). VA records (VASRD dated September 2006) noted a 3-day hospitalization in August 2006 (11 months after separation) and continuation of the VA 30% MH rating.

More remote VA records indicated a later MH hospitalization, worsened symptoms with decreased GAF scores, inclusion of Lithium as a medication a rating increase to 50% effective August 2006 and then a later diagnosis of PTSD (2008) and rating increase to 70% effective August 2010.

The Board directs attention to its rating recommendation based on the above evidence. The MH diagnosis and code was bipolar disorder coded 9432 for both the service and VA. The service rated the MH condition at 10% and cited language from DODI 1332.39 (rescinded) of “social and industrial impairment.” The VA rated the MH condition at 30% from a post-separation exam. The CI’s condition at the VA exam was noted with increased depressive symptoms, but a similar GAF to the in-service assessments.
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 next considered a rating under VASRD §4.130. The CI was on chronic medication and was not adjudged to have continuous occupational impairment; the deliberation settled therefore on arguments for a 30% versus a 10% permanent rating recommendation. The 30% rating criteria specifies occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) while the 10% criteria specify 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.

The Board considered the commander’s statement of essentially no current duty impairment, with the history of hospitalization, recurrent depressive episodes, non-judicial punishment, suicidality and poor coping skills and performance reports. The record also indicated increasing psychoactive medications between the NARSUM date and separation, although source MH treatment notes are not in evidence. The evidence indicated that there were “intermittent periods of inability” relative to occupational capacity, and the Board deliberated if these were “only during periods of significant stress,” (under the 10% criteria). The Board considered that the CI’s MH condition most likely involved financial difficulties which were considered a significant stress by the CI in both service and post-separation records. The Board considered the remote VA evidence of additional hospitalizations and symptom worsening were not indicative of the CI’s condition at the time of separation, but post-separation worsening. 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.

Contended PEB Conditions. The conditions of tobacco abuse (MEB), history of alcohol abuse (binging behavior) and obesity (overweight) are conditions or circumstances that do not constitute physical disabilities IAW DoDI 1332.38, Enclosure 5, and are therefore not compensable. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB noncompensable determination for the any of the contended conditions and so no additional disability ratings are recommended.


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 DoDI 1332.39 for rating bipolar disorder was operant in this case and the condition was adjudicated independently of that instruction by the Board. In the matter of the bipolar disorder condition, the Board unanimously recommends a disability rating of 30%, coded 9432 IAW VASRD §4.130. In the matter of the contended tobacco abuse (MEB), history of alcohol abuse (binging behavior) and obesity (overweight) conditions, the Board unanimously recommends no change from the PEB determinations as not compensable. 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 recharacterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
Bipolar Disorder 9432 30%
COMBINED 30%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140612, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




                 
XXXXXXXXXXXXXX
President
Physical Disability Board of Review


SAF/MRB
Dear XXXXXXXXXXXXXX:
         Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2013-02086.
         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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities. Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.
         I have carefully reviewed the evidence of record and the recommendation of the Board. I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly. The office responsible for making the correction will inform you when your records have been changed.
         As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP). Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election. If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

                                                               Sincerely,






XXXXXXXXXXXXXX
Director
Air Force Review Boards Agency
Attachment:
Record of Proceedings

cc:
SAF/MRBR

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