RECORD OF PROCEEDINGS AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS IN THE MATTER OF: DOCKET NUMBER: BC-2012-02157 COUNSEL: NONE HEARING DESIRED: NO ________________________________________________________________ APPLICANT REQUESTS THAT: Her narrative reason for separation be changed from adjustment disorder to medically retired. ________________________________________________________________ APPLICANT CONTENDS THAT: She should have been medically boarded and in turn, medically retired. She received a letter from the Air Force Personnel Center regarding personality disorder separations. While she does not believe her disability is related to post-traumatic stress disorder (PTSD), she does believe she should have received a medical board. In support of the appeal, the applicant provides her DD Form 214, Certificate of Discharge or Release from Active Duty and her rating from the Department of Veterans Affairs (DVA). The applicant’s complete submission, with attachments, is at Exhibit A. ________________________________________________________________ STATEMENT OF FACTS: The applicant enlisted in the Regular Air Force on 31 July 1996. On 21 May 2009, she was notified of her commander’s intent to discharge her from the Air Force for Conditions that Interfere with Military Service: Mental Disorder – Personality Disorder and Adjustment Disorder. Specifically, she was diagnosed with Adjustment Disorder with Mixed Anxiety and Depressed Mood and a Personality Disorder, as contained in the Diagnostic and Statistics Manual of Medical Disorders. Additionally, she had shown an inability to cope with her duties and instability to cope with interpersonal issues in her workplace. The applicant acknowledged her right to present her case to an administrative discharge board, to be represented by military counsel and to submit matters on her behalf to be considered by the discharge board. She waived her rights to a board hearing and counsel. She also declined to submit matters on her behalf. The staff Judge Advocate found the discharge legally sufficient on 27 May 2008. On 27 May 2008, the commander approved the discharge and directed she be separated with an honorable discharge. Her narrative reason for separation is listed as Adjustment Disorder. ________________________________________________________________ AIR FORCE EVALUATION: The BCMR Medical Advisor recommends denial. The applicant had excellent enlisted performance reports throughout her 12 years of service, except for a referral report in April 2008 due to her involvement in an off-base driving while under the influence incident. She was seen by a mental health provider on several occasions between 18 December 2007 and 6 March 2008. She repeatedly noted to the professionals that her emotional issues were directly related to her service. She was given an Axis I diagnosis of Adjustment Disorder with Mixed Anxiety and Depressed Mood. Her Axis II diagnosis was Personality Disorder. Despite a poor response to therapy, the applicant had no signs or symptoms of a diagnosable disqualifying medical condition warranting a Medical Evaluation Board under AFI 48-123, Medical Examinations and Standards, or further processing as a compensable disability. Adjustment Disorder is listed among mental disorders not considered a disability under AFI 36-3208, Administrative Separation of Airmen, and Department of Defense Instruction 1332.38. The fact that the applicant has been subsequently issued a different diagnosis after leaving military service does not invalidate the accuracy or appropriateness of the diagnostic conclusion reached by equally competent mental health authority, which was based on the applicant’s complaints and demonstrated pattern of behavior at the time of her military service. The applicant should be aware that the DVA operates under a different set of laws and is authorized to offer compensation for any medical condition for which it establishes a nexus with military service, without regard to its proven or demonstrated impact upon a service, nor the intervening period since release from service. This is why individuals may be discharged from military service for one reason, yet receive a compensation rating for one or more service connected medical conditions that were not military unfitting at the time of release from service. The applicant has not met the burden of proof of an error or injustice that warrants the desired change of record. The BCMR Medical Advisor’s complete evaluation is at Exhibit C. ________________________________________________________________ APPLICANT'S REVIEW OF AIR FORCE EVALUATION: The applicant does not deny stating she wanted out of the Air Force, however, she was not in the right state of mind and spoke out of frustration. She was diagnosed with Adjustment Disorder and Personality Disorder. She was also diagnosed with Major Depressive Disorder in June 2000, Dysthymic Disorder and Anxiety Disorder in February 2008 and Depression in April 2008. According to AFI 48-123, 5.3.12.2, mental conditions requiring Medical Evaluation Boards (MEB) include conditions that are expected to have persistent duty impairment, more than one year despite treatment; conditions associated with recurrent duty impairment, two or more episodes of impairment in 12 months and conditions which require continuing psychiatric support beyond one year. Not only did she have recurring episodes of depression with duty impairment, but she also required psychiatric support beyond one year. She continues to receive medical treatment as she still struggles with both conditions to this day. She explains that she felt she could not trust the Mental Health Clinic due to the adverse effects of the prescribed medication. She also explains the references to alcohol abuse and dependence in her medical records. She contends she self-identified to her first sergeant and was referred to a 30-day in-residence rehabilitation program in 2000. She also states that after her driving under the influence incident, the initial evaluation found that she did not meet the criteria for alcohol dependence. In her 12 years of military service, she had five duty stations and six deployments. She volunteered for each deployment, to include a remote tour to Alaska. She never complained and never attempted to get out of these deployments. She had an overall excellent career and loved being part of the military until depression and anxiety got in the way. Although she wanted to get out of the military, she feels she should have been diagnosed with Depression and Anxiety at the time of her discharge which would have prompted an MEB. The applicant’s complete response, with attachments, is at Exhibit E. ________________________________________________________________ ADDITIONAL AIR FORCE EVALUATION: The BCMR Medical Advisor recommends denial. After reviewing the new medical evidence submitted by the applicant, the Medical Consultant identified evidence of alternative diagnosis, twice by the same provider, in which the applicant was diagnosed with potentially compensable Axis I diagnosis. However, the Medical Consultant opines that although the applicant has received compensation by the DVA, this fact does not invalidate the accuracy of the findings and recommendation of the military department, particularly in the context of the applicant’s emphatic requests for administrative separation and the declination of further treatment. Under the Title 38 Code of Federal Regulations (CFR), Section 4.13, Effect of change of diagnosis, it provides that when a change is made of a previously assigned diagnosis or etiology the aim should at the reconciliation and continuance of the diagnosis or etiology upon which service connection for the disability had been granted. The relevant principle enunciated in Section 4.125, entitled "Diagnosis of Mental Disorders," should have careful attention in this connection. When any change in evaluation is made, the rating agency should assure that there has been an actual change in the conditions, for better or worse, and not merely a difference in thoroughness of the examination or in use in descriptive terms. This will not preclude the correction of erroneous ratings, nor will it preclude assignment of a rating in conformity with Section 4.7. Section 4.70, Inadequate Examinations, reads: If the report of examination is inadequate as a basis for the required consideration of service connection and evaluation, the rating agency may request a supplementary report from the examiner giving further details as to the limitations of the disabled person's ordinary activity imposed by the disease, injury, or residual condition, the prognosis for return to, or continuance of, useful work. When the best interests of the service will be advanced by personal conference with the examiner, such conference may be arranged through channels. Section 4.125, Diagnosis of Mental Disorders, reads: (a) If the diagnosis of a mental disorder does not conform to DSM-IV or is not supported by the findings on the examination report, the rating agency shall return the report to the examiner to substantiate the diagnosis. (b) If the diagnosis of a mental disorder is changed, the rating agency shall determine whether the new diagnosis represents progression of the prior diagnosis, correction of an error in the prior diagnosis, or development of a new and separate condition. If it is not clear from the available records what the change of diagnosis represents, the rating agency shall return the report to the examiner for a determination." While these rules are useful when considering ratings and accuracy of the diagnoses within the DVA, it does not have relevance when determining whether a condition was unfitting during military service; or the cause for career termination. The fact that another federal agency has utilized criteria under Section 4.129 (used in rating PTSD) in assigning the applicant's post-service disability rating, illustrates the latitude given to examiners and rating officials in applying the law. The diagnostic nomenclature assigned to a given set of psychiatric symptoms and stressors, as reported by a patient at a given point in time, not uncommonly may change over time; or may be reported differently at subsequent points in time. Therefore, with disclosure or presentation of a different clinical history or set of symptoms, a new mental health provider may reach a different final diagnostic conclusion, as was likely in the case under review. Professional diagnostic opinions may even vary between two different providers when given the same set of clinical symptoms from the same patient; and during the approximate same period of time, as also noted in the different diagnoses reached by a licensed clinical social worker and the psychologist. Furthermore, a change in diagnosis may legitimately occur following a greater period of observation and treatment; notwithstanding the fact that individuals may also experience symptoms that are shared by one or more other clinical diagnoses, for instance, the depressed mood seen in Adjustment Disorder, Major Depressive Disorder, Dysthymic Disorder, Anxiety Disorder, PTSD, or secondary to Alcohol Dependence; and the mood swings seen in Bipolar Disorder and Borderline Personality Disorder. Adjustment Disorder is generally considered a diagnosis for at least 6 months, following which, other diagnostic considerations would be made if symptoms persist or further evolve. Yet two or more mental disorders [Axis I and/or Axis II diagnoses] may even coexist concurrently, as co-morbid mental disorders in the same subject, often times making it difficult to attempt separation of the two due to their close association and shared clinical features. Thus, the fact that the applicant has been given compensation for a different diagnosis by the DVA provider is insufficient to invalidate the accuracy or appropriateness of the conclusions reached by equally competent military mental health authorities and the applicant's commander, who is most familiar with her expressed pattern of behavior at the time of her military service; notwithstanding her expressed desire to leave military service. The Board is reminded that, operating under Title 10 United States Code (U.S.C.), the military department can only, by law, offer compensation for the illness or injury which is the cause for career termination; and then only to the degree of impairment present at the "snap-shot" time of release from service. Whereas, operating under a different set of laws with a different purpose [Title 38 U.S.C.], the DVA is authorized to offer compensation for any medical diagnosis/condition for which it establishes a nexus with military service. Moreover, the DVA may conduct periodic reevaluations for the purpose of adjusting the disability rating compensation. The fact that the DVA has assigned a disability compensation for Depression does not invalidate the personnel action taken by the military department, is not determinative that this diagnosis was unfitting at the time of release from service, and thus, does not warrant a de facto Medical Evaluation Board and further processing through the military Disability Evaluation System. The BCMR Medical Consultant regrettably recommends denial of the applicant’s request to supplant her administrative discharge with a medical retirement. The BCMR Medical Consultant’s complete evaluation is at Exhibit F. ________________________________________________________________ APPLICANT'S REVIEW OF ADDITIONAL AIR FORCE EVALUATION: A copy of the Air Force evaluation was forwarded to the applicant on 24 September 2013, for review and comment within 30 days (Exhibit H). As of this date, this office has received no response. ________________________________________________________________ THE BOARD CONCLUDES THAT: 1. The applicant has exhausted all remedies provided by existing law or regulations. 2. The application was timely filed. 3. Insufficient relevant evidence has been presented to demonstrate the existence of an error or injustice. We carefully considered the available evidence of record; however, the Board majority found no indication the actions taken to effect the applicant’s discharge were improper or contrary to the provisions of the governing instructions. Therefore the majority of the Board agrees with the opinion and recommendation of the BCMR Medical Consultant and adopts his rationale as the basis for our conclusion that the applicant has not been the victim of an error or injustice. Therefore, in the absence of evidence to the contrary, the Board majority finds no basis to recommend granting the relief sought in this application. ________________________________________________________________ RECOMMENDATION OF THE BOARD: A majority of the Board finds insufficient evidence of error or injustice and recommends the application be denied. ________________________________________________________________ The following members of the Board considered AFBCMR Docket Number BC-2012-02157 in Executive Session on 21 February 2013 and 26 March 2013, under the provisions of AFI 36-2603: By a majority vote, the Board recommended denial of the application. XXXX XXXX voted to correct the record and submits a Minority Report. The following documentary evidence was considered: Exhibit A. DD Form 149, dtd 23 May 12, w/atchs. Exhibit B. Applicant’s Master Personnel Record. Exhibit C. Letter, BCMR Medical Consultant, dtd 22 Jan 13. Exhibit D. Letter, SAF/MRBR, dtd 22 Jan 13. Exhibit E. Letter, Applicant’s Response, undated, w/atchs. Exhibit F. Letter, BCMR Medical Consultant, dtd 20 Mar 13. Exhibit G. Minority Report, dtd 15 Apr 13. Exhibit H. Letter, SAF/MRBR 24 Sep 13.