RECORD OF PROCEEDINGS AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS IN THE MATTER OF: DOCKET NUMBER: BC-2014-01569 COUNSEL: NONE HEARING DESIRED: NO APPLICANT REQUESTS THAT: His Informal Physical Evaluation Board (IPEB) finding be reevaluated and that he be considered for a medical retirement. APPLICANT CONTENDS THAT: There was a violation of Air Force policy during his IPEB. His diagnosis of sleep apnea should have been considered during his IPEB. Instead of meeting a Medical Evaluation Board, he was separated. This injustice has resulted in the denial of medical retirement, medical and travel expenses and has caused financial hardship. He submitted a complaint to the Office of the Inspector General; however, no action was taken. He has incurred significant career and monetary damages by not having a Line of Duty determination. The applicant’s complete submission, with attachments, is at Exhibit A. STATEMENT OF FACTS: The applicant is a lieutenant colonel in the Air National Guard. He is currently serving as an Air Reserve Technician in a civilian capacity. The remaining relevant facts pertaining to this application are contained in the memoranda prepared by the Air Force offices of primary responsibility (OPRs), which are attached at Exhibits B and E. AIR FORCE EVALUATION: AFRC/SG recommends denial. A review of the database shows the applicant underwent fitness for duty evaluation for sleep apnea, chronic cough, PTSD and fibromyalgia on 24 July 2013. He was found disqualified by AFRC/SG and the case was forwarded to the IPEB on 28 July 2013. According to the documentation provided by the medical squadron, the applicant failed to disclose his conditions until he had repeated fitness assessment failures. He was placed in a no pay/no points status pending receipt of information, and appears to have developed other complaints after that time. The diagnoses he claimed subsequent to the board and not previously disclosed were not addressed by the medical squadron, AFRC/SGP or the IPEB as they were unknown at the time. The applicant desires to have his sleep apnea considered under the 2008 rule set. He provides documentation from unnamed individuals showing they received disability, and he wishes to be treated similarly as he claims his apnea dates to the 2007/08 time period. He was not, however disabled as he has a period of at least seven years presumed fitness in the intervening time period. It is clearly up to the board as to the rules they consider a member under, but in this case since no disability appears to have occurred, disabling him with back pay does not appear appropriate. The applicant also wishes to appeal the fit determination made by the IPEB but this was not approved. The board recommended a return to duty (fit for military duty) and he was returned by AFRC/SGP with an assignment limitation code. This implies that he is fit for military duty, but is not deployable without a waiver. He would not have been entered into the DES, as they appear to have felt he was duty capable and not disabled at that time. After return on the assignment limitation, he provided Post- Traumatic Stress Disorder (PTSD) documentation to the unit showing he could not participate. At that time, he was placed in a status pending MEB. He has not provided that documentation despite repeated requests. He continues to participate in his position at the unit in his civilian status as an Air Reserve Technician. The unit is standing by to process his case, but is unable to do so without the applicant submitting the civilian medical documentation required to make appropriate medical assessment of his case. There is no evidence any injustice occurred. The applicant’s diagnoses as noted above were considered by the board, and he was returned to duty. There was no evidence he is disabled and should be medically retired. However, if he feels these are all line of duty conditions and deserve consideration as such, he should file the appropriate medical documents with his medical squadron and the line of duty cases should be worked to ensure he receives due consideration. The applicant is required to help the unit help him - and they cannot do so if he remains uncooperative. A complete copy of the AFRC/SG evaluation is at Exhibit B. APPLICANT'S REVIEW OF AIR FORCE EVALUATION: The applicant refutes the advisory provided by AFRC/SG. He states that he disclosed all of his conditions after he had been hospitalized for pneumonia and had been set up for a physical. It was during the annual disclosure that the medical squadron noticed that he had also been diagnosed for sleep apnea in 2007: the medical squadron failed to act and initiate a fitness for duty assessment in 2008 during his annual review. This is why he should be considered under the 2008 rule set. AFRC/SG states that he has had at least 7 years of presumed fitness and that he is not disabled. This statement is inaccurate as noted by his list of medications. He was frequently treated for respiratory issues to the point that he now takes several medications for respiratory issues which had left his exhaustion unchanged. It is true the IPEB recommended he be returned to duty; however, he contacted the board Chairman to discuss the situation and asked if he should have been considered under the 2008 standard and he stated yes. He also pointed out there was no mention of the amount of missed work because of those conditions. He explained what had happened and he agreed the record was incomplete as submitted. He has provided PTSD documentation to the unit and has asked for clarification as to what they need and instead of defining what they are looking for from his provider they have simply state stated all documents including therapist notes. Furthermore, he has cooperated with the unit in an effort to complete an LOD. The applicant’s complete response, with attachments, is at Exhibit E. ADDITIONAL AIR FORCE EVALUATION: AFBCMR Clinical Psychology Consultant recommends denial. The applicant is a traditional Reservist who also serves in an Air Reserve Technician capacity. His last period of active service was 1 October 2004 through 31 October 2008 during which time he was listed as the Security Forces Commander. Notes for rheumatology evaluations in 2012 and early 2013 indicate a “questionable history of PTSD” with no elaboration. It was suspected that underlying depression and psychiatric illness were playing a part in the applicant’s physical symptoms. A psychiatric evaluation was advised. On 24 July 2013, a narrative summary was completed by military medical personnel. The diagnoses included sleep apnea, chronic cough, PTSD, and fibromyalgia. PTSD was noted to be disqualifying IAW AFI 48-123 section 5.3.12.2.7. and disclosure of the condition was noted to have occurred following the applicant’s placement in a no points status for sleep apnea. The author wrote it was unknown whether PTSD was related to military duty or another traumatic event as it was unclear what he was doing at the point of onset. The condition was not treated during a deployment. The writer indicated the condition was not caused or aggravated by military service. The applicant was undergoing therapy at that time and deemed non-deployable. His prognosis was listed as poor with chronic symptomatology expected. The author noted the applicant had received minimal documentation from the applicant related to this condition. On 29 July 2013, HQ AFRC/SGPA determined the applicant to be medically disqualified for continued military duty and listed diagnoses of Sleep Apnea, PTSD, Chronic Cough, and Fibromyalgia. No line of duty (LOD) determinations with a positive determination for these conditions were finalized or noted to be in process. On 26 November 2013, the applicant began psychiatric services. His chief complaint was “anger, not being able to tolerate normal things, not being able to get the pleasure out of the things that he used to do, anxiety and depression, and not being able to sleep.” He was reported to have observed no changes since a last deployment in 2008 until recently, evidenced by his inability to watch a children’s show. The applicant reported decreased patience and not enjoying life as before. This prompted him to seek counseling. He was prescribed perphenazine, an antipsychotic medication. The psychiatrist noted he had experienced success when using this medication for treating Vietnam veterans with combat related PTSD A letter dated 5 February 2014 from the applicant’s psychiatrist to the Department of the Air Force states treatment was initiated on 15 January 2013. The diagnosis was PTSD with delayed expression. The applicant’s trauma was reportedly tied to combat actions during his deployment to Afghanistan in 2002 although there is no elaboration. The psychiatrist remarks the applicant is permanently unable to participate in military duty and should be medically retired. His symptoms were noted to interfere with all areas of functioning. The psychiatrist noted, “Another area of consideration related to his slow progress is in regards to the mefloquine he was exposed to.” The doctor did not elaborate further on this point. At that time, termination of treatment was not expected within the next 12 months. Documentation supplied for this case does not contain a description from the treating providers as to how the applicant’s symptoms meet criteria for PTSD with delayed expression. The BCMR Clinical Psychology Consultant does not intend to engage in an attempt to dismantle the applicant’s contentions and is aware that diagnostic variance can occur between medical professionals. This Consultant is sensitive to the applicant’s distress and the likely exacerbating effect career uncertainty can have on mental health conditions. Thus, this opinion should not be construed to imply the applicant does or does not suffer from a mental health disorder. At the same time, relevant military guidance, scientific literature, and evidence at hand must be integrated to provide objective input to the Board. Overall, the Clinical Psychology Consultant did not find information supplied for this case to be helpful for elucidating or supporting a claim of an error or injustice. The applicant has balked multiple times at releasing detailed therapy notes to medical providers at his home medical unit, citing the sensitivity of their content. Yet, concerns for sensitivity must be balanced against the needs of the Air Force in this case. Paragraph 10.4.2. of AFI 48-123 contains the urgency with which a change in medical status for a Reserve Component Service member should be reported to the home medical unit: “Each ARC member is responsible for promptly (within 72 hours) reporting an illness, injury, disease, operative procedure or hospitalization not previously reported to his or her commander or supervisor, and supporting medical facility personnel IAW AFI 36-2910. Any concealment or claim of disability made with the intent to defraud the government results in possible legal action and possible discharge from the ARC.” The letters from the applicant’s providers are vague in clinical information that would be useful for making a determination for his worldwide duty qualification, while containing very specific recommendations related to disposition of his case (i.e., he should be medically retired). Unfortunately, this Consultant opines that civilian providers are not likely to be familiar with current military guidance for entering a service member into the disability evaluation system nor are they likely to recognize the specific definitions employed by the military department for adjudicating whether a case meets the threshold for a combat related medical condition. The clinical recommendations were constructed within meetings of the applicant, his therapist, and his psychiatrist. Thus, it is difficult to conclude that the clinical opinion contained in such recommendations was not swayed by the needs of the applicant as opposed to an objective view of his symptomatology in the context of relevant military regulations. Some ambivalence in the applicant’s contentions and in statements from the therapist was also observed. There is a notable call for medical retirement based on combat related PTSD while at the same time the potential effects of mefloquine on his psychological condition is argued. The Clinical Psychology Consultant observes the applicant’s report of the cause of his symptoms is the only evidence to support PTSD with delayed expression as service related or exacerbated. There is no LOD investigation from his unit. Unfortunately, an LOD determination will be complicated by the many years that have passed since the alleged trauma and the rarity of his symptom presentation. Records supplied for this case suggest the applicant’s mental health symptoms emerged within the last few years. This Consultant is aware that the prevalence of delayed onset PTSD in veterans has been examined multiple times in the scientific literature with rates varying in accordance with the definition employed (e.g., new symptom onset versus exacerbation of subthreshold symptoms). For example, a rigorous cross-sectional study published in 2009 assessed the prevalence of delayed onset PTSD in 747 US military veterans using multiple definitions of this disorder1. Overall, delayed onset of PTSD in veterans was found to be rare regardless of the definition used (i.e., currently meets criteria for PTSD, currently has subthreshold symptoms of PTSD, or has had PTSD at some point in lifetime). In addition, only 3 of 747 veterans completing the structured clinical interviews for this study suffered from diagnosable PTSD with symptoms that had developed more than a year post- trauma. None experienced symptom onset more than 6 years post- trauma. Thus, the applicant’s diagnosis of PTSD with delayed expression of nearly 10 years is quite rare to say the least and will make an LOD determination challenging. At the same time, the guidance within DODI 1332.18 and AFI 48-123 is based on level of impairment from a medical condition rather than the specific diagnosis when determining whether to enter a Service member into the disability evaluation system. The applicant is advised, then, that meeting criteria for PTSD does not automatically render him unfit for military service. Information from his medical condition must be integrated with data from his work performance, often as assessed by the commander, in order for the Physical Evaluation Board to come to a fit or unfit conclusion. In sum, the Clinical Psychology Consultant did not find an error or injustice in this case based on the information provided. An LOD determination is needed and a mental health examination completed at a military treatment facility would aid significantly for such a determination. In this Consultant’s experience such examinations are common in the Reserve Component and the applicant’s concerns about the sensitive information contained in therapy notes should be moot when records are exchanged from one mental health provider to another. The complete AFBCMR Clinical Psychology Consultant 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 7 July 2015 for review and comment within 30 days (Exhibit G). As of this date, no response has been received by this office. 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 took notice of the applicant’s complete submission, to include his response to the Air Force advisory, in judging the merits of the case. While the applicant contends the Air Force violated policies with regard to the Informal Physical Evaluation Board (IPEB) and his diagnosis of sleep apnea should have been considered during his IPEB, he has not provided documentation to override the rationale provided by the Air Force office of primary responsibility and the BCMR Clinical Psychologist. Therefore, we agree with their opinions and recommendations and adopt their rationale as the basis for our conclusion the applicant has not been the victim of an error of injustice. In the absence of evidence to the contrary, we find no basis to recommend granting the requested relief. THE BOARD DETERMINES THAT: The applicant be notified the evidence presented did not demonstrate the existence of material error or injustice; the application was denied without a personal appearance; and the application will only be reconsidered upon the submission of newly discovered relevant evidence not considered with this application. The following members of the Board considered AFBCMR Docket Number BC-2014-01569 in Executive Session on 20 August 2015 under the provisions of AFI 36-2603: The following documentary evidence pertaining AFBCMR Docket Number BC-2014-01569 was considered: Exhibit A. DD Form 149, dated 11 Apr 14, w/atchs. Exhibit B. Letter, AFRC/SG, dated 27 May 14. Exhibit C. Letter, SAF/MRBR, dated 1 Oct 14. Exhibit D. Letter, Applicant’s Response, dated 14 Oct 14, w/atchs. Exhibit E. Letter, AFBCMR, Clinical Psychology Consultant, dated 22 Jun 15. Exhibit F. Letter, SAF/MRBR, dated 7 Jul 15.