RECORD OF PROCEEDINGS AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS IN THE MATTER OF: DOCKET NUMBER: BC-2015-00273 COUNSEL: NONE HEARING DESIRED: NO APPLICANT REQUESTS THAT: His administrative discharge be changed to a medical separation with retirement benefits. APPLICANT CONTENDS THAT: He was diagnosed with an Adjustment Disorder and administratively separated; however, the Department of Veterans Affairs (DVA) diagnosed him with Bipolar Disorder shortly after leaving the service, and he believes since he is experiencing the same symptoms he should have been medically separated. Based on his ongoing mental health treatment at the DVA, he believes the diagnosis of adjustment disorder by the Air Force is incorrect and the incorrect diagnosis of adjustment disorder is a miscarriage of justice. His separation code, as it stands right now, only entitles him to 90 percent of his Post 9/11 GI BILL; as a result, he is not entitled to the additional benefits provided by the DVA that are only available to veterans with 100 percent of their Post 9/11 GI BILL. Had he been diagnosed with Bi-Polar Disorder while on active duty and been referred to a Physical Evaluation Board/Medical Evaluation Board (PEB/MEB), he could have received a "medical discharge" and this would have made him eligible for the Post 9/11 GI BILL at the 100 percent rate. The applicant’s complete submission, with attachments, is at Exhibit A. STATEMENT OF FACTS: The applicant initially entered the Regular Air Force on 1 Oct 08. On 8 Aug 11, the squadron commander notified the applicant that he was initiating administrative discharge action for conditions that interfere with military service. The specific reason for the proposed action was that on or about 5 Jul 11, the applicant was diagnosed with an Adjustment Disorder with Mixed Emotional Features which significantly impaired his ability to function in the military environment. On that same date, the applicant acknowledged receipt of the discharge notification, and on 9 Aug 11, he submitted statements in his own behalf. The Staff Judge Advocate found the case file legally sufficient to support separation and recommended an honorable discharge, without probation and rehabilitation (P&R). On 12 Aug 11, the discharge authority approved the honorable discharge, without P&R. On 23 Aug 11, the applicant was honorably discharged, with a reason for separation of adjustment disorder and issued an RE code of 2C (involuntarily separated with an honorable discharge). He was credited with 2 years, 10 months, and 23 days of active duty service. On 31 Dec 12, the DVA assigned a 50 percent rating for Bipolar Disorder II based on a diagnoses of (depression, anxiety, adjustment disorder and insomnia/snoring). The remaining relevant facts pertaining to this application are described in the memoranda prepared by the Air Force offices of primary responsibility (OPR), which are included at Exhibits C. AIR FORCE EVALUATION: The AFBCMR Psychiatric Consultant recommends granting the applicant’s request and found the evidence sufficient to warrant placement on the TDRL, due to Bipolar Disorder, with a disability rating to 50 percent, under the Veterans Affairs Schedule for Rating Disabilities (VASRD) code 9432, effective his established date of separation; with reevaluation and a final disposition within the next 5 months. The Psychiatric Consultant has carefully reviewed this case and notes it is apparent that diagnosis of Bipolar Disorder was considered at some point by two different providers. The psychiatrist who evaluated the applicant on 31 May 11, had done a particularly excellent job by documenting his mood cycling and the symptoms consistent with possibly hypomanic behaviors. This consultant is not aware what diagnostic criteria was used by the DVA examiner during the Compensation and Pension (C&P) exam because that evaluation is not available for the review, but the applicant’s VA psychologist who continued documenting the diagnosis of Bipolar Disorder did not obtain good history to confirm it. However, the VA psychiatrist, on 13 Jan 15, appeared to be somewhat bedazzled by the diagnosis of Bipolar Disorder. He documented limited clinical evidence but decided on resuming the treatment of Bipolar Disorder, since he noted that all the medications prescribed by the military psychiatrist were mood stabilizers. This consultant would like to educate the Board members on the significance of that observation. Mood stabilizers is a class of medications consisting of antiepileptics, antipsychotics and Lithium, which are approved for treatment of Bipolar Disorder. Those medications can also be used for irritability, anger, sleep and pain in the conditions not related to Bipolar Disorder. Since the applicant’s military psychiatrist did not explain clearly in his documentation the justification for the use of those medications, and he never diagnosed the applicant with Bipolar Disorder, this consultant can only infer that he used mood stabilizers for treatment of the applicant’s irritability and anger. His military psychiatrist entertained the idea of mood instability due to the bipolar - borderline spectrum, and even referred the applicant for neuropsychological testing for diagnostic clarity. Bipolar Disorder is a mood disorder and Borderline Personality Disorder is a character disorder, but those two conditions can have analogous symptoms that might be difficult to distinguish and can also co-occur in the same individual thus complicating the clinical picture even further. Unfortunately, the results of the applicant’s neuropsychological testing were not valid or in other words not interpretable. This can happen for multiple reasons including but not limited to the patient magnifying symptoms, diminishing symptoms, providing inconsistent responses. Taking into account all the information that was provided in the record this consultant will agree with the applicant, that diagnosis of Bipolar Disorder is likely. However, this would be too simple of an answer and it almost never is. The question that the Board members are probably asking by now is “what about all the other diagnoses documented on the chart during his military service, are they erroneous?” The Diagnostic and Statistical Manual of Mental Disorders (DSM) V provides an answer “Bipolar II disorder is more often than not associated with one or more co-occurring mental disorders.” It further states “Approximately 60 percent of individuals with Bipolar II disorder have three or more co-occurring mental disorders.” In other words it is not that the other diagnoses were incorrect but it is most likely than not, that the applicant has suffered from symptoms of multiple psychiatric conditions and since many symptoms overlap the providers at times might have had difficulty differentiating them. This consultant has the advantage of reviewing this case retrospectively, which makes the job of arriving to the correct diagnosis less challenging. Adjustment Disorder has been, for decades, listed in Air Force and Department of Defense policies as a medical condition not considered a compensable disability by the military Disability Evaluation System. Although a recent revision of Department of Defense (DoD) policy [April 2013] now acknowledges that an individual with a Chronic Adjustment Disorder renders the individual eligible for processing via a MEB, this policy does not apply to the applicant since his discharge preceded the change in regulations. Readdressing the applicant’s implicit desire for a medical retirement, the military Disability Evaluation System (DES), established to maintain a fit and vital fighting force, can by law, under Title 10, United States Code (U.S.C.), only offer compensation for those service incurred diseases or injuries which specifically rendered a member unfit for continued active service and were the cause for career termination; and then only for the degree of impairment present at the “snapshot” time of separation and not based on post-service progression of disease or injury. In accordance with the regulation AFI 48-123 paragraph 5.3.2 anyone with the diagnosis of the Bipolar Disorder has to be referred to an Initial Review-In-Lieu-Of (RILO) or Fit for Duty (FFD) determination within the first 90 days of the diagnosis. Furthermore, the singular presence of a medical condition or medical symptoms does not in itself indicate that that a particular condition is unfitting for duty. Rather, the evidence that indicates that the condition and/or symptoms currently affect the member’s ability to satisfactorily complete his duties, that the condition/ symptoms have persisted for some period of time, and that the condition/ symptoms are not expected to resolve in the near future (i.e., that this is not an acute condition that can be reasonably expected to resolve in a relatively short period of time). Paragraph 5.3.1.2., from the same AFI specifies further the unfitting criteria: the individual’s health or well-being would be compromised if he or she were to remain in the military service. This includes, but is not limited to: dependence on medications or other treatments requiring frequent clinical monitoring, special handling or severe dietary restrictions. Knowing that the course of the Bipolar Disorder is chronic in nature and that patients with Bipolar disorder frequently require daily reliance on mood stabilizers to control their symptoms, which can greatly impact his/her ability to fulfill the duty obligations and compromise the mission; the MEB would find applicant unfit for duty. Since C&P exam performed by DVA for the rating determination, has been performed within a month following the applicant’s discharge from the military, this consultant opines the same DVA rating of 50 percent should be assigned to the applicant’s Bipolar Disorder upon his discharge. However, collectively taking into the account the multilayered presentation of the applicant’s condition at the time of his discharge, the degree of disability that interfered with his duty due to the Adjustment Disorder, and possible influence of other factors (pathological personality traits, history of childhood abuse), this consultant recommends placement of the applicant at the time of discharge on the Temporary Disability Retired List (TDRL) with future re-examination, to determine the degree of incapacity attributable to the Bipolar Disorder alone. However, since the statutory limit in TDRL status is 5 years, a final TDRL determination has to be made within the next 4-5 months. The evaluation should be performed by a psychiatrist or a PhD- level psychologist as soon as practicable, preferably concluding with a 5-Axis diagnostic format and level of impairment in civilian social and industrial adaptability. The results of the evaluation should be made available to officials within the USAF Disability Division for a final rating decision and disposition within the Integrated Disability Evaluation System (IDES). Alternatively, existing clinical assessments for other sources, e.g., DVA or civilian providers, may be utilized if deemed sufficient to reach an appropriate final disposition. This consultant recognizes that diagnostic error had been made and the applicant should have been released from military service by reason of a Bipolar Disorder. This psychiatric consultant also recognizes the sacrifices the applicant has made for this country and appreciates his service and also wants to congratulate applicant on his post-military accomplishments and his exemplary dedication to education. A complete copy of the Psychiatric Consultant evaluation is at Exhibit C. APPLICANT'S REVIEW OF AIR FORCE EVALUATION: The applicant agrees with the recommendation of the advisory consultant to update his discharge to reflect placement on the TDRL due to Bipolar Disorder, with a rating of 50 percent pursuant to VASRD code 9432. The applicant’s complete response is at Exhibit E. THE BOARD CONCLUDES THAT: 1. The applicant has exhausted all remedies provided by existing law or regulations. 2. The application was timely filed. 3. Sufficient relevant evidence has been presented to demonstrate the existence of an error or injustice. We took notice of the applicant's complete submission in judging the merits of the case and agree with the opinion and recommendation of the AFBCMR Psychiatric Consultant and adopt her rationale as the basis for our conclusion the applicant has been the victim of an error or injustice. Therefore, we recommend the applicant's records be corrected as indicated below. THE BOARD RECOMMENDS THAT: The pertinent military records of the Department of the Air Force relating to the APPLICANT be corrected to show that: a. On 22 Aug 11, he was found unfit to perform the duties of his office, rank, grade or rating by reason of physical disability incurred while entitled to receive basic pay; that the diagnosis in his case was Bipolar I Disorder; under Veterans Affairs Schedule for Rating Disabilities (VASRD) code 9432, with a disability rating of 50 percent; that the disability is temporary; that the disability was not due to intentional misconduct or willful neglect; that the disability was not incurred during a period of unauthorized absence; that the disability was in line of duty and the disability was not a direct result of armed conflict or caused by an instrumentality of war and was not combat-related. b. On 23 Aug 11, he was honorably discharged from active duty and on 24 Aug 11, his name was placed on the Temporary Disability Retired List (TDRL). Since this record correction was retroactive to 2011, the member is now overdue for a TDRL re-evaluation under 10 U.S.C. 1210 and AFI 36-3212. Such re-evaluation must occur as soon as practicable and be performed by a psychiatrist or PhD-level psychologist. The re-evaluation must be concluded with a 5-Axis diagnostic format and the applicant's level of impairment in civilian social and industrial adaptability documented. The results of the evaluation should be made available to officials within the USAF Disability Division for a final rating decision and disposition within the Integrated Disability Evaluation System (IDES). Alternatively, existing clinical assessments for other sources, e.g., Department of Veterans Affairs or civilian providers, may be utilized if deemed sufficient to reach an appropriate final disposition. c. His election of the Survivor Benefit Plan option will be corrected in accordance with his expressed preferences and/or as otherwise provided for by law or the Code of Federal Regulations. The following members of the Board considered AFBCMR Docket Number BC-2015-00273 in Executive Session on 9 Jun 16 under the provisions of AFI 36-2603: , Panel Chair , Member , Member All members voted to correct the records as recommended. The following documentary evidence was considered: Exhibit A. DD Form 149, dated 23 Jan 15, w/atchs. Exhibit B. Pertinent Excerpts from Personnel Records. Exhibit C. Memorandum, AFBCMR Psychiatric Consultant, dated 1 Apr 16, digitally signed, 5 Apr 16. Exhibit D. Letter, AFBCMR, dated 22 Apr 16. Exhibit E. Letter, Applicant, dated 30 Apr 16.