RECORD OF PROCEEDINGS
AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS

IN THE MATTER OF:				DOCKET NUMBER:  BC-2015-02728
		
XXXXXXXXXX					COUNSEL:  NONE

							HEARING DESIRED:  YES

APPLICANT REQUESTS THAT:

1.  Her discharge with severance pay be changed to a medical retirement with a 50 percent disability rating.

2.  Her records be corrected to indicate a diagnosis of Post-Traumatic Stress Disorder (PTSD) rather than bipolar disorder and that the PTSD was a direct result of armed conflict, incurred in the line of duty during a period of war, and was caused by an instrumentality of war.

APPLICANT CONTENDS THAT:

The findings of the Formal Physical Disability Board (FPEB) were based on an incorrect diagnosis.  As such the judgments from the board, their findings and the disability rating used are incorrect.  The Department of Veterans Affairs (DVA) corrected her diagnosis on 13 March 2013, with a service connection for the disability established on 20 June 2014.  Her claim of PTSD is well-grounded, supported by medical evidence, her service record, lay evidence of in-service stressors and medical evidence of a nexus between service and her PTSD.

The applicant’s complete submission, with attachments, is at Exhibit A.

STATEMENT OF FACTS:

The applicant initially entered the Regular Air Force on 15 October 1979.

The applicant was referred to the PEB via AF Form 618, Medical Board Report, dated 21 May 1997, for her diagnosis of “Bipolar I disorder, single manic episode, severe, with psychotic features in partial remission.  Degree of impairment for civilian social and industrial adaptability is CONSIDERABLE.”

According to AF Form 356, Findings and Recommended Disposition of USAF Physical Evaluation Board, dated 5 June 1997, the Informal PEB (IPEB) found the applicant unfit based on a diagnosis of “bipolar single manic episode with psychotic features, considerable social and industrial impairment” and recommended she be placed on the Temporary Disability Retired List (TDRL) with a 50 percent disability rating in accordance with Department of Defense (DoD) guidance for applying the Veterans Administration Schedule for Rating Disabilities (VASRD) code 9432.

According to AF Form 1180, Action on Informal Physical Evaluation Board Findings and Recommended Disposition, dated 16 June 1997, the applicant agreed with the findings of the IPEB.

According to Special Order Number ACD-1272 dated 23 June 1997, the applicant was relieved from active duty and placed on the TDRL effective 23 September 1997, in the retired pay grade of technical sergeant (E-6) with a 50 percent disability rating.

According to a TDRL Evaluation dated 3 February 1999, an Air Force staff psychologist indicated the applicant’s social/industrial impairment was marked for military duty and impairment for civilian social and industrial adaptability was definite.  The recommendation to the PEB states in part “Further care should include psychiatric care to continue her current pharmacological program.  Given her diagnosis, she will always be at risk for future manic episodes with psychotic features and therefore, reconsideration should be given towards medical retirement.”

According to AF Form 356 dated 24 February 1999, the IPEB found the applicant unfit based on a diagnosis of “bipolar single manic episode with psychotic features, in full remission, mild social and industrial adaptability impairment” and recommended discharge with severance pay with a 10 percent disability rating in accordance with DoD guidance for applying the VASRD code 9432.

On 11 March 1999, the applicant indicated that she did not concur with the recommended findings and requested an appearance before the FPEB.

According to AF Form 356 dated 21 April 1999, the FPEB upheld the decision of the IPEB.

AF Form 1180, dated 21 April 1999, indicates the applicant agreed with the findings and recommended disposition of the FPEB.

According to AFPC/DPPDS memorandum dated 26 April 1999, the Secretary of the Air Force directed the applicant be removed from the TDRL and discharged with severance pay.

According to Special Order ACD-00687 dated 26 April 1999, effective 20 May 1999, the applicant was removed from the TDRL and discharged in the grade of technical sergeant by reason of physical disability and entitled to disability severance pay.

A DVA Rating Decision dated 20 June 2014, determined service connection for PTSD was established.  This condition was combined with the applicant’s service-connected mental condition to become PTSD with a historical diagnosis of bipolar disorder, and the current evaluation of 50 percent disabling is confirmed and continued.

The remaining relevant facts pertaining to this application are described in the memoranda prepared by the Air Force office of primary responsibility (OPR) and the BCMR Psychiatric Consultant, which are included at Exhibits C and D.

AIR FORCE EVALUATION:

AFPC/DPFDD recommends denial indicating there is no evidence of an error or injustice.  A review of the applicant’s record reveals the 10 percent disability rating awarded by both the IPEB and the FPEB was appropriate based on the picture presented by the narrative summary written on 3 February 1999, and provided to the boards.  The diagnosis was bipolar disorder.  The applicant’s additional history of PTSD occurred after the FPEB hearing, and was not available to the boards at the time of disability processing.  As a matter of information, any discussion of fitness for disability under the Disability Evaluation System (DES) must be done solely with the medical information that was known and presented at the time of the original DES process.  Although the boards can consider additional information that reasonably could have or should have been available at the time of the DES process, it would not be reasonable to consider information that was generated and/or became available after the process was completed.  The medical documents available at the time of the DES process were consistent with bipolar disorder and although previous and potential traumatic events were mentioned, PTSD was not a working diagnosis at that time.  However, it should be noted that a change of diagnosis to PTSD would not have impacted the final disability rating of 10 percent or the decision for separation with disability severance pay as her condition at the time of reevaluation did not equate to a 30 percent disability rating required for medical retirement.  The applicant argues that her disability should be assessed as the direct result of armed conflict, incurred in the line of duty during a period of war, and was caused by an instrumentality of war.  However, AFPC/DPFDD does not recommend changing the diagnosis in question to PTSD; therefore, an assessment of combat-related cannot be applied to that diagnosis.  At the time of the DES, no reference was made to stressful events (other than pre-service sexual abuse); therefore, the PEBs would have had no reason to consider combat-relation at that time.

A complete copy of the AFPC/DPFDD evaluation is at Exhibit C.

The BCMR Psychiatric Consultant recommends the applicant be medically retired with a 30 percent disability.  The PEB’s decision to award the applicant a 10 percent disability rating was in error.  The applicant’s first encounter with mental health services was in March 1997.  She just returned from a 6-month deployment and immediately entered the Noncommissioned Officer Academy and then was denied leave due to mission requirements.  The above mentioned stress and most likely other predisposing factors precipitated her first manic episode, which resulted in a psychiatric hospitalization.  Her symptoms depict the “textbook” presentation of the manic episode.  Furthermore, there is clear documentation of the applicant’s improvement of symptoms following the initiation of the mood stabilizing medications.  It is very interesting to note, that the applicant’s medication regimen in 2016 consists only of Seroquel, which is not a treatment of choice for PTSD but rather a mood stabilizer used for management of bipolar disorder.  The applicant’s argument that she has not experienced another manic episode since 1997; therefore a bipolar diagnosis is not valid, and is entirely incorrect.  According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), the diagnosis of bipolar disorder “is characterized by the occurrence of one or more manic episodes.”  Consequently, since only one manic episode is required for the diagnosis of bipolar disorder, the lack of any manic episodes following the 1997 hospitalization does not discredit the diagnosis.  Furthermore, per the DVA’s rating decision, all but one of the provider’s involved in evaluating the applicant since 1997 agreed with the existing diagnosis of bipolar disorder and did not remove or invalidate it, but rather added PTSD as a comorbid condition.

The applicant emphasizes she experienced trauma during combat, nonetheless, she also reported that her mother died when she was 3 years old and suffered a “breakdown” at the age of 7.  In addition, her childhood history was brutally traumatic, which makes her vulnerable to mental illness.  A study published in a British Medical Journal on 20 January 2014, showed that losing a parent or sibling during childhood is linked to the development of a psychotic illness such as schizophrenia or bipolar disorder in later life.  This effect was most pronounced after a death in the nuclear family — that is, a parent or sibling.  The applicant had experienced a significant amount of trauma in her life that could result in the psychiatric disturbance.  However, only a minority of people who experience trauma develop PTSD.  Consequently, a PTSD diagnosis does not automatically invalidate the actions of the military department.  On review of all the medical records, there is no evidence the applicant has suffered from PTSD related symptoms during her military service.  In fact, her performance reports were exceptional and her presentation is indicative of rapid decompensation that would be consistent with a manic episode versus long-lasting PTSD.  The BCMR Psychiatric Consultant does not dispute the applicant’s current mental health diagnoses, but merely states the applicant has not been able to demonstrate that she has suffered from PTSD in the 1990s.  Furthermore, based on her presentation at that time, even if present, her PTSD would not be unfitting for the purpose of medical discharge or retirement.  In order to maintain a fit and vital force, the Secretary of the Air Force relies on statutory authorization (Title 10 United States Code [U.S.C.], Chapter 61) to separate service members from the Air Force who can no longer perform their military duties because of a mental or physical defect.  If a service member’s identified medical diagnosis, condition or physical or mental limitation prohibits or limits the individual from completing his or her duties and/or routinely interferes with his or her ability to obtain complete individual deployment readiness or worldwide duty reassignment qualification, and/or imposes unreasonable requirements on the military to either maintain or protect the member, the service member may be separated, discharged or retired from military service.  Based on the applicant’s record, bipolar disorder was a reason for her career termination - not PTSD.

Alternatively, the DVA, operating under a different set of laws, Title 38, U.S.C., is empowered to offer compensation for any medical condition with an established nexus to military service, without regard to its impact upon a member’s fitness to serve, the narrative reason for release from service, or the length of time since the date of discharge.  The DVA may also conduct periodic reevaluations for the purpose of adjusting the disability rating awards as the level of impairment from a given medical condition may vary [improve or worsen] over the lifetime of the veteran.  Therefore, even though the DVA has added a diagnosis of PTSD as a primary disorder in 2014, this evidence does not invalidate the appropriateness of the military discharge disposition, which was based upon the information present at the “snap shot” time of the applicant’s release from military service and no evidence is presented to demonstrate that PTSD was clinically present and unfitting at the time of the applicant’s discharge.

The last point of discussion will be the accuracy of the 10 percent disability rating for bipolar disorder assigned by the FPEB in 1999.  The applicant was initially placed on the TDRL in 1997.  Her bipolar disorder was found to be unfitting and she was rated at 50 percent with “considerable” impairment for civilian and industrial adaptability.  The applicant was reevaluated in 1999, at which time her impairment was “none-mild” as determined by the FPEB.  However, the psychologist who completed the TDRL evaluation did not agree with this decision.  Despite the applicant’s bipolar disorder being in remission, he opined she suffered from marked impairment for military duty and definite impairment for civilian social and industrial adaptability.  He based his recommendation on the following “Given her diagnosis, she will always be at risk for future manic episodes with psychotic features and therefore, reconsideration should be given towards medical retirement.”  According to the VASRD, a 30 percent disability rating for bipolar disorder corresponds to “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), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).”  A 10 percent disability rating corresponds to “Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.”  Due to the cyclic nature of the bipolar disorder and the expected degree of disability due to the manic or depressive episodes, the disability rating of 30 percent was more applicable, despite the stability of the applicant during the TDRL re-evaluation.

A complete copy of the BCMR Psychiatric Consultant’s evaluation is at Exhibit D.

APPLICANT'S REVIEW OF AIR FORCE EVALUATION:

The applicant concurs with the BCMR Psychiatric Consultant’s recommendation for a medical retirement with a 30 percent disability rating and would like to add context to several points.  First, the scenarios that the BCMR Psychiatric Consultant offered as possible “other underlying factors” were just that - scenarios.  They offer no real perspective into the applicant’s life.  Her combat experiences were totally missing.  The fact she flew combat missions during Desert Storm and Bosnia are well documented in official records.  The fact that her first hospitalization occurred only 24 months after her last combat missions over Bosnia was during a time of heightened risk is also evident.  Second, the BCMR Psychiatric Consultant makes note her childhood trauma, as if it would negate or minimize her combat trauma.  However, in spite of her childhood trauma, she performed her duties at the highest level for 17 years and it was only after three continuous years of combat stressors that problems arose.  PTSD is not what affected her career, it is what ended it.  Third, the BCMR Psychiatric Consultant states that “no evidence is presented to demonstrate that PTSD was clinically present” at the time of her discharge.  The reason there is no evidence of PTSD is because no one was looking for evidence.  PTSD was a relatively new diagnosis, only included in the DSM since 1980.  A diagnosis of PTSD within the Department of Defense was rare prior to 2008.  Lastly, the medication “Seroquel” is one of the most common alternatives to antidepressants for the treatment of PTSD.  However, she found the side effects of antidepressants too depilating.  Seroquel gives her the best quality of life to date. The fact she was with combat [sic] PTSD is not in dispute.  Since 2012, PTSD is the only diagnosis she is being treated for.

The applicant’s complete response is at Exhibit F.

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 to warrant changing the applicant’s records to indicate a diagnosis of PTSD as a direct result of armed conflict, incurred in the line of duty during a period of war, and was caused by an instrumentality of war. While the applicant’s comments in response to the evaluations are duly noted, we do not find her assertions sufficiently persuasive to override the rational provided by the Air Force OPR.  Therefore, we agree with the opinion and recommendation of the Air Force OPR and adopt the rationale expressed as the basis for our conclusion the applicant has not been the victim of an error or injustice. In view of the above and in the absence of evidence to the contrary, we find no basis to favorably consider this portion of the applicant’s request.

4.  Notwithstanding the above, sufficient relevant evidence has been presented to demonstrate the existence of error or injustice to warrant partial relief.  Having carefully reviewed this application, we agree with the BCMR Psychiatric Consultant’s recommendation that the applicant should be retired with a 30 percent disability rating.  While the applicant’s comments in response to the BCMR Psychiatric Consultant’s evaluation are duly noted, we do not find the assertions sufficiently persuasive to override the rational and recommendation provided by the BCMR Psychiatric Consultant. Accordingly, we recommend the applicant’s records be corrected to the extent indicated below.

5.  The applicant’s case is adequately documented and it has not been shown that a personal appearance with or without counsel will materially add to our understanding of the issues involved.  Therefore, the request for a hearing is not favorably considered.

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 19 May 1999, she was found unfit to perform the duties of her office, rank, grade or rating by reason of physical disability, incurred while she was entitled to receive basic pay; that the disability was not due to intentional misconduct or willful neglect; that the disability was not incurred during a period of unauthorized absence; and that the disability was not the direct result of armed conflict or caused by an instrumentality of war.

b. On 20 May 1999, she was not removed from the Temporary Disability Retired list and discharged by reason of physical disability with entitlement to disability severance pay, but rather her name was placed on the Permanent Disability Retired List due to the diagnosis of bipolar disorder, rated at 30 percent under the Veterans Administration Schedule for Rating Disabilities (VASRD) code 9432.

	c. The election of Survivor Benefit Plan option(s), will be corrected in accordance with the member’s 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-2015-02728 in Executive Session on 11 October 2016, under the provisions of AFI 36-2603:

, Panel Chair
, Member
, Member

All members voted to correct the records as recommended.  The following documentary evidence pertaining to AFBCMR Docket Number BC-2015-02728 was considered:

Exhibit A.  DD Form 149, dated 14 June 2015, w/atchs.
Exhibit B.  Applicant's Master Personnel Records.
Exhibit C.  Memorandum, AFPC/DPFDD, dated 12 November 2015.
Exhibit D.  Memorandum, BCMR Psychiatric Consultant, dated 
  15 August 2015.
Exhibit E.  Letter, AFBCMR, dated 24 August 2015.
Exhibit F.  Letter, Applicant, dated 3 September 2016.

Pursuant to paragraph 1 of AFI 36-2603 (Title 32 Code of Federal Regulations, Part 865.1), it is certified that a quorum was present at the Board's review and deliberations, and that the foregoing is a true and complete record of the Board's proceedings in the above entitled matter.