IN THE CASE OF: BOARD DATE: 28 March 2017 DOCKET NUMBER: AR20150018780 BOARD VOTE: _________ _______ ________ GRANT FULL RELIEF ________ ________ ________ GRANT PARTIAL RELIEF ________ ________ ________ GRANT FORMAL HEARING ___x____ ___x____ ___x____ DENY APPLICATION 2 Enclosures 1. Board Determination/Recommendation 2. Evidence and Consideration IN THE CASE OF: BOARD DATE: 28 March 2017 DOCKET NUMBER: AR20150018780 BOARD DETERMINATION/RECOMMENDATION: The evidence presented does not demonstrate the existence of a probable error or injustice. Therefore, the Board determined that the overall merits of this case are insufficient as a basis to amend the decision of the ABCMR set forth in Docket Number AR20120017654, dated 2 April 2013. ___________x______________ CHAIRPERSON I certify that herein is recorded the true and complete record of the proceedings of the Army Board for Correction of Military Records in this case. IN THE CASE OF: BOARD DATE: 28 March 2017 DOCKET NUMBER: AR20150018780 THE BOARD CONSIDERED THE FOLLOWING EVIDENCE: 1. Application for correction of military records (with supporting documents provided, if any). 2. Military Personnel Records and advisory opinions (if any). THE APPLICANT'S REQUEST, STATEMENT, AND EVIDENCE: 1. The applicant requests reconsideration of his previous request for correction of his DD Form 214 (Certificate of Release or Discharge from Active Duty) to show the narrative reason for separation as post-traumatic stress disorder (PTSD) instead of condition, not a disability. 2. The applicant states his Army records show he has a personality disorder, which was proven to be PTSD because he participated in battle and has been affected by it. 3. The applicant provides his DD Form 214. CONSIDERATION OF EVIDENCE: 1. Incorporated herein by reference are military records, which were summarized in the previous consideration of the applicant's case by the Army Board for Correction of Military Records (ABCMR) in Docket Number AR20120017654, dated 2 April 2013. 2. No new evidence (including, but not limited to, any facts or arguments as to why relief should be granted) was submitted with his request for reconsideration. However, the Secretary of Defense memorandum to the Service Discharge Review Boards and Service Boards for Correction of Military/Naval Records, dated 3 September 2014, regarding applications from former service members who were administratively discharged under other than honorable conditions (UOTHC) and who have been diagnosed with PTSD by competent mental health professionals was not published at the time of the ABCMR's prior consideration and warrants consideration at this time. 3. The applicant enlisted in the Regular Army on 17 October 2006. He completed training and he was awarded military occupational specialty 92Y (Unit Supply Specialist). 4. He served in Iraq as a supply specialist in support of Operation Iraqi Freedom from 1 June 2007 to 28 July 2007, a period of 58 days. 5. A DA Form 4856 (Developmental Counseling Form), dated 7 August 2007, shows his section sergeant stated he seemed emotionally distant from the platoon most of the time and was always depressed. His section sergeant advised him of his possible separation under the provisions of Army Regulation 635-200 (Personnel Separations – Enlisted Personnel), paragraph  5-13 or paragraph 5-17, if his conduct continued. The section sergeant hoped his upcoming mental evaluation would provide some clue as to what was happening. He was further counselled regarding the effects of an honorable discharge, a general discharge under honorable conditions, and a discharge UOTHC. His signature on this form does not resemble other documents of record containing his signature. 6. On 11 September 2007, he underwent a mental status examination at Madigan Army Medical Center, Fort Lewis, WA, following referral for a routine command-directed evaluation due to concerns about his emotional difficulties, which necessitated his redeployment from Operation Iraqi Freedom for mental health issues and suicidal and homicidal ideations. a. His diagnoses included major depressive disorder and noted borderline personality traits. b. The evaluating clinical psychologist observed: * his behavior was normal * he was fully alert * he was fully oriented * his mood or affect was depressed * his thinking process was clear * his thought content was normal * his memory was good c. The evaluating clinical psychologist determined: * he had the mental capacity to understand and participate in the proceedings * he was mentally responsible * he was not suitable for continued service due to ongoing emotional disturbance * he had severe anxiety, chronic depression, and intermittent suicidal ideation * his symptoms appeared to be long standing in nature and pre-dating his entrance into the military * his emotional instability was at a level that was currently impairing his occupational functioning capacity and would not likely change significantly as long as he remained in the military * he had a psychiatric condition that did not rise to the level of a medical board * the emotional disturbance will not likely respond to command efforts at rehabilitation or to any treatment methods currently available in the military mental health system d. The evaluating clinical psychologist recommended his immediate administrative separation under the provisions of Army Regulation 635-200, paragraph 5-17. 7. A DA Form 4856, dated 12 September 2007, shows his section sergeant advised him that he was recommending his separation from the military if there was no improvement in his mental state under the advice in his psychiatric report. The section sergeant stated he constantly walked around in a dazed state and seemed to have problems following instructions. His section sergeant again advised him of his possible separation under the provisions of Army Regulation 635-200. He was further counselled regarding the effects of an honorable discharge, a general discharge under honorable conditions, and a discharge UOTHC. His signature on this form does not resemble other documents of record containing his signature. 8. His records contain a DD Form 2697 (Report of Medical Assessment) for the purpose of separation, dated 24 September 2007, showing he indicated his overall health was worse compared to his last medical assessment/physical examination due to mental health issues, anxiety, and depression. He further indicated he intended to seek Department of Veterans Affairs disability compensation for PTSD. 9. His records contain a DD Form 2808 (Report of Medical Examination) for the purpose of separation, dated on or about 24 September 2007. The evaluating physician diagnosed the applicant with anxiety and depression and found him qualified for separation. 10. On 24 October 2007, his immediate commander notified him that he was initiating action to separation him for other designated physical or mental conditions under the provisions of Army Regulation 635-200, paragraph 5-17. His commander cited the applicant's diagnosis of major depressive disorder and borderline personality traits as the reason for the proposed action. His commander recommended the issuance of an honorable discharge and advised him of his rights. He was directed to undergo a complete medical examination and mental status evaluation in accordance with Army Regulation 40-501 (Standards of Medical Fitness). 11. On 24 October 2007, he acknowledged receipt of the proposed separation action and subsequently consulted with legal counsel. He acknowledged he was advised by his consulting counsel of the basis for the contemplated separation action for other designated physical or mental conditions under the provisions of Army Regulation 635-200, chapter 5, and its effects, the rights available to him, and the effect of waiving his rights. He further acknowledged he was not entitled to consideration of his case by an administrative separation board; however, he requested a personal appearance before an administrative separation board if he received any characterization less favorable than general under honorable conditions. 12. On 24 October 2007, his immediate commander recommended his separation from the Army prior to his expiration term of service under the provisions of Army Regulation 635-200, paragraph 5-17. He stated the specific factual reason for the recommended action as the applicant's diagnosis of major depressive disorder and borderline personality traits. 13. On 25 October 2007, the intermediate commander recommended approval of the discharge action with characterization of his service as honorable. 14. Consistent with the chain of command's recommendations, the separation authority approved his discharge for other designated physical or mental condition under the provisions of Army Regulation 635-200, paragraph 5-17, with characterization of his service as honorable. 15. He was discharged accordingly on 15 November 2007. He completed 1 year and 29 days of active service. 16. His records contain no evidence showing he was diagnosed with PTSD or indicating he suffered from an injury, illness, or medical condition that would have warranted his entry into the Army's Physical Disability Evaluation System (PDES). 17. In support of his original application, he provided an undated handwritten statement wherein he contends he was told he had PTSD, and then he was told he had a personality disorder when he was discharged. a. At that time, he submitted copies of two documents reportedly forged with his signature (DA Forms 4856) and a document from his psychologist (should read licensed independent clinical social worker), stating he does not have a personality disorder. b. He stated that although he wasn't in the service for long, he encountered a lot of things while he was deployed in support of the war on terrorism that normal persons should not see in their lifetimes. c. He was trying to do the right thing and trying to protect his family, even if it meant sacrificing his life. It was devastating to learn he was not given the right medical diagnosis. 18. The letter from a licensed independent clinical social worker at the Everett Veterans Center, Everett, WA, dated 9 October 2009, stated he provided psychological counseling to the applicant from 22 April 2009 to 5 June 2009. a. The focuses of his treatment were: * situational anxiety and depression, resulting from very high environmental stressors – out of work and trying to support a wife and two children – homelessness * symptoms of post-traumatic stress, anxiety, disturbed sleep, and intrusive memories, resulting from traumatic service in Iraq b. At no time did he observe any symptoms of borderline personality disorder (BPD). Given the level of stressors the applicant was facing, the symptoms would surely have been obvious had BPD been present. In fact, given the large disparity between what he observed and BPD, he wondered whether there might have been some sort of administrative error – confused medical files, or PTSD mistaken for BPD, or a medical records filing error. c. He noted the applicant's DD Form 214 carried the separation code that refers to "physical condition, not a disability, interfering with performance of duty." 19. The Army Review Boards Agency Medical Advisor provided a medical review of the applicant's records, dated 28 February 2013, wherein he stated the applicant purports to provide documents showing he was diagnosed with PTSD, not a personality disorder. The letter from the licensed independent clinical social worker does neither. a. The applicant had been in the Army for less than a year when he deployed to Iraq. Less than a month later, he was sent to Kuwait because of emotional problems. He was ultimately found to be incapable of functioning as a supply clerk in a combat zone and he was returned to the United States. b. Contrary to the applicant's licensed independent clinical social worker's misconception, the Department of the Army psychologist did not diagnose the applicant with a personality disorder. Accordingly, he was not discharged for personality disorder. The psychologist listed his diagnosis as major depressive disorder. There were no other diagnoses, but noted he had borderline personality traits. This meant he did not meet the criteria for borderline personality disorder, but did have some characteristics. The psychologist was clear that the applicant's psychiatric conditions did not rise to the level of consideration by a medical evaluation board. The letter from the applicant's licensed independent clinical social worker does not state he has PTSD; it states he had some symptoms of PTSD. 20. On 2 April 2013, the ABCMR denied the applicant's request for correction of his DD Form 214 to show the narrative reason for separation as PTSD instead of condition, not a disability. After carefully reviewing the evidence, the Board determined there was no basis for the requested relief. 21. The Army Review Boards Agency Psychiatrist provided an advisory opinion, dated 13 February 2017, wherein she stated the applicant's electronic Department of Veterans Affairs (VA) records indicate he is a nonservice-connected veteran who has been diagnosed with PTSD, major depression, and marital problems. a. A VA progress note, dated 27 March 2013, states the applicant "was in the Army and was deployed to Iraq for two and [a] half [2 1/2] months in 2007 where he was in supply and infantry. He lost two friends and saw people killed. He was in convoys that ran over small children. Veteran was hospitalized for Bipolar Disorder and Suicidal Ideation." b. A review of the applicant's military medical records shows he was in Iraq for approximately a month when he was sent to Kuwait for a hernia repair. While there, "in the Patient Administration division (PAD), he saw a childhood friend he did not know was in the military being carried into the hospital in blood soaked blankets. A half hour later, he overheard staff say that his friend had died. After hearing this, the applicant became depressed with near constant suicidal ideation." He was subsequently medically evacuated to the United States for evaluation and disposition. Once in the United States, he was noted to have continuing difficulties adjusting to the military environment. c. On 1 August 2007, the applicant underwent a psychiatric diagnostic interview. The applicant reported he did not witness the injury or death of his injured friend while he was in the hospital in Kuwait. He also reported "he did not see significant combat, was in Iraq for two months. He did not see combat, denies any PTS [Post Traumatic Stress] sxs [symptoms], reports low mood however while there." d. The applicant's command-directed mental status evaluation revealed he was not suitable for continued service due to ongoing emotional disturbance. The cause of the continuing emotional disturbance was the stress of the military lifestyle and duties. The psychiatric condition did not rise to the level of consideration by a medical evaluation board. e. A review of the applicant's records indicates he was not discharged from the Army with a diagnosis of personality disorder. The evaluating psychologist listed major depressive disorder as his diagnosis. There were no other diagnoses, but it noted he had borderline personality traits. This meant he did not meet the criteria for borderline personality disorder, but he exhibited some traits, such as becoming suicidal when under stress. f. The applicant received a diagnosis of PTSD from the VA. His military medical records show a diagnosis of major depressive disorder; there is no documentation of PTSD symptoms or a PTSD diagnosis. The medical records document that he had problems with depression prior to military service and they worsened with his deployment. The medical records clearly document that his emotional issues were the cause of his failure to adapt to a military lifestyle. g. The applicant's narrative reason for separation – condition, not a disability – is felt to be correct and supported by the available military medical documentation. 22. On 9 March 2017, he responded to the advisory opinion. a. He stated he never had any issues and was very happy before his enlistment. His mental health issues did not arise until after his deployment. He suggests that any person who saw horrific events in a combat zone would get depressed at some point. He lost close friends in the line of duty; he saw one of these friends die on a mission in Iraq with his own eyes. He began suffering sleep disturbances after his brief deployment, which never happened prior to his enlistment. b. He noted two documents he considers contradictory, both dated 7 August 2007. The command letter states, "Soldier is not pending UCMJ [Uniform Code of Military Justice] Action and is scheduled to remain in the Army until 3 March, 2011." The DA Form 4856 (Developmental Counseling Form) states he was "emotionally distant from the platoon most of the time." He doesn't understand how his commander can state he is to remain in the Army until 2011 when a staff sergeant completed a counseling form on the same exact date with his signature forged. He has several counseling forms that were signed without his knowledge. (1) He provided a memorandum for record from his brigade commander, dated 7 August 2007, subject: Statement of Service, wherein he stated the applicant was not pending UCMJ action and was scheduled to remain in the Army until 3 March 2011. (2) He also provided the DA Form 4856 from his section sergeant, dated 7 August 2007, wherein he stated the applicant seemed emotionally distant from the platoon most of the time and was always depressed. His section sergeant advised him that action might be initiated to separate him from the Army under the provisions of Army Regulation 635-200, paragraph 5-13 or paragraph 5-17, if his conduct continued. c. Numerous medical forms that stated he was suffering from PTSD were unable to be found when he returned to the United States and Madigan Army Medical Center, Fort Lewis, WA. He feels his PTSD diagnosis was overlooked when he was forced out of the military. He also feels he would have been able to return to his unit in Iraq if the Army had given him proper treatment. REFERENCES: 1. Army Regulation 635-200 (Active Duty Enlisted Administrative Separations) sets policies, standards, and procedures to ensure the readiness and competency of the force while providing for the orderly administrative separation of Soldiers for a variety of reasons. Paragraph 5-17 provides that commanders who are special court-martial convening authorities may approve separation under this paragraph on the basis of other physical or mental conditions not amounting to disability that potentially interfere with assignment to or performance of duty. 2. Army Regulation 635-40 (Physical Evaluation for Retention, Retirement, or Separation) establishes the Army PDES and sets forth policies, responsibilities, and procedures that apply in determining whether a Soldier is unfit because of physical disability to reasonably perform the duties of his or her office, grade, rank, or rating. It provides for medical evaluation boards (MEBs) which are convened to document a Soldier's medical status and duty limitations insofar as duty is affected by the Soldier's status. A decision is made as to the Soldier's medical qualifications for retention based on the criteria in Army Regulation  40-501. Paragraph 3-1 provides that the mere presence of impairment does not, of itself, justify a finding of unfitness because of physical disability. In each case, it is necessary to compare the nature and degree of physical disability present with the requirements of the duties the Soldier reasonably may be expected to perform because of their office, grade, rank, or rating. To ensure all Soldiers are physically qualified to perform their duties in a reasonable manner, medical retention qualification standards have been established in Army Regulation  40-501, chapter 3. These standards include guidelines for applying them to fitness decisions in individual cases. These guidelines are used to refer Soldiers to an MEB. 3. On 3 September 2014, the Secretary of Defense directed the Service Discharge Review Boards and Service Boards for Correction of Military/Naval Records to carefully consider the revised PTSD criteria, detailed medical considerations, and mitigating factors when taking action on applications from former service members administratively discharged UOTHC and who have been diagnosed with PTSD by a competent mental health professional representing a civilian healthcare provider in order to determine if it would be appropriate to upgrade the characterization of the applicants' service. 4. Army Regulation 15-185 (Army Board for Correction of Military Records) prescribes the policies and procedures for correction of military records by the Secretary of the Army, acting through the ABCMR. The regulation provides that the ABCMR begins its consideration of each case with the presumption of administrative regularity. The applicant has the burden of proving an error or injustice by a preponderance of the evidence. DISCUSSION: 1. The applicant requests reconsideration of his previous request for correction of his DD Form 214 to show the narrative reason for separation as PTSD instead of condition, not a disability. He contends he was misdiagnosed with a personality disorder when, in fact, he suffered from PTSD because he participated in battle and has been affected by it. 2. Although the applicant was not discharged UOTHC, his previous request for correction of his DD Form 214 to show the narrative reason for separation as PTSD instead of condition, not a disability, was not reviewed by a psychiatrist and the Board was not afforded the benefit of said medical expertise. It is currently customary for a psychiatrist or clinical psychologist to review all applicants' records involving claims of service-connected PTSD. 3. The evidence of record shows he was diagnosed with major depressive disorder and noted borderline personality traits at the time of his separation. A review of his records by the Army Review Boards Agency Psychiatrist revealed he had problems with depression prior to his military service and the problems worsened with his deployment. The medical records clearly document that his emotional issues were the cause of his failure to adapt to a military lifestyle. The Army Review Boards Agency Psychiatrist felt his narrative reason for separation – condition, not a disability – was correct and supported by the available military medical documentation. 4. He questions how his commander could state he was to remain in the Army until 2011 when his section sergeant completed a counseling form on the exact same date, stating action might be initiated to separate him from the Army. 5. Contrary to the applicant's contention, these are not contradictory statements. The statement of service rendered by his commander, stating he was scheduled to remain in the Army until 3 March 2011, merely identified his projected expiration term of service date and did not indicate a recommendation for retention on active duty. 6. The evidence of record shows he was properly discharged by reason of condition, not a disability, under the provisions of Army Regulation 635-200, paragraph 5-17. //NOTHING FOLLOWS// ABCMR Record of Proceedings AR20150000953 Enclosure 1 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS ABCMR Record of Proceedings (cont) AR20150018780 2 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 1 ABCMR Record of Proceedings (cont) AR20150018780 10 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 2