RECORD OF PROCEEDINGS AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS IN THE MATTER OF: DOCKET NUMBER: BC-2013-00990 COUNSEL: HEARING DESIRED: YES ________________________________________________________________ APPLICANT REQUESTS THAT: His discharge with severance pay be changed to a permanent retirement with a 50 percent disability rating for Delusional Disorder and Post-Traumatic Stress Disorder (PTSD). ________________________________________________________________ APPLICANT CONTENDS THAT: The applicant, thru counsel, contends that disagreements made by the mental health professionals in his case have made it virtually impossible for him to argue that both his disabilities are unfitting, ratable and compensable. The applicant testified at the Formal Physical Evaluation Board (FPEB) that he had been suffering from symptoms of PTSD since he returned from deployment in 2006 and wanted to remain on active duty. He was afraid of the stigma associated with mental illness and did not seek treatment at the time. The evidence supports that both Delusional Disorder and PTSD were present, unfitting and compensable at the time the applicant was placed on the TDRL. He was given a battery of tests by a clinical social worker who diagnosed him with Delusional Disorder based on his unrequited love and unrealistic pursuit of a woman in his graduate school class. The clinical social worker pursued his singular diagnosis of Delusional Disorder, despite his consistent complaints of PTSD symptoms as evidenced in the notes of other providers. His treating physician acknowledges the possibility of Delusional Disorder but states that he has not personally observed any delusional behavior. The has a history of family mental illness (schizophrenia), and a personal history of Traumatic Brain Injury (TBI). He was in a vehicle that was hit by an Improvised Explosive Device and at another time he was in the vicinity of a suicide bomber attack and almost stepped on the bomber's severed head. He currently works at a job that he gained through vocational rehabilitation services. The vocational rehabilitation counselor details the difficulty he has had due to post concussive syndrome and his struggles to improve memory, concentration and the ability to problem-solve. His condition has not improved since 2009, and he still suffers from significant PTSD symptoms, including nightmares, sleep deprivation, hyper-vigilance, and recurrent intrusive thoughts. He acknowledges maintaining an isolated lifestyle, having no social life and rarely venturing out unless he is going to work. In Jul 2010, he received a 60 percent disability rating from the Department of Veterans Affairs (DVA), with 50 percent for "PTSD also claimed as Delusional Disorder and memory loss." Medical opinions since 2008 have differed in mental health diagnosis, but agree that the applicant evidences a significant inability to function. His history of reported memory loss, inability to concentrate, impaired thinking, motivational and mood disturbances and difficulty in establishing and maintaining effective work and social relationships fits the criteria according to the Veterans Administration Schedule for Rating Disabilities (VASRD) of at least a 50 percent disability rating. In support of his request, the applicant provides copies of his AF Forms 356, Findings and Recommended Disposition of USAF Physical Evaluation Board; DVA Rating Decision; DD Form 214, Certificate of Release or Discharge from Active Duty; VA Form 9, Appeal to Board of Veterans’ Appeals; Standard Forms 600, Chronological Record of Medical Care, and various other documents associated with his request. His complete submission, with attachments, is at Exhibit A. ________________________________________________________________ STATEMENT OF FACTS: On 24 Jun 2009 the applicant was deemed unfit for military duty and was placed on the Temporary Disability Retirement List (TDRL) with a 50 percent disability rating for Delusional Disorder. According to the 7 Jul 2010, DVA Rating decision provided by the applicant the DVA granted him a 50 percent rating for PTSD also claimed as Delusional Disorder with memory loss. On 7 Feb 2012, the Informal Physical Evaluation Board (IPEB) rated the applicant’s “Delusional disorder, Erotomanic Type, in control off medication,” and recommended discharge with severance pay with a disability rating of zero percent. On 24 Apr 2012, the FPEB upheld the IPEB decision. On 24 Sep 2012, the applicant was separated from active service for physical disability under the provisions of 10 United States Code (USC) § 1203, with severance pay and a disability rating of 10 percent. He had 19 years, 3 months and 23 days of active duty. The remaining relevant facts pertaining to this application are contained in the letters prepared by the appropriate offices of the Air Force and the BCMR Medical Consultant at Exhibits C and D. ________________________________________________________________ AIR FORCE EVALUATION: AFPC/DPFD recommends denial. DPFD states that the preponderance of evidence reflects that no error or injustice occurred during the disability process or at the time of separation. In accordance with DoDI 1332.38, Physical Disability Evaluation, E3.P6.2.4. Compensability of New Diagnoses, when there is a new condition for which the service member was not placed on the TDRL, the PEB may find the condition ratable and compensable if the condition was caused by the condition for which the member was placed on the TDRL, or directly related to its treatment, or the evidence of record establishes that the condition was an unfitting disability at the time the member was placed on the TDRL. The applicant testified he did not miss any work due to his PTSD while in service. DVA evaluation notes dated 22 Jan 2009, state that he reported symptoms of “flashbacks, nightmares, and at times he emotionally withdraws,” but states that these occurrences “do not hinder his current life.” Since being placed on the TDRL, the applicant has maintained a full time position with the Department of Treasury. He takes no medications for his condition but continues to function adequately without it. He reported that he did not feel he needed any medications for his mental health condition. Although he testified he works from home an average of 1-2 days a week due to distress, he related this distress to PTSD symptoms, not to his Delusional Disorder. The FPEB found the applicant’s Delusional Disorder does not interfere with occupational and social functioning which decrease work efficiency and ability to perform tasks. However, his condition continues to be unfitting for military service as routine military duty and deployment stressors could exacerbate his condition with deterioration in functioning. Although the applicant submitted a copy of his DVA disability rating, the FBEB opines this disability rating, awarded on initial separation from service, is insufficient for purposes of determining the most appropriate current disability rating and thus refers to the recent TDRL evaluation and more recent DVA and medical treatment notes for rating determination purposes. The FPEB recommended discharge with severance pay with a disability rating of zero percent in accordance with the VASRD guidelines. The Department of Defense and the DVA disability evaluation systems operate under separate laws. The Air Force disability boards must rate disabilities based on the member's condition at the time of evaluation. It is the charge of the DVA to pick up where the Air Force must, by law, leave off. Under Title 38, the DVA may rate any service-connected condition based upon future employability or reevaluate based on changes in the severity of a condition. The complete DPFD evaluation is at Exhibit C. The BCMR Medical Consultant recommends denial of the applicant's request for inclusion of PTSD as unfitting at the time of his initial placement on the TDRL. The Medical Consultant alternatively recommends consideration for permanent retirement with a 30 percent disability rating due to Delusional Disorder, effective the established date of his removal from the TDRL. Existing Department of Defense policies prohibit the inclusion as unfitting any newly diagnosed medical condition or a previously diagnosed condition that was not determined unfitting or was not caused by the condition found unfitting at the time of initial placement on the TDRL. The applicant's service treatment record indicates he reported signs and symptoms that can be attributed to PTSD prior to his placement on the TDRL. Even though the military provider believed that the applicant did not meet the criteria for the diagnosis of PTSD, in order for the condition to be included in the disability rating computation, it would have to be determined unfitting for further military service at the time of initial TDRL placement; or found to be secondary to or the direct result of the Delusional Disorder. Despite the clinical history provided to the DVA examiner, the applicant's supplied service evidence of record does not reflect the applicant's PTSD was the condition that resulted in his referral to the military Disability Evaluation System (DES). Although the Medical Consultant and the Board have been confronted with "dueling doctors" opinions, the preponderance of evidence reflects it was the applicant's Delusional Disorder and not his PTSD that significantly interfered with his duties resulting in his release from active military service. Nevertheless, the Board’s attention is also directed to the matter of the TDRL narrative summary, which clearly states the applicant's level of impairment in social and industrial adaptability for his Delusional Disorder was "Definite." Such a designation by a mental health provider is generally accepted by adjudicating bodies as consistent with a 30 percent disability rating. The applicant's self-report of full-time work and his lack of need for medications to control his condition, likely led to the reduced rating decision of "0 percent" by the IPEB and FPEB; although subsequently increased to 10 percent by SAFPC. Moreover, although the DVA appears to have discarded Delusional Disorder as the primary diagnosis, as noted in its rating description of the condition as "PTSD also claimed as Delusional Disorder," it does not change the fact that Delusional Disorder was the condition that cut short the applicant's career at the "snap shot" time of his placement on the TDRL. Indeed, the rationale for the DVA rating decision for PTSD acknowledges the Delusional Disorder, but in no way illustrates a causal relationship between the two in the following: "Service connection for PTSD also claimed as a Delusional Disorder and memory loss has been established as directly related to military service. The DVA examination revealed a diagnosis of PTSD which the examiner linked to the applicant’s military service. The reader is reminded that, operating under Title 38, USC, the DVA is authorized to offer compensation for any medical diagnosis of record with a nexus to military service, without regard to and independent of its relationship with a member's retainability or fitness to serve. The Medical Consultant found no causal relationship between the applicant's PTSD and the performance of his duties nor as a cause for terminating his career. However, in order to remedy a possible injustice to the applicant, the Medical Consultant recommends amending the record to reflect that the applicant was permanently retired with a 30 percent disability rating due to the definite impairment caused by his Delusional Disorder. Conversely, if the argument stands that the applicant no longer has symptoms or a functional impairment due to Delusional Disorder, then the 10 percent rating reissued by SAFPC should stand. The Board should also be aware that a Delusional Disorder diagnosis is considered a thought disorder that could be a comparative occupational detriment [although not presently] to the applicant, as opposed to PTSD, a mood disorder, albeit a factual diagnosis in the record. The complete Medical Consultant’s evaluation is at Exhibit D. ________________________________________________________________ APPLICANT'S REVIEW OF AIR FORCE EVALUATION: Regarding the diagnosis of PTSD, counsel states that no matter how severe his condition became it does not appear the applicant sought out mental health treatment and may not have ever done so absent the command referral. From his first visit to mental health he complained of symptoms associated with combat-related PTSD and was referred to a psychologist or psychiatrist for an evaluation. The psychologist communicated to the social worker who referred him that he had made a diagnosis of combat-related PTSD. As PTSD is a severe mental condition and potentially service-unfitting, the condition should have been assessed and considered by the MEB. Counsel agrees that the determination of unfitness is a snapshot of the applicant’s condition at the time of separation, but it must also be an accurate snapshot. Any potentially unfitting condition should be evaluated by a military physician for possible referral to a MEB, if it is known. The determination of whether the applicant’s combat- related PTSD rendered him unfit was not accomplished at the time of his placement on the TDRL, and it is within the Board's authority to make that determination now based on the medical reports he received at the time. Given his current level of impairment and self-reports of combat-related PTSD symptoms, the likelihood that he would have eventually been separated from the service for combat-related PTSD is probable and counsel argues that combat-related PTSD should be added as a service unfitting medical condition for the purposes of a disability rating. Counsel agrees with the BCMR Medical Consultant’s recommendation regarding the diagnosis of Delusional Disorder. Therefore, counsel requests the Board disregard the AFPC/DPFD advisory opinion and adopt the rationale of the BCMR Medical Advisor. In the hope that the Board will have a better understanding of the complexities of combat- related PTSD and Delusional Disorder; counsel guides the Board to review the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). In further support of his request, counsel provided copies of the DVA rating decision for TBI, progress notes and DSM-V The complete response, with attachments, 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. We took notice of the applicant's complete submission in judging the merits of the case and do not find that it supports a determination that the applicant should have received a 50 percent disability for PTSD and Delusional Disorder. The applicant has provided no evidence which, in our opinion, successfully refutes the assessment of his case by the BCMR Medical Consultant. Therefore, we agree with the recommendation of the BCMR Medical Consultant and adopt his opinion as our findings in this case. In the absence of evidence to the contrary, we find no basis to recommend granting this portion of his application. 4. Notwithstanding the above, sufficient relevant evidence has been presented to demonstrate the existence of an error or injustice warranting partial relief. The thorough analysis performed by the BCMR Medical Consultant has raised sufficient doubt as to whether the applicant's 10 percent disability rating for his Delusional Disorder was correct. As pointed out by the BCMR Medical Consultant, the applicant’s level of impairment in social and industrial adaptability for his Delusional Disorder was “Definite,” is generally accepted by adjudicating bodies as consistent with a 30 percent disability rating. As such, we believe the applicant's medical condition may not have been rated properly at the time of his separation. Therefore, in the interest of equity and justice, we recommend the applicant’s records be corrected to reflect that he was medically retired from the Air Force by reason of a physical disability rather than “Disability, Severance Pay.” Accordingly, we recommend his 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 issue(s) 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 APPLICANT, be corrected to show that: a. On 23 Sep 2012, he was found unfit to perform the duties of his office, rank, grade, or rating by reason of physical disability, first incurred while he was entitled to receive basic pay; that the diagnosis in his case was "Delusional Disorder, VASRD Code 9208, that the degree of impairment in social and occupational adaptability was definite; 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 received in the line of duty as a direct result of armed conflict or caused by an instrumentality of war. b. On 24 Sep 2012, the applicant was not separated by reason of Physical Disability with a compensable rating of 10 percent, but, on that date he was removed from the Temporary Disability Retirement List and permanently retired with a 30 percent disability rating. c. The election of Survivor Benefit Plan option 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 this application in Executive Session on 5 Dec 2013, under the provisions of AFI 36-2603: , Panel Chair , Member , Member All members voted to correct the record as recommended. Due to the unavailability of , will sign as Acting Panel Chair. The following documentary evidence was considered in AFBCMR BC-2013-00990: Exhibit A. DD Form 149, dated 15 Feb 2013, w/atchs. Exhibit B. Applicant's Master Personnel Records. Exhibit C. Letter, AFPC/DPFD, dated 23 Apr 2013. Exhibit D. Letter, BCMR Medical Consultant, dated 6 May 2013. Exhibit E. Letter, SAF/MRBC, dated 7 May 2013. Exhibit F. Letter, Counsel, dated 5 Jun 2013, w/atchs. Acting Panel Chair