IN THE CASE OF: BOARD DATE: 16 June 2016 DOCKET NUMBER: AR20150003771 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: 16 June 2016 DOCKET NUMBER: AR20150003771 BOARD DETERMINATION/RECOMMENDATION: The evidence presented does not demonstrate the existence of a probable error or injustice. Therefore, the Board determined the overall merits of this case are insufficient as a basis for correction of the records of the individual concerned. __________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: 16 June 2016 DOCKET NUMBER: AR20150003771 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 her earlier request that her narrative reason for separation be changed from personality disorder to medical discharge due to post-traumatic stress disorder (PTSD). 2. The applicant states she: * was suffering from PTSD in the Iraq combat zone * was misdiagnosed as personality disorder * should have been medically evacuated from the war zone * should have been sent to a medical evaluation board (MEB) for PTSD 3. The applicant provides: * Department of the Veterans Affairs (VA) Rating Decision, dated 17 July 2014 * VA medical record, dated 3 October 2012 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 AR20130002666 on 9 July 2013. 2. The VA documentation provided by the applicant is new evidence that was not previously considered by the Board and warrants consideration at this time. 3. Having prior enlisted service in the Army National Guard, the applicant enlisted in the Regular Army on 25 January 2006 and she held military occupational specialty 31B (Military Police). 4. On 14 July 2006, nonjudicial punishment (NJP) was imposed against her for violating a general regulation by wrongfully traveling outside the 300 mile radius of Fort Lewis, Washington. 5. On 6 November 2006, she was assigned to Kuwait/Iraq. On 5 April 2007, she underwent a mental status evaluation and was diagnosed with an adjustment disorder. The examiner recommended more intense professional help than that locally available and provided. She further recommended the applicant's separation in accordance with paragraph 5-13 of Army Regulation 635-200 (Active Duty Enlisted Administrative Separations). 6. In April 2007, NJP was imposed against her for failing to go at the time prescribed to her appointed place of duty (twice), being disrespectful toward a noncommissioned officer (twice), and disobeying a lawful order. 7. On 9 May 2007, the applicant returned from Iraq to Fort Lewis, Washington. On 31 May 2007, she underwent a mental status evaluation and the clinical psychologist diagnosed her with a personality disorder. 8. On 8 August 2007, she was notified of her pending separation action for personality disorder under the provisions of Army Regulation 635-200, paragraph 5-13. Her commander cited she had been diagnosed with a long-standing disorder of character and chronic maladaptive behavior that significantly impaired her ability to adapt and function in a military environment. The recommendation was an honorable character of service. 9. On 13 August 2007, she acknowledged receipt of the notification of separation action. She consulted with legal counsel and was advised of the basis for the contemplated separation and of the rights available to her in connection with the action. Subsequent to receiving legal counsel, the applicant elected not to submit statements in her own behalf. 10. On 15 August 2007, the separation authority approved the applicant's separation under the provisions of Army Regulation 635-200, paragraph 5-13, by reason of personality disorder, and directed the issuance of an honorable characterization of service. On 7 September 2007, the applicant was discharged accordingly. 11. Her DD Form 214 shows in: * item 25 (Separation Authority) – Army Regulation 635-200, Paragraph  5-13 * item 26 (Separation Code) – JFX * item 28 (Narrative Reason for Separation) – Personality Disorder 12. There is no evidence of record showing she was diagnosed with PTSD prior to separation. 13. She provided a VA medical record, dated 3 October 2012, which shows she was diagnosed with severe PTSD, anxiety, traumatic brain injury, and asthma. 14. On 9 July 2013, the ABCMR denied her request to amend her narrative reason for separation. 15. She also provided a VA Rating Decision, dated 17 July 2014, which shows she was granted service-connection for: * PTSD with depressive and anxiety disorder (increased to 50 percent) * migraine headaches (increased to 50 percent) * degenerative disease of the lumbar spine (decreased to 10 percent) * asthma (10 percent) 16. In the processing of this case, an advisory opinion was obtained from the Tripler Army Medical Center clinical psychologist who stated: a. A detailed review of the applicant's electronic health records, as well as materials included in her application, was conducted. Based on documented evidence of the applicant's behavioral health status at the time of her separation, with consideration of Army regulations and policy in place at the time of her discharge, there is insufficient evidence to justify a medical retirement for PTSD or other mental health disorders. b. Within 6 months of entering active duty, the applicant demonstrated difficulty with effective military performance (e.g., NJP and adverse counseling statements). When comparing the time frame and nature of the applicant's history of impaired military performance to her documented Behavioral Health Services encounters, there are no apparent connections between her military functioning and any disabling mood or anxiety symptoms. During her deployment to Iraq, she attended a few Behavioral Health Services encounters focused on attention and concentration complaints. c. While the applicant did appear to experience symptoms of attention deficit hyperactivity disorder (ADHD) during her deployment, a diagnosis of ADHD would not account for all her adverse counseling statements. In addition, per Department of Defense Instruction 1332.38 (Physical Disability Evaluation), ADHD is included under "Certain conditions, circumstances and defects of a developmental nature designated by the Secretary of Defense do not constitute a physical disability..." Therefore, ADHD is not considered a disabling condition by the Army and would not be eligible for an MEB. There is no evidence she reported significant symptoms of PTSD during her deployment. The command-directed mental health evaluation on 5 April 2007 appeared to rule out any psychiatric condition, including personality disorders; however, the evaluator nonetheless recommended her discharge for personality disorder. The diagnosis of paranoid personality disorder was confirmed during a subsequent 31 May 2007 command-directed mental health evaluation. d. There is not sufficient evidence that the applicant's behavioral health status during her military service at any point warranted a diagnosis of PTSD per the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition, Text Revision. A ruled-out diagnosis of PTSD was present only once in her record on 8 May 2007 immediately following her redeployment from Iraq. Subsequent weekly therapy sessions and mental health evaluations by different providers failed to result in a diagnosis of PTSD. This does not preclude the possibility of developing a diagnosis of PTSD at a later date. However, throughout her active duty service and at the time of her military separation, the available evidence shows the applicant did not meet the diagnostic criteria for PTSD. e. In addition to not having met the diagnostic criteria for PTSD while serving on active duty, there is not sufficient evidence to suggest the applicant failed retention standards while serving on active duty. Following redeployment, she engaged in weekly individual therapy and a review of therapy notes indicated her condition improved in response to treatment. f. During the Behavioral Health Services encounters most proximal to her military separation, the applicant reported her symptoms had improved and were managed adequately with proper medication adherence. There is not sufficient evidence showing the applicant experienced an anxiety disorder or PTSD which required extended or recurrent hospitalizations, significantly interfered with duty performance, or necessitated duty limitations or duty in a protected environment. g. The applicant's behavioral health status during her military service at no point required referral to an MEB. There is not sufficient evidence she failed retention standards for any disabling behavioral health condition. As such, consideration for medical retirement for PTSD or another mental health disorder is not appropriate. 17. A copy of the advisory opinion was forwarded to the applicant for comment and/or rebuttal. She did not respond. REFERENCES: 1. Army Regulation 635-200 prescribes the policy for the administrative separation of enlisted personnel. Paragraph 5-13 provides for separating members by reason of personality disorder (not amounting to disability) that interferes with assignment or with performance of duty. 2. Army Regulation 635-5-1 (Separation Program Designator (SPD) Codes), in effect at the time, provided the specific authorities (regulatory or directive), reasons for separating Soldiers from active duty, and the SPD codes to be entered on the DD Form 214. It stated the SPD code of JFX was the appropriate code to assign Soldiers being separated under the provisions of Army Regulation 635-200, paragraph 5-13, by reason of personality disorder. 3. The DSM, chapter 7, addresses trauma and stress or related disorders. The DSM is published by the American Psychiatric Association (APA) and provides standard criteria and common language for classification of mental disorders. 4. In 1980, the APA added PTSD to the third edition of its DSM nosologic classification scheme. Although controversial when first introduced, the PTSD diagnosis has filled an important gap in psychiatric theory and practice. From a historical perspective, the significant change ushered in by the PTSD concept was the stipulation that the etiological agent was outside the individual (i.e., a traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis). The key to understanding the scientific basis and clinical expression of PTSD is the concept of "trauma." 5. PTSD is unique among psychiatric diagnoses because of the great importance placed upon the etiological agent, the traumatic stressor. In fact, one cannot make a PTSD diagnosis unless the patient has actually met the "stressor criterion," which means that he or she has been exposed to an event that is considered traumatic. Clinical experience with the PTSD diagnosis has shown, however, that there are individual differences regarding the capacity to cope with catastrophic stress. Therefore, while most people exposed to traumatic events do not develop PTSD, others go on to develop the full-blown syndrome. Such observations have prompted the recognition that trauma, like pain, is not an external phenomenon that can be completely objectified. Like pain, the traumatic experience is filtered through cognitive and emotional processes before it can be appraised as an extreme threat. Because of individual differences in this appraisal process, different people appear to have different trauma thresholds, some more protected from and some more vulnerable to developing clinical symptoms after exposure to extremely stressful situations. 6. The Fifth Edition of the DSM was released in May 2013. This revision includes changes to the diagnostic criteria for PTSD and acute stress disorder. The PTSD diagnostic criteria were revised to take into account things that have been learned from scientific research and clinical experience. The revised diagnostic criteria for PTSD include a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. The sixth criterion concerns duration of symptoms, the seventh criterion assesses functioning, and the eighth criterion clarifies symptoms as not attributable to a substance or co-occurring medical condition. a. Criterion A – Stressor: The person was exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows (one required): (1) direct exposure; (2) witnessing, in person; (3) indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental; or (4) repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders collecting body parts, professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures. b. Criterion B – Intrusion Symptoms: The traumatic event is persistently re-experienced in the following way(s) (one required): (1) recurrent, involuntary, and intrusive memories; (2) traumatic nightmares; (3) dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness; (4) intense or prolonged distress after exposure to traumatic reminders; or (5) marked physiologic reactivity after exposure to trauma-related stimuli. c. Criterion C – Avoidance: Persistent effortful avoidance of distressing trauma-related stimuli after the event (one required): (1) trauma-related thoughts or feelings or (2) trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations). d. Criterion D – Negative Alterations in Cognitions and Mood: Negative alterations in cognitions and mood that began or worsened after the traumatic event (two required): (1) inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs); (2) persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous"); (3) persistent distorted blame of self or others for causing the traumatic event or for resulting consequences; (4) persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame); (5) markedly diminished interest in (pre-traumatic) significant activities, feeling alienated from others (e.g., detachment or estrangement); and (6) constricted affect, persistent inability to experience positive emotions. e. Criterion E – Alterations in Arousal and Reactivity: Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event (two required): (1) irritable or aggressive behavior; (2) self-destructive or reckless behavior; (3) hypervigilance; (4) exaggerated startle response; (5) problems in concentration; and (6) sleep disturbance. f. Criterion F – Duration: Persistence of symptoms (in Criteria B, C, D, and E) for more than 1 month. g. Criterion G – Functional Significance: Significant symptom-related distress or functional impairment (e.g., social, occupational). h. Criterion H – Exclusion: Disturbance is not due to medication, substance use, or other illness. 7. Army Regulation 635-40 (Physical Evaluation for Retention, Retirement, or Separation) governs the evaluation of physical fitness of Soldiers who may be unfit to perform their military duties because of physical disability. The unfitness must be of such a degree that a Soldier is unable to perform the duties of his or her office, grade, rank, or rating in such a way as to reasonably fulfill the purposes of his or her employment on active duty. 8. Title 10, U.S. Code, chapter 61, provides disability retirement or separation for a member who is physically unfit to perform the duties of his or her office, rank, grade, or rating because of disability incurred while entitled to basic pay. DISCUSSION: 1. The applicant contends she should have been medically discharged due to PTSD. 2. She also contends her personality disorder was misdiagnosed. However, the medical evidence of record shows she underwent two mental status evaluations and was diagnosed with an adjustment disorder and personality disorder. 3. There is no evidence of record and she provided no evidence showing she was diagnosed with PTSD prior to separation. 4. There is no evidence of record showing she failed retention standards for any disabling mental health condition. 5. The VA letter she provided that shows she was diagnosed with PTSD in 2012 was noted. However, there is no evidence showing she was suffering from an unfitting PTSD condition prior to separation on 7 September 2007. 6. There is no evidence showing her narrative reason for separation was not administratively correct and in conformance with applicable regulations at the time of separation. //NOTHING FOLLOWS// ABCMR Record of Proceedings AR20150000953 Enclosure 1 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS ABCMR Record of Proceedings (cont) AR20150003771 2 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 1 ABCMR Record of Proceedings (cont) AR20150003771 9 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 2