BOARD DATE: 9 July 2014
DOCKET NUMBER: AR20130017939
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 the medical diagnosis on his Physical Evaluation Board (PEB) Proceedings be changed from bipolar disorder to post-traumatic stress disorder (PTSD).
2. The applicant states that:
a. He was discharged for bipolar disorder. He is not bipolar. He went for treatment five times and three of the five were at PTSD clinics. The other two were for self-safety checks. He was sent to a military PTSD clinic in Colorado on two occasions.
b. His Medical Evaluation Board (MEB) was handled thorough Madigan Army Medical Center (MAMC) in early 2012. During that time MAMC was found to have changed many diagnoses from PTSD to bipolar. He believes that his case was one of them.
3. The applicant provides copies of his medical records.
CONSIDERATION OF EVIDENCE:
1. The applicant was retired due to permanent disability effective 5 July 2011 as a staff sergeant (SSG)/E-6.
2. He served two tours in Iraq and one tour in Afghanistan. He was awarded the Bronze Star Medal, Army Commendation Medal (5 Awards), and the Army Achievement Medal (2 Awards).
3. His MEB Proceedings are not available for review.
4. A PEB was convened on 29 March 2011. The DA Form 199 (Physical Evaluation Board Proceedings) shows the applicant was found unfit for continued military service by reason of bipolar disorder and degenerative arthritis listed as chronic back pain. The board recommended a combined rating of 40% and permanent disability retirement. The applicant concurred and waived a formal hearing on his case.
5. In support of his application, he provides copies of his medical records showing:
a. He was seen on 8 July 2010 at the Community Mental Health Clinic, Fort Leonard Wood, Missouri. His complaint was that he had a "bad night" and had not slept all night, and had been having suicidal thoughts, with plans of cutting his wrists. The Assessment shows:
(1) Axis I: Major Depression; Anxiety Not Otherwise Specified (NOS).
(2) Axis II: OCPD (Obsessivecompulsive personality disorder).
(3) Axis III: Review medical record.
(4) Axis IV: social; occupational.
(5) Axis V: Global Assessment of Functioning (GAF): 75-80.
b. He agreed to hospitalization and was seen on 8 July 2010 at the St. Mary's Health Center, Jefferson City, Missouri. His chief complaint was: "I don't know what's wrong so I don't know how to fix it. I need some help to figure his out." The Diagnostic Impression shows:
(1) Axis I: Major depressive disorder, single episode. Rule out recurrent with anxiety. Rule out underlying generalized anxiety disorder. History of obsessive-compulsive disorder.
(2) Axis II: Obsessive compulsive traits versus personality traits versus disorder.
(3) Axis III: History of glucose-6-phosphates dehydrogenase deficiency.
(4) Axis IV: Psychological stressors include work, family stressors.
(5) Axis V: Global assessment of functioning: 35.
c. He was seen on 25 August 2012 at the Haven Behavioral-Pueblo, St. Mary-Corwin Medical Center. His chief complaint was "I was hearing voices." The diagnosis shows:
(1) Axis I: Major depressive disorder with psychotic features PTSD.
(2) Axis II: No diagnosis.
(3) Axis III: Status low back pain.
(4) Axis IV: Problems with primary support system
(5) Axis V: GAF: 20.
d. The Progress Notes from a 4 May 2011 examination at the Columbia, Missouri, VA Medical Center, shows on page 71 that he met the DSM-IV (Psychiatric Disorders. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria for a diagnosis of PTSD.
(1) Axis I: Major depressive disorder with psychotic features, PTSD.
(2) Axis II: None.
(3) Axis III: Chronic pain.
(4) Axis IV: Occupational difficulties.
(5) Axis V: Global Assessment Functioning: 55.
6. Army Regulation 40-501 (Standards of Medical Fitness) governs medical fitness standards for enlistment; induction; appointment, including officer procurement programs; retention; and separation, including retirement. Once a determination of physical unfitness is made, the physical evaluation board rates all disabilities using the VA Schedule for Rating Disabilities. Ratings can range from 0 to 100%, rising in increments of 10%.
7. 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. Paragraph 2-9 states the ABCMR begins 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 AND CONCLUSIONS:
1. The applicant contends the medical diagnosis on his PEB Proceedings should be changed from bipolar disorder to PTSD. His MEB was handled thorough MAMC in early 2012. During that time MAMC was found to have changed many diagnoses from PTSD to bipolar. He believes that his case was one of them.
2. The applicant has not provided any evidence to substantiate his assertion that the medical diagnosis on his MEB was changed from PTSD to bipolar disorder.
3. His medical records show diagnoses of PTSD, but the MEB proceedings are not available for review. In the absence to evidence to the contrary, the MEB/PEB process must be presumed to have been in accordance with applicable law and regulations.
4. In view of the above, the applicant's request should be denied.
BOARD VOTE:
________ ________ ________ GRANT FULL RELIEF
________ ________ ________ GRANT PARTIAL RELIEF
________ ________ ________ GRANT FORMAL HEARING
___x_____ __x______ __x___ DENY APPLICATION
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 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.
ABCMR Record of Proceedings (cont) AR20120003593
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ABCMR Record of Proceedings (cont) AR20130017939
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