IN THE CASE OF:	 

		BOARD DATE:	  3 September 2015

		DOCKET NUMBER:  AR20150011617 


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 a review of the military disability evaluation pertaining to a mental health (MH) condition.

2.  The applicant states, in effect, the case file should be reviewed in accordance with the Secretary of Defense directive for a comprehensive review of members who were referred for a disability evaluation between 11 September 2001 and 
30 April 2012 and whose MH diagnosis was changed during that process.

3.  The applicant submitted an application through the DOD Physical Disability Board of Review (PDBR) MH Special Review Panel (SRP).

CONSIDERATION OF EVIDENCE:

1.  The PDBR SRP conducted a comprehensive review of the applicant’s submissions and records for evidence of inappropriate changes in the diagnosis of an MH condition during processing through the military disability system.  

2.  The Department of Defense memorandum, dated 27 February 2013, directed the Service Secretaries to conduct a review of MH diagnoses for service members completing a disability evaluation process between 11 September 2001 and 30 April 2012 in order to determine if service members were disadvantaged by a changed diagnosis over the course of their physical disability process.

3.  In the processing of this case, an advisory opinion was obtained from the PDBR SRP and the applicant was provided a copy.

4.  The applicant did not respond to the advisory opinion.  

DISCUSSION AND CONCLUSIONS:

1.  After a comprehensive review of the applicant’s case, the SRP determined by unanimous vote that there be no change of the applicant’s disability and separation determination. 

2.  The SRP reviewed the records for evidence of inappropriate changes in
diagnosis of the MH condition during processing through the pilot military disability evaluation system (DES-pilot).  The evidence of the available records shows the diagnoses of insomnia and mild traumatic brain injury (TBI) were rendered during DES processing.  The diagnostic variance determined that the condition diagnosed as primary insomnia was not the appropriate diagnosis and that the applicant’s insomnia was secondary to his back pain, and there was no Axis I diagnosis.  The SRP agreed there were no changes in diagnoses.  Therefore the applicant did not meet the inclusion criteria in the Terms of Reference of the MH Diagnosis Review Project.

3.  The SRP acknowledged the Department of Veterans Affairs (VA) Compensation and Pension (C&P) examiner’s assessment of primary insomnia; however, noted the examiner indicated that the insomnia was likely related to the back condition.  The SRP also noted that the documentation in the majority of the record in evidence did not support a primary diagnosis of insomnia.  The SRP reviewed the August 2010 psychological evaluation (civilian) and noted the absence of an identified stressor, insufficient documentation for Criterion B symptoms, and no documentation of Criterion C symptoms.  That evaluation noted some mild post-traumatic stress disorder (PTSD) symptoms with some nightmares and flashbacks of the war.  The SRP also noted that the applicant becomes angry easily and said he was cautious when he was out in public, but he said he was not hypervigilant when driving.  The SRP concluded there was insufficient evidence to support a diagnosis of PTSD.  The diagnosis of mild TBI was judged to have met retention standards.  Both the VA mental examiner and the neuropsychology (NP) examiner determined that, if he had a TBI, the reported cognitive symptoms were not directly attributable to a TBI.  Neither examiner assessed him with a TBI or a cognitive disorder.  Furthermore, there was insufficient evidence that the applicant met the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), diagnostic criteria for any Axis I pathology.

4.  The SRP considered whether any MH conditions were unfitting for continued military service, regardless of specific diagnosis.  The SRP noted the applicant was not assessed with a primary mental disorder, and although he was referred to behavioral health (BH) for “depression” there were no documented visits in the record in evidence.  The record did document a missed appointment in March of 2010.  There were three mental status exams in evidence and all three were normal.  The applicant was not prescribed psychotropic medication to treat any MH condition, was never hospitalized for MH concerns, never presented to the emergency room for MH issues, had no history of frequent panic attacks, and did not report suicidal or homicidal thoughts.  He reported he had received benefit from the Ambien when he took it.  No MH condition was implicated in the Commander’s Performance Statement and none was ever profiled.  

5.  After due deliberation in consideration of the preponderance of the evidence, 
the SRP concluded there was insufficient evidence that any MH condition rose to the level of being unfitting at the time of separation and none were subject to service disability rating.

6.  The available evidence shows the SRP’s assessment should be accepted.  

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)                                         AR20040003532



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ABCMR Record of Proceedings (cont)                                  AR20150011617



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