DEPARTMENT OF THE NAVY
BOARD FOR CORRECTION OF NAVAL RECORDS

NAVY 

ANNEX

2 

WASHINGTON DC 20370-5100

JRE
Docket No. 07329-02
11 September 2003

This is in reference to your application for correction of your
naval record pursuant to the provisions of title 10 of the
United States Code, section 1552.

A three-member panel of the Board for Correction of Naval
Records, sitting in executive session, considered your
application on 11 September 2003.
injustice were reviewed in accordance with administrative
regulations and procedures applicable to the proceedings of this
Board.
of your application, together with all material submitted in
support thereof, your naval record and applicable statutes,
regulations and policies.
advisory opinion furnished by Specialty Leader for Psychiatry
dated 28 July 2003, a copy of which is attached.

Documentary material considered by the Board consisted

In addition, the Board considered the

Your allegations of error and

After careful and conscientious consideration of the entire
record, the Board found that the evidence submitted was
insufficient to establish the existence of probable material
error or injustice.
concurred with the comments contained in the advisory opinion.
Accordingly, your application has been denied.
The names and
votes of the members of the panel will be furnished upon
request.

In this connection,

the Board substantially

It is regretted that the circumstances of your case are such
that favorable action cannot be taken.
the Board reconsider its decision upon submission of new and
material evidence or other matter not previously considered by

You are entitled to have

In this regard,

the Board.
a presumption of regularity attaches to all official records.
Consequently, when applying for a correction of an official
naval record, the burden is on the applicant to demonstrate the
existence of probable material error or injustice.

it is important to keep in mind that

Sincerely,

National Naval Medical Center
Adult Behavioral Healthcare Department

8901 Wisconsin Ave.
Bethesda, MD 20889

28 Jul 03

Staff Psychiatrist
Chairman, Board for Correction of Naval Records

E CASE OF 

FORME

(a) 10 U.S.C. 1552
BCNR ltr of 6 Nov 02 and attachments
(b) Chairman,
(c) The Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition.
Psychiatric Association, 1994.

Washington:

American

(1) Findings from Review of

_VAMC Examination

(2) Pertinent Entries From the Military Medical Record
(3) Interpretation of Pertinent Entries From The Military

Report

Medical Record

FROM:
TO:

SUBJ:

Ref:

Encl:

This letter is written in response to reference (b),

1.
requesting general comments and recommendations on this case.
Having reviewed available materials,
key issues at issue:

I believe there are three

(a) Do the VA records support a diagnosis of Bipolar

Disorder?

(b) Do the USN records suggest a missed diagnosis of

Bipolar Disorder?

(c) If the answer to (a) is yes and the answer to (b) is no,

do the USN records reflect an early stage of psychopathology
which later manifested itself as Bipolar Disorder -- supporting
a determination of service connection for the  
Bipolar Disorder?

VA's diagnosis of

2.

Comments on each identified issue

(a) Do the VA records support a diagnosis of Bipolar

Disorder?

(1) Short answer:   perhaps

(2) Per Reference (b) Mr. Wolfram has been treated since
,v and Bell and was assessed
The latter assessment is the only

the late 1980's by
on 1 April 2002 by
one available to me for review.

(3) Details of my review are contained in Enclosure (1).
'F.1 documentation provides modest support for a
Briefly, 
diagnosis of Bipolar Disorder and does not preclude the presence
of a personality disorder.

~1

(b) Do the USN records suggest a missed diagnosis of

Bipolar Disorder?

(1) Short answer:

not in my opinion

(2) I reviewed Mr.

Wolfram's entire military medical

record dating from his initial enlistment.
pertinent entries, described in detail in Enclosure (2).

There are numerous

(3) A detailed interpretation of these entries is

contained in Enclosure (3).
supports a diagnosis of a personality disorder.
symptoms (e.g. depressed mood, irritability) are also seen in
major mood disorders (such as Bipolar Disorder), but the
documented time course, context,
consistent with a personality disorder than with a major mood
disorder.

Briefly, the documentation strongly
Some documented

and pattern is much more

(c) If the answer to (a) is yes and the answer to (b) is no,

do the USN records reflect an early stage
which later manifested itself as Bipolar Disorder -- supporting
a determination of service connection for the  
Bipolar Disorder?

 of psychopathology

VA's diagnosis of

(1) Short answer:

not in my opinion

(2) The sum of the USN and VA documentation suggests the

ongoing presence of a personality disorder beginning early in
life, continuing throughout Mr. Wolfram's enlistment, and
persisting to this day.

(3) If Bipolar Disorder is indeed present now, the

record suggests that it is a newly emerging condition appearing
on top of the longstanding personality disorder.
scenario is not rare.

Such a

(4) The condition documented in the military medical

record was described in several reports as "lifelong" and there
is no evidence in the record that military service worsened Mr.
Wolfram's condition.
current diagnosis of Bipolar Disorder with Mr. Wolfram's
condition during Naval service, the record supports a
determination of EPTE-NSA.

Should the BCNR choose to connect the

.

Findings from Review of

VAMC Examination Report

report contains the following:

a. A notation that the patient has seen three other doctors,

each of whom has diagnosed him with Bipolar Disorder. A
notation that that Dr .-report was accompanied by "a good
description of the typical symptomatology".
included.

I

No details are

b.

History obtained from the patient:

"high anxiety and

deep depression... irritable... hateful, resentful, and
paranoid... poor sleep...
of his paranoia and because of his intrusiveness.,,

does not mix well with people because

C .

Mental status examination:

"unshaven and is clearly in

It is rather wordy and defensive.

a labile mood... hypertalkative with a push of speech and
intrusiveness... with a rather lengthy statement in support of
his claim.
circumstantial but does not show impairment of thought process.
His communication, however,
reports no delusions or hallucinations, although he labels
himself paranoid.
now, although he states he could have been homicidal in the
His personal hygiene is marginal...
past.
be obsessive, defensive, and argumentative.
swings with panic and anxiety attacks and poor sleep.,,

He reports no suicidal or homicidal thoughts

is rambling and loquacious. He

He has a tendency to
He reports mood

He is

d.

An Axis I diagnosis of
(sic) with supportive findings

"Bipolar affective disorder,,

e.

No Axis II diagnosis:

"Nowhere is there an indication

of a secondary diagnosis.
disorder is not sustained by virtue of lack of supporting
evidence to substantiate this diagnosis.
Rather, it is
classically that of a bipolar affective disorder sustained over
a longitudinal period of time.,,

The diagnosis of  

avoidant personality

In my opinion Dr.

2.
Pardo's diagnosis of Bipolar Disorder is
not fully supported and the diagnosis of Personality Disorder is
not fully excluded.

a.

Several features of depressive and manic episodes are

noted but they are not given a time course.
document and characterize episodes of mood disturbance as

The record does not

Enclosure 

(1)

required to meet DSM-IV  
Reference (c).
symptomatology is not a
disorders.

criteri
Contrary to Dr.
classic

’ olar Disorder  

- see
statement, sustained
of the bipolar

.

b.

In contrast,

Many of the symptoms  

sustained symptomatology is a key feature
Dr.-

of the personality disorders.
documents (sustained irritability, paranoia, not mixing well
with people) are seen in personality disorders, including the
one (Avoidant Personality Disorder) with which the Navy
psychiatrists diagnosed this patient.
The symptoms are not
fleshed out in sufficient detail in Dr
*%111111)9 examination to
confirm a personality disorder diagnosis, but this diagnosis
cannot be ruled out on the basis of the contents of this report.

C .

The report does not address the possibility of an Axis

II condition being present simultaneously with an Axis I
condition such as a bipolar disorder.
uncommon.

Such comorbidity is not

Enclosure (1)

Pertinent Entries

From The Military Medical Record

1.
The record contains 
for the following dates:
July 1980, 19 March 1981, and 6 October 1983.
the patient psychiatrically "normal,,.

SF93's ("Report of Medical Examination,,)

15 September 1975, 24 July 1978, 24

Each report deems

2.
health symptoms.

The record contains a number of entries regarding mental

A synopsis of each one is listed below.

a.

24 July 1981 report by
(psychiatrist). The documented
lifelong
difficulty controlling anger, being vengeful, with a history of
fighting and four  
occasional suicidal ideation without intent, and
The mental status examination describes the patient's
esteem.
mood as "concerned,, with appropriate affect, "not psychotic,,,
"insight poor,,, "judgment quite impulsive.,,
diagnosis is "Avoidant Personality Disorder with explosive
features.,,

NJP's during his first enlistment,  

(c) low 

(b)

 

self-

- claims he does not just like anybody at the shop  

- Refer

- personality disorder at

(sick call

b.

15 March 1982 entry by LCDR

physician), noting "still explosive  
work 
back to 

MHC"

C .

17 March 1982 report by

"explosive

His speech was clear

The documented history notes

(psychiatrist).
features in his personality,,, feeling "very distrustful of many
people in many situations,,, and having "arguments frequently,,.
The mental status examination is documented as follows:
alert, cooperative, and in no distress.
and he was quite expressive of his feelings.
loosened thought associations.
appropriate to his concerned mood.
suicidal ideation, homicidal ideation, evidence of
hallucinations or delusions.
intact.,,
that there is a pervasive and unwarranted suspiciousness and
mistrust of people.
situation.
disorder.
recommended, but there is no subsequent notation that this
occurred.

It is possible that this could form a personality
Therapy was

The impression is documented as follows:

There is no evidence of psychosis.,,

He is clearly hypersensitive to his

He was oriented with memory

Affect was full range and

There was no depression,

There were no

"It is clear

"He was

Enclosure (2)

d.

14 March 1983 evaluation by  

Dr.s(sick call

physician), noting "Patient relates two episodes of conflicts
with co-workers and superiors... unable to express anger.
he might hurt others.,,
The mental status examination is
documented as follows:
"thought process coherent, memory
intact; however relates in an immature, childlike manner.
Judgment and insight somewhat limited.
The
assessment is "Immature personality disorder with situational
stress.,,

Not suicidal.,,

Feels

e.

15 March 1983 brief MHC

17 March 1983 brief MHC

evaluation,,

17 March 1983 report by

noting "marked

‘I

difficulty in interpersonal relationships which has been a life
long problem for him,, and other similar descriptions.
Mental
status documented the following:
"mood was markedly dysphoric
with a concerned and tense affect... there was no evidence of a
thought disorder or current suicidal ideation... Thought content
centered on his unhappiness and difficulty controlling his anger
and being successful in personal relationships.,,
The diagnosis
was "Avoidant Personality Disorder with paranoid features.,,

f.

g-

h.

i.

j-

k.

1.

21 March 1983 brief MHC entry by  

"individual psychotherapy,,

28 March 1983 brief MHC entry by

possibly individual psychotherapy)

4 April 1983 brief MHC entry by

psychotherapy,,

11 April 1983 brief MHC entry by

"individual psychotherapy,,

18 April 1983 brief MHC entry by

"individual psychotherapy,,

m.

25 April 1983 brief MHC entry by

"individual psychotherapy,,

n.

16 May 1983 brief MHC entry by

psychotherapy,,

0 .

22 August 1983 brief MHC   entry by

"individual psychotherapy,,

m 

-

(unclear 

-

- "individual

-

"individual

Enclosure (2)

.

.

Interpretation of Pertinent Entries

From The Military Medical Record

There is remarkable consistency across time and between the

1.
two psychiatrists and one general physician who describe Mr.
Wolfram's psychiatric symptoms.
problems of interpersonal discord and difficulty managing anger
-- are described as nearly constant in severity over the three
years of documentation.
"lifelong" -- a characteristic of personality disorders.

The problems are clearly described as

These symptoms -- primarily

Multiple general medical entries (be they sick call notes or

2.
one of five  
as severe as Bipolar Disorder would be manifest not only in
specialty visits but in general medical visits as well.

SF93's) reveal no psychiatric symptoms.

A condition

*

The symptoms documented in the mental health assessments

3.
meet DSM-IV criteria for a personality disorder -- see Reference
The symptoms documented do not meet DSM-IV criteria for
(c) 
either manic, hypomanic, major depressive, or mixed episodes --
essential ingredients for an Axis I mood disorder (including one
of the bipolar disorders).

Enclosure (3)