RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE NUMBER:  PD1300073
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20130806
Separation Date:  20021101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty GMSA/E-2 (Gunners Mate) medically separated for conversion disorder.  The CI was originally diagnosed with right arm paresis and numbness.  After failing to regain use of her arm and receiving a thorough neurological evaluation, she was diagnosed with conversion disorder.  Despite psychological intervention, psychiatric medication and two episodes of limited duty (LIMDU) the CI failed to meet the physical requirements of her Rating and was referred for a Medical Evaluation Board (MEB).  A neurologic addendum to the MEB determined the CI had no objective physical findings to support a finding of a neurologic problem in her right arm.  A psychiatric addendum to the MEB, written after an adequate period of observation and evaluation by staff psychiatrists, identified her diagnoses as posttraumatic stress disorder (PTSD), conversion disorder with mixed presentation, and right arm paresis and numbness, for forwarding to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The PEB adjudicated the conversion disorder as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The PEB also identified the conversion disorder as a pre-existing condition, but did not reduce the rating.  Additionally, the PEB adjudicated the right arm paresis and numbness condition as a Category II condition (conditions that contribute to the unfitting conditions) and the PTSD as a Category III condition (conditions that are not separately unfitting and do not contribute to the unfitting condition).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Just wondering due to letter from VA.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting conversion disorder condition is addressed below and no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention either not requested in this application or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Naval Records.

RATING COMPARISON:

Service IPEB – Dated 20020823	VA - (43 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Conversion Disorder	9424	10%	PTSD with Conversion Disorder Manifested with Limited Functioning of the Right Arm and Hand	9411-9424	10%	20060623	
Right Arm Paresis and Numbness	Category II					
PTSD	Category III					
No Additional MEB/PEB Entries	Other x 0	20060914	
Combined:  10%	Combined:  10%*	
Derived from VA Rating Decision (VARD) dated 20061023 (most proximate to date of separation [DOS]), effective 20060207.

ANALYSIS SUMMARY: The Disability Evaluation System (DES) is responsible for maintaining a fit and vital fighting force.  While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition.  The Department of Veterans’ Affairs; however, the operating under a different set of laws (Title 38, United States Code) is empowered to compensate for service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time.

Conversion Disorder/PTSD Condition.  The CI injured her right arm 27 August 2000 when she fell aboard her ship during at-sea ship to ship refueling operations when the two ships collided.  According to historical records, her ship sustained light damage on the port side of its helicopter hangar about 8:45 p.m. when it bumped the starboard side of the refueler ship, which sustained negligible damage.  Weather was said to not be a factor (visibility unlimited, seas 2 to 4 feet, with light southeast winds).  Approximately five minor injuries were reported on the CI’s ship (including the CI; elbow injury).  The CI was evaluated in the ships clinic where she complained of pain of the right elbow after twisting it during the collision.  She was referred to the on-shore emergency department for evaluation.  The emergency department record, dated 28 August 2000, records CI complaint of no feeling in the right arm with no movement.  The CI reported striking the right elbow against a hatch on 20 August 2000, with subsequent re-injury with a fall on 27 August 2000.  The emergency room physician recorded loss of sensation below the elbow with weakness of the hand and wrist.  He suspected an injury to the nerves in the shoulder region (brachial plexus) as a result of twisting of the arm in the fall and referred the CI for neurology consultation.  Neurology evaluation on 10 October 2000 recorded persistent right arm weakness and loss of sensation.  Electrodiagnostic study (electromyogram and nerve conduction velocity testing) on 20 October 2000 noted changes indicating mild myelinopathy of the right lower cord of the brachial plexus consistent with brachial plexopathy.  Nerve conduction study (NCS) showed no evidence of peripheral nerve damage (axonopathy).  The significantly reduced volitional (subject effort) electromyographic activity was attributed the report of pain with use.  An initial 8-month limited duty (LIMDU) period began on 10 October 2000 and was scheduled to expire on 10 June 2001.  During this time, the CI became pregnant with a due date in August 2001 (her active duty husband was left behind when his unit deployed to help with the newborn baby).  The 6 February 2001 obstetrical examination noted the right arm impairment (R brachial plexus).  In May 2001, the neurologist noted that because of continued “profound weakness and numbness” but “relatively minor (EMG/NCV) abnormalities” studies would be repeated.  The CI delivered her baby in August 2001.  Repeat electrodiagnostic study (EMG/NCV) on 25 September 2001 was normal and was not consistent with the CI’s symptoms.  There were no EMG changes of denervation (when nerves supplying muscle is damaged, the muscles demonstrate abnormal EMG changes not present in the CI).  There was also marked reduction in voluntary muscle activity (subject effort).  The reported circumferential sensory loss was not consistent with the normal objective electrodiagnostic results.  At a neurology reevaluation on 4 October 2001, the CI reported very mild improvement but still a non-functional right arm.  On examination, the neurologist observed the absence of muscle atrophy (significant observable atrophy would be expected with a lack of extremity use after a one year period of time).  The neurologist concluded that there was no evidence for organic (physical) cause for the reported right arm symptoms.  At a 4 December 2001 neurology follow up, the CI reported little improvement.  Examination findings were unchanged.  The neurologist opined the CI had a somatization disorder.  Throughout the preceding year, no service treatment records reflected any psychological symptoms or distress.  The neurology Report of Medical Board exam performed on 1 November 2001 focused on the persistent pain, numbness and weakness in the right forearm.  The CI was undergoing intense physical therapy and had some improvement in motor function.  During the physical examination, there was no movement of the fingers with marked weakness of the entire right arm.  Sensation was decreased involving the entire forearm and hand.  The examination was also noted for absence of muscle atrophy and normal reflexes.  The examiner diagnosed right arm paresis and numbness probably secondary to a conversion disorder and recommended continued treatment on limited duty.  The CI was referred for an MEB and underwent MEB examination in March 2002.  On the DD Form 2697, Report of Medical Assessment, completed by the CI on 4 March 2002, the CI reported “depression, post partum.” On the DD Form 2807, Report of Medical History completed by the CI on 4 March 2002, the CI reported anxiety attacks, nervousness and depression/post partum.  The MEB examiner referred the CI to psychiatry for evaluation of PTSD/situational anxiety/situational depression.  The commander’s statement dated 4 March 2002 stated that the CI had consistently performed all duties assigned equal to or above her peers.  Duties included dispatcher and maintaining cleanliness and ground maintenance of an area covering over 450 acres.  The commander noted that the CI “has made great strides in overcoming her limited duty condition and has expressed a desire to continue her naval career, but realizes her condition will prevent further productive military service”.

The mental health evaluation on 25 April 2002 noted that in addition to the physical arm injury, “She also experienced an extended period (about ninety minutes) of psychological trauma as the two ships collided twice at night during which she witnessed chaos, extreme threat to personal safety, serious injuries of others, and was involved in the rescue and care of other injured persons.  Since that injury the patient has been on limited duty for inability to use her right arm and was recently found unfit by the PEB. She expects medical discharge in about two months.”  The psychologist noted that the anxiety demonstrated when the CI attended her PEB physical examination led to the psychological evaluation.  The CI endorsed symptoms of general nervousness, hypervigilance, separation anxiety (from husband and son), frequent nightmares about the collision (3-4 times per week), anxiety around ships and anything associated with water, and mild emotional numbing.  The CI stated that she had not discussed these symptoms or the collision to any great extent with anyone but her husband and briefly with her neurologist.  The mental status exam indicated a euthymic mood with good judgment and insight.  The examiner diagnosed PTSD, mild-moderate and determined it had not existed prior to service.  The examiner concluded that the CI was psychologically fit for return to duty.  

Two months later the CI underwent a psychiatry examination 20 June 2002, which recorded,

She was aboard USS Nicholson in AUG 00 when she sustained a R arm hyperextension injury at the shoulder when her ship crashed with the USS Detroit. She recalled feeling as if she would die at the time and witnessed and cared for several friends/crewmembers who were significantly injured. Since the incident she has experienced recurrent anxiety, nightmares of the collision, difficulty sleeping, hypervigilance, increased irritability, feeling anxious when away from her husband and decreased libido. She reported anxiety around water and avoidance of ships, swimming pools or taking baths. She recently began psychotherapy. In regard to her arm injury, she reported a complete inability to move her right forearm as well as loss of sensation below the elbow with intact sensation above the elbow. Per neurology evaluation, nerve conduction studies and two EMG's have been normal. During my evaluation there was no evidence of atrophy or fasciculation. DTR's were normal in both arms.  She reported being unable to make voluntary movements of the right forearm; although, some slight movements were noted during changes in seating posture.

A history of treatment for anxiety at age 12 in the setting of family difficulties was recorded.  The mental status examination revealed a slightly anxious mood with a full congruent affect.  The examiner opined that the CI’s PTSD symptoms were likely related to the psychological trauma of the ship collision.  The diagnoses were Axis I:  PTSD, conversion disorder; Axis III: right arm numbness/weakness; Axis IV: routine military and family stressors status post ship collision; and Axis V: GAF=55 (moderate difficulty in social, occupational, or school functioning in social, occupational, or school functioning).  The CI was started on an antidepressant (citalopram) for PTSD symptoms.  The findings of this evaluation were included in a psychiatric addendum to the Medical Board Report dated 21 June 2002 and the case was forwarded to the PEB.  
The psychiatric addendum stated that an adequate period of observation had occurred and a conference of three staff psychiatrists reviewed the available records and current findings.  They agreed that the CI suffered from conditions that needed to be taken into account by the PEB.  They opined the CI suffered from psychiatric conditions that did not exist prior to service and were of such a severity that they prevented her from remaining on full duty status in the military.  A neurologic addendum to the Medical Board Report was completed on 20 June 2002.  The neurologist summarized the findings noted above stating the CI had been seen in October, November and December 2001.  However the CI had not returned for follow-up in the neurology clinic after December 2001 as advised.  The neurology addendum restated the prior conclusion that no neurologic abnormality was present.  An obstetrical examination on 11 October 2002, three weeks before separation, makes no reference to arm or psychological impairment.  An obstetrical examination 13 February 2003 (CI was pregnant with her second child), 3 months after separation, notes a history of PTSD but makes no reference of an arm impairment and records a normal physical examination.  

There are no further treatment records available until the VA compensation and pension (C&P) examinations performed in 2006, 3 years after separation (the CI filed her original VA claim February 2006).

At the VA mental health C&P examination performed 23 June 2006, the examiner recorded:

“The veteran described a traumatic incident that occurred while she was in the Navy.  She stated that in August 2000 while aboard the USS Nicholson, her ship collided with the USS Detroit.  At the time of the collision the veteran sustained an injury in her right arm.  Following the collision the veteran stated that she spent approximately 1.5 to 2 hours caring for injured shipmates including a close friend.  The veteran stated chat she feared for her life as she believed the ship would likely sink and she and she would drown.”

The CI reported that she had been referred to a psychologist and attended 3 to 4 sessions after the traumatic event.  She denied the occurrence of any traumatic incidents after separation.  The CI denied any inpatient hospitalizations and she reported taking medication for a short while following her discharge but had not taken any psychiatric medication in the previous 3 years.  The CI was noted to endorse continuing symptoms of anxiety (including while driving with fear of collision), hyperarousal, intrusive thoughts about the collision (once per week), nightly nightmares, reaction to reminders of the event, avoidance (of water, boats, and taking a bath; previously an avid swimmer), exaggerated startle response, and excessive concern with germs.  She also reported continued physical symptoms in her right arm.  The CI reported that immediately following separation she had worked for approximately a month as a telemarketer and that her most recent period of employment was approximately 6 months in 2004 when she worked 30 to 40 hours per week at a retail store (where she reported she experienced difficulty lifting and moving merchandise due to her right arm injury and extreme anxiety when working in tight spaces in the stockroom; she had no problems working as a cashier but left the job when they scheduled her more hours than she anticipated).  She reported she was planning on applying for a job with the Department of Homeland Security.  The CI had separated from her husband of 6 years in September 2005 (frequent verbal conflicts, and husband had been unfaithful) and was living with her parents and her two sons.  She reported very good relationships with her children, her parents and her brother.  She experienced anxiety when separated from her children.  The examiner documented that after the CI moved back home in January 2004 the CI began to slowly regain use of her right arm.  She was able to write and to hold and lift objects with her right hand but was still functionally limited.  The mental status examination was normal.  The examiner diagnosed chronic PTSD and noted that diagnosis for conversion disorder would be appropriate if the scheduled orthopedic exam found no medical cause for the arm symptoms.  A global assessment of functioning of 70 (mild symptoms) was assigned and the examiner commented there was some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships.  At the VA C&P joint examination in September 2006, the examiner recorded, 
  
“She described to me that during a refueling maneuver she was stationed at the bow of the ship of which she was a crew member. This refueling exercise was underway in what she regarded as slightly rough sea. During that operation the two ships, that is her vessel and the fleet oiler made hull to hull contact. As a consequence she fell to the deck and at the time of a second impact between the two vessels she apparently fell again while trying to rise. The second fall was said to have occurred at a time that her arms were extended including wrist and elbow she fell backwards and to the right rolling thereafter to the left after which she was assisted to her feet by a division shipmate. This was then followed by a call to battle stations for purposes of being certain that no crew member was overboard. She said that she was able to go to her battle station descending a ladder to the deck below where she reported to her turret. She said that on the ladder she became aware of being unable to use her right upper limb. There was poor recollection of detail. She said that she experienced a headache on the right side as she was turning in a weapon with which she had been provided during this shipboard exercise. At that point she was stopped by a corpsman who told her that he had heard a pop and taped her arm to her coverall. She had at that point not yet returned her weapon to the ships armory but eventually able to do that after which she returned to her quarters, which were shared with other women members of the crew. She said that her rack was upper and she was unable to rise to it because of the condition of her arm, which was apparently now taped to her clothing. She was unable to find any place to sleep except on a couch in their quarters. She said that when she awoke she had a headache. Her arm was uncomfortable and cold. She was able to raise the shoulder but not the arm and was not able to use her fingers or hand. She said that in the midportion of her arm and somewhat below she experienced tingling. She had continued pain in the shoulder and her ship upon returning to birth at Norfolk referred her to a medical officer who examined the arm and found it unchanged. She was then sent to the Naval Hospital at Portsmouth where she was examined by a Neurologist after which her arm improved over the course of two years though she remains fatigable with pain at the elbow.

The CI reported she had used her left hand alone since her accident on active duty but that she had improved over the course of 2 years following the accident.  She continued to have pain and fatigability at the right elbow, numbness, an inability to bend her right 5th finger and tenderness to palpation at the right shoulder.  She reported an inability to use her fingers or forearm for “small things” but provided no examples and was apparently able to dress and undress herself without assistance.  She denied any difficulty eating.  On examination, all reflexes were 1+ and symmetric.  There was slight atrophy of the supraspinatus muscle but no other muscles of the right arm were observed to show atrophy.  There was reduced muscular power graded as 4/5 associated with pain.  Fourth and fifth finger extension was 3.5.  Sensation was decreased to pinprick, touch and temperature in the right upper extremity but the margins were variable with modality tested and repeated testing.  The examiner concluded the examination indicated the decreased sensation was not consistent with neurologic disease.  There was no evidence that fatigue, weakness, pain or lack of endurance altered her mobility.  The degree of mobility of which she was capable during the examination was less than that required for dressing.  The examiner concluded there was no evidence of structural disease or structural disorder in the innervation of the right upper extremity.  In addition, the CI failed to comply with obtaining X-rays and MRI; the examiner scheduled an EMG but was unsure whether the CI would report for the testing.  

The Board directs attention to its rating recommendation based on the above evidence.  The PEB concluded the conversion disorder was unfitting and rated it 10% (9424 conversion disorder).  The PEB concluded that PTSD was not separately unfitting.  The VA combined the two mental health conditions, PTSD with conversion disorder manifested with limited functioning of the right arm and hand condition and rated at 10% based on her level of functioning at the time of the C&P examination in 2006.  

The Board noted that the PEB determined that the symptoms attributable to the PTSD diagnosis were not separately unfitting.  Although the PEB considered the PTSD not separately unfitting, the PEB unfitting mental condition, conversion disorder, followed a perceived traumatic event that also formed the basis for the PTSD diagnosis.  While the Board agreed that the evidence of the commander’s statement indicated that there was no occupational impairment due to PTSD symptoms, the unfitting conversion disorder was related and followed the same traumatic event.  Therefore the Board considered the mental health conditions together were unfitting and considered the overall social and occupational impairment in its rating recommendations.  The PEB adjudication occurred prior to the promulgation of the National Defense Authorization Act 2008 mandate for DoD adherence to VASRD §4.129 and did not apply the §4.129 requirement.  A majority of the Board, IAW DoDI 6040.44 and DoD guidance (which applies current VASRD §4.129 to all Board cases as appropriate), agrees that the stipulations of §4.129 were met in this case for the unfitting mental health condition.  While the PEB separated the PTSD from the conversion disorder, the Board considered the overall social and occupational impairment due to both mental health conditions in determining if a rating higher than the minimum 50% TDRL rating mandated by §4.129 was supported.  Evidence from the time of initial separation, including information obtained from the MEB NARSUM and the initial C&P examination from June 2006, does not support a rating greater than the 50% TDRL rating required by §4.129.  The Board next considered the permanent §4.130 rating for the mental health conditions at the end of the constructive 6-month period of TDRL.  The most proximate source of comprehensive evidence on which to base the permanent rating recommendation in this case are the references in the C&P examinations to the CI’s physical and mental status throughout the reconstructed TDRL period in the 6 months after initial separation.  The CI described employment in the post-separation period impaired by arm symptoms and anxiety in closed spaces.  Social interactions were described as good except with her husband as detailed above.  The mental health C&P examination recorded report that improvement in the arm did not occur until after January 2004, while the orthopedic examination indicated improvement by 2 years after the injury, around the time of separation.  Despite improvement, the CI described continued significant functional arm impairments.  The objective examination findings did not find evidence of a medical cause for the right arm symptoms, and except for slight atrophy of the supraspinatus muscle; no atrophy was observed which would be expected after six years of disuse.  A Board majority adjudged that the evidence available demonstrates that the CI’s condition more closely approximates the 10% criteria at the end of the reconstructed TDRL period, as there was insufficient evidence to show that her level of functioning was best described by the 30% criteria.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) the Board recommends a TDRL rating of 50% and a permanent rating of 10%. 

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  In the matter of the conversion disorder condition, the Board by a vote of 2:1 recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129 as DOD directed and a 10% permanent rating at 6 months IAW VASRD §4.130.  The single voter for dissent who recommended adopting an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129 as DOD directed and a 30% permanent rating at 6 months IAW VASRD §4.130, submitted the appended minority opinion.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified to reflect a 6-month period on the TDRL with a disability rating of 50% (IAW §4.129 and DoD direction), and then permanently separated with severance pay by reason of physical disability with a final 10% rating:

UNFITTING CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Conversion Disorder	9424	50%	10%	
COMBINED	50%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130205, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MINORITY OPINION

This Board member agrees that the CI’s unfitting condition of conversion disorder developed as a result of a highly stressful event that was severe enough to bring about her separation from service and that therefore, §4.129 should be applied with a minimum 50% rating for a reconstructed 6-month period on the TDRL.  While the GAF at the time of the C&P examination was 70, the CI had shown improvement after moving home with her parents in January 2004 and her level of functioning at the time of this C&P examination was not representative of her lower level of functioning at the end of the reconstructed TDRL period in May 2003.  Additionally, based on the findings of the C&P examination, a GAF of 70 does not appear to accurately reflect the CI’s level of functioning at the time of that examination and a more accurate GAF would be lower.  The record clearly does show some improvement over the nearly 4 years between the MEB NARSUM and the C&P evaluations but the record does not contain specific information regarding her level of functioning at the end of the reconstructed TDRL period in May 2003.  The GAF of 55 and the level of functioning described in the psychiatric addendum of June 2002 support a rating of 50% at the time of separation.  Therefore, even with acknowledgement of some improvement during the initial 6 months after separation, the CI’s level of occupational and social impairment would still be sufficient to meet the 30% rating criteria in May 2003.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), this Board member recommends a TDRL rating of 50% and a permanent rating of 30%.

UNFITTING CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Conversion Disorder	9424	50%	30%	
COMBINED	50%	30%	

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
		                COMMANDER, NAVY PERSONNEL COMMAND
	     	          		           	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:   (a) DoDI 6040.44
          (b) XXXXXXXXXXXXXXXXXX
          (c) XXXXXXXXXXXXXXXXXX
          (d) PDBR ltr dtd 31 Dec 13 ICO XXXXXXXXXXXXXXXXXX 
                                               
1.  Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (d).

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

	a. XXXXXXXXXXXXXXXXXX

	b. XXXXXXXXXXXXXXXXXX

c. XXXXXXXXXXXXXXXXXX, former USN, XXX XX XXXX:  Placement on the Temporary Disability Retired List from 1 November 2003 through 30 April 2004 with a disability rating of 50% and final disability separation on 1 May 2004 with a final disability rating of 10%.
	
3.  Please ensure all necessary actions are taken, included the recoupment of disability severance pay if warranted, to implement these decisions and that subject members are notified once those actions are completed.