RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	 	CASE:  PD1301501
BRANCH OF SERVICE:  ARMY		BOARD DATE:  20140709
DATE OF PLACEMENT ON TDRL:  20031112
DATE OF PERMANENT SEPARATION:  20061211

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (91W10/Health Care Specialist) medically separated for undifferentiated somatoform disorder manifested by recurrent spells, headaches and diffuse pains.  His condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent P3/L3/S3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded undifferentiated somatoform disorder, chronic pain in the neck, shoulders, back and hips (left greater than right), fibromyalgia and recurrent spells and chronic incapacitating headaches conditions, as medically unacceptable IAW AR 40-501, to the Physical Evaluation Board (PEB) for adjudication.  The MEB also identified and forwarded “narcissistic and dependent traits, and hearing within normal limits in both ears.”  The Informal PEB adjudicated undifferentiated somatoform disorder, manifested by multiple somatic complaints and functional limitations in excess of that expected (subsuming the fibromyalgia, and recurrent spells and chronic incapacitating headaches conditions) as unfitting, rated 30% and placed the CI on the Temporary Disability Retired List (TDRL) effective on 12 November 2003.  The CI made no appeals.  He was reevaluated in 2006; it was determined his condition was improved and was stable.  Separation with severance pay was recommended at a 10% disability rating.  He made no appeals and was removed from TDRL and permanently separated.

CI CONTENTION:  “Was found to be much more disabled at a higher rating by the VA.  Fibromyalgia, sleep apnea, adjustment disorder with depressed mood. ”

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 applicant.  The ratings for conditions meeting the above criteria are addressed below.  In addition, the Secretary of Defense directed a comprehensive review of Service members with certain mental health conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The applicant was notified that he may meet the inclusion criteria of the Mental Health Review Terms of Reference.  The mental health condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may be eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Final Service PEB - 20061026	VA (Used STR) - Effective 20031113	
On TDRL - 20031112	Code	Rating	Condition	Code	Rating	Exam	
Condition		On TDRL	Off TDRL					
Undifferentiated Somatoform Disorder…	9423	30%	10%	No Direct Corresponding VA Condition	
No Direct Corresponding MEB/PEB Condition	Depression	9434	NSC	STR	
	Post-Traumatic Stress Disorder 	9411	NSC	STR	
Fibromyalgia	Subsumed w/ Unfitting Condition	Fibromyalgia Syndrome	5025	40%	STR	
Chronic Pain in the Neck, Shoulders, Back & Hips (Left > Right)		Lower Back Condition	5237	NSC	STR	
Recurrent Spells & Chronic Incapacitating Headaches		No Direct Corresponding VA Condition	
Narcissistic & Dependent Traits	Not Unfitting	No Direct Corresponding VA Condition	
Normal B/L Hearing 	Medically Acceptable	No Direct Corresponding VA Condition	
No Additional MEB/PEB Entries	Other x 5	STR	
Combined:  30% → 10%	Combined: 40%	
*Reflects VA rating decision (VARD) dated 20041126 closest to TDRL placement which includes the deferred issues; rating was based on the STR as CI failed to report for his C&P exam scheduled for 20041005.  NSC (non-service connected)

ANALYSIS SUMMARY:

Undifferentiated Somatoform Disorder Condition.  The first record found in evidence for the unfitting condition(s) was a 23 April 2001 evaluation in neurology for a primary myopathy (disorder of the muscles.)  He had been referred by pulmonary medicine which had evaluated him for a 1-year history of shortness of breath (SOB), dyspnea on exertion (exercise) and an abnormal pattern on testing.  The examiner noted that the CI had pulmonary problems in childhood.  The examination was unremarkable other than a sensory loss on the left side of the body.  Both the pulmonologist and neurologist recommended psychiatric referral.  Electro-diagnostic studies were suggestive of a myopathy on 15 August 2001, but normal on subsequent testing on 27 September 2001.  Laryngoscopy on 1 October 2001 was abnormal with vocal cord dysfunction, later thought to be causal in the abnormal pulmonary testing.  However, he was also thought to have posttraumatic stress disorder (PTSD) and a possible conversion disorder.  He also apparently had weakness during this period and required the use of crutches.  An evaluation on 26 November 2001 by a German neurologist was suspicious for conversion disorder, a diagnosis the CI rejected.  He was subsequently evaluated by psychology and a factitious disorder was suspected.  The Board noted that while each has physical manifestations, the former is an MH diagnosis without malingering whereas the latter implies deliberate intent.  The CI continued to be followed for these symptoms with the different specialists.  He was admitted for further evaluation from 16 March 2002 to 3 May 2002.  He was wheelchair bound due to weakness, but had an inconsistent motor examination.  Atrophy was specifically excluded on a physical medicine and rehabilitation (PMR) examination on 21 March 2002.

On or about 31 May 2002, the CI was diagnosed with a seizure disorder in a civilian hospital.  The clinical evaluation is not in evidence.  He was then seen in PMR on 5 June 2002 and noted a history of seizures “off and on” for the past 3 years.  The next day, in rheumatology, he was noted to have pain in his joints and muscles, but no evidence for an inflammatory connective tissue disease or rheumatoid arthritis.  Features of fibromyalgia syndrome (FMS) were present, but thought to be secondary to the underlying MH condition.  He was subsequently hospitalized by psychiatry from 15 July 2002 to 19 July 2002 for depression.  He was noted to have an adjustment disorder with disturbance of mood and conduct (and a) somatoform disorder, not otherwise specified (NOS) and on Axis II histrionic and anti-social traits.  He was reported as having presented to a local hospital with suicidal ideation, but denied ever having been suicidal at this hospitalization.  He was evaluated in the Gulf War Health Center for his symptoms from 29 July 2002 to 16 August 2002.  It was noted that he had been diagnosed with sleep apnea on 15 August 2002, however, the study is not in evidence.  No further entries were found for sleep apnea in the records until a VARD well after separation and the diagnosis was not carried forward in the clinical notes.  On 16 September 2002, he presented to the emergency room complaining of seizures.  A neurologist determined that further evaluation was needed.  The motor examination was noted to be normal other than right knee extension which had break-away weakness (consistent with either the conversion or factitious disorders previously considered).  He again presented to the emergency room the next day for seizures and was thought to have “pseudo-seizures.”  He was seen in rheumatology by a nurse practitioner on 19 May 2003 and thought to have FMS.  A continued multi-disciplinary approach was recommended.

The PMR PEB addendum to the narrative summary (NARSUM) was dated 12 June 2003.  The examiner noted that the CI ambulated with the aid of a forearm crutch.  He no longer used a wheelchair and could walk up to ½ mile.  He complained of pain in his neck, back, shoulders, hips, and left leg.  On examination, the sensory, motor and reflex examinations were normal.  The muscles were of normal tone and bulk.  The gait was antalgic (an abnormal gait due to avoiding painful motion) and the left hip painful with resisted motion.  The joints showed full range-of-motion (ROM) actively and passively.  The shoulder girdle, back, and hips were tender.  He was diagnosed with chronic pain of the neck, shoulders, back and hips which was not medically acceptable.  The CI was also noted to carry the diagnoses of FMS, depression, as well as seizures and migraine headaches, but these were deferred to rheumatology, MH and neurology, respectively.

The psychiatry PEB evaluation was dated 30 July 2003.  The CI was noted to have a history of multiple physical complaints without objective evidence of organic pathology suggestive of a diagnosis of a somatoform disorder.  He was subsequently diagnosed with a conversion disorder and a personality disorder NOS with strong narcissistic (self-love) and dependent traits.  He was noted to have made one suicide attempt in July 2002 by an overdose of a prescription medication; his diagnoses were changed to adjustment disorder and somatoform disorder.  He continued treatment afterwards, but was poorly compliant in follow-up.  His mental status examination (MSE) was unremarkable.  He was diagnosed with an undifferentiated somatoform disorder with narcissistic and dependent traits and limitations in excess of that expected.  He was assigned a Global Assessment of Function (GAF) of 65 consistent with mild symptoms or impairment.

The rheumatology PEB addendum was dated 11 August 2003.  It noted that at his initial evaluation in June 2002, he did not have evidence for a systemic, inflammatory rheumatologic disease, but did meet the criteria for FMS.  His examination was unremarkable other than 18/18 tender points being positive.  He was noted to carry the diagnosis of fibromyalgia and referred to the MEB.

The neurology PEB addendum to the NARSUM was dated 14 August 2003.  The CI reported a history of “spells” dating back to Thanksgiving of 2001.  He reported an “aura” of vague dizziness and impending collapse followed by loss of consciousness and generalized shaking.  He then had confusion for 20-30 minutes with could include excessive drowsiness and sleep.  He reported loss of bladder function, biting his tongue, and soft tissue injuries.  These had only been witnessed by his spouse.  He reported a decrease in frequency with an anti-convulsant medication.  It was noted that during one of his spells with generalized shaking, he had an electroencephalogram without epileptiform discharges (which would be expected were these seizure events).  He was diagnosed with recurrent spells, but was not diagnosed with a seizure disorder.  He was also noted to have frequent incapacitating headaches.  No history of head trauma was given.  Review of the record did not show that he had been on quarters for the headaches and that they had not been profiled.

The MEB was accomplished on 15 August 2003 and noted that the somatoform disorder with narcissistic and dependent traits, chronic pain (in the neck, shoulders, back, and hips), fibromyalgia, and recurrent spells and incapacitating headaches were medically unacceptable.  He was issued a P3/L3/S3 profile for leg weakness, fibromyalgia and somatoform disorder.  The PEB convened on 25 August 2003 and determined that the narcissistic and dependent traits were not unfitting.  The undifferentiated somatoform disorder was determined to be unfitting.  The chronic pain, fibromyalgia, recurrent spells, and incapacitating headaches were subsumed under the MH condition.  The PEB noted that the muscle strength was normal and atrophy absent; it also noted that the tender points varied from 11-18 at different examinations.  The CI concurred with the MEB and PEB adjudications and was then placed onto the TDRL on 12 November 2003 at 30% disability using code 9423, for undifferentiated somatoform disorder.

No VA Compensation and Pension (C&P) exam was performed at time of TDRL entry or removal; the CI had failed to report for his initial C&P exam scheduled for 5 October 2004.  The VARD was based on the service treatment records and rated the fibromyalgia at 40%, coded 5025.  There were no other compensable, service-connected conditions at TDRL entry.

The CI was seen for the TDRL re-evaluation by rheumatology on 12 July 2006.  The CI reported that he had pain in the “neck, back, hips, knee, and diffusely in the legs.”  He stretched, but did not exercise.  He worked at the Holocaust Museum where his duties were minimal and called in sick frequently.  It was not noted for what issues he took sick leave.  He denied depression or anxiety.  He had diffuse swelling at times of the finger joints and soft tissue.  On examination, he had diffuse tenderness throughout the lumbar spine, but was without spasm, swelling or tenderness.  There was pain with axial loading and 18/18 fibromyalgia trigger points were positive as well as “multiple” control points, the latter indicative of a low pain threshold.  His symptom complex was thought to fall within the spectrum of pain disorders classified as fibromyalgia, but it was confounded by the underlying MH diagnoses.

He was evaluated by neurology 2 weeks later on 27 July 2006.  He reported that his last “spell” had been 3 years previously and that he had missed 17 days of work the past year for various aches and pains.  He still had headaches once a week, but reported that they were improved from prior to discharge.  He reported that he was not being seen in psychiatry and that his depression was under better control.  He reported diffuse joint pains and low back pain.  His neurological examination was essentially normal.  He did grimace with motor testing, but had full strength.  His gait was wide based and he used a cane to walk into the office.  His headaches were noted to be chronic and incapacitating, but improved from TDRL entry.  A note from his supervisor dated 27 July 2006 noted that he had used a total of 156 hours of sick leave, but did not record for what reason or over what time period.

He was evaluated by orthopedics on 17 August 2006.  It was noted that he had received epidural blocks which were helpful.  He had been employed since discharge and was currently working full time at the Holocaust Museum in a sedentary job and took the Metrorail (subway).  He appeared comfortable while sitting.  He had an “awkward wobbling gait” and used a cane in his right hand.  The ROM of the neck was normal but there was discomfort at end range.  The ROM of the back was normal other than flexion which was reduced, but without a firm endpoint.  Three signs not expected to produce pain in his lower back were positive.  Sensation was reduced over his left lateral leg and foot, but the motor and reflex examinations were normal.  On magnetic resonance imaging, he had some moderate degenerative changes with a small herniated disc at L5-S1.  He was diagnosed with diffuse myofascial pain syndrome without a specific musculoskeletal diagnosis.
The psychiatric TDRL re-evaluation was on 22 September 2006.  It was noted that his “spells” had stopped the same time his narcotics were discontinued by pain management although he remained on Tramadol (a synthetic, narcotic like pain medication).  He reported that his depressive symptoms had improved after resolution of some financial difficulties.  He reported severe dysfunction from the severe chronic pain and leg weakness.  He had been working since November 2003 and had noted “substantial physical improvements in his condition” starting approximately in March 2005, although he had noticed a decline over the past 2 weeks.  He continued to work full time.  The MH examination was normal.  Walking was difficult and he utilized bilateral canes (a change from the orthopedic examination a month previously).  He was diagnosed with an undifferentiated somatoform disorder with pain in multiple areas of his body and leg weakness, both without specific organic etiology.  The examiner noted that his physical symptoms appear to be psychogenic in etiology (that is, secondary to the somatoform disorder).  He was assigned a GAF of 65 and noted to have had one of 69 in the past year, both indicative of mild symptomology.

The TDRL removal PEB determined that the undifferentiated somatoform disorder, coded 9423, had a mild impact on his industrial and social capabilities and rated him at 10%.  The CI concurred with this assessment and was removed from TDRL effective on 11 December 2006.

After TDRL removal, the CI was seen by the VA in neurology on 2 August 2007 for a “catching” left foot when he walked and a numb left leg.  Again, the motor and reflex examinations were normal.  There was left lower extremity sensory loss in a non-dermatomal pattern.  Electro-diagnostic studies were normal.  A physical therapy examination 2 weeks later noted a right foot drop on gait evaluation which was not consistent with the near normal motor testing.  The Board noted that these examinations are not consistent with an organic basis for the symptoms, but do fit the psychiatric diagnosis.

The Board directs attention to its rating recommendation based on the above evidence for the rating at TDRL entry and removal.  It noted that the CI carried multiple diagnoses which were subsumed under the MH diagnosis of somatoform disorder at TDRL entry and (presumably) at TDRL removal.  The Board considered if these represented separately unfitting conditions at TDRL entry and considered the chronic pain in multiple areas, fibromyalgia, recurrent spells and chronic headaches.  The Axis II listing of narcissistic and dependent traits was not a formal diagnosis of a personality disorder; even if a personality disorder had been present, it would not constitute a physical disability IAW DoDI 1332.38.  The Board noted that chronic pain is a symptom rather than a diagnosis.  It then considered the fibromyalgia, spells and headaches.  The CI was initially evaluated for a possible myopathy (muscle disorder) and breathing problem.  He reported weakness which required the use of a wheel chair at one time, but had an inconsistent motor examination.  He continued to report weakness and used crutches, but had a motor examination which was normal on most examinations and did not show muscle atrophy.  Electrodiagnostic testing was normal.  The CI did report positive trigger points as seen in fibromyalgia, but also had wide spread tenderness on multiple examinations and demonstrated pain with maneuvers not expected to be painful.  The CI complained of incapacitating headaches, but the Board found no evidence that he had been sent home from work or placed on quarters for the headache condition.  A conversion disorder is a MH condition in which there are physical symptoms in the absence of objective pathology which explains these symptoms.  The Board noted that this diagnosis accounted for the varied inconsistent symptoms over time, and that they were not supported by objective pathology.  After reviewing the evidence, the Board determined that the preponderance of evidence does not support a change in the PEB unfitting diagnosis.

The Board also considered the appropriateness of any changes in the MH diagnoses.  The MEB forwarded the MH diagnoses of undifferentiated somatoform disorder to the PEB for adjudication.  The PEB adjudicated the CI for the diagnosis of undifferentiated somatoform disorder at TDRL entry and undifferentiated somatoform disorder at TDRL removal.  However, on the MEB physical (DD Form 2808), PTSD was listed as a diagnosis.  The SRP determined that the MH diagnosis was changed during the disability evaluation process.  This applicant therefore did appear to meet the inclusion criteria in the Terms of Reference of the MH Review Project.

The Board then considered the rating at TDRL entry.  It noted that the CI had a GAF of 65 indicative of mild symptoms or impairment.  He was in a stable marriage and began employment shortly after separation.  The PEB adjudicated a 30% rating which corresponds to an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks…but generally functioning satisfactorily.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the somatoform condition at TDRL entry.

The Board then considered the rating at TDRL removal (permanent separation).  The PEB adjudicated a 10% rating; this is described as “occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.”  The CI had been employed full-time in a sedentary job since TDRL entry and was in his current job for about 18 months.  He had missed 156 hours of work (just under 20 days) since he had started the job, but it was not detailed regarding if the time off was due to other illness, his unfitting condition or medical appointments.  He reported that his symptoms had improved significantly over the past 2 years although he had noted a set back the past 2 weeks when evaluated by the psychiatrist.  His mental status examination was normal.  The physical disabilities which he reported were not consistent with objective findings on examination proximate to TDRL removal both before and after.  He was in a stable marriage and had no legal or substance abuse problems.  The Board considered both the 10% and 30% ratings.  Although he continued to be symptomatic, he was functioning adequately in both his occupational and social environments.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the somatoform condition at TDRL removal.

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the undifferentiated somatoform disorder condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication at TDRL entry and removal.  There were no other conditions within the Board’s scope of review.

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130912, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20140016133 (PD201301501)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						

CF: 
(  ) DoD PDBR
(  ) DVA