RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2013-01517
BRANCH OF SERVICE:  MARINE CORPS	BOARD DATE:  20141203
SEPARATION DATE:  20040630

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty LCPL/E-3 (3051/Warehouse Clerk) medically separated for conversion disorder.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was placed on limited duty and referred for a Medical Evaluation Board (MEB).  The conversion disorder condition, characterized as “conversion disorder (mild-moderate)” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded one other condition (migraine headaches).  The Informal PEB adjudicated “conversion disorder” as unfitting, rated at 10%, with likely application of Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be Category III condition.  The CI made no appeals and was medically separated.

CI CONTENTION:  “conversion disorder w/mixed presentations and anxiety have gotten worse where it affect by day to day activities.  I have problems with my balance.  Sometimes I have numbness in my feet and legs.  I have pain through my body.  I am always tense have racing thoughts.  Also have homicidal thoughts, and I sometimes revert to cutting myself when I feel a need to.  I still have tremors (secures) from time to time.  I have heart palpitations, always worrying sweating and depression.  Sometimes I can’t sleep because I am paranoid or my negative thoughts keep me awake.”

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; no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention 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 20040414	VA - (4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Conversion Disorder	9424	10%	Conversion Disorder	9424	30%	20041015	
Migraine Headaches	Cat III	Migraine Headaches	8100	0%	20041021	
Other x 0 (Not in Scope)	Other x 0 		
Combined:  10%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20050511 (most proximate to date of separation)

ANALYSIS SUMMARY:

Conversion Disorder Condition.  The CI was evaluated in the emergency room (ER) on 11 November 2003 for episodes of shaking over a 2-week period.  The CI reported she had episodes of shaking of the arms and legs in her sleep and when awake.  Physical examination was normal except she had “myoclonic jerks” during the exam.  The ER examiner noted the CI shook only when she was being observed.  She was referred to psychiatry for evaluation.  She was diagnosed with a movement disorder and conversion/anxiety disorder was rule out.  The following day at the psychological evaluation, the CI reported she had experienced shaking after the delivery of her baby who was now 30 days old and living with her parents.  The symptoms lasted for one day but re-appeared in the prior 2 weeks after an argument with her boyfriend, now husband of 3 days.  After the argument she and boyfriend came close to ending the relationship.  The CI noted her symptoms involved upper body movements with extensive flapping of the hands and some lower torso movements.  During her mental status examination (MSE) the CI exhibited upper body movement and stated her mood was irritated and tired.  All other aspects of the examination were unremarkable.  The psychologist recorded the diagnosis of conversion disorder with mixed presentation (provisional) and reported a Global Assessment of Functioning (GAF) score of 45 (serious).  Neurology consultation dated 1 December 2003 recorded a normal neurological examination.  The neurologist opined the symptoms were consistent with a conversion disorder.  However, she was started on anti-epileptic medication and had received medication for sleep issues.  The record demonstrated the CI participated in talk therapy and possibly hypnotherapy.  She continued to have “jerks” that was not responsive to anti-epileptic or neuroleptic (anti-psychotic) medications.  Neurology entry dated 9 January 2004 noted jerking at the initiation of the physical examination that terminated once the examination ended.  Motor examination was difficult to perform due to “large, dramatic arm, head, and body jerks associated with dystonic voluntary movements, fisting and extending of the arms when reflexes were being examined.”  There were no clinical findings.  The physician explained to the CI and her husband (accompanied her to the appointment) that the symptoms were psychologically based.  The diagnosis of conversion disorder was recorded.

At the narrative summary (NARSUM) performed on 2 February 2004, the psychiatrist noted the CI had extensive work-up to identify organic (physical) causes for her symptoms and none had been identified.  Blood chemistry evaluation was normal including tests to detect thyroid abnormalities.  The CI had a normal CT brain scan.  The diagnosis of conversion disorder was confirmed in November 2003.  The CI was absent from work for a short period of time in November, but was prescribed medications for sleep that improved her symptoms to where she was able to return to work with some duty restrictions.  The examiner indicated the CI’s motor behaviors had interfered with her ability to stand in formation.  MSE noted no abnormalities in mood, affect, speech or thought processes.  There were mild motor/behavioral abnormalities.  A GAF of 65 (mild) was recorded, and returning to full duty was not recommended.  The psychologist indicated the CI’s symptoms were directly related to the perceived stressor.  Her condition was documented as mild-moderate.

A month later the CI was admitted to psychiatry inpatient after an episode of disruptive and self-injurious behaviors (slapping self in the face) at work.  She reportedly became agitated and was escorted to mental health.  She was discharged the following day with the admission related diagnosis of acute adjustment reaction.  The CI was seen again in the ER on 28 March 2004 secondary to jerking symptoms.  She was triaged to psychiatry who noted all of the biological laboratory studies had been normal (TSH, B12, folate, CBC, etc.) and the CI had continued anti-anxiety and neuroleptic medication.  She no longer took the anti-epileptic medication.  The psychiatrist documented the CI reported she was able to go to work “mostly” without problems, except some minimal jerking behavior.  Her GAF was 55 and the diagnosis of conversion (pseudo seizures) continued.

At the VA Compensation and Pension mental evaluation on 15 October 2004, approximately 4 months after separation, the CI reported a history of one inpatient psychiatry admission in 2004 (24 hours), briefly took anti-epileptic medication and had completely discontinued all medication because they did not improve her symptoms.  The examiner noted the CI had no record of treatment for her condition since separation and had not worked since separation, primarily due to pregnancy.  She reported a history of abuse from the father of her child and noted she had given him custody and felt guilty about her decision.  Her current husband was supportive and attended appointments with her.  The CI had continued to have episodes, primarily at night, but also had 3-4 times per week during the daytime.  The MSE was unremarkable, and a GAF of 65 (mild) was recorded.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA chose the same coding option, code 9424 (conversion disorder), but assigned different ratings.  The PEB rated the condition at 10%, and the VA assigned a 30% rating.  The Board first unanimously agreed that VASRD §4.129 was inapplicable in this in the absence of a highly stressful causative event.  The NARSUM examination was 4 months before separation and the VA examination was 4 months after separation; both assessed the GAF score at 65 (mild symptoms but generally functioning well).  The Board considered if there was evidence for a §4.130 rating higher than 10% at the time of separation.  A rating of 30% requires “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.”  The records noted the CI had discontinued her medications after separation and had continued to experience pseudo seizures at or near same intensity when she received medication and therapy.  Her GAF remained the same.  There was no evidence in the record of recurrent suicidal behaviors or panic attacks.  The CI was hospitalized once for behavioral issues not related to the pseudo-seizures and was seen in the ER twice for pseudoseizures.  Medication and psychotherapy provided limited benefit.  The majority of her MSEs were normal.  Although the commander’s statement noted the CI had been absent from duty approximately 30 hours weekly due to treatment, evaluation and/or recuperation, the record recorded only one reported work place incident not associated with her diagnosed condition (after becoming agitated, she was slapping self in face, throwing chairs).  The inpatient psychiatrist noted the CI reported she had minimal pseudo-seizure behaviors at work (minimal jerking), the NARSUM recorded the condition was transient and mild to moderate in severity.  The Board noted the pseudo seizure episodes appeared to have presented in response to specific stressors, were transient, and seemed to have occurred only in situations where others were in the position to assist or come to her aid.  Four months after separation she remained chronically stable with no visits to the ER or psychiatric hospitalizations.  She was expecting a baby and was not taking psychotropic medications.  All Board members agreed the condition at the time of separation was best reflected in the 10% rating.  Thereupon, 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 conversion disorder condition.

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 conversion disorder condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

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

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131007, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 29 Apr 15

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXX, former USN