RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-01264
BRANCH OF SERVICE:  AIR FORCE
DATE OF PLACEMENT ONTO TDRL:  20021106            DATE OF REMOVAL FROM TDRL:  20060920

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E-5, Personnel Apprentice, medically separated from the Temporary Disability Retired List (TDRL) for “conversion disorder” with a disability rating of 10%.

CI CONTENTION:  The CI contends that she was given a higher rating for her condition by the VA.  Her complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20060815	VA Rating Decision1 - 20030611	
TDRL Placement – 20021106	Code	Rating	Condition	Code	Rating
Proximate	
Condition		TDRL
Placement	TDRL Removal			TDRL2
Placement	TDRL3
Removal	
Conversion Disorder	9424	30%	10%	Conversion Disorder	9424	30%	70%	
COMBINED RATING:  30% → 10%	COMBINED RATING FOR ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Conversion Disorder.  The service treatment record (STR) indicated the CI was admitted to inpatient Mental Health on 21 May 1996 for possible amnesia and disorientation after she noted missing a morning meal and a single dose of Zoloft (Sertraline, an antidepressant medication).  Workup was normal and the final diagnosis on discharge was rule out conversion disorder with mixed presentation.  At an emergency room (ER) visit in July 2002 the CI, who complained of left sided numbness/weakness, chest pain and headaches, experienced tonic-clonic (shaking) movements of her upper and lower extremities.  Conversion disorder was considered and she was admitted to the hospital.  A computed tomography (CT) scan showed no acute intracranial findings; a magnetic resonance imaging (MRI) study was normal; and a CT scan/angiogram (to visualize arterial and venous vessels) for atypical chest pain was normal.  Other than iron deficiency, the CI’s workup was normal.

At the Medical Evaluation Board (MEB) psychiatry narrative summary (NARSUM) dated 26 July 2002 listed Axis I diagnoses as conversion disorder, with mixed presentation, and undifferentiated somatoform disorder.  The Global Assessment of Functioning (GAF) in the hospital was 41 (serious symptoms or any serious impairment in social, occupational, or school functioning) with considerable social/industrial impairment and marked military impairment.  She had an S-4 profile.

During the post-TDRL placement neuropsychological testing in 12 December 2002 reflected normal cognitive strengths and weaknesses, but provided no clear evidence of significant neuropsychological impairment nor did she appear to have a major mood or thought disorder.  Her behavior occasionally appeared dramatic or attention-seeking, particularly during times of stress.  Outpatient mental health services were recommended “to help her better understand the previously diagnosed relationship between her mental/emotional functioning and her physical health.  She may benefit from additional training in stress/anger management, and health psychology interventions to manage her ongoing chest pain and sleep disturbances.”

On 24 January 2003 she had an ER visit with the complaint of three episodes of seizures with numbness and lack motion of the extremities.  Symptoms resolved in the ER.  Psychological testing in June 2003 revealed a high level of psychological distress and the CI appeared both “depressed and anxious…and seemed prone to somatization.”  The psychologist opined the CI was “likely to be angry, resentful and suspicious” and had “poor self-esteem, few coping resources, and appear[ed] to be somewhat skeptical regarding the chances of obtaining some benefit from treatment.”  He further believed the CI had “an affective disorder.”  In July 2003 she was treated with Sertraline (antidepressant), and Temazepam (insomnia).

The commander’s statement dated 20 August 2002 indicated the CI could and did work full shifts; however, he did not know how she would satisfy duty requirements anywhere in the world.  He recommended the CI be returned to duty with restrictions.

At the VA Compensation and Pension (C&P) examination performed 8 April 2003, 5 months after TDRL placement, the CI reported daily symptoms of depression since separation in November 2002 as well as anxiety, irritability, and anger on a daily basis.  On examination she demonstrated left-sided stiffness with difficulty walking and using her left arm and hand.  The CI’s thinking was vague and lacked coherency.  She was oriented and denied suicidal or homicidal ideation.  She showed some moderate-severe impairment in delayed recall of verbal items and her speech was imprecise and tangential, but normal in volume and rate.  Her affect fluctuated from euthymic to tearful and she endorsed several symptoms of depression and reported she had not slept well since July 2002.  The Axis I diagnoses were conversion disorder and major depressive disorder; her GAF was 52 (moderate symptoms or moderate difficulty in social, occupational, or school functioning) based on severe symptoms of depression and moderate-severe somatic symptoms as well as moderate-severe impairment in social/occupational functioning.

The Board directed attention to its rating recommendation based on the above evidence for TDRL placement.  The PEB assigned a 30% rating using code 9424 (conversion disorder [functional neurological symptom disorder]) for the Category I conversion disorder associated with an undifferentiated somatoform disorder.  The VA assigned a 30% rating using code 9424.  While the CI had occupational and social impairment, she did not have a flattened affect, circumstantial, circumlocutory, or stereotyped speech; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood.  However, she did have panic attacks, although not more than once a week, and difficulty in establishing and maintaining effective work and social relationships.  Board members discussed the CI’s condition and she had some features warranting a 50% rating, but overall her condition did not rise to a 50% rating.  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 at TDRL placement.

After TDRL placement neuropsychological testing in 12 December 2002 reflected normal cognitive strengths and weaknesses and provided no clear evidence of significant neuropsychological impairment.  It was also negative for a major mood or thought disorder, although her behavior occasionally appeared dramatic or attention-seeking during stressful times.  Outpatient mental health services were recommended “to help her better understand the previously diagnosed relationship between her mental/emotional functioning and her physical health.”

In January 2003 she had an ER visit with the complaint of three episodes of seizures with numbness and lack motion of the extremities.  Symptoms resolved in the ER.

Psychological testing in June 2003 revealed a high level of psychological distress and the CI appeared both “depressed and anxious…and seemed prone to somatization.”  The psychologist opined the CI was “likely to be angry, resentful and suspicious” and had “poor self-esteem, few coping resources, and appear[ed] to be somewhat skeptical regarding the chances of obtaining some benefit from treatment.”  He further believed the CI had “an affective disorder.”  In July 2003 she was treated with Sertraline (antidepressant) and Temazepam (insomnia).

Mental health care was continued through January 2004 when the CI was admitted for psuedoseizures (pseudoepileptic seizures of a psychological origin) and atypical chest pain.  Workup revealed normal awake and sleep electroencephalograms (EEGs), a normal cardiology workup and CK (creatine kinase) levels (markers of potential mental health or medication issues), and a urinary tract infection.  Treatment consisted of Prozac (antidepressant), an antibiotic, and Vicodin (pain reliever), which seemed to ease her pain.

At a VA Mental Disorders examination dated 10 March 2005 referenced a 29 December 2004, which was 21 months before TDRL removal, the CI complained of “mood problems,” had suicide ideation during the prior 5 years, but no attempts, and reported “panic attacks” consisting of chest pain, hyperventilation, and syncope at least once a week and a pseudoseizure occurred 3 weeks earlier.  On examination she ambulated slowly using a walker, appeared anergic (deficiency of energy).  She responded to questions in a soft and whispery voice and grimaced and frowned when asked questions in the sensorial examination.  She did not have a depressed facies or show evidence of depression in the tone of her voice.  She had no delusions or hallucinations, but had “much somatic ideation,” but no suicidal ideation.  Her mood was depressed based on the content of her thoughts; however, her affect was inappropriately pleasant.  She was determined to be not competent to manage her finances.  The Axis I diagnosis was conversion reaction and depressive disorder NOS and the Axis II diagnosis was histrionic personality disorder. Her GAF was 40 (50% due to the conversion disorder and depression and 50% due to the personality disorder).

On 1 April 2004 and 30 July 2005 she was hospitalized for conversion disorder.  By October 2005 the CI reported her conversion disorder and panic attacks had been under control even though she had been in and out of the hospital for abdominal pain for adhesions and endometriosis.  On examination her mood was euthymic and affect was congruent to her mood.  Trazadone (an antidepressant medication) was prescribed for insomnia; however the CI declined antidepressants since she did not have symptoms of depression.

In May 2006 the CI reported she was mainly concerned about abdominal pain, which was felt to be pancreatitis with elevated liver enzymes.  She denied any significant depressive, anxiety, or other psychiatric symptoms. In June 2006 a psychologic evaluation was “no psychiatric diagnosis or condition on Axis I” or Axis II.  On a patient evaluation intake form in June 2006 the CI noted she had severe anxiety problems and was diagnosed with a conversion disorder in 2002.  She noted stress was an inducer of the disorder and it improved with stress relief, talking, removal from the situation, and “plan out problem(s).”  She was planning on a BA college degree and “had a great relationship with her son as a single parent.”  She listed medications she took for pancreatitis and nausea, but none for any psychiatric condition.

At the CI’s third TDRL evaluation dated 23 June 2006, 2 months prior to TDRL separation for the conversion disorder, she reported significant improvement clinically and functionally.  The CI had no anxiety in the prior year, had occasional symptoms of chest discomfort exacerbated by stress and developed coping strategies, had a recent decrease in sleep and a mild level of feeling hopeless due to uncertainty about her military career.  She stopped work to attend classes, complete homework assignments, and to raise her son and reported a good level of social interaction with friends.  On examination the CI was oriented to person, place, time, and situation.  Concentration, attention, and eye contact were within normal limits.  She displayed no psychomotor agitation and speech was normal.  Her mood was “nervous” and affect was appropriate and congruent with her mood.  Thought content showed no evidence of psychotic symptoms or processes and she denied any suicidal or homicidal ideation, plan, or intent.  The Axis I diagnosis was conversion disorder, resolved and the GAF score was 80 (If symptoms are present, they are transient and expectable reactions to psychosocial stressors; no more than slight impairment in social, occupational, or school).

A mental health note on 22 August 2006, 1 week before TDRL removal, indicated the CI denied current depression and anhedonia and had not had a panic attack since July 2005.  Her biggest problem was severe and incapacitating abdominal pain with nausea and vomiting.  She did not endorse core symptoms of dysthymia, schizophrenia, bipolar disorder, general anxiety disorder, or obsessive compulsive disorder, and she did not take any psychotropic medications.  During her mental status examination her appearance was conservative; grooming and hygiene were good; speech was fluid; eye contact was normal; psychomotor activity was normal; mood was not depressed; affect was euthymic at all times; thought process was circumferential and over inclusive; thought content was without delusions, hallucinations, suicidal ideation or homicidal ideation; insight was good; judgment was good; and cognition was alert with normal attention per conversation.  Axis I diagnoses were conversion disorder, somatoform disorder, MDD (major depressive disorder) in remission, and panic disorder in remission.  The Axis II diagnosis was histrionic traits and Axis IV diagnoses were health problems and chronic mental illness.  Her GAF was 45 (serious symptoms).  Treatment consisted of Temazepam for insomnia.

At a VA C&P Mental Disorders examination on 4 October 2006, 2 months after TDRL removal, the CI reported she could handle her finances and had not had a panic attack since June 2006.  She had not had a seizure in the last 3 months.  She reported not working in the prior 12 months due to chronic pancreatitis, gynecological problems, and multiple hospitalizations.  During her prior examination she had been on five medications; at this examination she was only on one medication, Bentyl (dicyclomine, an antispasmodic medication for the bowel).  On examination the CI’s thought process was logical and goal directed; there were no delusions, hallucinations, or suicidal or homicidal thoughts, intent or plan.  She was capable of maintaining personal hygiene and basic activities of daily living and was oriented to person, place, and date.  There were no deficits of memory loss or impairment and no obsessive or ritualistic behavior.  Speech was spontaneous, relevant and otherwise normal.  No panic attacks were observed.  She denied current depression or a depressed mood and denied she was depressed during her examination in March 2005.  Additionally, she denied impaired impulse control, sleep impairment, or other symptoms.  The examiner opined that the CI was capable of managing her financial affairs and the CI verified this capability by keeping a note book and spreadsheet to manage these affairs.  The CI was diagnosed with Axis I panic disorder without agoraphobia; conversion disorder (pseudoseizure); history of major depressive disorder, recurrent, in full remission.  The Axis II diagnosis was possible histrionic traits and the Axis III diagnosis was chronic pancreatitis, status post hysterectomy, ovarian remnant syndrome, status post cholecystectomy, and chronic headaches.  Her GAF was 40-45 (serious symptoms).

At a psychology assessment in 23 January 2007, 4 months post TDRL removal, the CI indicated she did not believe there was any psychological element to her problems; she denied that stress exacerbated her problems; and she denied that conversion disorder was an accurate diagnosis.  Based upon an interview and testing the Axis I diagnosis of a somatoform disorder was made and her GAF was 55 (moderate symptoms).  The examiner opined the CI had either conscious or unconscious downplay of her psychological problems.  This could mean either she genuinely is negative to psychopathology, or that she is not admitting to psychopathology.  Due to her defensiveness, it is difficult to ascertain.

During at Mental Health visit dated 24 April 2007, 7 months after TDRL removal, the CI reported not being employed, had no history of violence or suicide attempts and was not taking psychotropic medication.  Her mental status exam revealed:  good grooming and hygiene; fluid speech; normal eye contact and psychomotor activity; no startle response seen; less frustrated mood; calm affect;  linear thought process; no delusions, hallucination, suicidal or homicidal ideations; with fair insight and judgement; and cognition was alert with normal attention per conversation.  An Axis I diagnosis and GAF were not rendered.

At a mental health visit dated 24 August 2007, 11 months after TDRL removal, the CI noted she was not having anxiety or depression since 2002.  She did not agree with her conversion disorder and pain disorder diagnoses.  She was just there to follow up.  She reported the Temazepam caused pancreatic pain and Tales Diazepam (an anti-anxiety medication also used for muscle spasms and seizures) was prescribed in its place.  The mental health examination revealed her mood “not so good” with tearful affect talking about her pain.  She took notes of their interview.  Her speech was large in volume and preoccupied with her physical pain.  No evidence of psychosis, suicidal or homicidal [ideations].  She had limited insight with fair judgment.  An Axis I diagnosis and GAF were not rendered.

The Board directed attention to its rating recommendation based on the above evidence for TDRL removal.  The PEB assigned a 10% rating using code 9424 for the Category I conversion disorder, resolved.  The VA assigned a 70% rating using code 9424 for conversion disorder.  The Board sought a route for a higher rating and noted a 30% rating, which the CI received on TDRL placement, requires an “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).”  

The CI reported not working because she was either pursuing academic studies or experiencing abdominal pain.  She was capable of making her own financial decisions and reported her depressed mood had improved with no panic attacks since June 2006.  The Board unanimously agreed the CI’s post-TDRL removal mental health impairments did not meet the 100% impairment or 70% (impaired in most areas) $4.130 mental health criteria.  A 50% rating requires an “occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.”  The CI had limited relationships outside of her immediate family, but at the time of TDRL removal did not have flattened affects, abnormal speech, panic attacks, difficulty in understanding or difficulty with her memory or impaired judgment or abstract thinking.  While the GAF is in itself not sufficient for rating purposes, Board members noted that the CI’s GAF scores remained in the serious symptoms range through the TDRL period except for the TDRL removal examination when it rose to 80 (transient symptoms), which may not have taken into account the CI gastrointestinal pain and was disparate from subsequent GAF scores.  The Board majority determined the low GAF scores (40s) issued after TDRL placement were over-estimated since the CI’s mental condition did not require further hospitalized.  The Board majority found the CI’s mental condition to be mild and transient at TDRL removal based on her semblance of academic, family, social success and stability, which was relatively higher than TDRL placement.  Consequently, the Board majority determined the CI she would only experience decrease in work efficiency and the ability to perform occupational tasks only during periods of significant stress at the time of TDRL removal.  Therefore, the Board majority found retention of the PEB’s 10% rating for the conversion disorder was not unreasonable.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the conversion disorder condition at TDRL removal.  The single voter for dissent submitted the appended minority opinion.

BOARD FINDINGS.  In the matter of the conversion disorder condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication for TDRL placement and the Board majority recommends no change in the PEB adjudication for TDRL removal.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determinations.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140312, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Minority Opinion			           CASE:  PD-2014-01264

The CI received a 30% rating on TDRL placement and should receive a 30% rating on TDRL separation.  The CI had a conversion disorder for years and the symptoms of the disorder were such to not only have the CI be placed on TDRL in 2002, but for her to have remained on TDRL for almost 4 years thereafter.  While there is evidence to point to her having improved somewhat related to fewer symptoms and increased functionality, the NARSUM TDRL examination that resulted in TDRL removal did not take into account her years of symptoms that warranted the diagnosis of a conversion disorder.  Furthermore, the assignment of a GAF score of 80 seemingly failed to account for her significant abdominal symptoms and the score was also inconsistent with all GAF scores prior to that examination, which were in the moderate range, and those that were subsequent to it, which were in the serious range or moderate range.  More importantly the CI fulfilled the VASRD requirements significantly better for a 30% rating that requires “Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events)” rather than a 10% rating that requires “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.”  It is conceded that the mild memory loss resolved when Ambien was discontinued and around the time of the TDRL removal examination the CI was only taking medication for her abdominal pain; however, the VA nonetheless assigned a 70% rating, which is exceedingly disparate from the PEB TDRL removal assignment of 10%.  DoDI 6040.44 clearly directs that “the PDBR should compare any DVA disability rating for the specifically military unfitting condition(s) with the PEB combined disability rating and consider any variance in its deliberations and any impact on the final PEB combined disability rating, particularly if the DVA rating was awarded within 12 months of the Service member’s separation.”  

A comparison of reported symptoms at the TDRL removal examination to the VA examinations proximal to TDRL removal points to a rational basis for a higher rating than 10%.  While the CI reported she had “occasional symptoms of chest discomfort exacerbated by stress,” had “a recent decrease in sleep and a mild level of feeling hopeless,” and noted “her mood was “nervous,” 1 week after TDRL removal she indicated she “had a history of recurrent spontaneous panic attacks (chest pain, shortness of breath, dizziness, and anxiety) and trouble sleeping” and her biggest problem was severe and incapacitating abdominal pain with nausea and vomiting that involved multiple visits and medical examinations.  At 5 months after TDRL removal, based upon an interview and testing the Axis I diagnosis of a somatoform disorder was made and her GAF was 55 (moderate symptoms).

For all the aforementioned reasons, especially related to the CI’s history, her ongoing physical symptoms, and her continuous diagnosis of conversion disorder and a subsequent VA diagnosis of a somatoform disorder (a pattern of many physical complaints over several years), and in consideration of VASRD §4.3 (Resolution of reasonable doubt), which states “It is the defined and consistently applied policy of the Department of Veterans Affairs to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant,” a 30% rating at TDRL removal is more accurate and reasonable than a 10% rating.  

RECOMMENDATION:  The minority member recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Conversion Disorder	9424	30%	30%	
RATING	30%	30%	

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-01264.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings