RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02121
BRANCH OF SERVICE:  Army	BOARD DATE:  20141103
SEPARATION DATE:  20070417

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (91W/Medic) medically separated for conversion disorder, pseudo seizures.  The 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/S1 profile and referred for a Medical Evaluation Board (MEB).  The conversion disorder condition characterized by “recurrent seizure-like events with normal electroencephalogram (EEG)” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also forwarded 11 other conditions (charted below) for PEB adjudication.  The Informal PEB adjudicated “conversion disorder…” as unfitting, rated at 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) and did not address the remaining MEB conditions.  An administration PEB adjudicated the remaining 11 conditions as meeting medical retention standards. The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions found unfitting and not unfitting by the physical evaluation board”

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 ratings for the unfitting conversion disorder and the conditions that met medical retention standards are 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 Military Records.

RATING COMPARISON:  The MEB also noted occupational stress.  This is not a diagnosis.

Service Admin Corrected PEB – Dated 20070222	VA - (2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Conversion Disorder…	9424	10%	Conversion Disorder, …	9424	30%	20070605	
Anxiety Disorder, NOS	Meets Medical Retention Stds					
Alcohol Abuse …	Meets Medical Retention Stds	No VA Entry				
Migraine Headaches	Meets Medical Retention Stds	Migraine Headaches	8100	30%	20070606	
Malignant Melanoma, Stage IIb.	Meets Medical Retention Stds	No VA Entry				
Hypertension	Meets Medical Retention Stds	Hypertension	7101	0%	20070606	
Ulnar Neuropathy	Meets Medical Retention Stds	Left Ulnar Nerve Compression	8616	10%	20070606	
Lung Nodules	Meets Medical Retention Stds	Lung Nodules, R Lung	6820	NSC	20070606	
Renal Cyst	Meets Medical Retention Stds	Renal Cyst, Right Kidney	7529	NSC	20070606	
Chronic Sinusitis	Meets Medical Retention Stds	Chronic Sinusitis	6512-6513	0%	20070606	
Low HDL	Meets Medical Retention Stds	No VA Entry				
Slight Regurgitation w/o Emesis	Meets Medical Retention Stds	Traction Esophageal Diverticulum…	7205-7203	NSC	20070606	
Other x 0  (Not in Scope)	Other x 1	20070606	
Combined:  10%	Combined:  70%	
Derived from VA Rating Decisions (VARDs) dated 20070627 (most proximate to date of separation) and 20070713.   

ANALYSIS SUMMARY:  The PEB rating preceded the promulgation of the National Defense Authorization Act 2008 mandate for DoD adherence to the VA Schedule for Rating Disabilities (VASRD) §4.129.  The Board, IAW DoDI 6040.44 and DoD guidance (which applies current VASRD §4.129 to all Board cases as appropriate), must consider if the definition of §4.129 is met for any psychiatric condition resulting in medical separation; i.e., “a mental disorder that develops in service as a result of a highly stressful event.”  If the Board judges that application of §4.129 is appropriate, it will recommend a minimum 50% rating for a retroactive 6-month period on the Temporary Disability Retired List (TDRL).  The Board must then determine the most appropriate fit with VASRD 4.130 criteria at 6 months for its permanent rating recommendation, based on the facts in evidence that are most probative for that interval.  Although numerous conditions were evaluated by both the MEB and PEB, only the conversion disorder was found to be unfitting.  All the conditions in scope developed following the appendectomy performed in theater and there is considerable overlap in service records as many notes address multiple conditions including the evaluations in specialty clinics.  Therefore, the Board determined that discussing the conditions in chronological sequence was both appropriate and preferable to addressing each condition separately.  They are separated for adjudication as appropriate.

Conversion Disorder, Pseudoseizures Condition: The CI entered active service on 7 May 2003 and was seen for left and right knee pain, a left great toe contusion and abdominal pain in the first year after accession.  On 15 November 2004, while deployed, he had an emergent appendectomy and was then evacuated from theater.  The notes for this procedure were not in evidence.  While at Landstuhl hospital (Germany) for recovery, he was also evaluated for chest pain (the evaluation was negative) and right upper extremity pain.  He was seen in cardiology on 29 November 2004 and reported almost continuous chest pain which began after his appendectomy.  An extensive evaluation was normal other than hypertension (high blood pressure).  The CI reported left anterior chest wall pain since his appendectomy which radiated into the left arm and up into the left neck.  Also, he reported a sensation of choking on the left and pain radiating into his left lower extremity to just above the knee.  That same day, he was found to have a left cephalic vein thrombosis (a bold clot in a large vein of the upper arm) in the emergency room.  This was treated; however, he had persistent sensory changes and further evaluation including blood work, magnetic resonance imaging (MRIs) of the brain and spinal cord and electro-diagnostic testing.  He diagnosed with a compressive injury to the ulnar nerve, presumably secondary to the surgery which was done under field conditions.

He was evacuated on 11 December 2004 back to his home unit.  On 17 December 2004, he reported that his pain had resolved.  However, when he was seen in follow-up in primary care on 3 January 2005, he reported continued, intermittent left upper chest and shoulder pain which lasted about 30 seconds and was associated with subsequent numbness which lasted a variable length of time and was relieved with a change in position.  A neurology evaluation performed on 1 March 2005 as part of his pain evaluation.  He noted the persistent chest wall and left upper arm pain which began 2 weeks after the appendectomy.  He also noted weakness of the left arm and occasional dropping of objects which he was carrying.  The examination was unremarkable.  Further studies were ordered, but no diagnosis was given.

A primary care note dated 4 March 2005 documented that a work-up for a bleeding disorder (for the blood clot) was normal.  During another primary care appointment, 3 days later, the CI presented with the complaints of chest pain, left sided weakness, numbness and a one-month history of blackouts (the first these are recorded).  He reported little interest in anything and that his wife took care of everything.  He was thought to have depression with somatoform complaints.

At a primary care follow-up on 15 March 2005, he again endorsed fluctuating chest pain with radiation to the left side of his neck and left arm.  He further stated that a neurologist had told him that nerve damage was evident on electrodiagnostic testing.  The CI was seen in follow-up in neurology on 28 March 2005 for the chronic left shoulder and arm pain, chronic left hip and knee pain, chronic headaches and blackout spells.  The CI reported that his blackouts had improved since starting an anti-convulsant medication (not previously recorded).  He was thought to have syncopal (fainting) episodes.  An EEG, ordered to evaluate a possible seizure disorder, was normal.

He was again seen in neurology on 25 April 2005.  In addition to the normal EEG, the examiner noted the normal MRI of the brain and normal electrodiagnostic testing of the lower extremities and no left cervical radiculopathy (damage to the nerve root) on testing of the upper extremities (no comment was made regarding a distal neuropathy, such as an ulnar neuropathy).  He continued to complain of headaches and syncope episodes.

On 13 May 2005, during a primary care appointment, he reported that he was still in pain.  The CI denied depressive symptoms on screening, but active problems included a seizure disorder, to note an aura prior to the syncopal episodes and that he got a headache and had loss of urine and tongue biting, once each.

The CI was examined in occupational therapy on 13 June 2005 and reported a 3-month history of numbness and tingling from his left elbow to the 4th and 5th digits of the left hand.  On examination, weakness was present as was atrophy of the muscles.  He was again seen in neurology on 21 July 2005 for the syncopal episodes, headaches and chronic low back pain (LBP).  The syncope episodes were twice a week, for the past month, and reported 3 episodes of loss of urine control and had bit his tongue.  He reported a loss of consciousness for approximately 2 hours.  He denied present stress, but had recently been home for a month due to the death of family members.  His headaches had improved, but he reported numbness and tingling in his legs and weakness in his arms and legs.  On examination, he did not appear to be in any discomfort and had a normal neurological examination.  Atrophy was not recorded on this examination.

At a primary care appointment on 12 August 2005, he reported a 4-month history of a seizure disorder.  The seizures were typically at night and associated with lethargy the next morning.  He denied symptoms of depression.  He also reported that after the appendectomy, he had developed chronic arthralgias (joint pain) in his knees and left wrist, a left “ulnar” neuropathy (damage to the ulnar nerve, one of the nerves which innervate the hand).  He reported nearly daily episodes of the “seizures.”  He was noted to have some weakness of the left hand and some sensory changes.

In physical therapy on 15 August 2005, he noted that his health had gone downhill since his appendix had ruptured.  He reported bilateral knee pain, two types of seizures and back pain.  At the appointment, he was observed to have a right calf skin lesion which ultimately was resected and shown to be a malignant melanoma.  In orthopedics on 18 August 2005, he reported that his strength had returned, but he still had (apparently) sensory changes of the 4th and 5th digits.  He was also seen in neurology that same day and reported that his black out episodes had improved since his previous visit.  His headaches had also improved.  He was noted to have no focal weakness (indicative damage to a nerve or nerve root).

At a dermatology follow-up appointment on 22 August 2005, he was informed that a recent biopsy of a skin lesion of the right calf was invasive malignant melanoma and a further evaluation begun.  An MRI of the lumbar spine on 23 August 2005 revealed degenerative disc disease (DDD) with a bulge at L4-5.  No impingement of the nerve roots or spinal cord was noted.  An MRI of the brain the same day showed no brain metastases.  He was also seen in primary care that day for the melanoma follow-up.  He was informed that he would be referred to cardiology to evaluate his “loss of consciousness” episodes if the neurology evaluation for a possible seizure disorder was negative.

The CI was seen in cardiology on 31 August 2005.  The syncope was not thought to be from a cardiac cause (non-cardiogenic).  A CT scan of his chest, done for the melanoma evaluation, on 1 September 2005 (see pulmonary note) showed three nodules in the right lung.  The same pulmonary note documented that another test, a PET scan, which measures metabolic activity, showed no pathology in the chest.

He was again evaluated in neurology (at a referral center) on 2 September 2005 for “spells of an unknown etiology.”  He was thought to have a history classic for a seizure and findings concerning for a left hemispheric lesion (left side of the brain) and was admitted for a further evaluation.  The same day, an MRI of the brain was normal.  No seizures were observed while in the hospital.  He was noted to have a left ulnar neuropathy.  A permanent P3 profile for pseudoseizures versus seizures was issued 19 December 2005.  No other conditions were listed.
 
The CI was referred to an epilepsy center on 9 January 2006.  He reported that recent stressors had contributed to his “seizure disorder.”  These included the loss of three members of his wife’s family, his diagnosis of melanoma and his father’s recent open heart surgery.  He noted that the frequency of these had been twice a day initially, but was now once every 1 to 2 weeks.  He also had migraines and the LBP.  He had some left sided weakness consistent with the ulnar neuropathy.  The Board noted that previously at both orthopedic and neurology evaluations the weakness had been absent.

He was evaluated in nephrology (kidney specialist) on 23 January 2006.  He was noted to have uncontrolled hypertension and a cyst on the right kidney.  He also reported frequent headaches at this appointment.  It was noted that the evaluation for his hypertension had been unremarkable and that the kidney cyst was benign and no treatment needed.  A follow-up ultrasound evaluation was recommended in 6 to 9 months.  A modification in the treatment for his hypertension was recommended.

Pulmonary function tests on 31 January 2006 were normal.  A pulmonary evaluation for the lung nodules (see above) on the same day noted a 2-month history of shortness of breath and some chest discomfort with deep breathing.  The nodules were thought to represent an old infection (changes from histoplasmosis, a common condition in many parts of the USA and typically of no significance).  The chest wall pain was thought to be from the inflammation at the chest wall cartilage/rib junction (costo-chondritis).  The shortness of breath had no clear etiology, but poor condition was thought to be an explanation.  A repeat CT scan for comparison was recommended.

The CI was admitted from 1 February - 8 February 2006, for long-term monitoring to evaluate his “medically refractory seizures.”  The CI had an event while being monitored and showed no epileptiform activity.  (The EEG was normal during an episode, excluding a seizure).  He was evaluated by mental health (MH) and found to have multiple risk factors for psychogenic non-epileptic attacks and this was the discharge diagnosis.  There was “no evidence for epilepsy.”  The consultant thought that this was more consistent with either a somatoform disorder not otherwise specified (NOS) or a conversion disorder.  (For both diagnoses, there are physical symptoms related to MH issues).  Posttraumatic stress disorder (PTSD) symptoms were not significant.  Discontinuation of the seizure medications and mental health referral were recommended.

At a follow-up pulmonary medicine appointment on 28 February 2006, the repeat CT was noted to be stable.  Periodic CT scans were suggested to follow this, but no further evaluation recommended.  At a follow-up appointment in neurology on 20 March 2006, he was noted to have psychogenic non-epileptic attacks.  He had stopped the anti-seizure medications, but had not initiated MH treatment.  He was advised not to drive as he continued to have attacks.  No further follow-up in neurology was deemed necessary.  The CI was re-evaluated in nephrology on 3 April 2006 for his hypertension.  He reported persistent LBP which was attributed to DDD.  He stated that when he bent, he developed numbness in his legs and was unable to keep his balance.  He was thought to have essential hypertension (high blood pressure which is not secondary to another cause such as a kidney problem) and was also noted to have painful urination.  A follow-up echocardiogram on 12 May 2006, performed to evaluate the chest pain, was normal.  A chemical stress test, to evaluate the chest pain, on 17 May 2006 was normal and the chest pain was not reproduced.

The general narrative summary was dated 29 May 2006 (performed 11 months prior to separation), the CI had been diagnosed with psychogenic non-epileptic attacks.  The ulnar neuropathy, perioperative from the appendectomy, was noted to be improving.  The examination referenced was from August 2005 and recorded above.  Diagnoses at MEB referral included psychogenic seizures, right lower extremity invasive melanoma, hypertension, ulnar neuropathy, lung nodules, renal cyst, chronic sinusitis on MRI, a low HDL (a laboratory finding), and slight regurgitation without emesis.  MRIs of the brain with and without contrast on 7 July 2006 were unremarkable other than some indications of sinusitis.

The psychiatry addendum dated 12 July 2006 (9 months prior to separation), reported “treating many inured Iraqi children” and specifically remembered troubling memories from witnessing the burning of a 6 year old child.  He endorsed jumpiness and anxiety in the morning, increased irritability and occasional nightmares.  These symptoms and history had not been previously recorded.  He denied symptoms consistent with a major depression, mania, psychosis, obsessive compulsive disorder or substance abuse.  He reported that he and his spouse had dealt with “numerous miscarriages over the past couple of years that have been difficult.”  He reported the loss of a sister at age three (drowning) and physical abuse growing up.  He gave a past history of heavy alcohol abuse.  On examination, his speech was mildly monotonal and affect mildly constricted.  His mood was described as “ok today.”  He had significant anxiety and some PTSD like symptoms.  He was responding to medications.  He was thought to have a conversion disorder with mild to definite social and occupational impairment and an anxiety disorder with mild impairment.  He was assigned a Global Assessment of Function (GAF) of 65, indicative of mild impairment or symptoms.  The condition was thought to not meet retention standards.

The dermatological addendum was the next day.  The malignant melanoma was noted to be medically acceptable.  The CI was evaluated in oncology for his malignant melanoma on 29 August 2006 (not in record) and seen in follow up on 11 September 2006.  The latter note documented that he had a normal physical examination and laboratory tests at the initial visit.  Periodic surveillance for melanoma recurrence was recommended.

The commander’s letter was dated 12 October 2006 and noted that he was an excellent soldier, but his condition (seizures) rendered him unable to function in a combat environment.

A psychiatry note on 17 January 2007, which was prepared for the PEB, documented that the CI had two migraine headaches a month and was treated with a prophylactic medication.  The migraines were medically acceptable.  The administrative PEB corrected DA Form 199-1 dated 22 February 2007, noted that 2 months prior to separation, the MEB process, the CI “works from 0930-1630 as a clinical specialist for the rear detachment.”  The MH condition was thought to have a “mild impact on his industrial and social capabilities.”

At the VA MH Compensation and Pension (C&P) exam (performed 2 months after separation), the CI reported that he was unemployed, but looking for a medically related job close to his home.  He was also ready to start college.  He reported heavy alcohol use from age 22 to 24 (pre-service), but now only drank socially and had not drank to excess for over a year.  He noted violent outbursts in which he broke things and periods of depression with crying.  This had not been previously recorded and it was not clear if this was a current or historical issue.  He also reviewed his history of the “spells” and migraines.  He again noted the stress from the miscarriages his wife had had as well as the trauma growing up including physical abuse and the loss of a sister.  He reported, for the first time, that 13 friends were killed during deployment and the loss of a local civilian, that he provided care after he was shot.  He again reported the injuries to children, adding that several had died in his arms.  Also, he endorsed nightmares involving these children and his own which he stated had started a year prior.  On examination, he had poor eye contact and psychomotor retardation.  He was soft spoken and the rate of speech was slow.  Affect was blunted.  He reported poor sleep for which he took a sleeping aid.  He stated that loud noises bothered him, but denied avoidant behavior, hypervigilance or hyper-arousal.  He was diagnosed with a conversion disorder and anxiety disorder, NOS.  A GAF of 65 was assigned, unchanged from the PEB assessment.  The general VA C&P examination was the next day.  He was found to have a sensory loss of the left fourth and little fingers (consistent with ulnar neuropathy) and on mental status examination, to have a flat affect and depressed mood.

The Board first considered if the application of VASRD §4.129 was appropriate.  As discussed above, the application of VASRD §4.129 is warranted if the underlying mental health condition results from a traumatic stressor.  In this case, the initial presentation was for chest wall pain and left upper arm pain during the recovery period for an appendectomy.  The chest wall pain was diagnosed as costo-chondritis and the left upper arm pain was secondary to both a blood clot and a neuropathy of the ulnar nerve.  The CI also had numerous other stressors including the death of multiple family members, his wife’s repeat miscarriages, his father’s recent serious illness, and a past history remarkable for both childhood physical abuse and the loss of his sister at age three.  The CI later endorsed trauma from taking care of injured children while deployed; but this history was not recorded until the CI was in the MEB process and over 18 months after the initial symptoms. The Board did observe that the MEB psychiatrist attributed the conversion disorder, in part, to experiences in Iraq.  However, it was also linked to the other stressors including the multiple miscarriages, family deaths and father’s illness which were reported over a year earlier in previous MH interviews.  After deliberation, members agreed that, although some contribution of stressors to the psychiatric condition was likely present; the requisite §4.129 link that the conditions occurred as a result of a highly stressful event was not adequately satisfied.  The Board therefore will consider only the VASRD §4.130 impairment present at separation for a single rating recommendation.

The Board then considered the appropriate rating IAW VASRD §4.130 based on the above evidence.  The VA examiner recorded that the CI was planning to attend college and was looking for another medically related job near his home, but that during one of his “spells”, the CI would be unable to perform any duties until he recovered.  This is consistent with the description for a 30% rating “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).”  However, the Board also noted that the CI was described by his commander as an excellent soldier, although the commander also commented that he had a “seizure disorder” and could not function in a combat environment.  The Board observed that the PEB specifically annotated that the CI was working in his occupational specialty in a rear detachment from 0930-1630 daily.  The Board determined that while the concern raised by the VA examiner was reasonable, it was not supported by the actual level of function in evidence proximate to separation as recorded by the PEB.  The Board further noted that there were no emergency room visits, no hospitalizations, no history of panic attacks, and that the symptoms were improving on medications.  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.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that the contended not unfitting conditions were not unfitting.  These included the anxiety disorder (the effects of which are subsumed under the unfitting conversion disorder), the alcohol abuse, migraine headaches, malignant melanoma, hypertension, ulnar neuropathy, lung nodules, renal cyst, chronic sinusitis, low HDL and regurgitation.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  None were profiled or implicated in the commander’s statement.  All were judged to be medically acceptable.  The migraine headache condition was not specifically determined to be medically acceptable by the MEB, however the MEB psychiatrist noted that it was acceptable.  All were reviewed by the action officer and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended conditions and so no additional disability ratings are recommended.

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.  In the matter of the contended anxiety disorder, the alcohol abuse, migraine headaches, malignant melanoma, hypertension, ulnar neuropathy, lung nodules, renal cyst, chronic sinusitis, low HDL and regurgitation conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20140502, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

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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 AR20150006591 (PD201402121)

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						     XXXXXXXXXXXXXXXXXX