RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02072
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20030922

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Pharmacy Apprentice, medically separated for “conversion disorder,” with a disability rating of 10%.  

CI CONTENTION:  “Incorrect diagnosis.  Claimed I had conversion disorder.  I have neurocardiogenic syndrome.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20030616	VARD - 20070525	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Conversion Disorder	9424	10%	Conversion Disorder	9424	NSC	20070424	
			Major Depressive Disorder	9434	30%	20070424	
			Neurocardiogenic Syncope, Associated With Seizure Activity …	8099-8910	40%	20060919	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Conversion Disorder.  According to the service treatment record (STR) and the mental health Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed loss of consciousness episodes with “seizure-like” activity in 2002 while pregnant.  The CI was first seen by psychiatry in May 2003 as an inpatient transfer for non-epileptic seizures occurring on average 2-3 times per day.  The CI had evaluations for presumed syncopal episodes, then presumed seizure disorder, with a final diagnosis of conversion disorder.  Internal Medicine found no cardiac etiology for the loss of consciousness events.  Neurology specialist evaluation and MEB NARSUM, dated 2 June 2002, indicated that the CI’s initial spells during pregnancy were refractory to treatment and the referring neurologist was suspicious that they were non-epileptic.  “Per husband - seizures described as 10-15 min prodrome of giddiness and confusion followed by passing out and unresponsiveness that is quickly followed by activity described as knees kicking up to head and arms scratching behind head and scratching scalp for 20-45 secs followed again by confusion for 10-15 min.  Episodes seem to increase with stress, +h/o up to 10 episodes occurring at work.”  As part of the specialist’s evaluation, the CI had five episodes during EEG monitoring and videotaping that showed no seizure activity.  The neurology diagnosis was “non-epileptic psychogenic paroxysms” and the CI was referred and transferred to inpatient mental health.  The neurology NARSUM indicated that the CI was “unable to perform her duties due to the occurrence of non-epileptic spells which seem to increase under increased times of stress.”  

The mental health NARSUM, dated 9 June 2003, 4 months prior to separation, indicated the CI reported the "seizures" started about 3 months into her pregnancy and that they got progressively worse.  The CI reported that she had two to three episodes a day on average.  They seemed to increase with stress and lasted for less than a minute with a 10-minute period of confusion afterward.  The CI was 3 months postpartum and not able to work secondary to having frequent spells and was medically evacuated to CONUS to have a work-up for the spells.  On psychiatric review of symptoms the patient denied any depressive, manic or psychotic symptoms.  She states her spells got worse when she read in her out patient record that she had been raped.  She claimed she had no memory of the rape, but did remember being in the hospital after.  There were differences in the rape history details from different examiners and various sources.  

On mental status examination (MSE) the CI “did not seem to be to be concerned about her disorder or the fact that she was separated by thousands of miles from her newborn daughter (baby was left in England).  Her insight and judgement were fair to poor.  There was no active suicidal ideation, delusional or hallucinatory symptoms, or other symptoms suggestive of psychosis, speech disturbance, objective cognitive impairment, or other abnormality.  

The final diagnosis was “conversion disorder as evidenced by loss of voluntary movement and "seizure-like" activity with negative EEG's.  Symptoms become worse with stress.”  The examiner stated “symptoms do not appear to be feigned and may be a dissociative event secondary to rape if in fact patient was raped.  She has a labile-indifference to her plight, which is also seen in this disorder.  Although one could argue for PTSD her major presentation is the seizure-like spells with minimal other symptoms.”  The Global Assessment of Functioning was 50 (serious symptom range 50-41).  The examiner indicated there was marked military impairment and mild social and industrial impairment.  The commander’s statement, dated 10 June 2003, noted the CI was not performing her primary duties, could not work full shifts, was not worldwide assignable, and was on quarters and not available for duty.  The MEB forwarded “conversion disorder” for PEB adjudication.  

There was no VA Compensation and Pension (C&P) evaluation proximate to separation.  The first non-mental disorders C&P examination was 19 September 2006, 36 months after separation with an impression of “neurocardiogenic syncope, some of these episodes, the patient reports associated with seizure activity, grand mal type, with tonic-clonic seizures, urinary incontinence and tongue bite that happens two to three times per year and the last one in last week of May this year (4 months prior to C&P).”  The first mental disorders C&P examination was 24 April 2007, 43 months after separation, and included a medical opinion.  At that evaluation, the CI reported depression and neurocardiogenic syncope.  History included a suicide attempt in 2003 by overdose, and another a few months later by cutting her wrist.  Since separation “she has held a number of jobs which have ended with an episode of syncope.  Employers then regard her as a safety hazard and are concerned about liability.”  The CI reported that she limits her activity markedly for safety because of the syncope episodes, did not shower alone, drove only to medical appointments, and never drove with her children in the car; “I cannot do anything that is dangerous.”  On MSE her mood was markedly depressed and the affect was constricted in range.  Psychomotor activity was mildly irritable, but not agitated. There was no suicidal ideation, delusions, hallucinations or other symptoms suggestive of psychosis, speech disturbance, objective cognitive impairment, or other abnormality.  The examiner stated that the CI was not traumatically stressed by the rape incident – she was drugged to a degree that she has few memories of the rape.  The diagnosis was major depressive disorder, chronic, moderate.  Conversion disorder was not found since there was a medical basis for cardiovascular syncope symptoms, and post-traumatic stress disorder was not found.  The GAF was 53 (in the moderate symptom range 60 – 51) “based on moderate symptoms and impairments of depression apart from other diagnoses.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the conversion disorder condition 10%, coded 9424 (conversion disorder), citing mild social and industrial adaptability.  The VA did not service-connect the conversion disorder condition, based on the C&P examination 36 months after separation, citing conversion disorder not found; however, the VA rated the CI’s “seizure” symptoms as neurocardiogenic syncope associated with seizure activity at 40%, coded 8099-8910 (epilepsy, grand mal); and also rated the mental health condition of major depressive disorder at 30%, coded 9434 (major depressive disorder), based on examination 43 months after separation.  

The panel considered whether the provisions of VASRD §4.129 (mental disorders due to traumatic stress) were applicable.  There were minimal symptoms of stress-type reactions, although the NARSUM psychiatrist noted that “symptoms do not appear to be feigned and may be a dissociative event secondary to rape if in fact patient was raped.”  The CI had no memory of the rape, and symptoms worsened after she read about her rape in her outpatient record.  Remote VA mental health evaluation also indicated the history of rape was not a major trigger of the CI’s mental health symptoms.  All panel members agreed that the evidence of the record did not support a traumatic stressor as the cause of the mental condition for which application of VASRD §4.129 would be appropriate.  

The panel next considered the §4.130 rating at the time of separation.  The higher rating of 30% requires evidence of “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks” 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 panel considered the MEB psychiatrist’s assessment reflecting a GAF in the serious symptom range, marked military impairment with mild social/industrial impairment, frequency of loss of voluntary movement with “seizure-like” activity, and the commander’s June 2003 statement indicating the CI was unable to work shifts and was unavailable for duty.  The panel noted that the CI had experienced non-epileptic spells which increased under increased times of stress, but were present in less stressful periods.  The panel considered that loss of voluntary movement with “seizure-like” activity was not a mild symptom.  All panel members agreed the CI’s condition at the time of separation supported the higher 30% disability rating, and that her level of impairment was better described as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the conversion disorder condition, coded 9424.  

BOARD FINDINGS:  In the matter of the conversion disorder condition, the panel unanimously recommends a disability rating of 30%, coded 9424 IAW VASRD §4.130.  There were no other conditions within the panel’s scope of review for consideration.  

The panel 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Conversion Disorder	9424	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150626, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-02072.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at XXXXXXXXXXXXXXXXXX to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

 XXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings