RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02540
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20040830

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

CI CONTENTION:  “I am 100% disabled by the VA, I was unable to perform any task that would allow me to stay in but was only 10% disabled?”  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 - 20040712	VARD - 20040927	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Conversion Disorder	9424	10%	Conversion Disorder with Pseudo-seizures	9424	30%	20040225	
Anxiety Disorder	Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Conversion Disorder.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI first presented for mental health evaluation as a self-referral on 14 February 2003, 6 months after accession.  He reported being overwhelmed by family obligations and complications which began 3 months earlier, after his family had moved to the local area following boot camp.  He was also noted to have what were diagnosed as pseudo-seizures.  Over the course of the following year, he was treated in mental health without improvement in his symptoms.  He was also seen in emergency room for evaluation after pseudo-seizures on multiple occasions.  It was noted at a mental health evaluation on 2 January 2004 that the CI was frustrated because he felt that the emergency room (ER) staff did not believe him.  He reported that he had hit his head against concrete after a spell and was now having headaches.  The documentation of this ER visit was not in evidence.  On 6 February 2004, the CI was seen with his parents who reported that the CI had tics and obsessive behavior in childhood.  The mother reported that the CI had made “poor choices” his senior year in high school without elaboration.  

At the VA mental health Compensation and Pension (C&P) evaluation performed on 25 February 2004, 6 months before separation, the CI reported poor attendance in high school and that he had gotten C’s and D’s.  He reported that he wanted to see how much disability (pay) he could get as he wanted to use the money for further training (ideally as a policeman).  He reported that he had been on probation for 2 years and had to repay the money he took after stealing from his parents’ business.  He reported that he wanted to make the business fail so his parents could spend more time at home.  He noted that he had been on medications for Tourette ’s syndrome as a child and had seen a psychiatrist for acting out problems.  The panel noted that none of this history had been disclosed at accession.  He reported marital problems with his wife and financial difficulties.  Sometime in March (it is not clear) he separated from his wife.  On examination, he was casually dressed and displayed mildly pressured speech which was somewhat circumstantial.  He was nervous and restless and somewhat vague.  The examination was otherwise unremarkable.  

At a mental health appointment on 29 February 2004, the CI reported that had twisted his knee after a pseudo seizure and had been told that he might have damaged a ligament.  He was using crutches.  These records are not in evidence.  Due to an inability to deploy or go to sea, he was referred into the MEB process, although it is not clear from the record exactly when the MEB process was initiated.  It was recorded that he could resist a seizure, but that he would then have a strong one once it occurred.  

On 26 March 2004, the CI was seen by neurology.  It was noted that he was using a cane, but refused an orthopedic evaluation.  In mental health on 1 April 2004, the CI reported that he was pursuing a divorce and that he was hurting his body due to the episodes in which he hit the furniture, walls, and the floor.  The examiner did not record the presence of any injuries.  

On 26 April 2004, the CI presented to the ER for blunt head trauma following a pseudo seizure.  No pathological clinical findings were documented.  He was seen again in the ER on 30 April 2004 for head trauma reporting that he had bumped his right temple.  A small contusion was seen on the right forehead.  In the ER on 7 May 2004, he reported dizziness associated with the pseudo seizure.  No trauma was documented.  

He was seen in the ER on 12 May 2004 and reported that he had hit his forehead on a picture frame the previous Saturday (4 days earlier).  Fresh blood was noted from the abrasion.  He was noted to be moving his limbs in a “dramatic” fashion.  

The MEB NARSUM examination (report of the medical board) was dated 20 May 2004, 3 months prior to separation.  It noted that the CI had multiple stressors including marital difficulties (he subsequently divorced) and financial problems.  One hospitalization was recorded and was for the initial evaluation of the pseudo-seizure condition.  The mental status examination noted that he was alert and oriented, but had been poorly groomed at times.  He had been depressed at times and had a tendency to withdraw with poor eye contact.  Formal psychological testing was done and the CI was diagnosed with a conversion disorder and anxiety disorder which did not exist prior to service.  He was also noted to have Tourette’s disorder which was resolved.  He was not thought to be fit for full duty and his prognosis was poor.  

The non-medical assessment was dated 25 May 2004.  It noted that the CI was working in parking enforcement and missed one day a week due to appointments/evaluation/recuperation without specifically attributing the time lost to any one cause.  

In mental health on 26 May 2004, the CI was evaluated for the consideration of psychotropic drugs as well as to review the PEB report.  It was noted that there was a significant history of neuropathic traits in childhood which included fire starting, promiscuity, numerous arrests, and lying.  He stated that he had been fired from over 3 dozen jobs prior to joining the USN.  He had been separated from his wife for 2 months after 1-2 years of marital discord (he had been on active duty 1 year and 10 months).  

In mental health on 27 May 2004, the CI was noted to have significant improvement from the previous sessions.  He reported a few episodes, but had not been to the ER or been hurt.  (It was also recorded that there had been no improvement, but this is not consistent with the body of the note).  

The CI was seen in neurology on 25 June 2004, 2 months prior to separation.  It was noted that he did not lose consciousness with the episodes and that he could resist them although he later had a worse spell.  The neurological examination remained normal.  It was recorded that he had undergone five EEGs (electroencephalograms) including video monitoring.  

At the VA mental health C&P evaluation on 14 January 2005, 5 months after separation, the CI was prompt for his appointment and clean and well groomed.  He was unemployed but seeking a job.  He had worked at a local chain restaurant in August and September when he was let go secondary to the seizure disorder.  This was not further explained.  He was engaged and had lived with his fiancé since the prior April.  He reported that he had been seen in the ER thirty six times over the prior year for injuries secondary to falls from the seizure disorder.  The panel observed that this was not supported by the evidence available for review.  The mental status examination was basically unremarkable other than for being mildly anxious and dysphoric.  It was noted that his present psychological distress would pose occupational challenges, but that he was employable.  

The panel directed attention to its rating recommendation based on the above evidence.   The Navy PEB rated the conversion disorder condition 10%, coded 9424 (conversion disorder).  The PEB also listed anxiety disorder as a related Category II condition (a condition that contributed to the primary unfitting condition but was not separately ratable).  The impairment from the anxiety disorder was properly subsumed under the overall rating for the conversion disorder IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The VA rated the conversion disorder condition 30%, also coded 9424, based on the C&P examination 6 months before separation, citing continued complaints of decreased energy, decreased socialization, nervousness and being mildly anhedonic (decreased interest in activities normally found pleasurable).  The rating was increased to 50% based on the post-separation C&P.  The examiner specifically noted that the CI had been seen in the ER thirty six times for injuries, although also commented that none of the reports were available.   

The panel considered the evidence.  It noted that the CI had been seen in the ER for injuries, but only small abrasions and/or contusions to the forehead were documented.  He reported an injury to the right knee and used crutches and then a cane, but declined an orthopedic evaluation.  The documented ER visits for injuries began after he reported frustration that he was not believed by the ER staff.  No ER visits were in evidence following the MEB.  He reported the ability to delay the onset of a pseudo seizure at one appointment even though it was later worse; it is not clear why he was not able to delay the onset until he was not in a position to fall down.  It was also noted that within weeks of separating from his wife, the CI was engaged and living with his fiancé.  Prior to separation and for 1 month after separation the CI was working in a restaurant.  He reported that he was let go due to the seizure disorder, but further details were not recorded.    The criteria for a 10% rating are "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.  Those for a 30% rating are "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).  Following the MEB, the CI was noted to be doing well and had not presented to the ER or been hurt.  He reported that he could control or at least delay the onset of a pseudo seizure.  He was in a new relationship living with his fiancé.  Prior to separation, he obtained employment which lasted until after separation.  It is not clear from the record why the job ended.    At the final mental health evaluation, he had a normal mental status examination.  He was in civilian clothing and his hygiene acceptable.  His condition at separation was thought to best described by the criteria for a 10% rating by the panel majority.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the conversion disorder condition.  

BOARD FINDINGS:  In the matter of the conversion disorder condition, the panel majority recommends a disability rating of 10%, coded 9424 IAW VASRD §4.130.  The single voter for dissent recommended modification to 30% and submitted the appended minority opinion.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20151116, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

	

Minority Opinion:

As the minority voter on this panel, I respectfully request the Designated Decision Authority (DDA) carefully review this CI’s record to establish the fact that at the time of his medical separation from the US Navy, he was mentally disabled due to his conversion disorder, at the 30% level per §4.130 of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  As stipulated in the record of proceedings above, the PEB rated the conversion disorder condition 10%, coded 9424 (conversion disorder).  The Navy PEB also listed anxiety disorder as a related Category II condition (a condition that contributed to the primary unfitting condition but was not separately ratable).  The impairment from the anxiety disorder was properly subsumed under the overall rating for the conversion disorder IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The VA rated the conversion disorder condition 30%, coded 9424 (conversion disorder), based on the C&P (compensation and pension) examination 6 months before separation, [with emphasis] citing continued complaints of decreased energy, decreased socialization, nervousness and being mildly an hedonic.  The rating was increased to 50% based on the post-separation C&P.  The following facts support my recommendation (as per the in service VA examination) that this CI was disabled at the 30% level at the time of medical separation:
1.	Per JDETS assessment on page 24 of the CPF, the CI was functioning at the 55-60 level for global assessment of function (GAF).  His past GAF was estimated at between 71-80.  55-60 GAF equates to a moderate level of impairment due to mental disorder and other factors and therefore equates to a disability above the 10% level per the VASRD (10% level stipulates “mild or transient symptoms”).
2.	The CI showed a consistently documented record of his behavior with respect to his conversion disorder symptomology, as being genuine and not representative of malingering or secondary gain.
3.	It was consistently documented in the record that stress played a significant exacerbating role in the contribution or cause of his pseudo seizures.  The Disability Evaluation System consistently recognizes and awards mental disability compensation based on service members’ reaction to stress.
4.	The mental status examination on pg. 30-31 of the CPF (part of the MEB NARSUM) stated the CI’s mood was depressed at times and was congruent.  The CI presented as poorly groomed at times (assumed during prior appointments).  During the examination, the CI had a tendency to withdraw and had poor eye contact.  Further on in the examination, it is documented the CI suffered from lack of energy, poor attention and concentration.  He also experienced problems with sleep.  All of these systems are clearly located under the 30% criteria in §4.130.  
5.	The CI underwent extensive treatment in order to cure his illness.  He was an active and willing participant.  The NARSUM examiner summarized:  It is felt that despite having an adequate course of treatment the member's prognosis is very poor.  It is considered highly unlikely that he will improve in treatment or be able to return to full duty status and complete his commitment to the military successfully.  Patient's pseudo-seizures have continued to increase within the last six months with no physiological explanation or way to control them despite intensive outpatient treatment.  Given these factors, this patient is deemed to be at increasing [with emphasis] risk for injury, as well as decreased social and occupational functioning while on active duty.”  The Examiner continued:  “Furthermore, this patient's current level of impairment is significant [with emphasis] to the point of interfering with his social and occupational functioning.  He currently requires regular therapy sessions.  It is the Board's opinion that he will continue to require regular therapy upon his discharge from the military, and will continue to experience significant difficulties in social and occupational functioning outside of the military [with emphasis] for the foreseeable future.”
6.	On page 37 of the CPF, the CI’s Commanding Officer stated:  “Seaman XXXXX is not reliable in his day-to-day duties [with emphasis] due to seizures.  He is not able to drive vehicles or perform his duties without being a risk to himself or his shipmates.  His seizures tend to be violent causing damage to himself and others.  His duty requires him to walk unless driven by other personnel.  His seizures happen with no warning to himself and he is at risk of hurting himself unless supervised at all times.  [with emphasis]…. Seaman XXXXX would like to be able to continue life in the military and be able to get his problem under control.  Hardship in his personal life has been affected greatly due to his medical condition.”
7.	It is a fact that the CI did physically injure himself due to these recurring seizures on multiple occasions leading up to separation.

The evidence in this case is clear.  Seizures in this condition are a symptom of a stress reaction (akin to a panic attack per VASRD §4.130).  They were debilitating for the CI, they occurred nearly every day and their psychological after effects were as well (see the mental status examination findings per above).  Those closest to him paint a picture of a significantly disabled young man, who could not be left alone, who had high aspirations for a Navy career, who tried in earnest to save his career yet was unable to fulfill this dream.  Post separation, there is evidence his conversion disorder got him fired (due to having seizures) at the employment site where he had begun his post Service career.  I urge the DDA to carefully review the criteria under VASRD 4.130 for the 10% level of disability for mental disorders.  The PEB correctly identified the CI’s anxiety disorder as contributing to the unfitting condition and not separately ratable (per reasons as stipulated above).  Understanding the CI’s mental disability in this context is of significant importance in this case, in order to translate the physical manifestations of the condition to the criteria under VASRD 4.130.  
As the minority voter, I respectfully recommend 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	
Anxiety Disorder	Category II	
COMBINED	30%	

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

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and 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:

		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC

		
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	     				  Acting