RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201536 SEPARATION DATE: 20020315 BOARD DATE: 20130226 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Soldier, PFC/E-3(73C/Finance Specialist), medically separated for conversion disorder manifested by subjective left lower extremity weakness and sensory deficits. The CI’s symptoms began in February 2001 upon her arrival in Korea. She was subsequently air evacuated to Ft. Sam Houston. The CI did not improve adequately with treatment to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent S4 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded conversion disorder with moderate deficit, S&I slight; and common migraine as medically unacceptable IAW AR 40-501. The MEB forwarded no other conditions for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated the conversion disorder manifested by subjective left lower extremity weakness and sensory deficits as unfitting, rated 10%. The PEB adjudicated the common migraine as not unfitting. The CI made no appeals, and was medically separated with a 10% disability rating. CI CONTENTION: The CI elaborated no specific contention in her application. SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44 Enclosure 3, paragraph 5.e.(2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. 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 Army Board for Correction of Military Records. RATING COMPARISON: Service PEB – Dated 20020109 VA – All Effective Date -- N/A Condition Code Rating Condition Code Rating Exam Conversion Disorder; Subjective Left Lower Extremity Weakness 9424 10% Conversion Disorder; Left Lower Extremity Weakness 8520-9410 NSC STRs Common Migraine Not Unfitting No VA Entry .No Additional MEB/PEB Entries. 0% X 0 / Not Service-Connected x 0 STRs Combined: 10% Combined: *The CI had no VA C&P Exams, initial VARD is approximately 8 years post-separation. ANALYSIS SUMMARY: Conversion Disorder. The narrative summary (NARSUM) notes the CI was evacuated from overseas in May 2001 secondary to left leg weakness. The CI had a first episode of muscle weakness in February 2001 when she noted decreased sensation of left arm and leg lasting one-two hours with total remission of symptoms. A few days later she had another episode of left arm and leg weakness and numbness. The left arm symptoms resolved immediately, however the left leg weakness and numbness persisted since that time, with unchanged quality or intensity. Magnetic resonance imaging (MRI) of the brain was performed immediately after each episode but on both occasions was normal, with no evidence of a causative abnormality. Conservative management was initiated but the CI complained she could not move her left leg, ambulated with a cane and eventually was sent back to the United States for further investigation and treatment. Despite thorough medical investigation, no objective physical cause for her symptoms was found. Eventually a psychiatric evaluation was recommended and the CI endorsed symptoms including sadness, crying spells, decreased energy, frustration and lack of interest in previous activities. However, the mental status exam (MSE) noted a full affect, without feeling of sadness or anxiety. Despite detailed questioning no specific bio- psycho-social stressors were identified. No specific treatment or follow up was recommended and the Global Assessment of Functioning (GAF) was 75 (slight impairment). The psychiatrist gave the CI a provisional diagnosis of conversion disorder and recommended psychological testing to validate the diagnosis. Results of the testing confirmed the CI’s tendency to convert psychological distress into somatic symptoms. It was also noted the CI had a rigid personality, intellectual functioning in the low to normal range, and narcissistic and histrionic personality disorder traits. Individual therapy was not considered a treatment option due to CI resistance and poor response to treatment. The CI received a permanent S4 profile and the MEB was initiated. The MEB NARSUM physical exam on 4 December 2001 noted normal muscular strength and tone, normal gait and deep tendon reflexes (DTRs). Sensory was intact except a patchy decreased pin prick on the left lateral calf without a sensory level. There was no VA Compensation and Pension (C&P) examination proximate to separation, and VA records indicate the CI did not file a claim with the VA until November 2009, 8 years after separation. The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the conversion disorder manifested by subjective left lower extremity weakness and sensory deficits, 10% (considering mild social and industrial impairment) under code 9424. The Board analyzed the social and occupational impairment secondary to CI conversion disorder symptoms and agreed with the 10% rating attributed by the PEB. The mental health specialists attributed the CI’s symptoms to psychological stress and poor coping mechanisms, considered her impairment for social and industrial adaptability “slight” and assigned the CI a GAF of 75. The MEB physical examination recorded resolved conversion symptom with recovered leg strength with normal gait. A higher rating of 30% would require mood symptoms like suspiciousness, panic attacks, and chronic sleep impairment which were not evidenced throughout the treatment records. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the conversion disorder condition. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. In the matter of the conversion disorder manifested by subjective left lower extremity weakness and sensory deficits condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING Conversion Disorder 9424 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120728, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxx, AR20130005363 (PD201201536) 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 xxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)