Diagnostic Assessment — Functional Neurological Disorder
Example 1 of 1 · fictitious patient (Veteran AD)
Diagnostic Assessment
Functional Neurological Disorder
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran AD, date of birth 05 April 1987, Australian Army, Combat Medical Technician (Medic), enlisted 16 January 2006, medically discharged 20 July 2017. Operational service: Afghanistan, 10 February 2009 to 20 September 2009 (warlike); Afghanistan, 15 March 2012 to 02 July 2012 (warlike, returned early after injury).
Occupational History
As a combat medic the veteran provided point-of-wounding care to soldiers and civilians with blast, gunshot and traumatic amputation injuries, often under fire, at night and in confined vehicles, and was repeatedly exposed to death, dying and grief. She carried medical packs and personal equipment of 30 to 40 kilograms on foot patrols and travelled in protected vehicles exposed to improvised explosive devices.
Medics have high rates of posttraumatic stress disorder, depression and anxiety from cumulative trauma exposure and moral distress, and of mild traumatic brain injury and musculoskeletal injury from blast and load carriage. These are recognised predisposing and precipitating factors for functional neurological disorder.
History
Veteran AD, a combat medic in the Australian Army, developed functional neurological disorder with functional left-sided weakness and functional seizures on 24 June 2012, twelve days after a blast on warlike service in Afghanistan that caused a mild traumatic brain injury and a left shoulder injury, on a background of posttraumatic stress disorder, depression, migraine, chronic back pain and a sexual assault during service. The disorder worsened in April 2015 after she witnessed a fatal training accident and fractured her wrist.
Timeline
- 22 Jun 2009 — On warlike service in Afghanistan the veteran was the only medic at a mass casualty incident after an improvised explosive device struck a patrol. She treated four casualties for over an hour under sporadic fire, and two soldiers died while in her care. She was not offered a critical incident debrief before resuming patrols. "mass casualty, two deaths in care"
- 14 Jul 2010 — The medical officer recorded low back pain present since early 2010, worse after patrols with the medic pack and limiting sleep, attributed to load carriage on deployment. Episodic migraine with visual aura, two to three attacks a month, was also recorded and treated with triptans. Low back pain persisted continuously thereafter. "chronic LBP, migraine with aura"
- 18 Nov 2010 — A psychiatrist diagnosed posttraumatic stress disorder related to the 2009 mass casualty incident, with nightmares, intrusive images, hypervigilance and avoidance. Sertraline and trauma-focused psychology were commenced. PCL-5 score 52. "PTSD, sertraline commenced"
- 04 Mar 2011 — The veteran reported a sexual assault by another member at a training establishment the previous week. She was referred to the sexual offence response team and the psychiatrist added a diagnosis of major depressive disorder, with a PHQ-9 score of 19. She continued sertraline at an increased dose and was later cleared to deploy. "sexual assault, major depression"
- 12 Jun 2012 — On warlike service in Afghanistan an improvised explosive device detonated beside the veteran's vehicle. She lost consciousness for under one minute, had post-traumatic amnesia for about two hours and was found to have a left shoulder labral injury and bruising of the left side of her body. CT brain at the role 3 hospital was normal and mild traumatic brain injury was diagnosed. "mild TBI, L shoulder injury"
- 24 Jun 2012 — During a rocket attack alarm at the role 3 hospital the veteran had a panic attack, then sudden weakness of her left arm and leg and an episode of generalised shaking with eyes closed, lasting six minutes, without injury or incontinence. Examination showed a positive Hoover sign, give-way weakness on the left and normal reflexes. Repeat CT brain was normal and she was aeromedically evacuated on 02 July 2012. "L weakness, Hoover sign positive"
- 03 Oct 2012 — A neurologist reviewed her with MRI brain and spine reported as normal. Video-EEG monitoring captured three typical events with side-to-side head movement, eyes closed and fluctuating limb shaking, with a normal EEG throughout. The neurologist diagnosed functional neurological disorder with functional seizures and functional left-sided weakness and recommended specialist physiotherapy and psychotherapy, for which the waiting list was nine months. "functional seizures, normal video-EEG"
- 05 May 2015 — On 16 April 2015, during a peacetime field exercise, the veteran witnessed a vehicle rollover in which a soldier was killed, and fractured her right distal radius while giving first aid. Her functional seizures increased from two a month to daily, and she developed a new functional gait disorder requiring a walking stick. The neurologist confirmed worsening of the functional neurological disorder. PCL-5 score 64. "daily seizures, new gait disorder"
Symptoms
At onset the veteran had sudden weakness and heaviness of the left arm and leg, a dragging gait and episodes of generalised shaking with her eyes closed and partial awareness, lasting several minutes, often triggered by loud noises or reminders of trauma. After onset she had intermittent left-sided weakness, numbness down the left side, fatigue, poor concentration and two functional seizures a month.
Since the worsening in 2015 she has had near-daily functional seizures, a functional gait disorder requiring a walking stick outdoors, episodes of speech arrest, profound fatigue and difficulty with memory and concentration. She cannot drive because of the seizures and needs help with shopping and household tasks.
Imaging
- 12 Jun 2012 — CT brain, role 3 hospital: "No intracranial haemorrhage, contusion or skull fracture."
- 24 Jun 2012 — CT brain, role 3 hospital: "Normal study. No change from 12 June 2012."
- 28 Sep 2012 — MRI brain and cervical spine: "Normal brain with no evidence of diffuse axonal injury or demyelination. Normal cervical spinal cord."
- 16 Apr 2015 — Radiographs right wrist: "Extra-articular fracture of the distal radius with dorsal angulation."
Onset Date
The most likely date of onset of this condition is 24 Jun 2012.
At that date the veteran was on warlike service in Afghanistan, an inpatient at a role 3 hospital twelve days after a blast that caused a mild traumatic brain injury and a left shoulder injury. During a rocket attack alarm she had a panic attack followed by sudden left-sided weakness and a prolonged shaking episode.
This date is appropriate because she had no neurological symptoms on examination at the role 3 hospital on 13 June 2012 apart from headache and left shoulder pain, and the left-sided weakness and first functional seizure were recorded by the treating team on 24 June 2012. It falls within her warlike service and within uninterrupted full-time service.
For the traumatic event cause, the 5 years before onset run from 24 Jun 2007 to 24 Jun 2012 and contain the mass casualty incident of 22 Jun 2009 and the blast of 12 Jun 2012. For the mild traumatic brain injury cause, the 1 year before onset runs from 24 Jun 2011 to 24 Jun 2012 and contains the blast of 12 Jun 2012. For the physical injury cause, the 3 months before onset run from 24 Mar 2012 to 24 Jun 2012 and contain the left shoulder injury of 12 Jun 2012. For the chronic pain cause, the 6 months before onset run from 24 Dec 2011 to 24 Jun 2012, throughout which her low back pain, present since early 2010, continued. Posttraumatic stress disorder (diagnosed 18 Nov 2010), major depressive disorder (04 Mar 2011) and migraine (14 Jul 2010) were each present at onset, the sexual assault occurred in Feb 2011, and the panic attack occurred at onset.
For the worsening causes, the documented worsening was confirmed on 05 May 2015, after the events of 16 Apr 2015. The 1 year before the worsening runs from 05 May 2014 to 05 May 2015 and the 3 months before it from 05 Feb 2015 to 05 May 2015, and both contain the fatal training accident and wrist fracture of 16 Apr 2015. Posttraumatic stress disorder and depression were present at the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Functional Neurological Disorder (ICD-10-AM F44.7, mixed dissociative [conversion] disorders), with functional seizures and functional left-sided limb weakness, later with a functional gait disorder. No Statement of Principles has been determined for functional neurological disorder.
Functional neurological disorder is a common neurological condition in which there is a problem with the functioning of the nervous system rather than structural damage. It causes genuine, involuntary symptoms such as limb weakness, abnormal movements, gait disturbance, sensory loss and functional (dissociative) seizures. The diagnosis is made on positive clinical signs that show internal inconsistency, such as the Hoover sign, and on the typical features of functional seizures captured on video-EEG, not merely by excluding other disease. Psychological trauma, posttraumatic stress disorder, depression, physical injury, mild traumatic brain injury and pain are recognised predisposing and precipitating factors, and further trauma or injury commonly worsens it.
The disorder began on warlike service in Afghanistan on 24 June 2012, was confirmed by a neurologist with video-EEG on 03 October 2012 and worsened in April 2015.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
24 June 2012.
When did the veteran first present to a health / medical provider for this condition?
24 June 2012.
When was the condition confirmed / formally diagnosed?
03 October 2012.
When did the veteran first present to you (or your practice) for this condition?
02 April 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by a neurologist on 03 October 2012. Video-EEG monitoring captured three of the veteran's typical events, with eyes closed, side-to-side head movement and fluctuating, asynchronous limb shaking, and a normal EEG before, during and after each event, which confirms functional seizures. Examination showed positive signs of functional weakness: a positive Hoover sign, give-way weakness and a dragging monoplegic gait, with normal tone, reflexes and plantar responses.
MRI of the brain and cervical spine and repeated CT brain were normal, excluding structural injury from the blast, demyelination and stroke. The diagnosis meets the DSM-5-TR criteria for functional neurological symptom disorder (conversion disorder), with mixed symptoms. The worsening was confirmed by the neurologist on 05 May 2015, with an increase from two to daily seizures and a new functional gait disorder.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
No Statement of Principles has been determined for functional neurological disorder. The claim is therefore decided on the sound medical-scientific evidence of what causes the condition and on whether, on that evidence, the condition is related to the veteran's service, without the limits of a Statement of Principles. The recognised causes below are drawn from the medical literature on functional neurological disorder and are set out in the style of Statement of Principles factors.
Legislation: the clinical onset of this condition was on 24 June 2012, after 1 July 2004, during warlike service in Afghanistan. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. The veteran's warlike service in Afghanistan in 2009 and 2012, where the mass casualty incident, the blast, the mild traumatic brain injury and the onset occurred, and her peacetime service in Australia, where the sexual assault and the 2015 training accident occurred, are each relevant service. Each cause must be related to that service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Recognised causes on the medical-scientific evidence (no Statement of Principles)
Causative factors
Cause 1: experiencing a category 1A or category 1B stressor within the 5 years before the clinical onset of functional neurological disorder; — MET
- On warlike service in Afghanistan on 22 June 2009 the veteran was the only medic at a mass casualty incident and two soldiers died in her care, a category 1A stressor. On 12 June 2012, also on warlike service, she was in a vehicle struck by an improvised explosive device. Both events fall within the 5 years before onset, from 24 June 2007 to 24 June 2012.
Cause 2: having posttraumatic stress disorder at the time of the clinical onset of functional neurological disorder; — MET
- A psychiatrist diagnosed posttraumatic stress disorder on 18 November 2010, related to the 2009 mass casualty incident on warlike service, with a PCL-5 score of 52. The disorder was active and treated with sertraline at onset on 24 June 2012, and the first functional seizure was triggered by a rocket attack alarm.
Cause 3: having a depressive disorder or an anxiety disorder at the time of the clinical onset of functional neurological disorder; — MET
- Major depressive disorder was diagnosed on 04 March 2011, with a PHQ-9 score of 19, following a sexual assault during service and on a background of service-related posttraumatic stress disorder. It was present and treated at onset on 24 June 2012.
Cause 4: experiencing sexual assault or severe physical abuse before the clinical onset of functional neurological disorder; — MET
- The veteran was sexually assaulted by another member at a training establishment in late February 2011, reported on 04 March 2011 and recorded by the sexual offence response team. The assault occurred during her service and before onset on 24 June 2012.
Cause 5: having a mild traumatic brain injury within the 1 year before the clinical onset of functional neurological disorder; — MET
- The blast on warlike service on 12 June 2012 caused loss of consciousness for under one minute and post-traumatic amnesia of about two hours, diagnosed as mild traumatic brain injury at the role 3 hospital. This was twelve days before onset and within the 1 year before onset, from 24 June 2011 to 24 June 2012.
Cause 6: sustaining a physical injury to the affected limb or side of the body within the 3 months before the clinical onset of functional neurological disorder; — MET
- In the blast of 12 June 2012 the veteran sustained a left shoulder labral injury and bruising of the left side of her body. The functional weakness developed in the same left arm and leg twelve days later, within the 3 months before onset, from 24 March 2012 to 24 June 2012.
Cause 7: having a chronic pain condition for at least the 6 months before the clinical onset of functional neurological disorder; — MET
- Chronic low back pain from carrying a 30 to 40 kg medic pack on deployment was recorded on 14 July 2010 as present since early 2010 and persisted continuously, including throughout the 6 months before onset, from 24 December 2011 to 24 June 2012.
Cause 8: having migraine at the time of the clinical onset of functional neurological disorder; — MET
- Migraine with visual aura, two to three attacks a month, was diagnosed on 14 July 2010 during service, at a time of sleep disruption from her back pain and posttraumatic symptoms, and was active and treated with triptans at onset on 24 June 2012.
Cause 9: experiencing a panic attack or an acute dissociative episode at the time of the clinical onset of functional neurological disorder; — MET
- On 24 June 2012, during a rocket attack alarm at the role 3 hospital on warlike service, the treating nurse recorded a panic attack with palpitations, breathlessness and fear of dying, immediately followed by the left-sided weakness and the first functional seizure.
Worsening factors
Worsening 1: experiencing a category 1A or category 1B stressor within the 1 year before the clinical worsening of functional neurological disorder; — MET
- On 16 April 2015, during a peacetime field exercise, the veteran witnessed a vehicle rollover in which a soldier was killed and gave first aid at the scene, a category 1A stressor. This was within the 1 year before the worsening confirmed on 05 May 2015, from 05 May 2014 to 05 May 2015, after which her seizures increased from two a month to daily.
Worsening 2: sustaining a physical injury within the 3 months before the clinical worsening of functional neurological disorder; — MET
- The veteran fractured her right distal radius while giving first aid at the rollover on 16 April 2015, confirmed on radiographs, within the 3 months before the worsening, from 05 February 2015 to 05 May 2015. A new functional gait disorder developed in the following weeks.
Worsening 3: having posttraumatic stress disorder, a depressive disorder or an anxiety disorder at the time of the clinical worsening of functional neurological disorder; — MET
- Posttraumatic stress disorder and major depressive disorder, both arising from service, were present at the worsening, and the PCL-5 score rose from 52 to 64 on 05 May 2015.
Worsening 4: inability to obtain appropriate clinical management for functional neurological disorder. — MET
- After diagnosis on 03 October 2012 the specialist physiotherapy and psychotherapy recommended by the neurologist were not available for nine months, and the veteran was treated only with medication in the meantime. The disorder became established and later worsened. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
The % contribution of the causes is 100% and significant.
Sequelae
The functional neurological disorder is a sequela of the veteran's accepted posttraumatic stress disorder and major depressive disorder and of the mild traumatic brain injury and left shoulder injury sustained on warlike service on 12 June 2012. Her inability to drive, loss of employment and dependence on others for household tasks are in turn consequences of the disorder.
Unintended Consequence
Met. The veteran's return to field duties without a specialist rehabilitation program, after the recommended physiotherapy and psychotherapy could not be provided by the Defence health system, allowed the disorder to become entrenched, and the sertraline prescribed for her service-related posttraumatic stress disorder was not reviewed when her symptoms escalated. These are unintended consequences of treatment provided by the Commonwealth while she was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. After the diagnosis on 03 October 2012 the neurologist recommended specialist functional neurological physiotherapy and psychotherapy, but the waiting list was nine months and no alternative was offered. The veteran continued to have functional seizures and weakness without targeted treatment, and the disorder was entrenched when it worsened in 2015. Early specialist rehabilitation is the recognised treatment and the strongest predictor of recovery. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), a delay of this length in obtaining recognised treatment amounts to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 22 Jun 2009, Field medical record and incident report, Afghanistan
- 14 Jul 2010, Outpatient health record, Medical Officer, Garrison health centre
- 18 Nov 2010, Psychiatric assessment, Consultant psychiatrist
- 04 Mar 2011, Psychiatric review and sexual offence response team referral, Consultant psychiatrist
- 12 Jun 2012, Trauma admission and CT brain, Role 3 hospital, Afghanistan
- 24 Jun 2012, Inpatient medical and nursing notes, Role 3 hospital, Afghanistan
- 28 Sep 2012, MRI brain and cervical spine, Radiologist
- 03 Oct 2012, Video-EEG report and neurology consultation, Neurologist
- 16 Apr 2015, Radiographs right wrist, Radiologist
- 05 May 2015, Neurology review, Neurologist
- Medical-scientific literature on the causes of functional neurological disorder (no Statement of Principles determined)
