[Federal Register Volume 60, Number 207 (Thursday, October 26, 1995)]
[Proposed Rules]
[Pages 54825-54831]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-26567]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 4
RIN 2900-AF01
Schedule for Rating Disabilities; Mental Disorders
AGENCY: Department of Veterans Affairs.
ACTION: Proposed rule.
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SUMMARY: The Department of Veterans Affairs (VA) is proposing to amend
that portion of its Schedule for Rating Disabilities dealing with
Mental Disorders. This is part of the first comprehensive review of the
rating schedule since 1945. The intended effect of this action is to
update the section of the rating schedule on mental disorders to ensure
that it uses current medical terminology and unambiguous criteria, and
that it reflects medical advances which have occurred since the last
review.
DATES: Comments must be received by VA on or before December 26, 1995.
ADDRESSES: Mail written comments to: Director, Office of Regulations
Management (02D), Department of Veterans Affairs, 810 Vermont Ave.,
NW., Washington, DC 20420 or hand deliver written comments to: Office
of Regulations Management, Room 1176, 801 Eye St., NW., Washington, DC
20001. Comments should indicate that they are submitted in response to
``RIN 2900-AF01.'' All written comments received will be available for
public inspection in the Office of Regulations Management, Room 1176,
801 Eye St., NW., Washington, DC 20001 between the hours of 8 a.m. and
4:30 p.m., Monday through Friday (except holidays).
FOR FURTHER INFORMATION CONTACT: Caroll McBrine, M.D., Consultant,
Regulations Staff, Compensation and Pension Service, Veterans Benefits
Administration, Department of Veterans Affairs, 810 Vermont Ave., NW.,
Washington, DC 20420, (202) 273-7210.
SUPPLEMENTARY INFORMATION: Prior to the start of its comprehensive
review of the rating schedule, VA contracted with an outside consulting
firm to offer suggestions for changes in the rating schedule to help
fulfill the goals of revising and updating the medical criteria. This
proposed amendment includes many of their suggestions. Some
recommendations, however, addressed areas other than evaluation
criteria, such as percentage evaluations and frequency of examinations.
Since these suggestions are clearly beyond the scope of the contract
and deal with issues which would affect the internal consistency of the
entire rating schedule rather than one section, we have generally not
adopted them. The comments of the consultants are incorporated into the
discussions below.
VA published an advance notice of proposed rulemaking in the
Federal Register on May 2, 1991 (56 FR 20170) in order to solicit
comments and suggestions from interested groups and the general public.
In response to this notice, we received comments from several employees
of VA and one from The American Legion. All of the commenters
recommended a change in the rating criteria for mental disorders,
urging more clarity and objectivity, and more extensive and definitive
guidelines.
In the current rating schedule, Secs. 4.125 through 4.131 and the
notes in Sec. 4.132 contain general information about mental disorders
and guidelines for their evaluation. The material is organized
randomly, however, and we propose to reorganize it so that everything
dealing with a single topic is grouped together. We also propose to
make a number of editorial changes in the material to make the
provisions clearer and less ambiguous and to make the terminology more
current. We further propose to remove material which is not regulatory,
i.e., which neither prescribes VA policy nor limits the action a rating
board may take. Additionally, we propose to incorporate regulatory
material from the notes in Sec. 4.132 into Secs. 4.125 through 4.129,
reorganizing and rewording it, and removing repetitious material. This
will assure that all of the regulatory provisions are in one area of
the schedule, in orderly groupings, rather than spread throughout.
Much of Sec. 4.125 contains general information stating, for
example, that there have been rapid advances in modern psychiatry
during and since World War II, which have produced a better
understanding of the etiology, psychodynamics, and psychopathological
changes which
[[Page 54826]]
occur in mental diseases and emotional disturbances, and that the field
of mental disorders represents the greatest possible variety of
etiology, chronicity, and disabling effects and requires differential
consideration in these respects. We propose to remove that material
because it neither prescribes VA policy nor establishes procedures a
rating board must follow and is, therefore, not appropriate in a
regulation.
The only information in Sec. 4.125 which is essential is the
statement that psychiatric nomenclature in the rating schedule is based
on the third edition of the Diagnostic and Statistical Manual (DSM-
III), published by the American Psychiatric Association in 1980, and
that rating specialists should familiarize themselves thoroughly with
that manual. The contract consultants recommended that we make changes
in the mental disorders section to assure that it is consistent with
the current DSM Manual, and we propose to update the terminology and
categories of mental disorders by basing them on the newest revised
edition, DSM-IV, which was published in 1994. The DSM Manuals are used
in the United States as the basis for the diagnosis and classification
of mental disorders. They are referred to by, and their terminology is
incorporated into, psychiatry textbooks. They represent the common
language of both VA and non-VA health care providers and researchers
and, therefore, provide rating specialists with a standard by which
examinations from all sources can be compared and assessed. The use of
DSM-IV as the basis for terminology and diagnostic classification of
mental disorders for VA purposes is, therefore, unquestionably
appropriate. We propose to present this material in a note rather than
assigning it an entire section of the CFR.
We propose to change the title of Sec. 4.125 from ``General
considerations'' to ``Diagnosis of mental disorders'' and to divide it
into two paragraphs, the first requiring that the rating board return
an examination report to the examiner if the diagnosis does not conform
to DSM-IV or is not supported by the findings in the report, and the
second directing the rating board to determine whether a change in
diagnosis of a mental disorder represents progression of a prior
diagnosis, correction of an error in a prior diagnosis, or development
of a new and separate condition. This material is taken from
Secs. 4.126 (Substantiation of diagnosis) and 4.128 (Change of
diagnosis).
We propose to place all material about evaluation of mental
disorders in Sec. 4.126 and to change the title from ``Substantiation
of diagnosis'' to ``Evaluation of disability from mental disorders.''
This material is taken from Secs. 4.129 and 4.130, a statement and
notes under DC 9511, notes (1) and (4) under DC 9325, and notes under
the general rating formula for psychoneurotic disorders. We propose to
divide this section into four paragraphs dealing with symptoms and
remissions, social impairment, organic mental disorders, and conditions
diagnosed both as physical and mental disorders.
Paragraph (a) of Sec. 4.126 establishes the general basis for
evaluating mental disorders as the frequency, severity, and duration of
psychiatric symptoms, the length of remissions, and the veteran's
capacity for adjustment during remissions. It further requires that an
evaluation be based on all evidence of record bearing on occupational
and social impairment. This material is derived from material currently
found at Sec. 4.130, Evaluation of psychiatric disability. We have
deleted the statement currently found in Sec. 4.130 that the examiner's
analysis of the symptomatology is an ``essential.'' Since we propose to
revise the evaluation criteria to rely on specific signs and symptoms
rather than on a subjective determination as to whether a disorder
results in total, severe, considerable, definite, or mild social and
industrial impairment, it is the signs and symptoms that the examiner
documents rather than his or her assessment of their level of severity
that will determine the evaluation that the rating specialist assigns.
We also propose to delete the statement that describes time lost from
gainful work and decrease in work efficiency as ``two of the most
important determinants of disability.'' Since the proposed evaluation
criteria are structured around the nature and extent of occupational
and social impairment, including decreased reliability, productivity,
and work efficiency, that statement is no longer necessary.
Paragraph (b) directs the rating board to consider the extent of
social impairment, but not to assign an evaluation solely on the basis
of social impairment. This is based on the current regulatory material
in Sec. 4.129 and in note (1) following the general rating formula for
psychoneurotic disorders, and represents no substantive change. The
contract consultants recommended a greater emphasis on social
impairment in rating mental disability, but because our statutory
authority to establish the rating schedule, 38 U.S.C. 1155, requires
that ratings be based, as far as practicable, upon the average
impairments of earning capacity, we do not propose to adopt that
recommendation.
Paragraph (c) directs the rating board to evaluate delirium,
dementia, and amnestic and other cognitive mental disorders under the
general rating formula for mental disorders and to combine this
evaluation with those for neurological or other physical impairments
stemming from the same etiology, e.g., a head injury. This represents
no substantive change from material currently contained in notes (1)
and (2) under DC 9325.
Paragraph (d) directs the rating board to evaluate a single
disability that has been diagnosed both as a physical condition and as
a mental disorder under the diagnostic code which represents the
dominant (more disabling) aspect of the condition. This represents no
substantive change from information in notes (4) and (2) at the end of
the rating schedules for psychoneurotic disorders and psychological
factors affecting physical condition, respectively, except that we have
deleted ``major degree of disability'' and substituted ``dominant (more
disabling) aspect of the condition'' for clarity.
We propose to change the title of Sec. 4.127 from ``Mental
deficiency and personality disorders'' to ``Mental retardation and
personality disorders,'' since the term ``mental deficiency'' is
obsolete and no longer in common use. This is not a substantive change.
We propose that Sec. 4.127 state that although mental retardation
and personality disorders will not be considered as disabilities under
the terms of the schedule, a mental disorder that is superimposed upon,
but clearly separate from, the mental retardation or personality
disorder may be a disability for VA compensation purposes. This
represents a revision of the language in the current Sec. 4.127 for the
sake of clarity but does not represent a substantive change.
Although the contract consultants suggested that we add a category
for psychoactive substance abuse disorders, we have not done so because
substance-related disorders are addressed elsewhere in regulations (38
CFR 3.1 (m) and 3.301).
We propose to change the title of Sec. 4.128 from ``Change of
diagnosis'' to ``Convalescence ratings following extended
hospitalization,'' and to include in it material from a note under DC
9210 regarding the need to continue a total evaluation following a
period of hospitalization lasting six months or more and to schedule a
mandatory examination six months after the
[[Page 54827]]
veteran is discharged or released to nonbed care. We propose to add a
requirement that a change in evaluation based on that or any subsequent
examination shall be subject to the provisions of 38 CFR 3.105(e),
which require a 60-day notice before VA can reduce an evaluation and an
additional 60-day notice before the reduced evaluation takes effect.
While the fact that an individual is no longer hospitalized usually
means there has been some improvement, stabilization and return to
usual activities in the face of a severe mental disorder is often
difficult to achieve. Making changes subject to Sec. 3.105(e) will
preclude changes in evaluation unless a stable level of improvement has
occurred, and will help to prevent a cycle of changes in evaluations
followed by further examinations, further changes in evaluations, etc.
We propose to move the regulatory material on social impairment
from Sec. 4.129 to Sec. 4.126, paragraph (b), as discussed above, and
to change the title of Sec. 4.129 from ``Social inadaptability'' to
``Mental disorders due to psychic trauma.'' We propose to include in
the revised Sec. 4.129 the regulatory material from Sec. 4.131, which
requires an evaluation of not less than 50 percent when a mental
disorder that develops in service as a result of a highly stressful
event is severe enough to cause the veteran's release from active
service.
As discussed above, we propose to delete the contents of
Sec. 4.130, titled ``Evaluation of psychiatric disability'' in favor of
the proposed paragraph (a) of Sec. 4.126 and the proposed evaluation
criteria for mental disorders.
We propose to retain the substance of Sec. 4.131, ``Mental
disorders due to psychic trauma,'' in Sec. 4.129 and to delete
Sec. 4.131.
There are currently four notes in Sec. 4.132 following the rating
formula for psychoneuroses. Notes (1), prohibiting assignment of
evaluations based on social impairment only, and (4), concerning
evaluation of a single disability which has been diagnosed both as a
physical and mental disability, have been incorporated into Sec. 4.126,
as discussed above. We propose to delete note (2), which discusses the
requirements for a compensable rating from mental disorders; it is
redundant since the proposed Secs. 4.125 and 4.126 and general rating
formula set forth clear diagnostic and evaluation requirements. We also
propose to incorporate the regulatory content of note (3), regarding
the return of an inadequate examination report to the examiner, and
note (1) under DC 9511, concerning the diagnosis of psychological
disorders, into Sec. 4.125, the section on diagnosis. We propose to
delete the part of note (3) that discusses requirements for the
diagnosis of conversion disorder, as this is discussed in detail in
DSM-IV.
We propose to incorporate the regulatory content of note (2) under
DC 9511, about the evaluation of a single condition diagnosed both as a
mental and a physical disorder, into Sec. 4.126, the section on
evaluation, in order to keep in one place all of the regulatory
material on evaluation of mental disorders.
The conditions included under Sec. 4.132 are currently divided into
four categories: psychotic disorders (DC's 9201 through 9210), organic
mental disorders (DC's 9300 through 9325), psychoneurotic disorders
(DC's 9400 through 9411), and psychological factors affecting physical
condition (DC's 9500 through 9511). The contract consultants
recommended that we reclassify some diseases in accordance with the
current version of the DSM, and we propose to do that. We propose to
reorganize the conditions into eight categories that conform more
closely to the categories in DSM-IV, thus making it easier for rating
specialists to correlate the diagnoses given on VA and non-VA exams
with the conditions in the rating schedule. This reorganization will
require a number of changes in the arrangement and titles of diagnostic
codes. We also propose to add diagnostic codes for several conditions
that are encountered frequently enough in VA claims to warrant their
inclusion in the rating schedule, but which are not currently found
there.
We propose a new category of ``Schizophrenia and other psychotic
disorders.'' Except for schizoaffective disorder, discussed below, we
propose no change in the diagnostic codes pertaining to schizophrenia
(DC's 9201 through 9205), which cover conditions with characteristic
psychotic symptoms during the active phase, involving delusions,
hallucinations, or certain characteristic disturbances in affect and
the form of thought. We do, however, propose to change the evaluation
criteria for schizophrenia and all other conditions in the section on
mental disorders, as will be discussed later in the preamble.
We propose to delete diagnostic codes 9206, bipolar disorder,
manic, depressed, or mixed, and 9207, major depression with psychotic
features, since we are providing a category for mood disorders that
will include conditions such as these, and these changes will be
addressed further when mood disorders are discussed.
We propose to update the title of diagnostic code 9208 from
``paranoid disorders (specify type)'' to ``delusional disorder'' and
place it in the category of schizophrenia and other psychotic
disorders, in accord with DSM-IV. This disorder is characterized by a
persistent, nonbizarre delusion that is not due to any other mental or
physical disorder.
We also propose to delete DC 9209, major depression with
melancholia, another condition that will be moved to the category of
mood disorders.
We propose to revise the title of DC 9210, ``atypical psychosis,''
to ``psychotic disorder, not otherwise specified (atypical
psychosis),'' and put it in the same category with other psychotic
disorders, in accord with DSM-IV. We also propose to put
schizoaffective disorder, now part of DC 9205 (schizophrenia, residual
type; schizoaffective disorder; other and unspecified types), in this
category as diagnostic code 9211. Although schizoaffective disorder is
linked to schizophrenia in the current schedule, DSM-IV names it as a
separate psychotic disorder rather than as a type of schizophrenia.
We propose to change the title of the current category of ``Organic
mental disorders'' to ``Delirium, dementia, and amnestic and other
cognitive disorders'' in accordance with DSM-IV. The conditions in this
section demonstrate a psychological or behavioral abnormality
associated with transient or permanent dysfunction of the brain. We
also propose to consolidate the 16 types of dementia in the current
schedule into fewer categories, since several, such as dementia
associated with endocrine disorder (DC 9322) and dementia associated
with systemic infection (DC 9324), are quite uncommon (only about one-
tenth of one percent of VA beneficiaries being compensated for dementia
have one of these types of dementia); and a number of others, such as
dementia associated with central nervous system syphilis (DC 9301),
dementia associated with intracranial infections other than syphilis
(DC 9302), and dementia associated with epidemic encephalitis (DC
9315), lend themselves to logical groupings based on etiology (in this
case, infection).
DSM-IV provides a classification of dementias that is more complex
than is needed or useful for VA purposes. For example, it has separate
categories for dementia due to Huntington's disease, due to Pick's
disease, and due to Creutzfeldt-Jacob disease, all of which are
uncommonly seen for VA rating purposes.
We propose a reorganization better suited to VA purposes, and
requiring
[[Page 54828]]
less revision of the schedule than would be needed to adopt the entire
DSM-IV structure. We propose to use six diagnostic codes for specific
dementias, many of them the same as are now present. We propose to
retain some types because of their frequent occurrence and relevance to
veterans, dementia due to head trauma, (DC 9304, dementia associated
with brain trauma in the current schedule), for example, and some
because they represent clusters of a particular etiology, as discussed
above. We propose to retain diagnostic codes for the types of dementia
most commonly seen in the general population, vascular dementia
(currently DC's 9305 and 9306, multi-infarct dementia with cerebral
arteriosclerosis and multi-infarct dementia due to causes other than
cerebral arteriosclerosis, respectively), and dementia of the
Alzheimer's type (currently DC 9312, primary degenerative dementia).
This reorganization will not affect how dementias are evaluated, since
all types will be evaluated under the same criteria, but will allow
separation of the most common types by etiology.
We propose to delete DC's 9303 (currently dementia associated with
alcoholism) and 9325 (currently dementia associated with drug or poison
intoxication (other than alcohol)), in accord with DSM-IV, which
categorizes them as subtypes of dementia due to general medical
conditions, further discussed below. We propose to change DC 9304
(dementia associated with brain trauma) to dementia due to head trauma,
because this is more modern terminology, and DC 9301 (dementia
associated with central nervous system syphilis) to dementia associated
with infection. We propose to include in the revised DC 9301 the
conditions now evaluated under DC's 9301, 9302 (dementia associated
with intracranial infections other than syphilis), 9315 (dementia
associated with epidemic encephalitis), and 9324 (dementia associated
with systemic infection), since the number of cases of dementia due to
infection is small, and the specific type of infection has no bearing
on the evaluation.
We propose to delete current diagnostic codes 9307 (dementia
associated with convulsive disorder), 9308 (dementia associated with
disturbances of metabolism), 9309 (dementia associated with brain
tumor), and 9322 (dementia associated with endocrine disorder), and to
rate these conditions under a single new diagnostic code, 9326, titled
dementia due to other neurologic or general medical conditions
(including endocrine disorders, metabolic disorders, drugs, alcohol,
poisons, Pick's disease, brain tumors, etc.). This category encompasses
in a single miscellaneous category a number of uncommon conditions that
DSM-IV names separately.
We propose to change the title of DC 9305 from multi-infarct
dementia with cerebral arteriosclerosis to vascular dementia and to
have it encompass multi-infarct dementia due to causes other than
cerebral arteriosclerosis (DC 9306), which we propose to delete, since
both are due to vascular disease and may be difficult to distinguish.
They are addressed as a single entity in DSM-IV.
In practice, it may be impossible to determine whether a dementia
fits into DC 9310 (dementia due to unknown cause) or DC 9311 (dementia
due to undiagnosed cause). We therefore propose to delete DC 9311 and
revise DC 9310 to encompass both as dementia of unknown etiology. We
propose to retain DC 9312 but to alter the title from dementia,
primary, degenerative, to dementia of the Alzheimer's type, in accord
with DSM-IV.
We also propose to add diagnostic code 9327, organic mental
disorder, other, to provide a code for conditions such as amnestic
disorder, organic personality disorder, and other cognitive disorders
that are not dementias.
We propose to create a new category for anxiety disorders, in
accord with DSM-IV. This category will include several of the
conditions currently listed under the category of psychoneurotic
disorders: ``generalized anxiety disorder'' (DC 9400), ``obsessive
compulsive disorder'' (DC 9404), ``other and unspecified neurosis'' (DC
9410), ``post-traumatic stress disorder'' (DC 9411), and ``specific
(simple) phobia; social phobia'' (DC 9403) (modified from the current
``phobic disorder,'' in accord with terminology in DSM-IV).
We propose to move some of the conditions now listed under
psychoneurotic disorders to new categories: DC 9401, dissociative
amnesia; dissociative fugue; dissociative identity disorder (currently
psychogenic amnesia; psychogenic fugue; multiple personality) and DC
9408, depersonalization disorder, to the category of dissociative
disorders, as discussed below; DC 9402, conversion disorder;
psychogenic pain disorder, and DC 9409, hypochondriasis, to somatoform
disorders, as discussed below; and to delete DC 9405, dysthymic
disorder; adjustment disorder with depressed mood; major depression
without melancholia, also as discussed below. We also propose to add to
anxiety disorders two conditions that occur frequently enough that
diagnostic codes are needed and which are not now included in the
rating schedule: ``panic disorder and/or agoraphobia'' (DC 9412) and
``anxiety disorder, not otherwise specified'' (DC 9413). While ``other
and unspecified neurosis'' (DC 9410 in the current schedule) is not
limited to anxiety disorders, we propose to place it in this category
as a matter of convenience, rather than giving it a separate category.
We propose to create a category for dissociative disorders,
conditions, according to DSM-IV, where there is a disturbance in the
usually integrated functions of identity, memory, consciousness, or
perception of the environment. Included in this category will be:
``dissociative amnesia; dissociative fugue; dissociative identity
disorder (multiple personality disorder)'', (DC 9416, changed from 9401
to keep conditions in this category together) and ``depersonalization
disorder'' (DC 9417, changed from 9408 for the same reason).
In accord with DSM-IV, we propose to add a category for somatoform
disorders, conditions characterized by the presence of physical
symptoms that suggest a general medical condition and are not explained
by a general medical condition, by the direct effects of a substance,
or by another mental disorder. We propose to move two disorders,
``conversion disorder; psychogenic pain disorder'' (DC 9402) and
``hypochondriasis'' (DC 9409), that are currently listed under the
category of psychoneuroses to this category and give them new
diagnostic codes (DC's 9424, 9422, and 9425) so that the somatoform
disorders can be grouped together. We propose to split ``conversion
disorder; psychogenic pain disorder'' into ``conversion disorder,'' DC
9424, and ``pain disorder'' (the current term for psychogenic pain
disorder), DC 9422, since the two conditions are distinct, and to
change the diagnostic code for ``hypochondriasis'' from DC 9409 to DC
9425. We also propose to add two other conditions: ``somatization
disorder'' (DC 9421), a commonly seen somatoform disorder not included
in the present schedule, and ``undifferentiated somatoform disorder''
(DC 9423), for somatoform disorders that do not fit elsewhere and for
which there is no suitable code in the current schedule.
We propose to establish a new category in the rating schedule for
mood disorders, which are characterized, according to DSM-IV, by a
disturbance in mood as the predominant feature. We
[[Page 54829]]
propose to place in this category: bipolar disorder (DC 9432),
dysthymic disorder (DC 9433), and major depressive disorder (DC 9434).
Major depressive disorder is currently included under three diagnostic
codes: 9207 (major depression with psychotic features), 9209 (major
depression with melancholia), and 9405 (dysthymic disorder; adjustment
disorder with depressed mood; major depression without melancholia).
Since DSM-IV does not recognize three varieties of major depressive
disorder, we propose to evaluate it under a single diagnostic code,
9434 (major depressive disorder). We also propose to change the
diagnostic codes for dysthymic disorder (currently dysthymia, DC 9405)
and bipolar disorder (DC 9206) to DC's 9433 and 9432, respectively, in
order to group the mood disorders together.
For the sake of completeness, we propose to provide diagnostic
codes for two additional mood disorders not currently included in the
rating schedule: cyclothymic disorder (DC 9431), which, although
related to bipolar disorder, is classified as a separate entity by DSM-
IV, and mood disorder, not otherwise specified (DC 9435), which allows
the evaluation of conditions with mood symptoms that do not meet the
criteria for any specific mood disorder. As part of this
reorganization, we propose to remove DC 9405 (``dysthymic disorder;
adjustment disorder with depressed mood; major depression without
melancholia'') since we are providing separate diagnostic codes for
both ``dysthymic disorder'' (DC 9433) and ``major depressive disorder''
(DC 9434) under the category of mood disorders.
A category of mental disorders that the current rating schedule
does not specifically address, but that is seen fairly often in the
veteran population, is adjustment disorder. The essential feature of an
adjustment disorder is the development of clinically significant
emotional or behavioral symptoms in response to an identifiable
psychosocial stressor or stressors. We propose to add a new category
and diagnostic code (9440) for chronic adjustment disorder.
The current rating schedule provides separate rating formulas for
psychotic disorders, organic mental disorders, and psychoneurotic
disorders. The formula for psychoneurotic disorders provides some
specific criteria at each evaluation level, but also uses ``mild,''
``definite,'' ``considerable,'' and ``severe'' industrial impairment at
certain levels. Formulas for the other two provide specific criteria
only at the 100 percent level and assign less than total evaluations
based on whether there is ``mild,'' ``definite,'' ``considerable,'' or
``severe'' impairment of social and industrial adaptability at the
other levels. Because those are non-specific terms, they are subject to
interpretation by individual rating boards, and it is possible that
they may not be applied consistently. For example, the current
criterion for the 50 percent level of evaluation for psychotic
disorders is: ``considerable impairment of social and industrial
adaptability.'' This offers no objective guidance for the rating board
and makes comparison of one exam with another difficult. We propose to
provide more objective criteria that will in turn result in more
consistent evaluations.
The contract consultants recommended that we base the evaluation of
mental disorders on more extensive objective descriptions of their
possible effects and with examples of signs and symptoms at various
levels. In keeping with that recommendation, we propose to evaluate all
mental disorders except eating disorders under a single formula,
providing objective criteria based on signs and symptoms which
characteristically produce a particular level of disability. For
example, we propose criteria for the 50 percent level to be:
``moderately severe impairment in social and occupational functioning
with reduced reliability and productivity due to such symptoms as:
flattened affect; circumstantial, circumlocutory, or stereotyped
speech; panic attacks more than once a week; difficulty in
understanding complex commands; impairment of short--and long-term
memory (e.g., retention of only highly learned material, forgetting to
complete tasks); impaired judgment; impaired abstract thinking;
disturbances of motivation and mood; difficulty in establishing and
maintaining effective relationships at work and socially.'' These
criteria are clearly more objective than the present rating formulas,
and providing such objective criteria at each level of evaluation will
result in more consistent evaluations and will offer greater ease in
comparing examinations.
The symptoms indicated at each level are not intended to be
comprehensive (and could not be, because of the multitude of symptoms
in mental disorders), but to provide an objective framework that will
enable rating boards to assign consistent evaluations for mental
disorders based on signs and symptoms. The proposed criteria are more
objective than the current ones because they focus on the level of
impairment of occupational and social functioning as related to the
specific symptoms which are present, whether the symptoms are
persistent or transient, their frequency (e.g., of panic attacks), and
their severity (e.g., degrees of memory loss are given at different
levels). With more specific and objective criteria, the rating board
can make a determination of the level of severity based on all the
evidence of record, including the detailed report of all signs and
symptoms, relevant information regarding employment, report of daily
activities, etc., and will not have to attempt an assessment based on
whether the evidence corresponds to the non-specific language in the
current schedule.
In the current rating schedule, DC's 9500 through 9511 represent
psychological factors affecting physical conditions in various body
systems, and they are in their own category. Evaluation is directed to
be made under the general rating formula for psychoneurotic disorders.
In DSM-IV, the condition of ``psychological factors affecting physical
condition'' has been renamed ``psychological factors affecting medical
condition'' (PFAMC) and placed in a new category, ``Other conditions
that may be a focus of clinical attention.'' DSM-IV states that PFAMC
refers to the presence of one or more specific psychological or
behavioral factors that adversely affect a general medical condition.
There are therefore two components in PFAMC: a medical condition and
psychological factors. There is no need for a separate code and
evaluation criteria for this condition, and we propose to delete DC's
9500 through 9511. Psychological factors that do not constitute a
recognized mental disorder would not be service-connectable in their
own right. A separate evaluation for each service-connected component
would be made as usual under the appropriate diagnostic code(s). An
additional separate evaluation for PFAMC would not be warranted, and in
fact would represent pyramiding (see 38 CFR 4.14).
We propose to add one other category, ``eating disorders,'' a group
of mental disorders characterized by gross disturbances in eating
behavior. This category will include anorexia nervosa (DC 9520) and
bulimia nervosa (DC 9521), conditions which are commonly diagnosed but
cannot be appropriately rated under the proposed general rating
criteria for mental disorders because their more disabling aspects are
manifested primarily by physical findings rather than by psychological
symptoms. We propose that the criteria be based partly on the extent of
weight loss (per DSM-IV) and partly on the extent of incapacitating
episodes and needed periods of hospitalization.
The contract consultants suggested we include the categories of
sexual
[[Page 54830]]
disorders and sleep disorders in the revised schedule. Sexual
disorders, which include sexual dysfunctions such as sexual desire
disorders and orgasmic disorders, paraphilias such as fetishism and
sexual sadism, and gender identity disorders, do not have any inherent
effect on employability, and we do not propose to include them in the
schedule. Sleep disorders are often manifested by significant physical
manifestations, and narcolepsy is currently addressed in the rating
schedule under neurologic disorders (as DC 8108). We published a
proposed revision of the respiratory disorders section of the rating
schedule (58 FR 4962-69) that will include sleep apnea (as DC 6846). We
therefore do not propose to add a separate category for sleep disorders
to the mental disorders section of the schedule.
Section 4.16 of 38 CFR was established to assure that any veteran
unable to secure or follow a substantially gainful occupation because
of service-connected disabilities will be awarded a total evaluation
even though the schedular evaluation does not reach that level. Section
4.16(c) provides that where the only service-connected disability is a
mental disorder assigned a 70 percent schedular evaluation, but which
nonetheless precludes the veteran from securing or following a
substantially gainful occupation, the mental disorder will be assigned
a 100 percent schedular evaluation rather than an extra-schedular total
evaluation. We propose to delete Sec. 4.16 (c), because, in our
judgment, it is possible that a veteran may be properly evaluated at a
level less than 100 percent based on average impairment, but because of
unique aspects of his or her individual situation, might still be
unable to secure or follow a substantially gainful occupation. In order
to allow rating specialists the flexibility to fairly evaluate such
situations, we propose to have Sec. 4.16(a) apply to mental disorders
in the same manner that it does to other disabilities.
The Secretary hereby certifies that this regulatory amendment will
not have a significant economic impact on a substantial number of small
entities as they are defined in the Regulatory Flexibility Act (RFA), 5
U.S.C. 601-612. The reason for this certification is that this
amendment would not directly affect any small entities. Only VA
beneficiaries could be directly affected. Therefore, pursuant to 5
U.S.C. 605(b), this amendment is exempt from the initial and final
regulatory flexibility analysis requirements of sections 603 and 604.
This rule has been reviewed under Executive Order 12866 by the
Office of Management and Budget.
The Catalog of Federal Domestic Assistance program numbers are
64.104 and 64.109.
List of Subjects in 38 CFR Part 4
Disability benefits, Individuals with disabilities, Pensions,
Veterans.
Approved: July 19, 1995.
Jesse Brown,
Secretary of Veterans Affairs.
For the reasons set out in the preamble, 38 CFR part 4 is proposed
to be amended as set forth below:
PART 4--SCHEDULE FOR RATING DISABILITIES
1. The authority citation for part 4 continues to read as follows:
Authority: 38 U.S.C. 1155.
Sec. 4.16 [Amended]
2. In Sec. 4.16, paragraph (c) is removed.
Subpart B--Disability Ratings
3. Section 4.125 is revised to read as follows:
Sec. 4.125 Diagnosis of mental disorders.
(a) If the diagnosis of a mental disorder does not conform to DSM-
IV or is not supported by the findings on the examination report, the
rating board shall return the report to the examiner to substantiate
the diagnosis.
(b) If the diagnosis of a mental disorder is changed, the rating
board shall determine whether the new diagnosis represents progression
of the prior diagnosis, correction of an error in the prior diagnosis,
or development of a new and separate condition. If it is not clear from
the available records what the change of diagnosis represents, the
rating board shall return the report to the examiner for a
determination.
4. Section 4.126 is revised to read as follows:
Sec. 4.126 Evaluation of disability from mental disorders.
(a) When evaluating a mental disorder, the rating board shall
consider the frequency, severity, and duration of psychiatric symptoms,
the length of remissions, and the veteran's capacity for adjustment
during periods of remission. The rating board shall assign an
evaluation based on all the evidence of record that bears on
occupational and social impairment rather than on the examiner's
assessment of the level of disability at the moment of the examination.
(b) When evaluating the level of disability from a mental disorder,
the rating board will consider the extent of social impairment, but
shall not assign an evaluation solely on the basis of social
impairment.
(c) Delirium, dementia, and amnestic and other cognitive disorders
shall be evaluated under the general rating formula for mental
disorders; neurologic deficits or other impairments stemming from the
same etiology (e.g., a head injury) shall be evaluated separately and
combined with the evaluation for delirium, dementia, or amnestic or
other cognitive disorder (see Sec. 4.25 of this part).
(d) When a single disability has been diagnosed both as a physical
condition and as a mental disorder, the rating board shall evaluate it
using a diagnostic code which represents the dominant (more disabling)
aspect of the condition (see Sec. 4.14 of this part).
5. Section 4.127 is revised to read as follows:
Sec. 4.127 Mental retardation and personality disorders.
Mental retardation and personality disorders will not be considered
as disabilities under the terms of the schedule, but a mental disorder
that is superimposed upon, but clearly separate from, the mental
retardation or personality disorder may be a disability for VA
compensation purposes.
6. Section 4.128 is revised to read as follows:
Sec. 4.128 Convalescence ratings following extended hospitalization.
If a mental disorder has been assigned a total evaluation due to a
continuous period of hospitalization lasting six months or more, the
rating board shall continue the total evaluation indefinitely and
schedule a mandatory examination six months after the veteran is
discharged or released to nonbed care. A change in evaluation based on
that or any subsequent examination shall be subject to the provisions
of Sec. 3.105(e) of this chapter.
7. Section 4.129 is revised to read as follows:
Sec. 4.129 Mental disorders due to psychic trauma.
When a mental disorder that develops in service as a result of a
highly stressful event is severe enough to bring about the veteran's
release from active military service, the rating board shall assign an
evaluation of not less than 50 percent and schedule an examination
within the six month period following the veteran's discharge.
8. Section 4.130 is revised to read as follows:
[[Page 54831]]
Sec. 4.130 Schedule of ratings--mental disorders.
Note: The nomenclature employed in this portion of the rating
schedule is based upon the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, of the American Psychiatric
Association (DSM-IV). Rating boards must be thoroughly familiar with
this manual to properly implement the directives in Sec. 4.125
through Sec. 4.129 and to apply the general rating formula for
mental disorders in Sec. 4.130.
Schizophrenia and Other Psychotic Disorders
9201 Schizophrenia, disorganized type
9202 Schizophrenia, catatonic type
9203 Schizophrenia, paranoid type
9204 Schizophrenia, undifferentiated type
9205 Schizophrenia, residual type; other and unspecified types
9208 Delusional disorder
9210 Psychotic disorder, not otherwise specified (atypical psychosis)
9211 Schizoaffective disorder
Delirium, Dementia, and Amnestic and Other Cognitive Disorders)
9300 Delirium
9301 Dementia due to infection (HIV infection, syphilis, or other
systemic or intracranial infections)
9304 Dementia due to head trauma
9305 Vascular dementia
9310 Dementia of unknown etiology
9312 Dementia of the Alzheimer's type
9326 Dementia due to other neurologic or general medical conditions
(endocrine disorders, metabolic disorders, drugs, alcohol, poisons,
Pick's disease, brain tumors, etc.)
9327 Organic mental disorder, other
Anxiety Disorders
9400 Generalized anxiety disorder
9403 Specific (simple) phobia; social phobia
9404 Obsessive compulsive disorder
9410 Other and unspecified neurosis
9411 Post-traumatic stress disorder
9412 Panic disorder and/or agoraphobia
9413 Anxiety disorder, not otherwise specified
Dissociative Disorders
9416 Dissociative amnesia; dissociative fugue; dissociative identity
disorder (multiple personality disorder)
9417 Depersonalization disorder
Somatoform Disorders
9421 Somatization disorder
9422 Pain disorder
9423 Undifferentiated somatoform disorder
9424 Conversion disorder
9425 Hypochondriasis
Mood Disorders
9431 Cyclothymic disorder
9432 Bipolar disorder
9433 Dysthymic disorder
9434 Major depressive disorder
9435 Mood disorder, not otherwise specified
Chronic Adjustment Disorder
9440 Chronic adjustment disorder
General Rating Formula for Mental Disorders
Total occupational and social impairment, due to such symptoms as:
gross impairment in thought processes or communication; persistent
delusions or hallucinations; grossly inappropriate behavior; persistent
danger of hurting self or others; intermittent inability to perform
activities of daily living (including maintenance of minimal personal
hygiene); disorientation to time or place; memory loss for names of
close relatives, own occupation, or own name--100.
Severe occupational and social impairment, with deficiencies in
most areas, such as work, school, family relations, judgment, thinking,
or mood, due to such symptoms as: Suicidal ideation; obsessional
rituals which interfere with routine activities; speech intermittently
illogical, obscure, or irrelevant; near-continuous panic or depression
affecting the ability to function independently, appropriately and
effectively; impaired impulse control (such as unprovoked irritability
with periods of violence); spatial disorientation; neglect of personal
appearance and hygiene; difficulty in adapting to stressful
circumstances (including work or a worklike setting); inability to
establish and maintain effective relationships--70,
Occupational and social impairment with reduced reliability and
productivity due to such symptoms as: Flattened affect; circumstantial,
circumlocutory, or stereotyped speech; panic attacks more than once a
week; difficulty in understanding complex commands; impairment of
short- and long-term memory (e.g., retention of only highly learned
material, forgetting to complete tasks); impaired judgment; impaired
abstract thinking; disturbances of motivation and mood; difficulty in
establishing and maintaining effective work and social relationships--
50.
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), 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)--30.
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--10.
A mental condition has been formally diagnosed, but symptoms are
not severe enough either to interfere with occupational and social
functioning or to require continuous medication--0.
Eating Disorders
9520 Anorexia nervosa
9521 Bulimia nervosa
Rating Formula for Eating Disorders
Self-induced weight loss to less than 80 percent of expected
minimum weight, with incapacitating episodes of at least six weeks
total duration, and requiring hospitalization more than twice a year
for parenteral nutrition or tube feeding--100.
Self-induced weight loss to less than 85 percent of expected
minimum weight with incapacitating episodes of six or more weeks total
duration per year--60.
Self-induced weight loss to less than 85 percent of expected
minimum weight with incapacitating episodes of more than two but less
than six weeks total duration per year--30.
Binge eating followed by self-induced vomiting or other measures to
prevent weight gain, or resistance to weight gain even when below
expected minimum weight, with diagnosis of an eating disorder and
incapacitating episodes of up to two weeks total duration per year--10.
Binge eating followed by self-induced vomiting or other measures to
prevent weight gain, or resistance to weight gain even when below
expected minimum weight, with diagnosis of an eating disorder but
without incapacitating episodes--0.
Note: An incapacitating episode is a period during which bed
rest and treatment by a physician are required.
Secs. 4.131 and 4.132 [Removed]
9. Sec. 4.131 and Sec. 4.132 are removed.
[FR Doc. 95-26567 Filed 10-25-95; 8:45 am]
BILLING CODE 8320-01-P