[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