[Federal Register Volume 79, Number 149 (Monday, August 4, 2014)]
[Rules and Regulations]
[Pages 45093-45103]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2014-18150]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Parts 3 and 4
RIN 2900-AO96
Schedule for Rating Disabilities--Mental Disorders and Definition
of Psychosis for Certain VA Purposes
AGENCY: Department of Veterans Affairs.
ACTION: Interim final rule.
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SUMMARY: The Department of Veterans Affairs (VA) is amending the
portion of its Schedule for Rating Disabilities (VASRD) dealing with
mental disorders and its adjudication regulations that define the term
``psychosis.'' The
[[Page 45094]]
VASRD refers to the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV), and VA's adjudication regulations
refer to the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition Text Revision (DSM-IV-TR). DSM-IV and DSM-IV-TR were
recently updated by issuance of the Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition (DSM-5). This rulemaking will remove
outdated DSM references by deleting references to DSM-IV and DSM-IV-TR
and replacing them with references to DSM-5. Additionally, this
rulemaking will update the nomenclature used to refer to certain mental
disorders to conform to DSM-5.
DATES: Effective Date: This interim final rule is effective August 4,
2014. The incorporation by reference of certain publications listed in
the rule is approved by the Director of the Federal Register as of
August 4, 2014.
Comment Date: Comments must be received on or before October 3,
2014.
Applicability Date: The provisions of this interim final rule shall
apply to all applications for benefits that are received by VA or that
are pending before the agency of original jurisdiction on or after the
effective date of this interim final rule. The Secretary does not
intend for the provisions of this interim final rule to apply to claims
that have been certified for appeal to the Board of Veterans' Appeals
or are pending before the Board of Veterans' Appeals, the United States
Court of Appeals for Veterans Claims, or the United States Court of
Appeals for the Federal Circuit.
ADDRESSES: Written comments may be submitted through
www.Regulations.gov; by mail or hand-delivery to Director, Regulation
Policy and Management (02REG), Department of Veterans Affairs, 810
Vermont Avenue NW., Room 1068, Washington, DC 20420; or by fax to (202)
273-9026. Comments should indicate that they are submitted in response
to ``RIN 2900-AO96--Schedule for Rating Disabilities--Mental Disorders
and Definition of Psychosis for Certain VA Purposes.'' Copies of
comments received will be available for public inspection in the Office
of Regulation Policy and Management, Room 1068, between the hours of
8:00 a.m. and 4:30 p.m., Monday through Friday (except holidays).
Please call (202) 461-4902 for an appointment. (This is not a toll-free
number.) In addition, during the comment period, comments may be viewed
online through the Federal Docket Management System (FDMS) at
www.Regulations.gov.
FOR FURTHER INFORMATION CONTACT: Ioulia Vvedenskaya, Medical Officer,
VASRD Regulations Staff (211C), Compensation Service, Veterans Benefits
Administration, Department of Veterans Affairs, 810 Vermont Avenue NW.,
Washington, DC 20420, (202) 461-9700. (This is not a toll-free
telephone number.)
SUPPLEMENTARY INFORMATION: The Diagnostic and Statistical Manual of
Mental Disorders (DSM) is published by the American Psychiatric
Association and provides a common language and standard criteria for
the classification of mental disorders. DSM-IV, the version that is
referenced in VA's current regulations, was initially published in
1994, with minor changes published in 2000 as the DSM-IV-TR. DSM-5,
which replaces DSM-IV and DSM-IV-TR, was published in May 2013.
The DSM is referenced in VA's adjudication regulations and VASRD to
ensure that claims for disability benefits for mental disorders are
adjudicated in a consistent and objective manner. Additionally,
reference to the DSM is included so that VA adjudicators apply the same
principles and criteria that are used by both VA and non-VA health care
providers. 61 FR 52695, Oct. 8, 1996.
In order to keep VA regulations, including the VASRD, current for
immediate use in accordance with DSM-5, 38 CFR 3.384, 4.125, 4.126,
4.127, and 4.130 must be updated. This update will require VA rating
personnel to use the diagnostic nomenclature contained in DSM-5 when
adjudicating claims for mental disorders. This update to incorporate
the current DSM will not affect evaluations assigned to mental
disorders as it does not change the disability evaluation criteria in
the VASRD.
Section 3.384: DSM Reference and DSM-5 Nomenclature Change
Currently, Sec. 3.384 reads, ``For purposes of this part, the term
`psychosis' means any of the following disorders listed in Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision, of the American Psychiatric Association (DSM-IV-TR).''
Reference to DSM-IV-TR is outdated in light of the publication of the
most recent fifth edition of the DSM and is, by this rulemaking,
replaced with reference to DSM-5. Additionally, the reference to Shared
Psychotic Disorder as a distinct diagnosis in Sec. 3.384(h) is removed
as the DSM-5 now classifies it as a part of Delusional Disorder. Also
included in current Sec. 3.384 are the following listed disorders:
Psychotic Disorder Due to General Medical Condition; Psychotic Disorder
Not Otherwise Specified; and Substance-Induced Psychotic Disorder. To
reflect the current nomenclature of the DSM-5, VA is updating the names
of these disorders to Psychotic Disorder Due to Another Medical
Condition, Other Specified Schizophrenia Spectrum and Other Psychotic
Disorder, and Substance/Medication-Induced Psychotic Disorder,
respectively.
Section 4.125: DSM Reference and DSM-5 Nomenclature Change
Section 4.125(a) currently reads, ``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 agency shall return the report to
the examiner to substantiate the diagnosis.'' Now that DSM-5 has been
published, continued VASRD reference to DSM-IV will lead to inaccurate
Compensation and Pension diagnoses and inefficient processing of
related benefits claims. Additionally, mandating use of an outdated
version of the DSM would not be consistent with VA's goal of using the
most up-to-date medical information to describe veterans' rated
disorders. Therefore, VA is removing the reference to DSM-IV and
replacing it with reference to DSM-5.
Section 4.126: DSM-5 Nomenclature Change
Currently, Sec. 4.126(c) reads, ``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).''
DSM-5 renames the ``Delirium, Dementia, and Amnestic and Other
Cognitive Disorders'' category as ``Neurocognitive Disorders.''
Therefore, VA is deleting the reference to ``Delirium, dementia, and
amnestic and other cognitive disorders'' as a disease category in Sec.
4.126(c) and replacing it with ``Neurocognitive Disorders'' to be
consistent with the terminology in DSM-5.
Section 4.127: DSM-5 Nomenclature Change
Currently, Sec. 4.127 is titled ``Mental retardation and
personality disorders.'' It reads, ``Mental retardation and personality
disorders are not diseases or injuries for compensation purposes, and,
except as provided in Sec. 3.310(a) of this chapter, disability
resulting from them may not be service-connected.
[[Page 45095]]
However, disability resulting from a mental disorder that is
superimposed upon mental retardation or a personality disorder may be
service-connected.'' The term ``mental retardation'' was used in DSM-
IV. However, the term ``intellectual disability (intellectual
developmental disorder)'' has replaced ``mental retardation'' in common
use over the past two decades among medical, educational, and other
professionals and conforms with nomenclature in the DSM-5. Therefore,
VA is deleting the reference to ``Mental retardation'' and replacing it
with ``Intellectual disability (intellectual developmental disorder)''
in Sec. 4.127 and its title.
Section 4.130: DSM Reference and DSM-5 Nomenclature Change
Currently, Sec. 4.130 reads, ``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).'' As explained above, continued
reference to the DSM-IV will lead to inaccurate Compensation and
Pension diagnoses and inefficient processing of related benefits
claims. Additionally, mandating the use of an outdated version of the
DSM would not be consistent with VA's goal of using the most up-to-date
medical information to describe veterans' rated disorders. Therefore,
VA is deleting the reference to DSM-IV in Sec. 4.130 and replacing it
with a reference to DSM-5.
Section 4.130: Deletion of Organizational Categories
Currently, Sec. 4.130 lists 38 diagnostic codes that are divided
under eight organizational headers: Schizophrenia and Other Psychotic
Disorders; Delirium, Dementia, and Amnestic and Other Cognitive
Disorders; Anxiety Disorders; Dissociative Disorders; Somatoform
Disorders; Mood Disorders; Chronic Adjustment Disorder; and Eating
Disorders. These headers are based on the chapters in the DSM-IV and
reflect classification of mental disorders in DSM-IV. The headers are
not part of the actual rating criteria that pertain to how a mental
disability is evaluated under the VASRD.
VA is changing Sec. 4.130 terminology to conform to DSM-5.
Accordingly, VA is deleting the organizational headers within the
VASRD. This change adheres to the classification of mental disorders in
DSM-5 and allows for accurate classification of mental disorders under
the VASRD. For example, in the DSM-5, the Anxiety Disorders chapter no
longer includes obsessive-compulsive disorder, which is in a new
chapter ``Obsessive-Compulsive and Related Disorders,'' or
posttraumatic stress disorder (PTSD), which is in the new chapter
``Trauma- and Stressor-Related Disorders.'' This change is technical
and does not amend the criteria currently used to evaluate mental
disorders under the VASRD.
In addition to deletion of these organizational categories, VA is
adding a note to Sec. 4.130. This note instructs rating specialists to
evaluate mental disorders according to the general rating formula for
mental disorders and to evaluate eating disorders according to the
rating formula for eating disorders. This note is necessary due to the
DSM-5 deletion of organizational categories. There is no change made to
VA's criteria or method for evaluating mental and eating disorders. The
note will read as follows: ``Note: Ratings under diagnostic codes 9201
to 9440 will be evaluated using the General Rating Formula for Mental
Disorders. Ratings under diagnostic codes 9520 and 9521 will be
evaluated using the General Rating Formula for Eating Disorders.''
Section 4.130: Diagnostic Codes and DSM-5 Nomenclature
Of the 38 diagnostic codes in Sec. 4.130, 25 require updating to
reflect the current terminology contained in the DSM-5. The changes do
not affect the evaluation of these mental disorders. For reference
purposes, the following table lists all affected diagnostic codes under
amended Sec. 4.130 and includes the nomenclature under DSM-IV and the
new nomenclature under DSM-5:
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Diagnostic code DSM-IV DSM-5
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9201................ Schizophrenia, Schizophrenia.
disorganized type.
9202................ Schizophrenia, catatonic Schizophrenia (DC 9201).
type.
9203................ Schizophrenia, paranoid Schizophrenia (DC 9201).
type.
9204................ Schizophrenia, Schizophrenia (DC 9201).
undifferentiated type.
9205................ Schizophrenia, residual Schizophrenia (DC 9201).
type; other and
unspecified types.
9210................ Psychotic disorder, not Other specified and
otherwise specified unspecified
(atypical psychosis). schizophrenia spectrum
and other psychotic
disorders.
9301................ Dementia due to Major or mild
infection (HIV neurocognitive disorder
infection, syphilis, or due to HIV or other
other systemic or infections.
intracranial
infections).
9304................ Dementia due to head Major or mild
trauma. neurocognitive disorder
due to traumatic brain
injury.
9305................ Vascular dementia....... Major or mild vascular
neurocognitive
disorder.
9310................ Dementia of unknown Unspecified
etiology. neurocognitive
disorder.
9312................ Dementia of the Major or mild
Alzheimer's type. neurocognitive disorder
due to Alzheimer's
disease.
9326................ Dementia due to other Major or mild
neurologic or general neurocognitive disorder
medical conditions due to another medical
(endocrine disorders, condition or substance/
metabolic disorders, medication-induced
Pick's disease, brain major or mild
tumors, etc.) or that neurocognitive
are substance-induced disorder.
(drugs, alcohol,
poisons).
9327................ Organic mental disorder, Unspecified
other (including neurocognitive disorder
personality change due (DC 9310).
to a general medical
condition).
9403................ Specific (simple) Specific phobia; social
phobia; social phobia. anxiety disorder
(social phobia).
9410................ Other and unspecified Other specified anxiety
neurosis. disorder (DC 9410);
Unspecified anxiety
disorder (DC 9413).
9413................ Anxiety disorder, not Unspecified anxiety
otherwise specified. disorder.
9416................ Dissociative amnesia; Dissociative amnesia;
dissociative fugue; dissociative identity
dissociative identity disorder.
disorder (multiple
personality disorder).
9417................ Depersonalization Depersonalization/
disorder. Derealization disorder.
9421................ Somatization disorder... Somatic symptom
disorder.
9422................ Pain disorder........... Other specified somatic
symptom and related
disorder.
9423................ Undifferentiated Unspecified somatic
somatoform disorder. symptom and related
disorder.
[[Page 45096]]
9424................ Conversion disorder..... Conversion disorder
(functional
neurological symptom
disorder).
9425................ Hypochondriasis......... Illness anxiety
disorder.
9433................ Dysthymic disorder...... Persistent depressive
disorder (dysthymia).
9435................ Mood disorder, not Unspecified depressive
otherwise specified. disorder.
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The changes in the table will also be reflected in identical
amendments to Appendix A--Table of Amendments and Effective Dates Since
1946, Appendix B--Numerical Index of Disabilities, and Appendix C--
Alphabetical Index of Disabilities, all contained in 38 CFR Part 4. In
addition, diagnostic code 9412 in Appendix B--Numerical Index of
Disabilities has been corrected to read ``Panic disorder and/or
agoraphobia.'' This change is a correction as the previous listing in
Appendix B omitted ``and/or agoraphobia'' from the listed diagnosis.
Incorporation by Reference
The Director of the Federal Register approves the incorporation by
reference of the American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (2013)
for the purposes of 38 CFR 4.125(a) in accordance with 5 U.S.C. 552(a)
and 1 CFR part 51. You may obtain a copy from the American Psychiatric
Association, 1000 Wilson Boulevard, Arlington, VA 22209-3901. You may
inspect a copy at the Office of Regulation Policy and Management,
Department of Veterans Affairs, 810 Vermont Avenue NW., Room 1068,
Washington, DC 20420 or the Office of the Federal Register, 800 North
Capitol Street NW., Suite 700, Washington, DC. Although Sec. Sec.
3.384 and 4.130 also mention DSM-5, incorporation by reference is not
required because those sections merely refer to the DSM-5 as a source
and not as a requirement. In contrast, Sec. 4.125 requires claims
adjudicators to use the DSM-5.
Administrative Procedure Act
In accordance with 5 U.S.C. 553(b)(B) and (d)(3), the Secretary of
Veterans Affairs finds that there is good cause to dispense with the
opportunity for prior notice and comment and good cause to publish this
rule with an immediate effective date. The Secretary finds that it is
impracticable, unnecessary, and contrary to the public interest to
delay this regulation for the purpose of soliciting prior public
comment.
It is impracticable to provide opportunity for prior notice and
comment for this rulemaking because a delay in implementation will
require the Veterans Health Administration (VHA) to continue to
diagnose mental disorders under two versions of the DSM until this
regulation is effective, one for clinical purposes (under DSM-5) and
one for compensation purposes (under DSM-IV). In order to maintain the
highest and most modern level of care for veterans, and as required by
the American Psychiatric Association, VHA clinicians must use the DSM-
5-based clinical guidelines to appropriately diagnose and treat
veterans with mental disorders. This use of the DSM-5 not only provides
veterans with the most up-to-date care for mental disorders, but also
ensures that non-VA health care providers who employ the DSM-5 are able
to understand, interpret, and continue the care documented in VA
treatment records.
Similarly, the Veterans Benefits Administration's (VBA) failure to
employ DSM-5 will place VASRD diagnostic terminology and
classifications of mental disorders at odds with the DSM-5-based
diagnostic criteria and terminology now standard in the psychiatric
community. Continued reliance on the DSM-IV would also potentially
place VBA at odds with its own regulations, which require ``accurate
and fully descriptive medical examinations'' in order to apply the
VASRD. 38 CFR 4.1. Failure to adopt the most current medical standards
for the diagnosis of mental disorders, as contained in the DSM-5, would
thus result in an inability to apply the VASRD, as DSM-IV-based
examinations are now outdated and therefore inaccurate.
It is therefore imperative that VBA adopt the DSM-5 as the
diagnostic standard for disability compensation purposes. As described
above, prior notice and comment period for this rulemaking will result
in negative consequences for both the VHA treatment and VBA evaluation
of mental health disorders. Specifically, without this immediate
change, VHA medical professionals would be required to diagnose and
record their clinical findings using two standards. Under commonly
accepted American Psychiatric Association and medical guidelines, the
DSM-5, the current authoritative standard, must be used for the
purposes of clinical diagnosis and treatment of mental disorders.
However, under the existing requirement to diagnose mental disorders
under DSM-IV when performing Compensation and Pension examinations,
these same VHA clinicians would be required to record their clinical
findings using the obsolete and now-irrelevant DSM-IV. This would put
VHA physicians at odds with their professional responsibilities as
members of the medical community and providers of veterans' care.
Moreover, asking VHA to continue providing medical evidence based on
DSM-IV ignores the numerous advances in mental health science reflected
in the DSM-5.
VA notes that it is unnecessary to provide opportunity for prior
notice and comment for this rulemaking because it is inevitable that
VBA will adopt the DSM-5 for diagnostic purposes. With its foundations
based upon the most current medical science as determined by experts in
the field of mental health, the new and current DSM-5 terminology and
classification of mental disorders must be applied to the adjudication
process without undue delay. In this context, VA recognizes that
applying the new and current DSM-5-based updates to the VASRD
immediately upon publication of this rule will enable the Secretary of
Veterans Affairs to make available to all veterans who are diagnosed
with mental health disorders, including those who suffer from PTSD,
timely access to benefits based on current and accurate clinical
diagnostic criteria already adopted by the psychiatric community.
Taking this step will avoid disruption in providing accurate disability
benefits to veterans for mental health disorders in a timely manner.
Upon publication of the DSM-5, the American Psychiatric Association
and the Centers for Medicare and Medicaid Services instructed health
care providers to begin using the DSM-5 immediately. VHA clinicians
followed thereafter and began utilizing the DSM-5 in treatment of
mental disorders on November 1, 2013. However, the American Psychiatric
Association also noted that there will be a period of time during which
insurers and other agencies, to include VA, will need to
[[Page 45097]]
update forms and data systems associated with the transition from DSM-
IV to DSM-5. For the purposes of VA disability benefits, the forms and
data systems that must be updated include, but are not limited to,
Disability Benefits Questionnaires, the Veterans Benefits Management
System, and VA's own Compensation and Pension adjudication regulations.
In addition, the National Academy of Sciences' Institute of Medicine
(IOM) has recommended that VA adopt systematic reviews of clinical
guidelines. The goal of these systematic reviews is to enhance the
quality and reliability of health-care guidance for veterans. VA has
reviewed DSM-5 and has found that its implementation for diagnostic
purposes is appropriate.
Furthermore, it is inevitable that VBA will eventually rely on the
DSM-5-based terminology and classification of mental disorders to
describe diagnosed mental disorders. Use of the DSM-5 as a standard for
the diagnosis of mental disorders is not a decision that rests with VA,
VHA, or VBA. VHA clinicians, as well as all mental health providers,
have a professional duty as licensed medical practitioners to use the
most current medical guidelines, in this case the DSM-5. In addition,
IOM has encouraged VBA to review the VASRD to ensure that it relies on
current medical science. With successive editions over the past 60
years, DSM has become the standard reference for clinical practice in
the mental health field. Its fifth edition, DSM-5, presents the most
current classification of mental disorders with associated criteria
designed to facilitate more reliable diagnosis of these disorders. VBA
must eventually rely on the DSM-5 in order for VHA physicians to comply
with their professional obligations and to ensure adherence to guidance
from the IOM.
The change to the references from DSM-IV to DSM-5 in VBA's
adjudication regulations does not present a change in how mental
disorders are evaluated under the VASRD, nor are any disorders removed
from the VASRD. The only foreseeable substantive public comments would
be limited to the contents of the DSM-5 itself, something over which
VBA has no control or input. VBA has reviewed the contents of the DSM-5
to ensure that, while some disabilities have been renamed, re-
categorized, or consolidated into another diagnosis, all mental
disorders currently listed in the VASRD are accounted for. The changes
made to diagnostic nomenclature, however, are beyond the scope and
expertise of VBA, and any comments suggesting changes to how
disabilities are diagnosed could not be answered by VBA. In cases of
periodic updates of clinical guidelines and medical terminology used by
the medical community, such as DSM-5, VBA has no authority to comment,
challenge, or change the content, terminology, or nomenclature based on
public comment. VBA's use of the DSM-5 is limited to conforming to the
most current medical standards and practices in diagnosing mental
disabilities. While an interim final rulemaking forgoes prior notice
and comment, VBA will still accept and consider all significant
comments received in response to the publication of this rulemaking and
can make changes through future rulemakings if necessary.
As the understandings of mental disorders and their treatments have
evolved, clinical professionals have developed strong, objective, and
consistent scientific validators of individual disorders. As a result,
the DSM-5 has moved to a non-axial documentation of diagnoses, based on
dimensional concepts in the diagnosis of mental disorders. The DSM-IV
incorporated a Global Assessment of Functioning (GAF) scale, which was
used to measure the individual's overall level of functioning on a
scale of 1 to 100. The American Psychiatric Association has determined
that the GAF score has limited usefulness in the assessment of the
level of disability. Noted problems include lack of conceptual clarity
and doubtful value of GAF psychometrics in clinical practice.
Currently, VA's mental health examinations performed under DSM-IV
include the GAF score in evaluating PTSD and all other disorders, but
the score is only marginally applicable to PTSD and other disorders
because of its emphasis on the symptoms of mood disorder and
schizophrenia and its limited range of symptom content.
During VA's review of the DSM-5, questions were raised as to the
impact of DSM-5 changes in PTSD diagnostic criteria and, therefore, the
number of veterans eligible to receive disability compensation for this
mental disorder. Specifically, there was concern that a change in the
diagnostic criteria for PTSD in the DSM-5 would result in fewer
diagnoses, given that the DSM-5 includes more explicit definitions for
stressors. The new diagnostic criteria for PTSD no longer include the
subjective reaction to the traumatic event (Criterion A2), such as
experiencing fear, helplessness, or horror, but the revised stressor
criterion (Criterion A) includes a more explicit definition for
stressors as exposure to actual or threatened death, serious injury or
sexual violation. According to DSM-5, the exposure must result from at
least one of the following scenarios, in which the individual: Directly
experiences the traumatic event; witnesses the traumatic event in
person; learns that the traumatic event occurred to a close family
member or close friend (with actual or threatened death being either
violent or accidental); or experiences first-hand repeated or extreme
exposure to aversive details of the traumatic event (not through media,
pictures, television, or movies unless work-related).
The DSM-5 also includes four diagnostic clusters for PTSD, instead
of the three clusters under the DSM-IV. These clusters are described as
re-experiencing, avoidance, negative alterations in cognition and mood,
and arousal. The number of symptoms that must be identified to support
a diagnosis depends on the cluster in which the symptoms fall. Most
importantly, the DSM-5 only requires that a disturbance continue for
more than one month and eliminates the distinction between acute and
chronic PTSD; this will likely result in more veterans meeting the
diagnostic criteria for PTSD.
Although DSM-5 does present minor changes in the manner in which
PTSD is diagnosed--i.e., it includes more explicit definitions for
stressors for purposes of clinical diagnosis, it is important to note
that such changes do not impact VA's adjudication regulations, which
provide evidentiary criteria for establishing the existence of an in-
service stressor, in certain circumstances. For example, 38 CFR
3.304(f)(3) provides the relaxed evidentiary criteria for establishing
a stressor based on fear of hostile military or terrorist activity
under which an examiner determined that the stressor criteria for a
diagnosis of PTSD under the DSM-5 have been satisfied. 75 FR 39843,
July 13, 2010. VA also provides for full development of potential
sources of stressor evidence in claims based on military sexual trauma
under 38 CFR 3.304(f)(5). In addition, it is important to note that the
DSM-5 now specifically lists sexual violation/assault as a traumatic
event to satisfy the stressor criteria. Also, once a diagnosis is
established, DSM-5 does not change how the existing VASRD evaluation
criteria are applied to diagnosed mental disorders to determine an
appropriate disability rating.
To the extent that VA and non-VA physicians will no longer use GAF
scores in their examinations, such discontinuance will only alter the
form in which physicians make and report
[[Page 45098]]
their findings regarding disability levels. There will be no effect on
the rating criteria in the VASRD or the manner in which VA applies the
VASRD criteria to the medical evidence of record. In order to provide a
global measure of disability, DSM-5 recommends using the World Health
Organization Disability Assessment Schedule, Version 2; this assessment
can also be used over time to track changes in a patient's
disabilities. DSM-5 benefits veterans by improving the quality and
consistency of the mental disorder diagnoses, consequently improving
the quality and consistency of disability evaluations. In order to
maintain the most accurate level of clinical care for veterans with
mental disabilities, VHA has already deployed the DSM-5 in a clinical
setting. VBA must utilize the DSM-5 in its adjudication regulations as
soon as possible to ensure that disability compensation is as accurate
and up to date as the current standards used to diagnose and treat
these mental disorders.
Finally, it is contrary to the public interest to provide
opportunity for prior notice and comment for this rulemaking because a
delay in VBA's transition to the DSM-5 will negatively impact the
current claims backlog. For example, if mental health conditions
continue to be adjudicated based on DSM-IV nomenclature while VHA
treats mental conditions based on DSM-5 nomenclature, VHA records will
not be relevant for the purposes of adjudicating claims for mental
disabilities. This outcome will require additional development by VBA
leading to increased processing times. Therefore, immediate
implementation of the DSM-5 in VBA's regulations will ensure rating
decisions reflect current diagnostic standards and promote consistency
between VHA and VBA.
The regulations under 38 CFR Parts 3 and 4 require that all
pertinent evidence of record be considered when evaluating a veteran's
disability for compensation purposes. The mental health regulations of
the VASRD currently require that all mental conditions be diagnosed in
accordance with the standards set under DSM-IV. However, VHA currently
uses the DSM-5 criteria for the purposes of diagnosis and treatment of
mental disorders. As such, DSM-5 VA treatment records are not legally
sufficient for VA disability evaluations under VASRD's current
reference to DSM-IV. Ready availability of VHA treatment records
expedites VBA adjudicators' accurate evaluation of mental health
disorders, particularly when considering claims for increased benefits.
This discrepancy between the standards for diagnosis and treatment
and disability evaluation of mental disorders will ultimately add to
the current backlog of disability claims. Without the ability to
adjudicate claims based on existing medical evidence, VA will have no
choice but to require disability examinations for mental disorders
utilizing the criteria set forth in DSM-IV to ensure compliance with
current regulations. This will place an additional and unnecessary
strain on VHA and VBA resources. This will result in claim processing
delays and frustrate VA's efforts to achieve its stated agency priority
goal of eliminating the claims backlog.
Historically, in response to the previous update from DSM-III to
DSM-IV, VA employed a notice of proposed rulemaking prior to finalizing
changes to 38 CFR 4.125. DSM-IV was published in May 1994 and VA's
notice of proposed rulemaking to incorporate the newest version of the
DSM was published in the Federal Register on October 26, 1995, with a
60-day comment period. 60 FR 54825. The final rule to reference DSM-IV
in 38 CFR Part 4 was published on October 8, 1996, almost one calendar
year following the proposed rule, and more than two years after
publication of the updated DSM. 61 FR 52695. In addition to updating
references to the most current DSM in 38 CFR 4.125, the rulemaking
included changes to the VASRD evaluation criteria for mental disorders
under 38 CFR 4.130, which had not been revised since 1964 when the rule
was first published for public viewing. The previous rulemaking also
proposed changes to four other portions of 38 CFR Part 4. Due to the
significant nature of the changes made, a proposed rule was required to
provide prior notice and solicit public comment on the nature and
impact of the changes. It should also be noted that, at that time, the
concept of an interim final rule did not exist.
In stark contrast, the current rule only updates nomenclature in
the VASRD and other regulations to be consistent with DSM-5; evaluation
criteria under Sec. 4.130 remain unchanged. Given that the current
rulemaking does not change evaluation criteria and given the need to
ensure veterans receive timely and accurate disability compensation, VA
is making these changes through an interim final rule. VA stresses that
it will consider and address significant comments received within 60
days of the date this interim final rule is published in the Federal
Register.
As previously noted, the American Psychiatric Association released
the DSM-5 for clinical use in May 2013. At that time, clinicians from
VHA and medical officers from VBA, as part of a workgroup, reviewed the
DSM-5 for changes in diagnostic criteria, disability nomenclature, and
any other pertinent shifts from the previous version. Based upon their
review of the DSM-5, the changes from the DSM-IV were then reviewed by
VBA personnel with a focus on the disability compensation claims
process. VBA determined that the DSM-5 required that changes be made to
the VASRD nomenclature and certain adjudication regulations. VBA
undertook an extensive development process to ensure that all potential
issues were considered and adequately addressed in the regulations.
While this process took considerable time, it allowed VBA to anticipate
and address potential problems with rulemaking prior to publication,
ultimately saving time.
For the foregoing reasons, the Secretary of Veterans Affairs finds
it is impracticable, unnecessary, and contrary to public interest to
delay this rulemaking for the purpose of soliciting advance public
comment or to have a delayed effective date. Accordingly, VA is issuing
this rule as an interim final rule with an immediate effective date. We
will consider and address significant comments that are received within
60 days of the date this interim final rule is published in the Federal
Register.
Executive Orders 12866 and 13563
Executive Orders 12866 and 13563 direct agencies to assess the
costs and benefits of available regulatory alternatives and, when
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, and other advantages; distributive impacts;
and equity). Executive Order 13563 (Improving Regulation and Regulatory
Review) emphasizes the importance of quantifying both costs and
benefits, reducing costs, harmonizing rules, and promoting flexibility.
Executive Order 12866 (Regulatory Planning and Review) defines a
``significant regulatory action,'' which requires review by the Office
of Management and Budget (OMB), as ``any regulatory action that is
likely to result in a rule that may: (1) Have an annual effect on the
economy of $100 million or more or adversely affect in a material way
the economy, a sector of the economy, productivity, competition, jobs,
the environment, public health or safety, or State, local, or tribal
governments or
[[Page 45099]]
communities; (2) Create a serious inconsistency or otherwise interfere
with an action taken or planned by another agency; (3) Materially alter
the budgetary impact of entitlements, grants, user fees, or loan
programs or the rights and obligations of recipients thereof; or (4)
Raise novel legal or policy issues arising out of legal mandates, the
President's priorities, or the principles set forth in this Executive
Order.''
The economic, interagency, budgetary, legal, and policy
implications of this interim final rule have been examined, and it has
been determined not to be a significant regulatory action under
Executive Order 12866. VA's impact analysis can be found as a
supporting document at http://www.regulations.gov, usually within 48
hours after the rulemaking document is published. Additionally, a copy
of this rulemaking and its impact analysis are available on VA's Web
site at http://www1.va.gov/orpm/, by following the link for ``VA
Regulations Published.''
Regulatory Flexibility Act
The Secretary hereby certifies that this interim final rule will
not have a significant economic impact on a substantial number of small
entities as they are defined in the Regulatory Flexibility Act, 5
U.S.C. 601-612. This interim final rule will not affect any small
entities. Only certain VA beneficiaries could be directly affected.
Therefore, pursuant to 5 U.S.C. 605(b), this rulemaking is exempt from
the initial and final regulatory flexibility analysis requirements of
sections 603 and 604.
Unfunded Mandates
The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C.
1532, that agencies prepare an assessment of anticipated costs and
benefits before issuing any rule that may result in the expenditure by
State, local, and tribal governments, in the aggregate, or by the
private sector, of $100 million or more (adjusted annually for
inflation) in any one year. This interim final rule will have no such
effect on State, local, and tribal governments, or on the private
sector.
Paperwork Reduction Act
This interim final rule contains no provisions constituting a
collection of information under the Paperwork Reduction Act of 1995 (44
U.S.C. 3501-3521).
Catalog of Federal Domestic Assistance Numbers and Titles
The Catalog of Federal Domestic Assistance program numbers and
titles for this rule are 64.009, Veterans Medical Care Benefits;
64.104, Pension for Non-Service-Connected Disability for Veterans;
64.109, Veterans Compensation for Service-Connected Disability; and
64.110, Veterans Dependency and Indemnity Compensation for Service-
Connected Death.
Signing Authority
The Secretary of Veterans Affairs, or designee, approved this
document and authorized the undersigned to sign and submit the document
to the Office of the Federal Register for publication electronically as
an official document of the Department of Veterans Affairs. Jose D.
Riojas, Chief of Staff, Department of Veteran Affairs, approved this
document on July 24, 2014, for publication.
List of Subjects
38 CFR Part 3
Administrative practice and procedure, Claims, Disability benefits,
Health Care, Pensions, Radioactive materials, Veterans, Vietnam.
38 CFR Part 4
Disability benefits, Incorporation by reference, Pensions,
Veterans.
Dated: July 29, 2014.
Robert C. McFetridge,
Director, Regulation Policy and Management, Office of the General
Counsel, Department of Veterans Affairs.
For the reasons set forth in the preamble, the Department of
Veterans Affairs amends 38 CFR parts 3 and 4 as follows:
PART 3--ADJUDICATION
Subpart A--Pension, Compensation, and Dependency and Indemnity
Compensation
0
1. The authority citation for part 3, subpart A continues to read as
follows:
Authority: 38 U.S.C. 501(a), unless otherwise noted.
0
2. Revise Sec. 3.384 to read as follows:
Sec. 3.384 Psychosis.
For purposes of this part, the term ``psychosis'' means any of the
following disorders listed in the American Psychiatric Association's
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5) (see Sec. 4.125 for availability information):
(a) Brief Psychotic Disorder;
(b) Delusional Disorder;
(c) Psychotic Disorder Due to Another Medical Condition;
(d) Other Specified Schizophrenia Spectrum and Other Psychotic
Disorder;
(e) Schizoaffective Disorder;
(f) Schizophrenia;
(g) Schizophreniform Disorder; and
(h) Substance/Medication-Induced Psychotic Disorder.
(Authority: 38 U.S.C. 501(a), 1101, 1112(a) and (b))
PART 4--SCHEDULE FOR RATING DISABILITIES
Subpart B--Disability Ratings
0
3. The authority citation for part 4 continues to read as follows:
Authority: 38 U.S.C. 1155, unless otherwise noted.
0
4. Revise Sec. 4.125(a) to read as follows:
Sec. 4.125 Diagnosis of mental disorders.
(a) If the diagnosis of a mental disorder does not conform to DSM-5
or is not supported by the findings on the examination report, the
rating agency shall return the report to the examiner to substantiate
the diagnosis. Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5), American Psychiatric Association (2013), is
incorporated by reference into this section with the approval of the
Director of the Federal Register under 5 U.S.C. 552(a) and 1 CFR part
51. To enforce any edition other than that specified in this section,
the Department of Veterans Affairs must publish notice of change in the
Federal Register and the material must be available to the public. All
approved material is available from the American Psychiatric
Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209-
3901, 703-907-7300, http://www.dsm5.org. It is also available for
inspection at the Office of Regulation Policy and Management,
Department of Veterans Affairs, 810 Vermont Avenue NW., Room 1068,
Washington, DC 20420. It is also available for inspection at the
National Archives and Records Administration (NARA). For information on
the availability of this information at NARA, call 202-741-6030 or go
to http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_publications.html.
* * * * *
0
5. Revise Sec. 4.126(c) to read as follows:
Sec. 4.126 Evaluation of disability from mental disorders.
* * * * *
(c) Neurocognitive disorders shall be evaluated under the general
rating
[[Page 45100]]
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
neurocognitive disorders (see Sec. 4.25).
* * * * *
0
6. Revise Sec. 4.127 to read as follows:
Sec. 4.127 Intellectual disability (intellectual developmental
disorder) and personality disorders.
Intellectual disability (intellectual developmental disorder) and
personality disorders are not diseases or injuries for compensation
purposes, and, except as provided in Sec. 3.310(a) of this chapter,
disability resulting from them may not be service-connected. However,
disability resulting from a mental disorder that is superimposed upon
intellectual disability (intellectual developmental disorder) or a
personality disorder may be service-connected.
(Authority: 38 U.S.C. 1155)
0
7. Revise Sec. 4.130 to read as follows:
Sec. 4.130 Schedule of ratings--Mental disorders.
The nomenclature employed in this portion of the rating schedule is
based upon the American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (see
Sec. 4.125 for availability information). Rating agencies 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. The schedule for
rating for mental disorders is set forth as follows:
9201 Schizophrenia
9202 [Removed]
9203 [Removed]
9204 [Removed]
9205 [Removed]
9208 Delusional disorder
9210 Other specified and unspecified schizophrenia spectrum and
other psychotic disorders
9211 Schizoaffective disorder
9300 Delirium
9301 Major or mild neurocognitive disorder due to HIV or other
infections
9304 Major or mild neurocognitive disorder due to traumatic brain
injury
9305 Major or mild vascular neurocognitive disorder
9310 Unspecified neurocognitive disorder
9312 Major or mild neurocognitive disorder due to Alzheimer's
disease
9326 Major or mild neurocognitive disorder due to another medical
condition or substance/medication-induced major or mild
neurocognitive disorder
9327 [Removed]
9400 Generalized anxiety disorder
9403 Specific phobia; social anxiety disorder (social phobia)
9404 Obsessive compulsive disorder
9410 Other specified anxiety disorder
9411 Posttraumatic stress disorder
9412 Panic disorder and/or agoraphobia
9413 Unspecified anxiety disorder
9416 Dissociative amnesia; dissociative identity disorder
9417 Depersonalization/Derealization disorder
9421 Somatic symptom disorder
9422 Other specified somatic symptom and related disorder
9423 Unspecified somatic symptom and related disorder
9424 Conversion disorder (functional neurological symptom disorder)
9425 Illness anxiety disorder
9431 Cyclothymic disorder
9432 Bipolar disorder
9433 Persistent depressive disorder (dysthymia)
9434 Major depressive disorder
9435 Unspecified depressive disorder
9440 Chronic adjustment disorder
General Rating Formula for Mental Disorders
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
Total occupational and social impairment, due to such 100
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.
Occupational and social impairment, with deficiencies in most 70
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.
Occupational and social impairment with reduced reliability 50
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.
Occupational and social impairment with occasional decrease 30
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).
Occupational and social impairment due to mild or transient 10
symptoms which decrease work efficiency and ability to
perform occupational tasks only during periods of
significant stress, or symptoms controlled by continuous
medication.
A mental condition has been formally diagnosed, but symptoms 0
are not severe enough either to interfere with occupational
and social functioning or to require continuous medication.
------------------------------------------------------------------------
9520 Anorexia nervosa
9521 Bulimia nervosa
Rating Formula for Eating Disorders
------------------------------------------------------------------------
Rating
------------------------------------------------------------------------
Self-induced weight loss to less than 80 percent of expected 100
minimum weight, with incapacitating episodes of at least six
weeks total duration per year, and requiring hospitalization
more than twice a year for parenteral nutrition or tube
feeding.
Self-induced weight loss to less than 85 percent of expected 60
minimum weight with incapacitating episodes of six or more
weeks total duration per year.
[[Page 45101]]
Self-induced weight loss to less than 85 percent of expected 30
minimum weight with incapacitating episodes of more than two
but less than six weeks total duration per year.
Binge eating followed by self-induced vomiting or other 10
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.
Binge eating followed by self-induced vomiting or other 0
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.
------------------------------------------------------------------------
Note 1: An incapacitating episode is a period during which bed rest and
treatment by a physician are required.
Note 2: Ratings under diagnostic codes 9201 to 9440 will be evaluated
using the General Rating Formula for Mental Disorders. Ratings under
diagnostic codes 9520 and 9521 will be evaluated using the General
Rating Formula for Eating Disorders.
(Authority: 38 U.S.C. 1155)
0
8. Amend Appendix A to part 4 by revising the entries for Sec. 4.130 to
read as follows:
Appendix A to Part 4--Table of Amendments and Effective Dates Since
1946
------------------------------------------------------------------------
Diagnostic
Sec. code No.
------------------------------------------------------------------------
* * * * * * *
4.130..................... .............. Re-designated from Sec.
4.132 November 7, 1996.
9200 Removed February 3, 1988.
9201 Criterion February 3, 1988;
Title August 4, 2014.
9202 Criterion February 3, 1988;
removed August 4, 2014.
9203 Criterion February 3, 1988;
removed August 4, 2014.
9204 Criterion February 3, 1988;
removed August 4, 2014.
9205 Criterion February 3, 1988;
criterion November 7, 1996;
Removed August 4, 2014.
9206 Criterion February 3, 1988;
removed November 7, 1996.
9207 Criterion February 3, 1988;
removed November 7, 1996.
9208 Criterion February 3, 1988;
removed November 7, 1996.
9209 Criterion March 10, 1976;
criterion February 3, 1988;
removed November 7, 1996.
9210 Criterion March 10, 1976;
criterion February 3, 1988;
criterion November 7, 1996;
Title August 4, 2014.
9211 Added November 7, 1996.
9300 Criterion March 10, 1976;
criterion February 3, 1988;
criterion November 7, 1996.
9301 Criterion March 10, 1976;
criterion February 3, 1988;
criterion November 7, 1996;
Title August 4, 2014.
9302 Criterion March 10, 1976;
criterion February 3, 1988;
removed November 7, 1996.
9303 Criterion March 10, 1976;
criterion February 3, 1988;
removed November 7, 1996.
9304 Criterion March 10, 1976;
criterion February 3, 1988;
criterion November 7, 1996;
Title August 4, 2014.
9305 Criterion March 10, 1976;
criterion February 3, 1988;
criterion November 7, 1996;
Title August 4, 2014.
9306 Criterion March 10, 1976;
criterion February 3, 1988;
removed November 7, 1996.
9307 Criterion March 10, 1976;
criterion February 3, 1988;
removed November 7, 1996.
9308 Criterion March 10, 1976;
criterion February 3, 1988;
removed November 7, 1996.
9309 Criterion March 10, 1976;
criterion February 3, 1988;
removed November 7, 1996.
9310 Criterion March 10, 1976;
criterion February 3, 1988;
criterion November 7, 1996;
Title August 4, 2014.
9311 Criterion March 10, 1976;
criterion February 3, 1988;
removed November 7, 1996.
9312 Added March 10, 1976;
criterion February 3, 1988;
criterion November 7, 1996;
Title August 4, 2014.
9313 Added March 10, 1976;
removed February 3, 1988.
9314 Added March 10, 1976;
removed February 3, 1988.
9315 Added March 10, 1976;
criterion February 3, 1988;
removed November 7, 1996.
9316-9321 Added March 10, 1976;
removed February 3, 1988.
9322 Added March 10, 1976;
criterion February 3, 1988;
removed November 7, 1996.
9323 Added March 10, 1976;
removed February 3, 1988.
9324 Added March 10, 1976;
criterion February 3, 1988;
removed November 7, 1996.
9325 Added March 10, 1976;
criterion February 3, 1988;
removed November 7, 1996.
9326 Added March 10, 1976;
removed February 3, 1988;
added November 7, 1996;
Title August 4, 2014.
9327 Added November 7, 1996;
removed August 4, 2014.
9400-9411 Evaluations February 3,
1988.
9400 Criterion March 10, 1976;
criterion February 3, 1988.
9401 Criterion March 10, 1976;
criterion February 3, 1988;
removed November 7, 1996.
9402 Criterion March 10, 1976;
criterion February 3, 1988;
removed November 7, 1996.
9403 Criterion March 10, 1976;
criterion February 3, 1988;
criterion November 7, 1996;
Title August 4, 2014.
9410 Added March 10, 1976;
criterion February 3, 1988;
Title August 4, 2014.
9411 Added February 3, 1988.
9412 Added November 7, 1996.
9413 Added November 7, 1996;
Title August 4, 2014.
9416 Added November 7, 1996;
Title August 4, 2014.
9417 Added November 7, 1996;
Title August 4, 2014.
9421 Added November 7, 1996;
Title August 4, 2014.
9422 Added November 7, 1996;
Title August 4, 2014.
9423 Added November 7, 1996;
Title August 4, 2014.
[[Page 45102]]
9424 Added November 7, 1996;
Title August 4, 2014.
9425 Added November 7, 1996;
Title August 4, 2014.
9431 Added November 7, 1996.
9432 Added November 7, 1996.
9433 Added November 7, 1996;
Title August 4, 2014.
9434 Added November 7, 1996.
9435 Added November 7, 1996;
Title August 4, 2014.
9440 Added November 7, 1996.
9500 Criterion March 10, 1976;
criterion February 3, 1988.
9501 Criterion March 10, 1976;
criterion February 3, 1988.
9502 Criterion March 10, 1976;
criterion February 3, 1988.
9503 Removed March 10, 1976.
9504 Criterion September 9, 1975;
removed March 10, 1976.
9505 Added March 10, 1976;
criterion February 3, 1988.
9506 Added March 10, 1976;
criterion February 3, 1988.
9507 Added March 10, 1976;
criterion February 3, 1988.
9508 Added March 10, 1976;
criterion February 3, 1988.
9509 Added March 10, 1976;
criterion February 3, 1988.
9510 Added March 10, 1976;
criterion February 3, 1988.
9511 Added March 10, 1976;
criterion February 3, 1988.
9520 Added November 7, 1996.
9521 Added November 7, 1996.
------------------------------------------------------------------------
* * * * *
0
9. Amend Appendix B to part 4 by revising the entries for diagnostic
codes 9201 through 9521 to read as follows:
Appendix B to Part 4--Numerical Index of Disabilities
------------------------------------------------------------------------
Diagnostic code No.
------------------------------------------------------------------------
* * * * * * *
------------------------------------------------------------------------
Mental Disorders
------------------------------------------------------------------------
9201.......................... Schizophrenia.
9208.......................... Delusional disorder.
9210.......................... Other specified and unspecified
schizophrenia spectrum and other
psychotic disorders.
9211.......................... Schizoaffective Disorder.
9300.......................... Delirium.
9301.......................... Major or mild neurocognitive disorder
due to HIV or other infections.
9304.......................... Major or mild neurocognitive disorder
due to traumatic brain injury.
9305.......................... Major or mild vascular neurocognitive
disorder.
9310.......................... Unspecified neurocognitive disorder.
9312.......................... Major or mild neurocognitive disorder
due to Alzheimer's disease.
9326.......................... Major or mild neurocognitive disorder
due to another medical condition or
substance/medication-induced major or
mild neurocognitive disorder.
9400.......................... Generalized anxiety disorder.
9403.......................... Specific phobia; social anxiety disorder
(social phobia).
9404.......................... Obsessive compulsive disorder.
9410.......................... Other specified anxiety disorder.
9411.......................... Posttraumatic stress disorder.
9412.......................... Panic disorder and/or agoraphobia.
9413.......................... Unspecified anxiety disorder.
9416.......................... Dissociative amnesia; dissociative
identity disorder.
9417.......................... Depersonalization/derealization
disorder.
9421.......................... Somatic symptom disorder.
9422.......................... Other specified somatic symptom and
related disorder.
9423.......................... Unspecified somatic symptom and related
disorder.
9424.......................... Conversion disorder (functional
neurological symptom disorder).
9425.......................... Illness anxiety disorder.
9431.......................... Cyclothymic disorder.
9432.......................... Bipolar disorder.
9433.......................... Persistent depressive disorder
(dysthymia).
9434.......................... Major depressive disorder.
9435.......................... Unspecified depressive disorder.
9440.......................... Chronic adjustment disorder.
9520.......................... Anorexia nervosa.
9521.......................... Bulimia nervosa.
* * * * * * *
------------------------------------------------------------------------
[[Page 45103]]
0
10. In Appendix C to part 4, revise the entries for mental disorders to
read as follows:
Appendix C to Part 4--Alphabetical Index of Disabilities
------------------------------------------------------------------------
Diagnostic
code No.
------------------------------------------------------------------------
* * * * * * *
Mental disorders:
Anorexia nervosa.................................... 9520
Bipolar disorder.................................... 9432
Bulimia nervosa..................................... 9521
Chronic adjustment disorder......................... 9440
Conversion disorder (functional neurological symptom 9424
disorder)..........................................
Cyclothymic disorder................................ 9431
Delirium............................................ 9300
Delusional disorder................................. 9208
Depersonalization/derealization disorder............ 9417
Dissociative amnesia; dissociative identity disorder 9416
Generalized anxiety disorder........................ 9400
Illness anxiety disorder............................ 9425
Major depressive disorder........................... 9434
Major or mild neurocognitive disorder due to 9312
Alzheimer's disease................................
Major or mild neurocognitive disorder due to another 9326
medical condition or substance/medication-induced
major or mild neurocognitive disorder..............
Major or mild neurocognitive disorder due to HIV or 9301
other infections...................................
Major or mild neurocognitive disorder due to 9304
traumatic brain injury.............................
Major or mild vascular neurocognitive disorder...... 9305
Obsessive compulsive disorder....................... 9404
Other specified and unspecified schizophrenia 9210
spectrum and other psychotic disorders.............
Other specified anxiety disorder.................... 9410
Other specified somatic symptom and related disorder 9422
Panic disorder and/or agoraphobia................... 9412
Persistent depressive disorder (dysthymia).......... 9433
Posttraumatic stress disorder....................... 9411
Schizoaffective disorder............................ 9211
Schizophrenia....................................... 9201
Somatic symptom disorder............................ 9421
Specific phobia; social anxiety disorder (social 9403
phobia)............................................
Unspecified somatic symptom and related disorder.... 9423
Unspecified anxiety disorder........................ 9413
Unspecified depressive disorder..................... 9435
Unspecified neurocognitive disorder................. 9310
* * * * * * *
------------------------------------------------------------------------
[FR Doc. 2014-18150 Filed 8-1-14; 8:45 am]
BILLING CODE 8320-01-P