Professional Documents
Culture Documents
TO
LAWS AND REGULATIONS
RELATING TO
PSYCHIATRIC DISORDERS
PREPARED BY:
TRESA SCHLECT, COUNSEL
SARAMAE KREITLOW, ASSOCIATE COUNSEL
BOARD OF VETERANS' APPEALS
EDUCATIONAL SEMINAR
APRIL 17, 2008
TABLE OF CONTENTS
PAGE
1. SERVICE CONNECTION
A. General
B. Presumptions
38 U.S.C.A. § 1112. Presumptions relating to certain diseases and disabilities 7
38 C.F.R. § 3.307. Presumptive service connection 8
38 C.F.R. § 3.309. Disease subject to presumptive service connection 9
38 C.F.R. § 3.384. Psychosis 9
38 U.S.C.A. § 1117. Compensation for disabilities in Persian Gulf War veterans 10
C. AGGRAVATION
38 U.S.C.A. § 1111. Sound condition 11
38 C.F.R. § 3.304(b). Presumption of Soundness 11
38 U.S.C.A. § 1153. Aggravation 12
D. SPECIAL PROVISIONS
38 C.F.R. § 3.302. Service connection for mental unsoundness in suicide 12
38 C.F.R. § 3.304(f). Direct service connection: PTSD. 13
Related: 38 U.S.C.A. § 1154 Combat Presumption. 14
A. Statute
38 U.S.C.A. § 1155 15
B. Current Regulations
2
38 C.F.R. §. 4.127 Mental retardation and personality disorders. 16
38 C.F.R. § 4.128 Convalescence ratings following extended hospitalization. 16
38 C.F.R. § 4.129 Mental disorders due to traumatic stress. 17
38 C.F.R. § 4.130 Schedule ofratings--mental disorders. 17
Interpretation, Current Regulations 20
3
I. SERVICE CONNECTION
A. GENERAL
For disability resulting from personal injury suffered or disease contracted in line
of duty, or for aggravation of a preexisting injury suffered or disease contracted in
line of duty, in the active military, naval, or air service, during a period of war, the
United States will pay to any veteran thus disabled and who was discharged or
released under conditions other than dishonorable from the period of service in
which said injury or disease was incurred, or preexisting injury or disease was
aggravated, compensation as provided in this subchapter, but no compensation
shall be paid if the disability is a result of the veteran's own willful misconduct or
abuse of alcohol or drugs.
NOTE: In 1990, Pub. L. 101-508 added the phrase "or abuse of alcohol or drugs"
following "a result of the veteran's own willful misconduct." This additional
language has been the subject of numerous interpretations. For example:
Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001) (holding that a veteran could receive
compensation for an alcohol or drug abuse disability acquired as secondary to, or as a
symptom of, a veteran's service-connected disability, for purposes of benefits other than
compensation); Barela v. West, 11 Vet. App. 280, 283 (1998) (distinguishing the
question of service connection from the question of compensation).
VAOPGCPREC 11-96 (holding that service connection established for a disability that
resulted from a veteran's own alcohol or drug abuse, in a compensation claim filed on or
before October 31, 1990, may form the basis of an award in a DIC claim filed after
October 31, 1990).
VAOPGCPREC 7-99 (holding (a) that the 1990 amendments do not preclude granting
secondary service connection under 38 C.F.R. § 3.310(a) ofa substance-abuse disability
that is proximately due to or the result of a service-connected disease or injury, but no
disability compensation may be paid for such a disability; and (b) although the veteran
may not be compensated for such disability, DIC may be paid to a veteran's survivors
based on the veteran's death from a substance-abuse disability secondarily service
connected under 38 C.F.R. § 3.31O(a) (entitlement established under 38 V.S.c. § 1310) or
based on a veteran's death while in receipt of or entitled to receive compensation for a
substance-abuse disability secondarily service connected under section 3.31 O( a) and
continuously rated for the period required for DIC) (noting that secondary service
connection does not involve a line of duty determination).
(a) Line of duty. Direct service connection may be granted only when a disability
or cause of death was incurred or aggravated in line of duty, and not the result of
the veteran's own willful misconduct or, for claims filed after October 31, 1990,
(b) Willful misconduct. Disability pension is not payable for any condition due to
the veteran's own willful misconduct.
5
(2) The simple drinking of alcoholic beverage is not of itself willful
misconduct. The deliberate drinking of a known poisonous substance or
under conditions which would raise a presumption to that effect will be
considered willful misconduct. If, in the drinking of a beverage to enjoy its
intoxicating effects, intoxication results proximately and immediately in
disability or death, the disability or death will be considered the result of
the person's willful misconduct. Organic diseases and disabilities which are
a secondary result of the chronic use of alcohol as a beverage, whether out
of compulsion or otherwise, will not be considered of willful misconduct
origin. (See §§ 21.1043, 21.5041, and 21. 7051 of this title regarding the
disabling effects of chronic alcoholism for the purpose of extending
delimiting periods under education or rehabilitation programs.)
(3) Drug usage. The isolated and infrequent use of drugs by itself will not
be considered willful misconduct; however, the progressive and frequent
use of drugs to the point of addiction will be considered willful misconduct.
Where drugs are used to enjoy or experience their effects and the effects
result proximately and immediately in disability or death, such disability or
death will be considered the result of the person's willful misconduct.
Organic diseases and disabilities which are a secondary result of the chronic
use of drugs and infections coinciding with the injection of drugs will not
be considered of willful misconduct origin. (See paragraph (d) of this
section regarding service connection where disability or death is a result of
abuse of drugs.) Where drugs are used for therapeutic purposes or where
use of drugs or addiction thereto, results from a service-connected
disability, it will not be considered of misconduct origin.
(d) Line of duty; abuse of alcohol or drugs. An injury or disease incurred during
active military, naval, or air service shall not be deemed to have been incurred in
line of duty if such injury or disease was a result of the abuse of alcohol or drugs
by the person on whose service benefits are claimed. For the purpose of this
paragraph, alcohol abuse means the use of alcoholic beverages over time, or such
excessive use at anyone time, sufficient to cause disability to or death of the user;
drug abuse means the use of illegal drugs (including prescription drugs that are
illegally or illicitly obtained), the intentional use of prescription or non-
prescription drugs for a purpose other than the medically intended use, or the use
of substances other than alcohol to enjoy their intoxicating effects.
38 V.S.C.A. § 105 creates a presumption of service connection for injuries that occur
during active duty unless a preponderance of the evidence establishes that the injury was
the result of the person's own willful misconduct. See Thomas v. Nicholson, 423 F.3d
6
1279,1284-85 (Fed.Cir. 2005); Shedden v. Principi, 381 F.3d 1163, 1166 (Fed.Cir.
2004); see 38 C.F.R. § 3.1(m).
VAOPGPREC 2-97 (definition of line of duty excludes injury or disease resulting from
the person's own willful misconduct, including abuse of alcohol or drugs).
(a) General. Service connection connotes many factors but basically it means that
the facts, shown by evidence, establish that a particular injury or disease resulting
in disability was incurred coincident with service in the Armed Forces, or if
preexisting such service, was aggravated therein ....
B. PRESUMPTIONS
(a) For the purposes of section] 1] 0 of this title, and subject to the provisions of
section 1113 of this title, in the case of any veteran who served for ninety days or
more during a period of war--
7
(b)(l) For the purposes of section 1110 of this title and subject to the provisions of
section 1113 of this title, in the case of a veteran who is a former prisoner of war--
(B) if the veteran was detained or interned as a prisoner of war for not less
than thirty days, a disease specified in paragraph (3) which became
manifest to a degree of 10 percent or more after active military, naval, or air
service shall be considered to have been incurred in or aggravated by such
service, notwithstanding that there is no record of such disease during the
period of service.
(a) General. A chronic, [or]. .. prisoner of war related disease ... listed in § 3.309
will be considered to have been incurred in or aggravated by service under the
circumstances outlined in this section even though there is no evidence of such
disease during the period of service. No condition other than one listed in §
3.309(a) will be considered chronic.
(3) Chronic disease. The disease must have become manifest to a degree of
10 percent or more within 1 year ... from the date of separation from
servIce ....
8
38 C.F.R. § 3.309 Disease subject to presumptive service connection.
(a) Chronic diseases. The following diseases shall be granted service conriection
although not otherwise established as incurred in or aggravated by service if
manifested to a compensable degree within the applicable time limits under §
3.307 following service in a period of war or following peacetime service on or
after January 1,1947, provided the rebuttable presumption provisions of § 3.307
are also satisfied....
Psychoses ....
Psychosis.
Any of the anxiety states.
Dysthymic disorder (or depressive neurosis) ....
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):
9
(NOTE: In comments accompanying 38 C.F.R. § 3.384, VA noted that it had considered
defining the term "psychosis" to include major depression with psychotic features, but
had decided to explude that illness because it did not conform to terminology used in the
American Psychiatric Association, Diagnostic And Statistical Manual of Mental
Disorders 32 (4th ed.) (1994) (DSM IV). 71 Fed. Reg. 42,758-60 (JuI. 28, 2006). Thus,
for example, a grant of service connection for major depression with psychotic features
does not serve to establish service connection for a psychosis.)
(a)(1) The Secretary may pay compensation under this subchapter to a Persian
Gulf veteran with a qualifying chronic disability that became manifest--
(A) during service on active duty in the Armed Forces in the Southwest
Asia theater of operations during the Persian Gulf War; or
(2) For purposes of this subsection, the term "qualifying chronic disability"
means a chronic disability resulting from any of the following (or any
combination of any of the following):
(NOTE: 38 C.F.R. § 3.317 is very similar to the statute and will not be repeated here.)
10
C. AGGRAVATION
For the purposes of section 1110 of this title, every veteran shall be taken to have
been in sound condition when examined, accepted, and enrolled for service, except
as to defects, infirmities, or disorders noted at the time of the examination,
acceptance, and enrollment, or where clear and unmistakable evidence
demonstrates that the injury or disease existed before acceptance and enrollment
and was not aggravated by such service.
The veteran will be considered to have been in sound condition when examined,
accepted and enrolled for service, except as to defects, infirmities, or disorders
noted at entrance into service, or where clear and unmistakable (obvious or
manifest) evidence demonstrates that an injury or disease existed prior thereto and
was not aggravated by such service. Only such conditions as are recorded in
examination reports are to be considered as noted.
11
(3) Signed statements of veterans relating to the origin, or incurrence of any
disease or injury made in service if against his or her own interest is of no
force and effect if other data do not establish the fact. Other evidence will
be considered as though such statement were not of record.
D. SPECIAL PROVISIONS
(a) General.
(1) In order for suicide to constitute willful misconduct, the act of self-
destruction must be intentional.
(1) Whether a person, at the time of suicide, was so unsound mentally that
he or she did not realize the consequence of such an act, or was unable to
resist such impulse is a question to be determined in each individual case,
based on all available lay and medical evidence pertaining to his or her
mental condition at the time of suicide.
12
(3) A reasonable adequate motive for suicide may be established by
affirmative evidence showing circumstances which could lead a rational
person to self-destruction.
(1) If the evidence establishes that the veteran engaged in combat with the
enemy and the claimed stressor is related to that combat, in the absence of
clear and convincing evidence to the contrary, and provided that the
claimed stressor is consistent with the circumstances, conditions, or
hardships of the veteran's service, the veteran's lay testimony alone may
establish the occurrence of the claimed in-service stressor.
(2) If the evidence establishes that the veteran was a prisoner-of-war under
the provisions of § 3.1(y) of this part and the claimed stressor is related to
that prisoner-of-war experience, in the absence of clear and convincing
evidence to the contrary, and provided that the claimed stressor is
consistent with the circumstances, conditions, or hardships of the veteran's
service, the veteran's lay testimony alone may establish the occurrence of
the claimed in-service stressor.
13
or physicians; pregnancy tests or tests for sexually transmitted diseases; and
statements from family members, roommates, fellow service members, or
clergy. Evidence of behavior changes following the claimed assault is one
type of relevant evidence that may be found in these sources. Examples of
behavior changes that may constitute credible evidence of the stressor
include, but are not limited to: a request for a transfer to another military
duty assignment; deterioration in work performance; substance abuse;
episodes of depression, panic attacks, or anxiety without an identifiable
cause; or unexplained economic or social behavior changes. VA will not
deny a post-traumatic stress disorder claim that is based on in-service
personal assault without first advising the claimant that evidence from
sources other than the veteran's service records or evidence of behavior
changes may constitute credible supporting evidence of the stressor and
allowing him or her the opportunity to furnish this type of evidence or
advise VA of potential sources of such evidence. VA may submit any
evidence that it receives to an appropriate medical or mental health
professional for an opinion as to whether it indicates that a personal assault
occurred.
Related: 38 V.S.C.A. § 1154 Combat Presumption (If a veteran engaged in combat and
the claimed stressor is combat related, the veteran's lay testimony is generally sufficient
to establish the occurrence of the claimed in-service stressor, see Collette v. Brown, 82
F.3d 389, 392 (Fed. Cir. 1996).
Pentecost v. Principi, 16 Vet. App. 124 (2002) (stating that a veteran need not
corroborate a noncombat stressor of enemy rocket attacks on a base where his unit was
stationed with evidence of his physical proximity to, or firsthand experience with, the
attacks, but rather that his presence with the unit at the time the attacks occurred
corroborates his statement that he experienced such attacks personally); Cohen v. Brown,
10 Vet. App. 128 (1997) (stressors where there is no finding that the veteran has
personally engaged in combat with the enemy).
Hernandez-Toyens v. West, 11 Vet. App. 379 (1998) (stating that, in listing military
experience as an Axis IV psychosocial stressor the examiner made a determination
that the event was an etiologically significant psychosocial stressor contributing to the
current condition, and this notation in Axis IV constituted positive evidence to
support the veteran's claim).
14
II. INCREASED RATINGS
A. STATUTE
38 V.S.C.A. § 1155
The Secretary shall adopt and apply a schedule of ratings of reductions in earning
capacity from specific injuries or combination of injuries. The ratings shall be
based, as far as practicable, upon the average impairments of earning capacity
resulting from such injuries in civil occupations. The schedule shall be
constructed so as to provide ten grades of disability and no more, upon which
payments of compensation shall be based, namely, 10 percent, 20 percent, 30
percent, 40 percent, 50 percent, 60 percent, 70 percent, 80 percent, 90 percent, and
total, 100 percent. The Secretary shall from time to time readjust this schedule of
ratings in accordance with experience. However, in no event shall such a
readjustment in the rating schedule cause a veteran's disability rating in effect on
the effective date of the readjustment to be reduced unless an improvement in the
veteran's disability is shown to have occurred.
B. CURRENT REGULATIONS
The repercussion upon a current rating of service connection when change is made
of a previously assigned diagnosis or etiology must be kept in mind. The aim
should be the reconciliation and continuance of the diagnosis or etiology upon
which service connection for the disability had been granted. The relevant
principle enunciated in § 4.125, entitled "Diagnosis of mental disorders," should
have careful attention in this connection. When any change in evaluation is to be
made, the rating agency should assure itself that there has been an actual change in
the conditions, for better or worse, and not merely a difference in thoroughness of
the examination or in use of descriptive terms. This will not, of course, preclude
the correction of erroneous ratings, nor will it preclude assignment of a rating in
conformity with § 4.7.
(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 agency shall return
the report to the examiner to substantiate the diagnosis.
(b) If the diagnosis of a mental disorder is changed, the rating agency shall
determine whether the new diagnosis represents progression of the prior diagnosis,
15
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 agency shall return the report to the examiner for a
determination.
(a) When evaluating a mental disorder, the rating agency 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 agency shall assign an evaluation based on all the evidence of record
that bears on occupational and social impairment rather than solely 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
agency 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).
(d) When a single disability has been diagnosed both as a physical condition and
as a mental disorder, the rating agency shall evaluate it using a diagnostic code
which represents the dominant (more disabling) aspect of the condition (see Sec.
4.14).
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. However, disability
resulting from a mental disorder that is superimposed upon mental retardation or a
personality disorder may be service-connected.
16
evaluation based on that or any subsequent examination shall be subject to the
provisions of Sec. 3.1 05(e) of this chapter.
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 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:
Rating
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
17
9326 Dementia due to other neurologic or general medical conditions (endocrine
disorders, metabolic disorders, Pick's disease, brain tumors, etc.) or that are
substance- induced (drugs, alcohol, poisons)
9327 Organic mental disorder, other (including personality change due to a general
medical condition)
Anxiety Disorders
Dissociative Disorders
Somatoform Disorders
Mood Disorders
18
General Rating Formula for Mental Disorders:
19
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
Eating Disorders
Note: An incapacitating episode is a period during which bed rest and treatment by a
physician are required.
Mittleider v. West, 11 Vet. App. 181 (1998) (when it is not possible to separate the
effects of the service-connected condition versus a nonservice-connected condition (such
as a personality disorder), 38 C.F.R. § 3.102 requires that reasonable doubt be resolved in
20
the claimant's favor, thus attributing such signs and symptoms to the service-connected
disability) .
Best v. Brown, 10 Vet. App. 322 (1997) (denial of service connection for personality
disorder and adjustment reaction did not constitute a final denial of service connection for
generalized anxiety disorder, as these are distinct conditions).
Hart v. Mansfield, 21 Vet. App. 505 (2007) (in determining the present level of a
disability for any increased evaluation claim, the Board must consider the application of
staged ratings) and Fenderson v. West, 12 Vet. App. 119 (1999) (staged ratings in initial
ratings following a grant of service connection) apply to ratings of psychiatric disability.
21
C. OLD REGULATIONS (PRE-1996 CHANGES)
The field of mental disorders represents the greatest possible variety of etiology,
chronicity and disabling effects, and requires differential consideration in these
respects. These sections under mental disorders are concerned with the rating of
psychiatric conditions, specifically psychotic and psychoneurotic disorders and
psychological factors affecting physical conditions as well as organic mental
disorders. Advances in modem psychiatry during and since World War II have
been rapid and profound and have extended to the entire medical profession a
better understanding of and deeper insight into the etiological factors,
psychodynamics, and psychopathological changes which occur in mental disease
and emotional disturbances. The psychiatric nomenclature employed is based upon
the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-
III), American Psychiatric Association. This nomenclature has been adopted by
the Veterans Health Services and Research Administration of the Department of
Veterans Affairs. It limits itself to the classification of disturbances of mental
functioning. To comply with the fundamental requirements for rating psychiatric
conditions, it is imperative that rating personnel familiarize themselves thoroughly
with this manual (American Psychiatric Association Manual, 1980 Edition) which
will be hereinafter referred to as the APA manual.
It must be established first that a true mental disorder exists. The disorder will be
diagnosed in accordance with the APA manual. A diagnosis not in accord with this
manual is not acceptable for rating purposes and will be returned through channels
to the examiner. Normal reactions of discouragement, anxiety, depression, and
self-concern in the presence of physical disability, dissatisfaction with work
environment, difficulties in securing employment, etc., must not be accepted by
the rating board as indicative of psychoneurosis. Moreover, mere failure of social
or industrial adjustment or the presence of numerous complaints should not, in the
absence of definite symptomatology typical of a psychoneurotic or psychological
factor affecting physical condition, become the acceptable basis of a diagnosis in
this field. It is the responsibility of rating boards to accept or reject diagnoses
shown on reports of examination. If a diagnosis is not supported by the findings
shown on the examination report, it is incumbent upon the board to return the
report for clarification.
22
38 C.F.R. § 4.127. Mental deficiency and personality disorders.
Social integration is one of the best evidences of mental health and reflects the
ability to establish (together with the desire to establish) healthy and effective
interpersonal relationships. Poor contact with other human beings may be an index
of emotional illness. However, in evaluating impairment resulting from the ratable
psychiatric disorders, social inadaptability is to be evaluated only as it affects
industrial adaptability. The principle of social and industrial inadaptability as the
basic criterion for rating disability from the mental disorders contemplates those
abnormalities of conduct, judgment, and emotional reactions which affect
economic adjustment, i.e., which produce impairment of earning capacity.
23
symptomatology are the essentials. The examiner's classification of the disease as
"mild," "moderate," or "severe" is not determinative of the degree of disability, but
the report and the analysis of the symptomatology and the full consideration of the
whole history by the rating agency will be. In evaluating disability from psychotic
disorders it is necessary to consider, in addition to present symptomatology or its
absence, the frequency, severity, and duration of previous psychotic periods, and
the veteran's capacity for adjustment during periods of remission. Repeated
psychotic periods, without long remissions, may be expected to have a sustained
effect upon employability until elapsed time in good remission and with good
capacity for adjustment establishes the contrary. Ratings are to be assigned which
represent the impairment of social and industrial adaptability based on all of the
evidence of record. (See § 4.16 regarding the issue of individual unemployability
based on mental disorder.) Evidence of material improvement in psychotic
disorders disclosed by field examination or social survey should be utilized in
determinations of competency, but the fact will be borne in mind that a person
who has regained competency may still be unemployable, depending upon the
level of his or her disability as shown by recent examinations and other evidence
of record.
PSYCHOTIC DISORDERS
Rating
24
9205 Schizophrenia, residual type; schizoaffective disorder; other and unspecified types.
9206 Bipolar disorder, manic, depressed, or mixed.
9207 Major depression with psychotic features.·
9208 Paranoid disorders (specify type).
9209 Major depression with melancholia.
9210 Atypical psychosis.
Upon regular discharge or release to non-bed care from a hospital where a beneficiary has
been under care and treatment for a continuous period in the hospital of not less than 6
months, an open rating of 100 percent will be continued for 6 months. A VA examination
is mandatory at the expiration of the 6-month period, after which the condition will be
rated in accordance with the degree of disability shown. Where the beneficiary has been
under hospital care and treatment for less than 6 months and is not ratable at 100 percent
under the rating formula, consideration should be given to § 4.29.
Rating
25
9306 Multi-infarct dementia due to causes other than cerebral arteriosclerosis.
9307 Dementia associated with convulsive disorder (idiopathic epilepsy).
9308 Dementia associated with disturbances of metabolism.
9309 Dementia associated with brain tumor.
9310 Dementia due to unknown cause.
9311 Dementia due to undiagnosed cause.
9312 Dementia, primary, degenerative.
9315 Dementia associated with epidemic encephalitis.
9322 Dementia associated with endocrine disorder.
9324 Dementia associated with systemic infection.
9325 Dementia associated with drug or poison intoxication (other than alcohol).
Before attempting to rate organic mental disorders, rating specialists should become
thoroughly acquainted with the relevant concepts presented by the current Diagnostic and
Statistical Manual of the American Psychiatric Association and the following:
(1) Under the codes above, the basic syndrome of organic mental disorder may be
the only mental disturbance present or it may appear with related "psychotic"
manifestations. An organic mental disorder with or without such qualifying phrase
will be rated according to the general rating formula for organic mental disorders,
assigning a rating which reflects the entire psychiatric picture.
26
PSYCHONEUROTIC DISORDERS
Rating
Read well notes (1) to (4) following general rating formula before applying the general
rating formula.
The attitudes of all contacts except the most intimate are so adversely
affected as to result in virtual isolation in the community. Totally
incapacitating psychoneurotic, symptoms bordering on gross repudiation
of reality with disturbed thought or behavioral processes associated with
almost all daily activities such as fantasy, confusion, panic and explosions
of aggressive energy resulting in profound retreat from mature behavior.
Demonstrably unable to obtain or retain employment 100
Ability to establish and maintain effective or favorable relationships
with people is severely impaired. The psychoneurotic symptoms are
of such severity and persistence that there is severe impairment in the
ability to obtain or retain employment 70
Ability to establish or maintain effective or favorable relationships
with people is considerably impaired. By reason of psychoneurotic
symptoms the reliability, flexibility and efficiency levels are so
reduced as to result in considerable industrial impairment 50
Definite impairment in the ability to establish or maintain effective
and wholesome relationships with people. The psychoneurotic
symptoms result in such reduction in initiative, flexibility, efficiency
and reliability levels as to produce definite industrial impairment 30
27
Less than criteria for the 30 percent, with emotional tension or
other evidence of anxiety productive of mild social and industrial
impairment 10
There are neurotic symptoms which may somewhat adversely affect
relationships with others but which do not cause impairment of working
ability 0
NOTE (1). Social impairment per se will not be used as the sole basis for any specific
percentage evaluation, but is of value only in substantiating the degree of disability based
on all of the findings.
NOTE (2). The requirements for a compensable rating are not met when the psychiatric
findings are not more characteristic than minor alterations of mood beyond normal limits;
fatigue or anxiety incident to actual situations; minor compulsive acts or phobias;
occasional stuttering or stammering; minor habit spasms or tics; minor subjective sensory
disturbances such as anosmia, deafness, loss of sense of taste, anesthesia, paresthesia, etc.
When such findings actually interfere with employability to a mild degree, a 10 percent
rating under the general rating formula may be assigned.
NOTE (3). It is to be emphasized that vague complaints are not to be erected into a
concept of conversion disorder. A diagnosis of conversion disorder must be established
on the basis of specific distinctive findings characteristic of such disturbance and not
merely by exclusion of organic disease. If a diagnosis of conversion disorder is found by
the rating board to be inadequately supported by
findings, the report of examination will be returned through channels to the examiner for
reconsideration.
NOTE (4). When two diagnoses, one organic and the other psychological or
psychoneurotic, are presented covering the organic and psychiatric aspects of a single
disability entity, only one percentage evaluation will be assigned under the appropriate
diagnostic code determined by the rating board to represent the major degree of
disability. When the diagnosis of the same basic disability is changed from an organic
one to one in the psychological or psychoneurotic categories, the
condition will be rated under the new diagnosis.
Rating
28
9505 Psychological factors affecting musculoskeletal condition.
9506 Psychological factors affecting respiratory condition.
9507 Psychological factors affecting hemic and lymphatic condition.
9508 Psychological factors affecting genitourinary condition.
9509 Psychological factors affecting endocrine condition.
9510 Psychological factors affecting condition of organ of special sense (specify
sense organ).
9511 Psychological factors affecting other type of physical condition.
Evaluate psychological factors affecting physical condition by the general rating formula
for psychoneurotic disorders.
NOTE (1). It is to be emphasized that vague complaints are not to be erected into a
concept of psychological disorder. A diagnosis of a psychological disorder affecting
physical condition must be established on specific distinctive findings characteristic of
such disturbance and not merely by exclusion of organic disease. If a diagnosis of a
psychological disorder is found by the rating board to be inadequately supported by
findings, the report of examination will be returned.
NOTE (2). When two diagnoses, one organic and the other psychological or
psychoneurotic, are presented covering the organic and psychiatric aspects of a single
disability entity, only one percentage evaluation will be assigned under the appropriate
diagnostic code determined by the rating board to represent the major degree of
disability. When the diagnosis of the same basic disability is changed from an organic
one to one in the psychological or psychoneurotic categories, the
condition will be rated under the new diagnosis.
VAOPGCPREC 07-89 (effective in February 1988, the Rating Schedule was amended
to describe the impairment as 'total' for a 100% rating, 'severe' for a 70% rating,
'considerable' for a 50% rating, 'definite' for a 30% rating, and 'mild' for a 10% rating for
all three categories of psychiatric disorders, psychotic disorders, organic disorders, and
psychoneurotic disorders; prior to the amendments, some differences existed within the
several categories of disorders, e.g., for a neurosis or psychophysiologic disorder, 'severe'
impairment had warranted a 50% rating, whereas for a psychosis or organic brain
disorder, 'severe' impairment warranted a 70% rating; this opinion held that there was no
requirement that existing ratings in neuropsychiatric cases remain unaffected by the
adjustments in terminology).
29
Note that 38 C.F.R. § 4.16(c) was deleted from the "new" regulations. See BVA
Chairman's Memo 01-91-12 for interpretation of 38 c.P.R. § 4.16(c), where it is
applicable.
Johnson v. Brown, 7 Vet. App. 95, 97 (1994) (holding that the criteria in 38 C.P.R.
§ 4.132, Diagnostic Code 9411 [attitudes of all contacts except the most intimate were so
adversely affected as to result in virtual isolation in the community, or when there were
totally incapacitating psychoneurotic, symptoms bordering on gross repudiation of reality
with disturbed thought or behavioral processes associated with almost all daily activities
such as fantasy, confusion, panic and explosions of aggressive energy resulting in
profound retreat from mature behavior, or when the veteran was demonstrably unable to
obtain or retain employment] are independent alternative qualifying criteria for a total
(100 percent) evaluation.
VAOPGCPREC 9-93 (holding that the term "definite" as used in 38 C.P.R. § 4.132
should be construed to mean distinct, unambiguous and moderately large in degree,
more than moderate but less than rather large); see Hood v. Brown, 4 Vet. App. 301
(1993).
30