C&P Exam for Somatic symptom disorder (DC 9421)

Diagnostic code: 9421Condition: Somatic symptom disorderRegulation: 38 CFR § 4.130DBQ: DBQ PSYCH Mental Disorders

Which form the examiner uses

For somatic symptom disorder (DC 9421), the C&P examiner completes the following Disability Benefits Questionnaire (DBQ):

DBQs are Department of Veterans Affairs Form 21-0960 series documents. Public DBQs are hosted on benefits.va.gov. A handful are examiner-only and are not posted publicly.

What the examiner records

The fields below are reproduced from the DBQ form the examiner completes for this diagnostic code. This is the structural map of the form, showing what the examiner is asked to measure, observe, and record. It is a factual reproduction of the public DBQ, not advice on how to answer.

This DBQ evaluates mental disorders (other than PTSD and eating disorders) for VA disability rating, documenting diagnosis, clinical findings, symptoms, behavioral observations, and competency.

How DC 9421 maps to this DBQ: for this diagnostic code specifically, the examiner typically completes sections I-VII of this form. Section I is the condition-specific section for this code.

DIAGNOSIS (Section I)
  • A1. Does the Veteran now have or has he or she ever been diagnosed with a mental disorder(s)?
  • Mental Disorder Diagnosis #1:
  • ICD Code: (Diagnosis #1)
  • Comments, if any: (Diagnosis #1)
  • Mental Disorder Diagnosis #2:
  • ICD Code: (Diagnosis #2)
  • Comments, if any: (Diagnosis #2)
  • Mental Disorder Diagnosis #3:
  • ICD Code: (Diagnosis #3)
  • Comments, if any: (Diagnosis #3)
  • If additional diagnoses, list using the above format:
  • A2. Medical diagnosis relevant to the understanding or management of the mental health disorder (to include TBI):
  • ICD Code (A2)
  • Comments, if any: (A2)
CLINICAL FINDINGS (Section II)
    SYMPTOMS (Section III)
    • 3A. For VA rating purposes, check all symptoms that apply to the Veteran's diagnoses
    • Depressed Mood
    • Anxiety
    • Suspiciousness
    • Panic attacks that occur weekly or less often
    • Panic attacks more than once a week
    • Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively
    • Chronic sleep impairment
    • Mild memory loss, such as forgetting names, directions or recent events
    • Impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks
    • Memory loss for names of close relatives, own occupation, or own name
    • Flattened affect
    • Circumstantial, circumlocutory or stereotyped speech
    • Speech intermittently illogical, obscure, or irrelevant
    • Difficulty in understanding complex commands
    • Impaired judgment
    • Impaired abstract thinking
    • Gross impairment in thought processes or communication
    • Disturbances of motivation and mood
    • Difficulty in establishing and maintaining effective work and social relationships
    • Difficulty adapting to stressful circumstances, including work or a work like setting
    • Inability to establish and maintain effective relationships
    • Suicidal ideation
    • Obsessional rituals which interfere with routine activities
    • Impaired impulse control, such as unprovoked irritability with periods of violence
    • Spatial disorientation
    • Persistent delusions or hallucinations
    • Grossly inappropriate behavior
    • Persistent danger of hurting self or others
    • Neglect of personal appearance and hygiene
    • Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene
    • Disorientation to time or place
    BEHAVIORAL OBSERVATIONS (Section IV)
    • 4A. Behavioral Observations
    OTHER SYMPTOMS (Section V)
    • 5A. Does the Veteran have any other symptoms attributable to mental disorders that are not listed above?
    • If 'Yes,' describe
    COMPETENCY (Section VI)
    • 6A. Is the Veteran capable of managing his or her financial affairs?
    • If 'No,' specify each injury or disease resulting in incompetency and provide a rationale to support this finding:
    REMARKS (Section VII)
    • 7A. Remarks (Including any testing results), if any:

    Rating Levels for DC 9421

    The following tiers are reproduced from 38 CFR Part 4, the VA Schedule for Rating Disabilities. Toggle between the official VA criteria and a Plain English explanation.

    Plain-English summaries are AI-generated to explain the official criteria. The official 38 CFR language is the binding legal standard. When in doubt, ask a VSO.

    Evidence cited in published BVA decisions for DC 9421

    The counts below are aggregated from published Board of Veterans Appeals decisions for this diagnostic code. Each row reports how often a given evidence type was discussed in the decision text, broken down by outcome. This is a factual aggregate of the public record, not a prediction or recommendation about any specific claim.

    • Private medical opinion: appeared in 12 granted decisions (0 denied, 1 remanded; 13 total)
    • Medical literature: appeared in 7 granted decisions (0 denied, 0 remanded; 7 total)
    • VA examination: appeared in 6 granted decisions (2 denied, 1 remanded; 9 total)
    • Nexus letter: appeared in 2 granted decisions (0 denied, 0 remanded; 2 total)
    • Buddy / lay statements: appeared in 1 granted decision (1 denied, 0 remanded; 2 total)
    • Service treatment records: appeared in 0 granted decisions (1 denied, 0 remanded; 1 total)

    Standardized screening instruments at the C&P exam

    The following standardized screens are administered at the C&P exam for this diagnostic code. Questions and scoring are reproduced verbatim from VA's General Medical Separation Health Assessment DBQ (the same instruments are used at compensation and pension exams).

    Patient Health Questionnaire-2 (PHQ-2) Depression Screen

    Two-item depression screen. Each item scored 0-3 (0 = Not at all, 1 = Several days, 2 = More than half the days, 3 = Nearly every day). Total range 0-6.

    1. Over the past two weeks, how often have you been bothered by little interest or pleasure in doing things?
    2. Over the past two weeks, how often have you been bothered by feeling down, depressed, or hopeless?

    Scoring: Positive screen if total score is 3 or greater.

    Suicide Risk Secondary Screen (Columbia-style)

    Eight-item secondary screen administered when the primary suicide-risk question elicits any response above 'Not at all'. Positive screen = 'yes' to questions 3, 4, 5, or 8.

    1. Over the past month, have you wished you were dead or wished you could go to sleep and not wake up?
    2. Have you actually had any thoughts of killing yourself?
    3. Over the past month, have you been thinking about how you might do this?
    4. Over the past month, have you had these thoughts and had some intention of acting on them?
    5. Over the past month, have you started to work out or worked out the details of how to kill yourself?
    6. If yes to question 5: At any time in the past month, did you intend to carry out this plan?
    7. In your lifetime, have you ever done anything, started to do anything, or prepared to do anything to end your life?
    8. If yes to question 7: Was this within the past three months?

    Scoring: Positive screen if 'yes' to question 3, 4, 5, or 8. Immediate emergency response procedures apply when there is concern about an immediate threat.

    Alcohol Use Disorders Identification Test - Consumption (AUDIT-C)

    Three-item alcohol-use screen. Items scored 0-4 each. Mental-health screening commonly includes AUDIT-C because substance use frequently co-occurs with PTSD, depression, and anxiety.

    1. How often did you have a drink containing alcohol? (Never / Monthly or less / 2-4 times per month / 2-3 times per week / 4 or more times per week)
    2. How many drinks containing alcohol did you have on a typical day when you were drinking? (1 or 2 / 3 or 4 / 5 or 6 / 7 to 9 / 10 or more)
    3. How often did you have six or more drinks on one occasion in the past year? (Never / Less than monthly / Monthly / Weekly / Daily, or almost daily)

    Scoring: Positive screen if total score is 5 or more (men). Women's threshold uses a four-or-more-drinks variant of question 3.

    What the Board discussed in granted decisions for DC 9421

    The themes below were extracted by clustering 164 grant-factor sentences from published Board of Veterans Appeals decisions for this diagnostic code. Frequencies indicate how often each theme appeared in the sample. This is a factual aggregate of the public record, not advice or strategy for any specific claim.

    1. 44% Benefit of the doubt doctrine stated or applied
      The Board cited the legal standard that when positive and negative evidence is in approximate balance or nearly equal, VA must resolve the doubt in the claimant's favor, and applied or declined to apply that doctrine to the claim at hand.
      72 of 164 sample sentences
    2. 23% Medical nexus opinion cited as at least as likely as not
      A VA or private examiner opined that a current disability was at least as likely as not incurred in, caused by, or related to active service or a service-connected condition.
      37 of 164 sample sentences
    3. 12% Evidence found in equipoise supporting grant of rating or service connection
      The Board found the lay and medical evidence at least in approximate balance or relative equipoise on a specific rating level, earlier effective date, or service-connection question, resulting in a grant in the Veteran's favor.
      20 of 164 sample sentences
    4. 12% Preponderance of evidence against claim; benefit of doubt inapplicable
      The Board determined that the weight of evidence persuasively stood against the claim, making the benefit of the doubt doctrine inapplicable and resulting in denial.
      20 of 164 sample sentences
    5. 5% Somatic symptom disorder secondary to service-connected disability
      The Board or an examiner recorded a finding that the Veteran's somatic symptom disorder was proximately due to, caused by, or aggravated by a service-connected disability such as knee pain, tinnitus, or PTSD.
      9 of 164 sample sentences
    6. 5% TDIU entitlement supported by service-connected disabilities
      The Board found that the evidence supported or was in equipoise as to whether the Veteran's service-connected disabilities precluded securing and maintaining substantially gainful employment, warranting a TDIU award.
      9 of 164 sample sentences
    7. 5% Increased disability rating granted after symptom review
      The Board reviewed the Veteran's symptomatology and, affording benefit of the doubt, found that the overall disability picture more nearly approximated a higher rating percentage under the applicable diagnostic code.
      8 of 164 sample sentences
    8. 5% Examiner opinion question framed for nexus determination
      The Board or remand order recorded a structured question to an examiner asking whether a disability was at least as likely as not related to service or a service-connected condition, with the standard defined.
      8 of 164 sample sentences
    9. 2% Current diagnosis of somatic symptom disorder noted in record
      The Board or an examiner recorded that the Veteran had a current confirmed diagnosis of somatic symptom disorder, satisfying a threshold element for service connection or rating purposes.
      4 of 164 sample sentences
    10. 2% Lay statements and continuous symptom history noted
      The Board recorded the Veteran's consistent lay statements and treatment history as supporting a finding of continuous or persistent symptoms throughout the appeal period.
      4 of 164 sample sentences
    View the full DC 9421 pageSearch BVA decisions for this codeAbout DBQ forms

    Disclaimer: This page reproduces public Department of Veterans Affairs forms (DBQs) and verbatim text from 38 CFR Part 4 (the VA Schedule for Rating Disabilities). It is informational only and is not legal or medical advice. For guidance on a specific claim, contact a VA-accredited representative.