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

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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 to expect at your C&P exam

An exam for depression, anxiety, bipolar disorder, or a similar condition is an interview with a psychologist or psychiatrist. The examiner gathers your history, observes how you present, and gives an opinion on how much your symptoms impair your work and social life, which is what 38 CFR 4.130 rates.

1Initial interview (history)

  • When your symptoms began and how they have changed over time.
  • Your specific symptoms: mood, sleep, energy, appetite, concentration, panic, or mood swings, and how often and how severe.
  • Treatment history: therapy, medications, hospital or ER visits.
  • Alcohol or substance use.
  • Relationships, family, and social life.
  • Work history and how symptoms affect your job.
  • Any thoughts of self-harm or suicide.

2Mental status examination

  • Appearance, grooming, and behavior during the interview.
  • Speech, mood, and affect (emotional expression).
  • Thought process and content, and any delusions or hallucinations.
  • Orientation, memory, and concentration.
  • Insight, judgment, and impulse control.
  • Whether you report thoughts of harming yourself or others.

3Diagnostic tests the examiner may rely on

The examiner may use a validated questionnaire or a structured interview. These are scored tools, not pass/fail tests.

PHQ-9 (depression screen) what's this?
A 9-item questionnaire measuring the presence and severity of depression symptoms.
Mental status examination what's this?
The structured set of observations described above; the standard framework for describing mental functioning at one point in time.
Structured clinical interview
A standardized question set the clinician follows to confirm a DSM-5 diagnosis. The examiner selects the tool that fits your condition.

4Functional assessment

  • How your symptoms affect work: missed days, conflict, trouble concentrating or keeping a job.
  • How they affect relationships, family, and social activities.
  • Your ability to handle daily routines and self-care.
  • The examiner gives an overall opinion on your level of occupational and social impairment, the scale 38 CFR 4.130 uses to set the rating from 0 to 100 percent.

If you are in crisis or thinking about suicide, call the Veterans Crisis Line at 988 and press 1, or text 838255. It is free, confidential, and available 24/7.

Test explainers open MedlinePlus (NIH National Library of Medicine), or Wikipedia where MedlinePlus has no matching page. This describes what happens and what is measured, not how to influence a result.

What the examiner records (full DBQ form)

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.

7 of 7 sections apply to DC 9421 on this DBQ
DIAGNOSIS (Section I) CLINICAL FINDINGS (Section II) SYMPTOMS (Section III) BEHAVIORAL OBSERVATIONS (Section IV) OTHER SYMPTOMS (Section V) COMPETENCY (Section VI) REMARKS (Section VII)
DIAGNOSIS (Section I)
  • A1. Does the Veteran now have or has he or she ever been diagnosed with a mental disorder(s)? NOTE: If the Veteran has a diagnosis of an eating disorder, complete the Eating Disorders Questionnaire, in lieu of this questionnaire. NOTE: If the Veteran has a diagnosis of PTSD, the Initial PTSD Questio
CLINICAL FINDINGS (Section II)
  • 2A. Relevant social/marital/family history (pre-military, military, and post-military) Mental Disorders (Other Than PTSD and Eating Disorders)
  • 2B. Relevant occupational and educational history (pre-military, military, and post-military)
  • 2C. Relevant mental health history, to include prescribed medications and family mental health (pre-military, military, and postmilitary)
  • 2D. Relevant legal and behavioral history (pre-military, military, and post-military)
  • 2E. Relevant substance abuse history (pre-military, military, and post-military)
  • 2F. Other, if any:
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 Mental Disorders (Other Than PTSD and Eating Disorders)
BEHAVIORAL OBSERVATIONS (Section IV)
  • 4A. Behavioral Observations Mental Disorders (Other Than PTSD and Eating Disorders)
OTHER SYMPTOMS (Section V)
  • 5A. Does the Veteran have any other symptoms attributable to mental disorders that are not listed above? Yes No If "Yes," describe
COMPETENCY (Section VI)
  • 6A. Is the Veteran capable of managing his or her financial affairs? Yes No If "No," specify each injury or disease resulting in incompetency and provide a rationale to support this finding: Mental Disorders (Other Than PTSD and Eating Disorders)
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, among issues the Board granted or denied (remanded issues are not included). 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.

  • VA examination: appeared in 93 granted decisions (112 denied; 205 decided total)
  • Private medical opinion: appeared in 54 granted decisions (49 denied; 103 decided total)
  • Service treatment records: appeared in 40 granted decisions (54 denied; 94 decided total)
  • Buddy / lay statements: appeared in 36 granted decisions (47 denied; 83 decided total)
  • Nexus letter: appeared in 36 granted decisions (9 denied; 45 decided total)
  • Medical literature: appeared in 7 granted decisions (1 denied; 8 decided 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.