M21-1 Manual / Part V, Subpart iii, Chapter 13
Mental Disorders
M21-1, Part V, Subpart iii, Chapter 13
Overview
In This Chapter | | This chapter contains the topic "General Information on Mental Disorders." |
1. General Information on Mental Disorders
Introduction | | This topic contains general information about rating mental disorders, including- sympathetic reading and the scope of mental disorders claims
- applying guidance on sympathetic reading to mental disorders claims
- considering a change in the diagnosis of a psychiatric disorder
- making reductions in evaluations of psychiatric disorders
- considering service connection (SC) for mental unsoundness in suicide
- definition of psychosis
- handling a Veteran’s discharge from service for a mental disorder due to traumatic stress
- evaluating a disability diagnosed as both a physical and mental disorder
- somatic symptom disorder as a disability for Department of Veterans Affairs (VA) compensation purposes, and
- considering SC for
- neurodevelopmental disorders, and
- insomnia.
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V.iii.13.1.a. Sympathetic Reading and the Scope of Mental Disorders Claims | | A claim for a particular mental disorder should be read as a claim for any mental disability that may be reasonably defined by- the description of the claim
- the symptoms that the claimant describes
- the information and evidence that the claimant submits, and
- any other information and evidence obtained.
A sympathetic reading of pleadings cannot be based on a standard that requires legal sophistication and must consider whether all submissions taken together have articulated a claim. Note: Under 38 CFR 3.159, the duty to assist is triggered by a substantially complete application, which requires identification of the benefit claimed and any medical condition on which it is based, which could be a description of symptoms of a body part or system. Reference: For more information on sympathetic reading and scope of claims, see |
V.iii.13.1.b. Applying Guidance on Sympathetic Reading to Mental Disorders Claims | | When reviewing a claim for service connection (SC) based on a mental disorder- do notlimit consideration only to a particular mental disorder diagnosis or theory of SC identified by the claimant, and
- do sympathetically read the claim as including any chronic acquired mental disorder consistent with the analysis described in the previous block.
If additional development is needed to address an alternative diagnosis in the evidentiary record, ensure that this is completed before making a decision. It is impermissible to limit the scope of the claim for SC to the claimant’s lay hypothesis about the nature of a specific mental disorder disability. Because the Veteran is reasonably requesting benefits for symptoms of a mental disorder but is not competent to medically identify such symptoms, it is insufficient for the Department of Veterans Affairs (VA) to simply deny benefits for the claimed diagnosis and not address evidence in the record of other mental disorder diagnoses, as indicated in Clemons v. Shinseki, 23 Vet.App. 1 (2009). References: For more information on - sympathetic reading and scope of claims, see M21-1, Part V, Subpart ii, 3.A
- deciding claims for posttraumatic stress disorder (PTSD) when another mental disorder is diagnosed, see M21-1, Part VIII, Subpart iv, 1.D.2.j, and
- considering unclaimed theories of SC, see M21-1, Part II, Subpart iii, 1.A.2.f.
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V.iii.13.1.c. Considering a Change in the Diagnosis of a Psychiatric Disorder | | If the diagnosis of a psychiatric disorder previously recognized as service-connected (SC) is changed, the rating activity must determine if this represents- progression of the prior disorder
- correction of an error in the prior diagnosis, or
- development of a new and separate condition.
If this is not clear from the available records, a determination by an examiner is required.Example: The Veteran files a claim for increased evaluation for SC generalized anxiety disorder and an examination is requested. The examiner gives a current diagnosis of major depressive disorder but makes no mention of the previously diagnosed SC condition of generalized anxiety disorder. Clarification from the examiner is needed as to whether the current diagnosis represents a progression or correction of the prior SC diagnosis or development of a new and separate condition. References: For more information on - change in diagnosis of mental disorders, see
- handling a change in diagnosis of an SC disability, see M21-1, Part V, Subpart ii, 3.D.1.f
- clarification of examination reports showing a change in SC diagnosis, see M21-1, Part IV, Subpart i, 3.C.1.c, and
- resolving inconsistencies in diagnoses when SC has not previously been established, see M21-1, Part IV, Subpart i, 3.C.1.d-f.
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V.iii.13.1.d. Making Reductions in Evaluations of Psychiatric Disorders | | Do not make drastic reductions in evaluations in ratings for psychiatric disorders if a reduction to an intermediate rate is more in agreement with the degree of disability. Observe the general policy of gradually reducing the evaluation to afford the Veteran all possible opportunities for adjustment. Reference: For more information on the stabilization of disability evaluations, see |
V.iii.13.1.e. Considering SC for Mental Unsoundness in Suicide | | Whether a person, at the time of suicide, was so unsound mentally as to not realize the consequences 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 the individual’s mental condition at the time. The act of suicide or a bona fide attempt is considered to be evidence of mental unsoundness. Therefore, where no reasonable adequate motive for suicide is shown by the evidence, the act will be considered to have resulted from mental unsoundness.Important: Application of the provisions of 38 CFR 3.302 regarding mental unsoundness in suicide is not limited to acts of suicide or bona fide attempts that occur during service. Notes: - The finding of mental unsoundness applies to the determination of whether the suicide constitutes willful misconduct, as indicated in 38 CFR 3.302(a).
- In all instances, any reasonable doubt should be resolved favorably to support a finding of SC.
- As held in Elkins v. Brown, 8 Vet.App. 391 (1995), mental unsoundness by itself without evidence of an underlying psychiatric disability is not a service-connectable disorder.
- Therefore, when death from suicide has occurred after separation from active duty, SC may be granted only in the presence of a service-connectable disability that
- meets all of the requirements for SC, and
- is shown to have contributed to the state of mental unsoundness precipitating the act of suicide.
- When death from suicide has occurred while on active duty, it will be considered SC unless the evidence shows the suicide was due to willful misconduct or otherwise refutes a finding of SC.
References: For more information on |
V.iii.13.1.f. Definition: Psychosis | | For the purpose of presumptive SC under 38 CFR 3.309(a), a psychosis is any of the following disorders:- brief psychotic disorder
- delusional disorder
- psychotic disorder due to another medical condition
- other specified schizophrenia spectrum and other psychotic disorder
- schizoaffective disorder
- schizophrenia
- schizophreniform disorder, and
- substance/medication-induced psychotic disorder.
Reference: For more information on the definition of psychosis, see 38 CFR 3.384. |
V.iii.13.1.g. Handling a Veteran’s Discharge From Service for a Mental Disorder Due to Traumatic Stress | | Under 38 CFR 4.129, when a mental disorder that develops in service from a highly stressful event is severe enough to result in the Veteran’s discharge from active military service,- assign an SC evaluation of at least 50 percent, and
- schedule an examination within six months of the Veteran’s discharge to determine whether a change in the evaluation is warranted.
Note: In-service mental health treatment records are maintained by the military or civilian treating facility and are not stored by the Department of War with the traditional service treatment records. References: For more information on - adjudicating claims for PTSD, see M21-1, Part VIII, Subpart iv, 1
- developing for in-service mental health treatment records, see M21-1, Part VIII, Subpart iv, 1.A.2, and
- handling certain mental disorders that cause discharge from service, see M21-1, Part VIII, Subpart iv, 8.A.2.g.
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V.iii.13.1.h. Evaluating a Disability Diagnosed as Both a Physical and Mental Disorder | | Avoid assigning separate evaluations for SC disabilities based on the same manifestations as this constitutes pyramiding. To warrant separate evaluations, symptoms considered must be distinct and not overlap.Situation: A Veteran is SC for PTSD with anxiety considered in the assigned evaluation. The Veteran later files a claim for SC for fibromyalgia. The evidence associates fibromyalgia with service and anxiety is considered as a manifestation upon which fibromyalgia is diagnosed. Result: Fibromyalgia will be SC and rated separately from PTSD. However, anxiety may only be considered in determining the rating to be assigned for PTSD or fibromyalgia. Rationale: Consideration of anxiety in rating both disabilities would constitute pyramiding as the symptoms are obviously overlapping and would involve rating the same manifestations twice. References: For more information on- evaluating a single disability that has been diagnosed both as a physical condition and as a mental disorder, see 38 CFR 4.126
- evaluating comorbid mental disorders and fibromyalgia, see M21-1, Part V, Subpart iii, 1.F.1.c
- evaluating comorbid mental disorders and traumatic brain injury (TBI), see M21-1, Part V, Subpart iii, 12.B.2, and
- pyramiding, see
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V.iii.13.1.i. Somatic Symptom Disorder as a Disability for VA Compensation Purposes | | A diagnosis of somatic symptom disorder, which is widely recognized as a disabling condition, is accepted by VA as a disability for compensation purposes. Because somatic symptom disorder may also stem from an underlying disease such as multiple sclerosis or arthritis, and variations of somatic symptom disorder may be found throughout all body systems, the condition should be evaluated under the most appropriate diagnostic code (DC) based on the clinical picture demonstrated. Notes: - VA already recognizes conditions such as fibromyalgia and low back pain syndrome, which are forms of somatic symptom disorder, as disabilities for compensation purposes.
- Originally diagnosed as chronic pain syndrome, terminology was revised to somatic symptom disorder in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).
Important: Adequate medical evidence must be of record that identifies the specific manifestations of the disease present in order to accurately evaluate the condition. Reference: For more information on evaluating conditions that may be characterized by both physical and mental symptoms, see M21-1, Part V, Subpart iii, 13.1.h. |
V.iii.13.1.j. Considering SC for Neurodevelopmental Disorders | | Neurodevelopmental disorders are a group of conditions with onset in the developmental period. According to DSM-5, they typically manifest in early development and are characterized by developmental deficits in several functional domains. This group of disorders includes, but is not limited to, the following diagnoses: - attention-deficit/hyperactivity disorder (also referred to as attention deficit disorder)
- autism spectrum disorder
- specified learning disorder
- tic disorder
- child-onset fluency disorder (stuttering), and
- intellectual developmental disorder (intellectual disability).
Neurodevelopmental disorders are not considered diseases or injuries under 38 CFR 3.303(c). Since they are not diseases or injuries, they are not generally subject to direct SC. Exceptions: - If evidence clearly demonstrates the diagnosis developed as a result of an in-service injury (for example, as a result of a TBI), consider SC for any diagnosis directly related to the in-service injury.
- If there is progression of the condition at an abnormally high rate during service as discussed in M21-1, Part V, Subpart ii, 2.C and E, consider SC under 38 CFR 3.306.
References: For more information on |
V.iii.13.1.k. Considering SC for Insomnia | | Carefully consider the evidence of record when deciding SC for insomnia. Insomnia is generally considered a symptom of another disability due to coexisting medical or neurological conditions. Insomnia can occur as an independent condition or can be a symptom associated with another mental disorder (for example, major depressive disorder), medical condition (for example, pain), or another sleep disorder (for example, a breathing-related sleep disorder).Use the table below to determine the appropriate rating action for insomnia.| If there is ... | Then ... |
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| insomnia that is shown to be secondary to, or a symptom of, another underlying SC disability | - a separate SC evaluation on a secondary basis is not warranted for insomnia
- SC should be established for the underlying primary disability, if not already established, and
- the insomnia symptoms should be included in the evaluation assigned under the DC for the primary SC disability.
Important: - Discuss in the rating decision narrative for the primary SC disability that insomnia symptoms are included in the evaluation for the underlying disability as it was determined to be the cause of insomnia.
- An evaluation under a 38 CFR 4.130 DC is not warranted when insomnia is shown to be secondary to another disability, unless the primary SC disability causing the insomnia is another mental disorder with a DSM-5 diagnosis.
| - a current diagnosis of insomnia disorder meeting DSM-5 diagnostic criteria (meaning the insomnia is not associated with any other underlying disease or injury)
- an event in service (such as a diagnosis of primary insomnia or insomnia disorder in service), and
- a nexus establishing the current DSM-5 diagnosis of insomnia disorder is connected to the event in service
| - SC can be established on a direct basis for insomnia disorder, and
- the condition should be rated analogously under an appropriate DC in 38 CFR 4.130.
Important: A separate SC evaluation for a diagnosis of insomnia disorder is only warranted if all other potential causes are ruled out and SC can be established on a direct basis. |
Note: DSM-5 revised the diagnostic terminology from “primary insomnia” to “insomnia disorder.” In both the current and prior versions of DSM, the diagnostic criteria includes ruling out all other potential causes. Accordingly, a valid diagnosis of insomnia disorder meeting DSM-5 criteria means that the insomnia condition is not caused by (or secondary to) any other condition.References: For more information on - the requirement for a diagnosis in accordance with DSM-5, see 38 CFR 4.125(a), and
- analogous ratings, see
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Source: VA M21-1 Adjudication Procedures Manual, M21-1, Part V, Subpart iii, Chapter 13 (U.S. government work, reproduced for reference). Browse all sections →