Overview
In This Section |
This section contains the following topics:
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1. General Information on Mental Disorders
Introduction |
This topic contains general information about rating mental disorders, including
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Change Date |
October 19, 2018
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III.iv.4.O.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
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
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III.iv.4.O.1.b. Applying Guidance on Sympathetic Reading to Mental Disorders Claims |
When reviewing a claim for service connection (SC) based on a mental disorder
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 that he/she is not competent to medically identify, 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
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III.iv.4.O.1.c. Considering a Change in the Diagnosis of a Psychiatric Disorder |
If the diagnosis of a psychiatric disorder is changed, the rating activity must determine if this represents
If this is not clear from the available records, a determination by an examiner is required.
Reference: For more information on change in diagnosis of mental disorders, see
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III.iv.4.O.1.e. Considering SC for Mental Unsoundness in Suicide |
Whether a person, at the time of suicide, was so unsound mentally that he or she did 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.
Notes:
Reference: For more information on developing claims for in-service suicide, seeM21-1, Part III, Subpart iii, 2.A.8.c.
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III.iv.4.O.1.f. Definition: Psychosis |
For the purpose of presumptive SC under 38 CFR 3.309(a), a psychosis is any of the following disorders:
Reference: For the regulation governing the definition of psychosis, see 38 CFR 3.384.
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III.iv.4.O.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,
Note: In-service mental health treatment records are maintained by the military or civilian treating facility and are not stored by the Department of Defense with the traditional service treatment records (STRs).
References: For more information on
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III.iv.4.O.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 PTSDor 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
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III.iv.4.O.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:
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 additional guidance on considerations for conditions which may be characterized by both physical and mental symptoms, see M21-1, Part III, Subpart iv, 4.O.1.h.
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III.iv.4.O.1.k. Considering SC for Neurodevelopmental Disorders |
Neurodevelopmental disorders are a group of conditions with onset in the developmental period. According to the 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 Disability (Intellectual Developmental Disorder).
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.
Exception:
References: For more information on
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III.iv.4.O.1.l. 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).
When insomnia is adequately identified as a symptom of another underlying disability, SC should be established for that diagnosis rather than for “insomnia.” However, SC can be established for “insomnia” in the absence of a known or established underlying etiology if there is
Note: When evaluating primary insomnia, rate analogously under an appropriate DC in 38 CFR 4.130.
Reference: For more information on analogous ratings, see
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2. General Information on Rating PTSD
Introduction |
This topic contains general information about rating PTSD, including
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Change Date |
June 14, 2018
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III.iv.4.O.2.a. Responsibility of the RVSR or DRO in Deciding SC for PTSD |
Deciding the issue of SC for PTSD is the sole responsibility of the appropriate decision maker at the local level, generally a Rating Veterans Service Representative (RVSR) or a Decision Review Officer (DRO).
Note: Decision makers may request an opinion or guidance from CompensationService on complex cases.
Reference: For more information about requesting Compensation Service assistance, see M21-1, Part III, Subpart vi. 1.A.
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III.iv.4.O.2.b. Requirements for Establishing SC for PTSD From In-Service Stressors |
Under 38 CFR 3.304(f), SC for PTSD associated with an in-service stressor requires
Reference: For more information on establishing SC for PTSD, see
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III.iv.4.O.2.c. Considering the Relationship Between Stressor and Symptoms |
To establish SC for PTSD based on an in-service stressor, the relationship between stressor and symptoms must be
Reference: For more information on PTSD examination requirements, see M21-1, Part III, Subpart iv, 4.O.2.f and g.
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III.iv.4.O.2.d. Handling an In-Service Diagnosis of PTSD |
When PTSD is properly diagnosed in service, the Veteran’s testimony alone may establish that the claimed in-service stressor occurred, as long as the claimed stressor is
References: For more information on
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III.iv.4.O.2.e. In-Service Diagnosis of PTSD Related to a Pre-Service Stressor |
If a Veteran is sound on enlistment and develops delayed or late-onset PTSD in service related to a pre-service stressor, the claim may be granted under 38 U.S.C. 1110, which contains the general criteria for establishing SC for a chronic disability.
Notes:
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III.iv.4.O.2.f. Handling Insufficient PTSD Examination Reports |
When a PTSD examination report is insufficient for rating purposes follow procedures in M21-1, Part III, Subpart iv, 3.D.3.
Reasons that a PTSD examination report may be insufficient for VA purposes include
Notes:
References: For more information on
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III.iv.4.O.2.g. PTSD Examination Reports and DSM Criteria |
Based on the May 2013 publication of DSM-5, 38 CFR 4.125 was updated to specifically refer to DSM-5 effective August 4, 2014.
Important: Mental health examinations conducted after August 2014, to include PTSD examinations, must comply with DSM-5 standards.
References: For more information on
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3. Evaluating Evidence and Deciding a Claim for PTSD Based on Personal Trauma
Introduction |
This topic contains information about evaluating evidence in claims based on personal trauma, including
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Change Date |
January 16, 2019
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III.iv.4.O.3.a. General Information on Personal Trauma |
Personal trauma, for the purpose of VA disability compensation claims based on PTSD, refers broadly to stressor events involving harm perpetrated by a person who is not considered part of an enemy force.
Examples: Assault, battery, robbery, mugging, stalking, harassment.
Military sexual trauma (MST) is a subset of personal trauma and refers to sexual harassment, sexual assault, or rape that occurs in a military setting.
Reference: For more information on processing claims for PTSD based on personal trauma, see
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III.iv.4.O.3.b. Importance of Obtaining and Analyzing Available Evidence of Personal Trauma |
Prior to deciding a claim based on personal trauma, claims processors must
References: For more information on
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III.iv.4.O.3.c. Alternative Sources of Evidence of In-Service Personal Trauma |
If primary evidence, such as STRs and service personnel records, contain no explicit documentation that personal trauma, including in-service sexual assault, occurred, evidence from alternative sources other than the Veteran’s service records may corroborate the Veteran’s account of the stressor incident.
Examples of such alternative sources of evidence include, but are not limited to
Note: 38 CFR 3.304(f)(5) provides that in PTSD claims based on in-service personal assault, evidence from sources other than the Veteran’s service records may be used to corroborate the Veteran’s account of the stressor incident. However, VA Office of General Counsel concluded in VAOPGCPREC 3-2012 that PTSD personal assault regulation changes and guidance are not a sufficient basis for invocation of liberalizing law effective date rules.
Important: VA may not treat the absence of a service record documenting an unreported sexual assault as evidence that the sexual assault did not occur as indicated in AZ and AY v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013). In addition, VA may not rely on a Veteran’s failure to report an in-service sexual assault to military authorities as pertinent evidence that the sexual assault did not occur. Therefore, do not use the absence of service record documentation or lack of report of in-service sexual assault to military authorities as evidence to conclude that a sexual assault did not occur.
Reference: For more information on negative evidence, see
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III.iv.4.O.3.d. Evidence That May Constitute a Marker of Personal Trauma |
If primary evidence, such as STRs and service personnel records, contain no explicit documentation that personal trauma occurred, and alternative sources of evidence do not provide credible supporting evidence of the trauma, evidence of behavioral changes around the time of, and after, the incident(s), may constitute a marker of a personal trauma PTSD stressor.
The term marker means an indicator of the effect or consequences of the personal trauma on the Veteran. A marker could be one or more behavioral events, or a pattern of changed behavior. Even if there is no reference to the personal trauma, evidence of the behavior changes below may circumstantially support thepossibility that the claimed stressor occurred.
Evidence that may be a marker of trauma includes but is not limited to
Notes:
References: For more information on
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III.iv.4.O.3.e. Interpretation of Behavioral Changes as Markers of Personal Trauma |
Evidence of behavioral changes typically needs interpretation by a clinician in personal trauma claims.
Submit evidence received for a medical opinion as to whether the credible factual evidence of behavior changes demonstrated by the Veteran is consistent with the expected reaction or adjustment of a person who has been subjected to an assault.
If the examiner offers a credible, unequivocal, and nonspeculative assessment that the evidence of record is consistent with the occurrence of the claimed assault, that opinion can constitute credible supporting evidence that the claimed in-service stressor occurred. If the opinion is merely speculative, equivocal, contradictory, or otherwise insufficient for rating purposes, it should be returned for clarification.
References: For more information on
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III.iv.4.O.3.f. MST During INACDUTRA |
Veterans whose stressor occurred during inactive duty for training (INACDUTRA) are eligible for SC in the same manner as those whose stressor occurred during active duty or active duty for training. The VA Office of General Counsel concluded in VAOPGCPREC 8-2001 that “PTSD resulting from sexual assault may be considered a disability resulting from an injury.”
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III.iv.4.O.3.g. Training and Signature Requirements for MST Decisions |
All rating decisions that address an MST-related disability as an issue must only be worked/reviewed by an RVSR who has
Decisions for MST disabilities require two signatures until a decision maker has demonstrated an accuracy rate of 90 percent or greater based on a review of at least 10 MST cases.
Important: To ensure accurate claims processing, the following checklists/worksheet are recommended for completion and uploading to the claims folder:
Reference: For more information on two signature requirements in MST rating decisions, see M21-1, Part III, Subpart iv, 6.D.7.d.
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4. Evaluating Evidence and Deciding a Claim for SC for PTSD
Introduction |
This topic contains information about deciding a claim for SC for PTSD, including
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Change Date |
June 14, 2018
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III.iv.4.O.4.a. Determining the Occurrence of Stressors When Making the Decision |
When determining the occurrence of stressors to establish SC for PTSD, consider the following
Notes:
Reference: For more information on developing claims of PTSD, see M21-1, Part IV, Subpart ii, 1.D.
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III.iv.4.O.4.b. Determining Combat Service |
Every decision involving the issue of SC for PTSD that allegedly developed as a result of combat must include a factual determination as to whether or not the Veteran was engaged in combat, including the reasons or bases for that finding.
Important: In order to conclude that a Veteran “engaged in combat with the enemy,” the evidence must establish that the Veteran was present during an encounter with a military foe either as a combatant or as a service member performing duty in support of combatants.
Notes:
References: For more information on
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III.iv.4.O.4.c. Considering Secondary Evidence of Engagement in Combat |
Although secondary evidence may be used to confirm engagement in combat, it must be critically and carefully reviewed for sufficiency.
Note: It may not be necessary to confirm engagement in combat if the evidence in the claim meets the lower threshold of a fear of hostile military or terrorist activity.
Reference: For more information on secondary sources of evidence, see M21-1, IV, Subpart ii, 1.D.1.d.
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III.iv.4.O.4.d. Establishing a Stressor Related to the Fear of Hostile Military or Terrorist Activity |
When determining whether a stressor related to fear of hostile military or terrorist activity is established, consider places, types, and circumstances of service where risks or danger from such activity are most likely to exist. Deployed service overseas related to combat, security, or support of combat or security missions is the most likely to involve risks or danger from hostile military forces or terrorist attacks.
Primary evidence, such as the Veteran’s DD Form 214, Certificate of Release or Discharge From Active Duty, and other service records showing deployments, relevant awards or decorations, receipt of Combat/ Imminent Danger/ Hostile Fire Pay, and other conditions of service, will be key to proving service in an area of potential or actual hostile military or terrorist activity.
Note: The July 13, 2010, amendment of 38 CFR 3.304(f) is not considered a liberalizing rule under 38 CFR 3.114(a).
References: For more information on
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III.iv.4.O.4.e. Establishing SC for PTSD Relatedto Drone Aircraft Crew Member Duties |
Recent military operations and warfare have involved the expansive use of armed drone aircraft, such as the Predator and Reaper. SC for PTSD is warranted under38 CFR 3.304(f) when the evidence shows that the Veteran
References: For information on
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III.iv.4.O.4.f. Requirement for Credible Supporting Evidence of a Stressor |
The requirement for credible supporting evidence of a stressor means that there must be some believable evidence that tends to support the Veteran’s assertion. In determining whether evidence is credible, consider its
Note: Credibility is only a minimum requirement. (Evidence that is not believable is not entitled to any weight.) In addition to being credible, evidence must also
Reference: For more information on reviewing for credible supporting evidence, see M21-1, Part IV, Subpart ii, 1.D.3.b.
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III.iv.4.O.4.h. Reviewing Evidence for Corroboration of a Stressor |
When reviewing evidence for corroboration of a claimed stressor(s),
When corroborating evidence of a stressor is required, there is no requirement that the evidence must, and may only, be found in official documentary records. In most cases, however, official documentary records are the most reliable source of stressor verification.
Note: Generally, documents written or recorded by the lowest possible unit in the chain of the command are the most probative source of information to verify a claimed stressor, because they tend to include details of events with greater precision.
Examples:
Reference: For more information on the stressor verification review procedure, see M21-1, Part IV, Subpart ii, 1.D.3.c.
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III.iv.4.O.4.i. Obtaining Evidence Related to Claimed Stressors |
For more information on obtaining service records, medical treatment records, and evidence of stressors, see M21-1, Part IV, Subpart ii, 1.D.
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III.iv.4.O.4.j.Denying a PTSD Claim Because of an Uncorroborated Stressor |
When corroborating evidence of a stressor is required because the stressor may not be established by lay evidence alone and credible supporting evidence from other sources is not of record, a denial solely because of an unconfirmed stressor is improper unless
If JSRRC, NARA, or the Marine Corps requests a more specific description of the stressor in question, follow the procedures in M21-1, Part IV, Subpart ii, 1.D.2.g-ito ask the Veteran to provide the necessary information. If the Veteran provides additional substantive information, forward it to the requesting agency. Failure of the Veteran to respond substantively to the request for information will be grounds to deny the claim based on an unconfirmed stressor.
References: For more information on
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III.iv.4.O.4.k. Disposition of an Issue Claimed and/or Developed as SC for PTSD Case |
Use the table below in order to arrive at the proper disposition of an issue claimed and/or developed as SC for PTSD diagnosed after service and claimed as related to an in-service stressor.
Note: This table is intended to cover PTSD arising after service and claimed to be related to an in-service stressor event.
References: For more information on
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Historical_M21-1III_iv_4_SecO_6-14-18.docx | May 15, 2019 | 87 KB |
1-4-18_Key-Changes_M21-1III_iv_4_SecO.docx | May 15, 2019 | 88 KB |
1-16-19_Key-Changes_M21-1III_iv_4_SecO.docx | May 15, 2019 | 65 KB |
6-14-18_Key-Changes_M21-1III_iv_4_SecO.docx | May 15, 2019 | 118 KB |
10-19-18_Key-Changes_M21-1III_iv_4_SecO.docx | May 15, 2019 | 66 KB |
in Chapter 4 Rating Specific Disabilities, Part III General Claims Process, Subpart iv General Rating Process
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