The Diagnostic Code and Rating Criteria for Mental Health impairments.
First Thoughts on mental health ratings
Single Rating Rule
One rule that is important to understand for VA ratings generally, but especially with mental health ratings is the rule against "pyramiding." That is, the VA will not assign more than one rating for the same body part or condition. In most cases the VA will assign the higher rating when more than one option is available. But, you cannot receive a rating for PTSD and a separate rating for Bipolar disorder or any other diagnosis. You would receive only one rating for "any acquired psychiatric disorder."
More information about Pyramiding can be found here:
https://www.ecfr.gov/current/title-38/chapter-I/part-4/subpart-A/section-4.14
[See 4.14 in our knowledge base]
Continuity as a theory of service connection
Because the VA will only assign one rating for any psychiatric diagnosis, this can often work in favor of a veteran trying to establish service-connection for mental health. In order to establish service-connection a veteran must show a current condition, an onset during active duty and a link (nexus) between the two.
It is rare for a veteran to receive mental health treatment during a period of service. There is still in 2023 a stigma around treatment for mental health within the military. Instead, many vets may see changes in their performance, may have started exhibiting changes in behaviors noticed by friends or family during their service, or may take to unhealthy habits like increased drinking.
Especially in cases of PTSD or Military Sexual Trauma (MST) it can be very difficult to prove the circumstances that occurred in service. This is where focusing on continuity and "any acquired psychiatric disorder" rather than PTSD or MST specifically can help build a claim.
Focusing on continuity of the condition, a case can be built with buddy or family statements showing the onset of psychiatric symptoms during service and the cause is no longer important. Likewise, the actual underlying diagnosis becomes less important, and a stressor need not be proven, because the underlying onset of the condition itself can be shown.
Because of this, it's important that veterans seeking service connection for PTSD or MST not limit their focus to proving the in-service stressor, but also support the claim by showing onset during service of psychiatric symptoms as well as continuity of those symptoms through the present time of any application.
§ 4.130 Schedule of ratings—Mental disorders.
The nomenclature employed in this portion of the rating schedule is based upon the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM–5) (see § 4.125 for availability information). Rating agencies must be thoroughly familiar with this manual to properly implement the directives in § 4.125 through § 4.129 and to apply the general rating formula for mental disorders in § 4.130. The schedule for rating for mental disorders is set forth as follows:
9201 Schizophrenia
9202 [Removed]
9203 [Removed]
9204 [Removed]
9205 [Removed]
9208 Delusional disorder
9210 Other specified and unspecified schizophrenia spectrum and other psychotic disorders
9211 Schizoaffective disorder
9300 Delirium
9301 Major or mild neurocognitive disorder due to HIV or other infections
9304 Major or mild neurocognitive disorder due to traumatic brain injury
9305 Major or mild vascular neurocognitive disorder
9310 Unspecified neurocognitive disorder
9312 Major or mild neurocognitive disorder due to Alzheimer's disease
9326 Major or mild neurocognitive disorder due to another medical condition or substance/medication-induced major or mild neurocognitive disorder
9327 [Removed]
9400 Generalized anxiety disorder
9403 Specific phobia; social anxiety disorder (social phobia)
9404 Obsessive compulsive disorder
9410 Other specified anxiety disorder
9411 Posttraumatic stress disorder
9412 Panic disorder and/or agoraphobia
9413 Unspecified anxiety disorder
9416 Dissociative amnesia; dissociative identity disorder
9417 Depersonalization/Derealization disorder
9421 Somatic symptom disorder
9422 Other specified somatic symptom and related disorder
9423 Unspecified somatic symptom and related disorder
9424 Conversion disorder (functional neurological symptom disorder)
9425 Illness anxiety disorder
9431 Cyclothymic disorder
9432 Bipolar disorder
9433 Persistent depressive disorder (dysthymia)
9434 Major depressive disorder
9435 Unspecified depressive disorder
9440 Chronic adjustment disorder
General Rating Formula for Mental Disorders
| Rating | |
|---|---|
| Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. | 100 |
| Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. | 70 |
| Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. | 50 |
| Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). | 30 |
| 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 |
| A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. | 0 |
Notes about the Rating Criteria: Progressive criteria
The criteria for rating mental disorders is important to understand as it incrementally increases as certain symptoms become more prevalent. Most veterans who have a significantly symptomatic condition should be considered for a 50% rating at least. 30% should be reserved for only mildly troublesome problems, not requiring treatment with medication or regular therapy.
The gap between 50% and 70%
The leap between a 50% rating and a 70% rating is significant. As can be seen by reading the two ratings side by side there are significant additional symptoms for a 70% rating:
| 50% Rating | 70% Rating |
|---|---|
| Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. | Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. |
What's important to remember is that the key difference to support a 70% rating comes at the top of the rating. It is the "deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood." Comparing that to "reduced reliability and productivity. . . and difficulty in establishing and maintaining effective work and social relationships."
The examples that follow the deficiencies are just that, examples. Most individuals struggling with symptomatic PTSD will have "difficulty adapting to stressful circumstances" like work, and often will isolate and struggle to establish and maintain effective relationships. The difference here between 70% and 50% is whether the veteran has "difficulty" establishing and maintaining work and social relationships or is "unable" to establish and maintain effective relationships.
A lot of these questions come down to the judgment of the psychologist or psychiatric provider evaluating the veteran. There is a tremendous range and room for advocacy to show that a veteran awarded 50% should be considered for a 70% rating with solid documentation.
⚠️ About a 100% Rating
The VA has made the jump from 70% to 100% extremely difficult. The symptoms listed as examples are less important than the introductory requirement:
Total occupational and social impairment.
The criteria is unhelpfully nearly indistinguishable from a total rating secondary to individual unemployability. The only difference, is that in order to secure benefits for unemployability one need only be unable to secure and follow substantially gainful work. In other words, being unable to work secondary to a mental health disability (as might be expected from someone facing near continuous panic, or other symptoms described in a 70% rating) would be able to secure a 100% rating secondary to TDIU, as "total occupational impairment" would require an inability to work at any level, even well below substantial levels, and in the case of IU, the individual need not also suffer from total "social impairment" meaning an inability to even be around close family members.
Nonetheless, confusingly, an individual could be awarded a 100% schedular rating and still work, no matter how incongruent that is with the text of the code.
9520 Anorexia nervosa
9521 Bulimia nervosa
Rating Formula for Eating Disorders
| Rating | |
|---|---|
| Self-induced weight loss to less than 80 percent of expected minimum weight, with incapacitating episodes of at least six weeks total duration per year, and requiring hospitalization more than twice a year for parenteral nutrition or tube feeding. | 100 |
| Self-induced weight loss to less than 85 percent of expected minimum weight with incapacitating episodes of six or more weeks total duration per year. | 60 |
| Self-induced weight loss to less than 85 percent of expected minimum weight with incapacitating episodes of more than two but less than six weeks total duration per year. | 30 |
| Binge eating followed by self-induced vomiting or other measures to prevent weight gain, or resistance to weight gain even when below expected minimum weight, with diagnosis of an eating disorder and incapacitating episodes of up to two weeks total duration per year. | 10 |
| Binge eating followed by self-induced vomiting or other measures to prevent weight gain, or resistance to weight gain even when below expected minimum weight, with diagnosis of an eating disorder but without incapacitating episodes. | 0 |
Note 1: An incapacitating episode is a period during which bed rest and treatment by a physician are required.
Note 2: Ratings under diagnostic codes 9201 to 9440 will be evaluated using the General Rating Formula for Mental Disorders. Ratings under diagnostic codes 9520 and 9521 will be evaluated using the General Rating Formula for Eating Disorders.