28 July 2006
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[Federal Register: July 28, 2006 (Volume 71, Number 145)]
[Rules and Regulations]
[Page 42758-42760]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr28jy06-5]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 3
RIN 2900-AK21
Definition of Psychosis for Certain VA Purposes
AGENCY: Department of Veterans Affairs.
ACTION: Final rule.
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SUMMARY: This document amends the Department of Veterans Affairs (VA)
adjudication regulations to define the term ``psychosis.'' The term is
used but not defined in certain statutes that provide presumptive
service connection for compensation. The intended effect of this
amendment is consistent application of these statutory provisions.
[[Page 42759]]
DATES: Effective Date: This amendment is effective August 28, 2006.
Applicability Date: The provisions of this regulation shall apply
to all applications for benefits received by VA on or after August 28,
2006.
FOR FURTHER INFORMATION CONTACT: Bill Russo, Chief, Regulations Staff
(211D), Compensation and Pension Service, Veterans Benefits
Administration, Department of Veterans Affairs, 810 Vermont Ave., NW.,
Washington, DC, 20420, (202) 273-7211.
SUPPLEMENTARY INFORMATION: On October 11, 2002, VA published in the
Federal Register (67 FR 63352) a proposal to amend VA regulations to
define the term ``psychosis'' as used in statutory and regulatory
provisions concerning presumptive service connection for compensation
or health care purposes. Interested persons were invited to submit
written comments on or before December 10, 2002. We received three
comments: one from the American Psychiatric Association, one from the
American Association for Geriatric Psychiatry, and one from a member of
the general public.
In response to the proposed rule, which referenced Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) in the
preamble, one commenter observed that the DSM-IV is essentially out-of-
print, having been replaced by Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).
As a preliminary matter, we note that DSM-IV does not differ
materially from DSM-IV-TR as to which disorders are classified as
psychoses. (Compare page 19 of DSM-IV with pages 19-20 in DSM-IV-TR;
pages 273-274 in DSM-IV with pages 297-298 in DSM-IV-TR; and pages 694-
695 of DSM-IV with pages 750-751 in DSM-IV-TR). Although our proposed
rule relied on the DSM-IV to define ``psychosis,'' we will address the
comments to the proposed rule based on DSM-IV-TR and refer to DSM-IV-TR
in the final rule because it is the most updated and accessible version
of the manual. Furthermore, VA will update the regulation being added
by this rulemaking, 38 CFR 3.384, when a new edition of Diagnostic and
Statistical Manual of Mental Disorders is published in the future.
One commenter urged VA to replace the term ``Mood Disorder with
Psychotic Features'' with ``Bipolar Disorder (types I and II) With
Psychotic Features'' and ``Major Depressive Disorder With Psychotic
Features'' because ``Mood Disorder with Psychotic Features'' does not
appear as a listed disorder in DSM-IV, published by the American
Psychiatric Association in 1994. The commenter noted that the
definition of ``psychosis'' was much broader in the first edition of
the Diagnostic and Statistical Manual of Mental Disorders (DSM-I),
published by the American Psychiatric Association in 1952, compared to
its current usage. The commenter further noted that what we now refer
to as Bipolar Disorder (types I and II) and Major Depressive Disorder
were considered psychotic disorders when psychosis was designated as a
presumptive condition in 1958 by Public Law 85-857, 72 Stat. 1118.
We have reconsidered whether Mood Disorder with Psychotic Features
should be included in our definition of ``psychosis'' at all. We
included it in our proposed definition because that disorder appeared
in the decision tree for Differential Diagnosis of Psychotic Disorders
in the DSM-IV. In the preamble to the proposed rule, at 67 FR 63352, we
stated:
According to DSM-IV, pages 19 and 694-695, the following mental
disorders contain at least one of the above-mentioned DSM-IV,
Appendix A, psychotic symptoms: psychotic disorder due to a general
medical condition; substance-induced psychotic disorder;
schizophrenia; schizophreniform disorder; schizoaffective disorder;
mood disorder with psychotic features; delusional disorder;
psychotic disorder not otherwise specified; brief psychotic
disorder; and shared psychotic disorder.
The proposed rule itself listed these ten disorders as psychoses.
Neither the DSM-IV nor the DSM-IV-TR, however, lists Mood Disorder with
Psychotic Features as a psychotic disorder. We consider the actual
listing of psychotic disorders more significant than the appearance of
a disorder in the decision tree. The actual listing of psychotic
disorders in the DSM-IV-TR includes only disorders ``that include
psychotic symptoms as a prominent aspect of their presentation,''
whereas disorders such as Mood Disorder with Psychotic Features ``may
present with psychotic symptoms as associated features.'' DSM-IV-TR at
297.
Upon review of DSM-IV-TR and further consideration, we do not
believe that Mood Disorder with Psychotic Features, or other disorders
which may have psychotic features but are not listed in DSM-IV-TR as
psychoses, should be considered psychoses for purposes of this
regulation. Psychotic features may be temporary and not recur, but the
disorders listed as psychoses by the DSM-IV-TR include psychotic
symptoms as a prominent aspect of their presentation. Psychotic
features do not necessarily show that the veteran has an actual
psychosis. By analogy, it would be erroneous to consider a disease that
has symptoms also found in a cancer, but which is not actually a type
of cancer, to constitute a cancer for presumptive purposes.
We recognize that the disorders now referred to as Bipolar Disorder
(types I and II) and Major Depressive Disorder were once considered
psychotic disorders. However, we note that DSM-IV-TR states that the
definition of the term ``psychotic'' has evolved over time, and that at
least one prior definition (contained in DSM-II, which we note was
published in 1968) ``was probably far too inclusive.'' (DSM-IV-TR,
Appendix C, at page 827). We believe that it is appropriate for VA to
use current scientific knowledge in defining the term psychosis.
For the reasons stated above, we have not included Mood Disorder
with Psychotic Features, Bipolar Disorder (types I and II) With
Psychotic Features, or Major Depressive Disorder With Psychotic
Features in the definition of psychosis in the final rule.
Citing page 297 of the DSM-IV-TR, published by the American
Psychiatric Association in 2000, one commenter noted that catatonic
behavior is also a psychotic symptom. This commenter suggested that we
include the following disorders within the definition of psychosis:
``Catatonic Disorder Due to a General Medical Condition,'' ``Major
Depressive Disorder [W]ith Catatonic Features,'' ``Bipolar I Disorder
[W]ith Catatonic Features'' and ``Bipolar II Disorder [W]ith Catatonic
Features.''
Our review of DSM-IV-TR confirms the commenter's assertion that
catatonic behavior is also a psychotic symptom. However, as stated
above, we do not believe that all disorders presenting with psychotic
features should be considered psychoses. Only disorders listed by the
DSM-IV-TR as psychotic disorders should be considered psychoses. We
therefore decline to accept this suggestion.
One commenter suggested we add ``dementia with delusions'' to the
definition of psychosis because dementia is often accompanied by
psychotic symptoms. That commenter stated that other government or
private entities could adopt such a definition and use it in other
contexts. Another commenter suggested we add ``Vascular Dementia with
Delusions'' to the definition of psychosis because delusions are
considered a psychotic symptom.
We decline to adopt the first suggestion because ``dementia with
delusions'' is not a specific DSM-IV-TR diagnosis. However, Vascular
Dementia
[[Page 42760]]
With Delusions is a specific DSM-IV-TR diagnosis and its symptoms may
be psychotic. However, as stated above, we do not believe that all
disorders presenting with psychotic features should be considered
psychoses. Only disorders listed by the DSM-IV-TR as psychotic
disorders should be considered psychoses. We therefore decline to
accept this suggestion.
One commenter urged VA to adopt a policy of accepting a treating
physician's diagnosis as absolute. This suggestion is outside the scope
of this rulemaking, and we have made no change based on it.
This commenter also stated that VA should eliminate its proposed
definition of psychosis and accept evidence of any disorder listed in
DSM-IV as sufficient for adjudication purposes. DSM-IV lists numerous
mental disorders that are not classified as psychoses (e.g. anxiety
disorders). Furthermore, certain presumptions of service connection
apply to psychoses but not other mental disorders. We therefore make no
change based on this comment.
This commenter also stated that VA should not create any definition
of psychosis because it would create more red tape and place an
additional burden on veterans. For the reasons stated above and in the
supplementary information for the proposed rule, we believe that
adopting a clear definition of psychosis will actually make the claims
process simpler for veterans seeking service connection for a
psychosis. We therefore decline to make any change based on this
comment.
We have made one non-substantive formatting change to proposed 38
CFR 3.384 by listing the different psychoses in alphabetical order. We
believe this change will make it easier for the reader to quickly
locate a particular psychotic disorder.
In the preamble to the proposed rule, we noted that a statute
authorizing health care, specifically 38 U.S.C. 1702, uses the term
``psychosis'' and that new Sec. 3.384 was intended to affect the
application of that statute. The references to health care, and to
section 1702 in particular, were erroneously included in the preamble,
and we wish to clarify that, as stated in the proposed regulation text,
new Sec. 3.384 only concerns presumptions of service connection under
38 CFR part 3, which governs adjudication with respect to compensation,
pension, dependency and indemnity compensation, and burial benefits,
but not health care.
Paperwork Reduction Act
This document contains no provisions constituting a collection of
information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-
3521).
Regulatory Flexibility Act
The Secretary hereby certifies that this final rule will not have a
significant economic impact on a substantial number of small entities
as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-
612. The reason for this certification is that this amendment would not
directly affect any small entities. Only VA beneficiaries could be
directly affected. Therefore, pursuant to 5 U.S.C. 605(b), this final
rule is exempt from the initial and final regulatory flexibility
analysis requirements of sections 603 and 604.
Executive Order 12866
Executive Order 12866 directs agencies to assess all costs and
benefits of available regulatory alternatives and, when regulation is
necessary, to select regulatory approaches that maximize net benefits
(including potential economic, environmental, public health and safety,
and other advantages; distributive impacts; and equity). The Order
classifies a rule as a significant regulatory action requiring review
by the Office of Management and Budget if it meets any one of a number
of specified conditions, including: Having an annual effect on the
economy of $100 million or more, creating a serious inconsistency or
interfering with an action of another agency, materially altering the
budgetary impact of entitlements or the rights of entitlement
recipients, or raising novel legal or policy issues. VA has examined
the economic, legal, and policy implications of this final rule and has
concluded that it is a significant regulatory action because it may
raise novel legal and policy issues under Executive Order 12866.
Unfunded Mandates
The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C.
1532, that agencies prepare an assessment of anticipated costs and
benefits before issuing any rule that may result in the expenditure by
State, local, and tribal governments, in the aggregate, or by the
private sector, of $100 million or more (adjusted annually for
inflation) in any year. This final rule would have no such effect on
State, local, and tribal governments, or on the private sector.
Catalog of Federal Domestic Assistance
The Catalog of Federal Domestic Assistance program numbers and
titles for this rule are as follows: 64.101, Burial Expenses Allowance
for Veterans; 64.109, Veterans Compensation for Service-Connected
Disability; and 64.110, Veterans Dependency and Indemnity Compensation
for Service-Connected Death.
List of Subjects in 38 CFR Part 3
Administrative practice and procedure, Claims, Disability benefits,
Health care, Pensions, Radioactive materials, Veterans, Vietnam.
Approved: April 18, 2006.
Gordon H. Mansfield,
Deputy Secretary of Veterans Affairs.
0
For the reasons set forth in the preamble, 38 CFR part 3 is amended as
follows:
PART 3--ADJUDICATION
Subpart A--Pension, Compensation, and Dependency and Indemnity
Compensation
0
1. The authority citation for part 3, subpart A continues to read as
follows:
Authority: 38 U.S.C. 501(a), unless otherwise noted.
0
2. Section 3.384 is added under the undesignated center heading
``Rating Considerations Relative to Specific Diseases'' to read as
follows:
Sec. 3.384 Psychosis.
For purposes of this part, the term ``psychosis'' means any of the
following disorders listed in Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision, of the American
Psychiatric Association (DSM-IV-TR):
(a) Brief Psychotic Disorder;
(b) Delusional Disorder;
(c) Psychotic Disorder Due to General Medical Condition;
(d) Psychotic Disorder Not Otherwise Specified;
(e) Schizoaffective Disorder;
(f) Schizophrenia;
(g) Schizophreniform Disorder;
(h) Shared Psychotic Disorder; and
(i) Substance-Induced Psychotic Disorder.
(Authority: 38 U.S.C. 501(a), 1101, 1112(a) and (b))
[FR Doc. E6-12079 Filed 7-27-06; 8:45 am]
BILLING CODE 8320-01-P