Definition Of Psychosis For Certain Va Purposes

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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]

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.

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.

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print, having been replaced by Diagnostic and Statistical Manual of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 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.

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

1. The authority citation for part 3, subpart A continues to read as

follows:

Authority: 38 U.S.C. 501(a), unless otherwise noted.

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;

© 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

[carlie]

Thanks Adora,

That's going to my shrink next week.

carlie