Chapter 21 - Psychiatric Impairment

Introduction

This chapter provides criteria for assessing permanent impairment from entitled psychiatric conditions.

For VAC disability assessment purposes, this chapter is only used to assess chronic psychiatric conditions where the diagnosis has been established according to the "Diagnostic Statistical Manual of Mental Disorders" (DSM).

The criteria in this chapter are used to assess the following psychiatric conditions:

• adjustment disorders
• anxiety disorders
• bipolar and related disorders
• depressive disorders
• dissociative disorders
• feeding and eating disorders
• mood disorders
• obsessive-compulsive and related disorders
• *pain disorders / chronic pain syndrome
  Note: only applies to DSM-IV-TR Axis I diagnosis
• personality disorders
• schizophrenia (spectrum) and other psychotic disorders
• **somatic symptom disorder with predominant pain
• substance–related (and addictive) disorders
• trauma-and stressor-related disorders

*DSM-IV-TR somatoform disorders (excluding pain disorders) are rated on individual merits.

**DSM-5 somatic symptom and related disorders (excluding somatic symptom disorder with predominant pain) are rated on individual merits.

There is considerable overlap in the presenting signs, symptoms and effect on function (medical impairment) of psychiatric conditions. It is difficult to determine the extent to which each psychiatric condition contributes to the medical impairment. For this reason, the disability assessment of an entitled psychiatric conditions(s) includes the medical impairment resulting from both entitled and non-entitled psychiatric conditions.

If a non-entitled psychiatric condition(s) contributes to the psychiatric disability assessment, the Partially Contributing Table (PCT) is not applied.

For example, in the presence of entitled Posttraumatic Stress Disorder and non-entitled Substance Use Disorder, the disability assessment of Posttraumatic Stress Disorder will include the signs and symptoms of both psychiatric conditions.

If conditions which are not assessed in chapter 21 (e.g., dementia, postconcussion syndrome, fibromyalgia syndrome) contribute to the medical impairment, the PCT must be applied.

If more than one condition is to be rated from this chapter, the conditions are bracketed for assessment purposes.

The emphasis in this chapter is on rating psychiatric conditions, as seen by the effect of the condition(s) on emotion, behaviour, thought, cognition, coping (adaptability), the basic activities of daily living, and treatment needs. The effects of the psychiatric condition on personal relationships, social functioning, and activities of independent living (meal preparation, shopping, home care, etc.) are rated in Chapter 2, Quality of Life.

Under Tables 21.1 - 21.4, no signs or symptoms may be rated twice. Emotional and behavioural features or symptoms associated with physical disorders that do not meet DSM criteria are assessed as part of the physical condition and should not be rated within this chapter.

Assessing psychiatric impairment requires a thorough review of the history of the psychiatric disorder and the individual's signs and symptoms over time. Symptoms from a psychiatric disability can fluctuate in severity. It is important to obtain and evaluate Member/Veteran/Client information over at least a 6-month to 1-year period (with attention given to his or her worst and/or best period of functioning).

Impairment from neurological conditions which affect cognition (e.g., dementia, postconcussion syndrome) is rated within Chapter 20, Neurological Impairment.

When entitled psychiatric conditions result in permanent impairment of other organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

Rating Tables

This chapter contains three "Loss of Function" tables and one "Other Impairment" table which may be used to rate entitled psychiatric conditions.

The tables within this chapter are:

Loss of Function - Thought and Cognition

Table 21.1 is used to rate impairment from psychiatric conditions that affect thought and cognition. The table contains two columns (categories) which are rated independently. The ratings are compared and the highest selected.

The frequency, severity and duration of the psychiatric signs and symptoms are of major consideration when rating impairment. The signs and symptoms associated with disturbances of thought and cognition represent various points on the spectrum from normal to severe/extreme abnormal functioning.

In rating impairment from psychiatric conditions, the following areas of thought and cognition are considered: thinking processes, perception, and cognition.

The thinking process is the mental ability to appraise, evaluate, plan, create and will. Both the stream and content of thought are evaluated in the consideration of the thinking process. Disturbances of thought include: delusions, paranoia, preoccupation, obsession, phobia, cloudiness of thinking, disorientation, incoherence, loosening of association, flight of ideas, hypervigilance, suicidal ideation, rumination, and suspiciousness, etc.

Perception is the transference of physical stimulation into psychological information (mental process by which sensory stimuli are brought to awareness). Disturbances of perception include: hallucinations, illusions and dissociative phenomena such as derealization and depersonalization.

Cognition is the ability to sustain focussed attention for sufficient time to permit the timely completion of tasks (concentration), acquisition of knowledge (learning), retention and recall of knowledge (memory), and use of knowledge (reasoning and problem solving). Disturbances of cognition include: memory loss (immediate or remote), amnesia, paramnesia, disorientation to place, person and time, inability to think abstractly or understand concepts, and the inability to initiate decisions and perform planned activities.

Concentration is described in terms of frequency of errors, the time it takes to complete the task, and the extent to which assistance is required to complete the task.

Except for the psychiatric conditions listed on the first page of this chapter, if non-entitled conditions or conditions rated within another chapter/table are contributing to the impairment, then the PCT must be applied to the applicable table rating(s).

Loss of Function - Emotion, Behaviour and Coping (Adaptability)

Table 21.2 is used to rate impairment from psychiatric conditions that affect emotion, behaviour and coping (adaptability). The table contains three columns (categories) which are rated independently. The ratings are compared and the highest selected.

Emotional and behavioural impairment is based on the severity, frequency and duration of the disturbances in mood, affect, and behaviour and the adaptability of the individual's emotions and behaviour to changes in the environment.

Both mood and affect are considered when evaluating emotional state.

Mood refers to the predominant emotion such as: sadness, depression, fear, anxiety, panic, hopelessness, mania, anger, or hostility, etc. It has both a subjective (described by self) and objective (observed or described by others) component. The duration (persistence of mood measured in days, weeks or years), reactivity (mood change in response to external events or circumstances) and depth or severity of the mood are important indicators of impairment.

Affect refers to the expression and expressivity of the emotion. An important indicator of impairment is the capacity or limitation to vary emotional expression in concert with thought processing. Affect is described in terms of range and intensity (full, constricted, flat and blunted), change pattern (fluid, monotonic, labile), and appropriateness (different from what would be expected).

Behaviour refers to deportment or conduct. It includes any or all total activity, especially that which can be externally observed. Both the specific behaviour(s) and the frequency of that behaviour are important indicators of impairment.

Coping (adaptability) in this context refers to the ability to adapt to stressful circumstances (stress tolerance). In the face of stressful situations or experiences (e.g. therapist moves, death in the family, home relocation, etc.), the individual may experience an increase or worsening of symptoms or behaviours (e.g. substance abuse, panic attacks, somatic complaints, etc.) associated with his or her psychiatric disorder.

Except for the psychiatric conditions listed on the first page of this chapter, if non-entitled conditions or conditions rated within another chapter/table are contributing to the impairment, then the PCT must be applied to the applicable table rating(s).

Loss of Function - Activities of Daily Living

Table 21.3 is used to rate impairment from psychiatric conditions that impact activities of daily living. Only one rating may be selected. If more than one rating is applicable, the ratings are compared and the highest selected.

Activities of daily living include personal hygiene (bathing and grooming) tasks, dressing, eating, transfers/bed mobility, locomotion, and bowel and bladder control.

The quality of these activities is judged by the level of independence, effectiveness, and sustainability. It is necessary to determine the extent to which an individual is capable of initiating and participating in these activities independent of supervision or direction. The number of activities that are restricted is not as important as the overall degree of restriction.

The effects of the psychiatric illness on independent or instrumental activities of daily living such as shopping, home care, and meal preparation etc., are evaluated in the Quality of Life Chapter.

Except for the psychiatric conditions listed on the first page of this chapter, if non-entitled conditions or conditions rated within another chapter/table are contributing to the impairment, then the PCT must be applied to the applicable table rating(s).

Other Impairment - Treatment Needs

Table 21.4 is used to rate impairment associated with treatment needs. Only one rating may be selected. If more than one rating is applicable, the ratings are compared and the highest selected.

A variety of treatment options are available for persons with psychiatric conditions. These include medication/drug regimes, self-help and support groups, therapy/counselling from a licenced counsellor/general practitioner, regular therapy by a psychiatrist on an outpatient basis, in-patient care (short or longer duration), and institutional care.

Except for the psychiatric conditions listed on the first page of this chapter, if non-entitled conditions or conditions rated within another chapter/table are contributing to the impairment, then the PCT must be applied to the applicable table rating(s).

Definition of Terms

The following terms are used within Tables 21.1 - 21.4.

• Rare = at least once per year
• Occasional = once or twice per month
• Frequent = at least once per week
• Persistent = daily or almost daily

To rate all psychiatric conditions, a rating is obtained from each table, Table 21.1 to Table 21.4. When a rating is applicable from more than one table, the ratings are added.

Table 21.1 - Loss of Function - Thought and Cognition

Only one rating may be given from Table 21.1. Each column in Table 21.1 is rated independently. If more than one rating is applicable within a column, the highest rating is selected as the column rating. The ratings from each column are then compared and the highest selected.

Each bullet (•) represents one criterion. In order for a rating to be established for each column in Table 21.1, only one criterion must be met at a level of impairment.

Table 21.2 - Loss of Function - Emotion, Behaviour and Coping (Adaptability)

Only one rating may be given from Table 21.2. Each column in Table 21.2 is rated independently. If more than one rating is applicable within a column, the highest rating is selected as the column rating. The ratings from each column are then compared and the highest selected.

Each bullet (•) represents one criterion. In order for a rating to be established for each column in Table 21.2, only one criterion must be met at a level of impairment.

Table 21.3 - Loss of Function - Activities of Daily Living

Only one rating may be given from Table 21.3. If more than one rating is applicable, the ratings are compared and the highest selected.

Each bullet (•) represents one criterion. In order for a rating to be established for Table 21.3, only one criterion designated at that rating level must be met.

* Transfers/Transferring indicates the ability to move from bed to chair, from chair to bed, etc.

Table 21.4 - Other Impairment - Treatment Needs

Only one rating may be given from Table 21.4. If more than one rating is applicable, the ratings are compared and the highest selected.

Each bullet (•) represents one criterion. In order for a rating to be established for Table 21.4, only one criterion designated at that rating level must be met.

* Regular: recurring at fixed intervals.

Steps To Determine Psychiatric Impairment Assessment

Step 1:

Determine the rating from each column of Table 21.1 (Loss of Function - Thought and Cognition). Select the highest.

Step 2:

Does the Partially Contributing Table apply? If yes, apply to the Step 1 rating.

Step 3:

Determine the rating from Table 21.2 (Loss of Function - Emotion, Behaviour and Coping). Select the highest.

Step 4:

Does the Partially Contributing Table apply? If yes, apply to the Step 3 rating.

Step 5:

Determine the rating from Table 21.3 (Loss of Function - Activities of Daily Living).

Step 6:

Does the Partially Contributing Table apply? If yes, apply to the Step 5 rating.

Step 7:

Determine the rating from Table 21.4 (Other Impairment - Treatment Needs).

Step 8:

Does the Partially Contributing Table apply? If yes, apply to the Step 7 rating.

Step 9:

Add ratings at Step 2, Step 4, Step 6 and Step 8.

Step 10:

Determine the Quality of Life rating.

Step 11:

Add ratings at Step 9 and Step 10.

Step 12:

If partial entitlement exists, apply to Step 11 rating.

This is the Disability Assessment.