CHAPTER 4

EMOTIONAL AND BEHAVIOURAL

INTRODUCTION

This chapter is only to be applied to assess the emotional and behavioural consequences of accepted psychiatric conditions.

Only one final rating is to be determined using this chapter for any psychiatric condition or combination of psychiatric conditions. If one or more of the veteran’s psychiatric conditions are not accepted conditions, Chapter 19 (Partially Contributing Impairment) is to be applied.

The emotional and behavioural effects of other accepted non-psychiatric conditions are incorporated in the impairment ratings throughout the Guide and may also be taken into account when assessing lifestyle. Where the emotional and behavioural effects of other accepted conditions are such that they warrant a separate psychiatric diagnosis, that psychiatric condition may only be assessed under this chapter if the condition has been accepted as war-caused or defence-caused.

When applying the tables in this chapter, only the effects of the psychiatric condition are to be taken into account. For example, inability to work, reduced participation in recreational activities, and increased family conflict may all be present but not necessarily be consequences of the psychiatric condition.

Some conditions that affect emotional and behavioural function may have symptoms that are intermittent in nature. In these circumstances, Chapter 15 (Intermittent Impairment) should be used, and the rating obtained under that chapter compared with the rating obtained from this chapter. The higher rating is to be taken.

Somatic effects

Psychiatric disease may also be associated with somatic effects such as headache, dyspepsia and psychogenic impotence. If somatic effects occur, they are to be given separate ratings using the respective system-specific tables. It must be clearly established that the somatic effects are part of the psychiatric condition and do not constitute or form part of a separate disease or injury. Conditions in which stress may be implicated as an aetiological agent are not rated under this chapter. These are considered to be separate entitlement issues.

Substance abuse

Substance abuse is to be assessed using Chapter 4 of this Guide. (For purposes of this chapter “substance abuse” includes “substance dependence”.) Chapter 4 is also to be used if substance abuse has been diagnosed under a different, but still psychiatric, diagnostic label.

If substance abuse is an accepted condition in its own right, it is to be assessed by applying Tables 4.1 to 4.8.

If substance abuse is not an accepted condition in its own right but the veteran has an accepted psychiatric condition and substance abuse is a clinical feature of that condition, then substance abuse is to be assessed as part of the accepted psychiatric condition (by applying Tables 4.1 to 4.8) only if the substance abuse was present and part of the veteran’s psychiatric condition when it was originally accepted.

If substance abuse is a clinical feature of the veteran’s accepted psychiatric condition during the assessment period but was not present and part of that condition when it was originally accepted, then substance abuse can only be assessed if it is claimed and accepted as war-caused or defence-caused.

See also the Emotional and Behavioural Medical Impairment Worksheet at pages 83-84.

Calculation of the impairment rating for psychiatric conditions

Follow the steps below to calculate the impairment rating of accepted psychiatric conditions:

(Each step is elaborated in the following pages.)

STEP 1	Determine an impairment rating from each of Tables 4.1 to 4.8.	Page 74
STEP 2	Find the highest three impairment ratings from Tables 4.3 to 4.8.	Page 74
STEP 3	Add together: the impairment rating from Table 4.1; the rating from Table 4.2; and the three impairment ratings obtained at Step 2.	Page 75
STEP 4	If the veteran has non-accepted psychiatric conditions, apply Chapter 19 (Partially Contributing Impairment).	Page 75

Step 1: Determine a rating from each of Tables 4.1 to 4.8.

Each table addresses a different parameter of psychiatric functioning. The various parameters are described in text placed below the tables.

The examples given in the descriptions of the parameters are not exhaustive. Similar factors may be considered.

While there is some overlap between the various categories, the purpose of considering the condition under the eight headings is to ensure that a wide range of the possible effects of the psychiatric condition are taken into account in arriving at a final impairment rating for the psychiatric condition.

Step 2: Find the three highest impairment ratings from Tables 4.3 to 4.8.

If all or some of the highest impairment ratings are the same, then it does not matter which of these ratings is chosen. For example, if a veteran rates 2, 2, 2, 2, 2 and 2 from Tables 4.3 to 4.8, then the three highest are 2, 2 and 2. If a veteran rates 6, 2, 2, 2, 0 and 0 from Tables 4.3 to 4.8, then the three highest are 6, 2 and 2.

Not all of the criteria in the tables will apply equally to all veterans with accepted psychiatric conditions. For example, Table 4.5 will apply to a different extent to different veterans, depending on their domestic arrangements. Criteria in Table 4.8 will also vary in their application, depending on whether the veteran is receiving treatment. In order to ensure equity in assessment across a broad range of veterans, there are six tables but only the three highest ratings are taken into the assessment.

Step 3: Add together the impairment rating from Table 4.1, the impairment rating from Table 4.2, and the three impairment ratings obtained at Step 2.

Determine the arithmetic sum of the impairment rating from Table 4.1, the impairment rating from Table 4.2, and the three impairment ratings obtained in Step 2, by adding together the five ratings. Chapter 18 (Combined Values Chart) is not to be applied in this process. If the veteran has no non-accepted psychiatric conditions then the impairment rating obtained by adding the five ratings is the final impairment rating for accepted psychiatric condition(s).

Step 4: If the veteran has non-accepted psychiatric conditions, apply Chapter 19 (Partially Contributing Impairment).

Functional Loss Table 4.1
SUBJECTIVE DISTRESS
Impairment Ratings	General description and outcome
NIL	Intermittent emotional and behavioural changes that fall within the normal range of human experience.
TWO	Occasional symptoms causing minor distress. The veteran can easily distract himself or herself from the distress on most occasions.
THREE	Recurring symptoms causing mild distress. The veteran can distract himself or herself from the distress on most occasions.
SIX	Frequent symptoms causing moderate distress. The veteran will sometimes be unable to distract himself or herself from the distress.
TEN	Very frequent symptoms causing moderate distress. The veteran will often be unable to distract himself or herself from the distress.
FIFTEEN	Persistent symptoms causing considerable distress. Relief for the veteran from that distress is difficult to achieve even with a high level of support and re-assurance.
TWENTY	Persistent symptoms causing profound distress. The veteran can rarely distract himself or herself from the distress even with a high level of support and reassurance.
TWENTY-FOUR	Continuous symptoms causing overwhelming distress. The veteran cannot distract himself or herself from the distress even with a high level of support and reassurance.
	One rating is to be selected from this table for the subjective distress due to the accepted psychiatric condition being assessed.

No age adjustment permitted for this table

Subjective distress is the distress that is experienced by the veteran. It is the equivalent of the symptom complex experienced by a veteran with a physical condition.

Examples include feelings of anxiety, fear or depression, flashbacks, intrusive thoughts, loss of concentration, nightmares and hallucinations.

Functional Loss Table 4.2
MANIFEST DISTRESS
Impairment Ratings	General description and outcome
NIL	Nil, minimal, or rare signs of distress.
TWO	Disturbances of behaviour, emotion or thinking are occasionally noticeable.
THREE	Distress is sometimes apparent, and/or the veteran’s pre-occupation with the symptoms is sometimes noticeable to astute observers or persons familiar with the veteran.
SIX	Distress is apparent, and/or the veteran’s pre-occupation with the symptoms is noticeable to astute observers or persons familiar with the veteran.
TEN	Obvious distress and pre-occupation with the symptoms is evident to casual observers and even persons unfamiliar with the veteran.
FIFTEEN	Obvious continual distress.
TWENTY	Distress that draws attention to the veteran.
TWENTY- FOUR	All pervasive distress.
	One rating is to be selected from this table for the manifest distress due to the accepted psychiatric condition being assessed.

No age adjustment permitted for this table

Manifest distress is the manifestation of the distress that others observe in the veteran. It is the equivalent of the signs observed in a physical condition.

Examples include preoccupation, manic behaviour, inappropriate actions, restless pacing, nervous sweating, tremor, bursts of anger, pressured speech, perseveration, inability to follow a conversation, vocalisations during nightmares, compulsive or excessive drinking and compulsive gambling.

Functional Loss Table 4.3
FUNCTIONAL EFFECTS
Impairment Ratings	General description and outcome
NIL	Minimal or no interferences with most aspects of living.
ONE	Minor interference with function in some everyday situations.
TWO	Moderate interference with function in some everyday situations.
THREE	Moderate interference with functions in many everyday situations.
FIVE	Marked interference with function in many everyday situations.
SIX	The veteran may be able to continue to function in everyday situations, but with gross restrictions.
EIGHT	Profound psychiatric impairment. Virtually all recreational, social or otherwise purposeful activities abandoned.
	One rating is to be selected from this table for the functional effects of the accepted psychiatric condition being assessed.

No age adjustment permitted for this table

Functional effects are the effects of the condition on the veteran’s ability to function in a non-specific environment.

Relevant factors include the veteran’s ability to deal with personal hygiene, to prepare and consume food, to use electrical appliances, to find one’s way around, to return safely home after going to the shops etc, to avoid common dangers (such as in crossing the road), to remember the location and use of ordinary objects, the method of catching public transport etc.

Functional Loss Table 4.4
OCCUPATION
Impairment Ratings	General description and outcome
NIL	Minimal or no interference with work or occupation.
ONE	Exacerbation of symptoms may cause occasional days off work.
TWO	Short periods (more than one day at a time) of absence from work.
THREE	Long periods (weeks or months) of absence from work.
FIVE	An employed veteran will have major difficulties at work, which may be manifested by job modification or restriction of career opportunities. The disorder may contribute to the loss of a job.
SIX	The veteran may be unable to work or may still be working, but with marked loss of time and/or loss of productivity at work leading to loss of original vocation.
EIGHT	The veteran cannot work.
	One rating is to be selected from this table for the occupational effects of the accepted psychiatric condition being assessed.

No age adjustment permitted for this table

Occupation. This table relates to the effect of the psychiatric condition on the veteran’s ability to work.

Relevant factors include ability to concentrate on a task, ability to work with others, ability to take instructions from a supervisor and ability to interact appropriately with clients.

The criteria for gaining impairment ratings under Table 4.4 are different from the criteria of eligibility for benefits under sections 23, 24, and 25 of the Act. For purposes of applying Table 4.4, only the impairment from accepted psychiatric condition(s) of the veteran is to be taken into account.

Functional Loss Table 4.5
DOMESTIC SITUATION
Impairment Ratings	General description and outcome
NIL	Minimal or no effect on ordinary family life.
ONE	Occasional friction with family members.
TWO	Frequent discord with family members.
THREE	Frequent conflict with family members.
FIVE	Continual conflict with family members.
SIX	Family functioning is deteriorating, and estrangement or divorce are a likely consequence.
EIGHT	Virtually non-existent family life because of conflict with family members.
	One rating is to be selected from this table for the domestic effects of the accepted psychiatric condition being assessed.

No age adjustment permitted for this table

Domestic situation. This tables relates to the effect of the psychiatric condition on the veteran’s ability to continue or form domestic interpersonal relationships.

Relevant factors include the ability to maintain usual relationships with other family members and recognition of usual domestic relationships.

Functional Loss Table 4.6
SOCIAL INTERACTION
Impairment Ratings	General description and outcome
NIL	Minimal or no effect on ordinary social contacts.
ONE	Occasional friction with colleagues and friends.
TWO	Minor reduction in social interaction.
THREE	Significant reduction in social interaction.
FIVE	Substantial reduction in social interaction.
SIX	General social withdrawal.
EIGHT	Negligible social contact.
	One rating is to be selected from this table for the social effects of the accepted psychiatric condition being assessed.

No age adjustment permitted for this table

Social interaction. This table relates to the effect of the psychiatric condition on the veteran’s ability to continue or form interpersonal relationships with friends other than close family members and to interact with people in a casual way as required in social circumstances.

Relevant factors include ability to react appropriately to people in different roles; to follow the thread and purpose of a conversation; to restrict conversation to appropriate topics and to respond suitably to remarks.

Functional Loss Table 4.7
LEISURE ACTIVITIES
Impairment Ratings	General description and outcome
NIL	Minimal or no effect on leisure activities.
ONE	Some loss of interest in activities previously enjoyed.
TWO	Some reduction in recreational activities.
THREE	Significant reduction in recreational activities.
FIVE	Loss of interest in most recreational pursuits.
SIX	Substantial reduction in most recreational pursuits.
EIGHT	Virtually all recreational activities abandoned.
	One rating is to be selected from this table for the recreational effects of the accepted psychiatric condition being assessed.

No age adjustment permitted for this table

Leisure activities. This table relates to the effect of the psychiatric condition on the veteran’s ability to enjoy previously pleasurable activities.

Relevant factors include decreased ability to concentrate, decreased ability to understand complex activity (for example how to do crossword puzzles, how to play cards and sports, or to follow the plot of a movie or book), loss of interest in games and sports, perhaps even the inability to remember the purpose or rules of a game. (Inability to concentrate or remember may lead to embarrassment with avoidance of the activity.)

Functional Loss Table 4.8
CURRENT THERAPY
Impairment Ratings	General description and outcome
NIL	No regular treatment sought or recommended.
ONE	Medical therapy or some supportive treatment from LMO may be required, and if not commenced, may be recognised as being of use.
TWO	Psychiatric treatment, at least in the form of medication or psychotherapy, has been tried (or recommended), and/or some occasional supportive therapy given at an outpatient level or by an LMO or specialist and/or a friend or other person (eg a member of the clergy) has acted in a supportive role or as a sounding board.
THREE	Psychiatric treatment, at least in the form of medication or psychotherapy, has been used (or deemed necessary), and/or periods of regular supportive therapy at an outpatient level or similar.
FIVE	Need for intensive specialist psychiatric treatment on an outpatient basis, including medication and/or in-patient hospital care for short periods.
SIX	Longer periods of in-patient hospital care are necessary. Long term psychotropic drug regimes or ECT is being undertaken.
EIGHT	Continuous psychiatric treatment is essential, with a need for long periods in hospital and marked social support.
	One rating is to be selected from this table for the treatment effects of the accepted psychiatric condition being assessed.

No age adjustment permitted for this table

Current therapy is the treatment that is being given or has been recommended for the veteran’s psychiatric condition.

Such treatment includes but is not limited to medication such as hypnotics and sedatives, counselling, group therapy, hospitalisation, or ECT. The treatment may be administered or overseen by a psychiatrist, a general practitioner, a psychologist or other health workers. The term “therapy” also includes assistance to the veteran given by his or her spouse, or other close relatives, or friends, or clergy.

CHAPTER 5

NEUROLOGICAL IMPAIRMENT

INTRODUCTION

Loss of function tables (Tables 5.1–5.5)

Neurological impairment is measured by reference to multiple functions, many of which are rated using tables in other chapters. The additional functions considered in this chapter are:

cognitive function (Table 5.1);
communication (Tables 5.2 and 5.3); and
sensory function (Table 5.4).

Ratings from one functional loss table are to be combined with ratings from any other table for a different loss of function from the same condition. Ratings from functional loss tables are not to be combined with ratings from Other Impairment tables for the same condition.

Other Impairment table (Table 5.6)

Table 5.6 lists specific impairment ratings for a variety of neurological conditions which are based on prognosis and, in some cases, pain. When ratings for the same condition can be made from Table 5.6 and a functional loss table, the higher rating is to be chosen.

Calculation of the impairment rating for an accepted neurological condition

Follow the steps below to determine the impairment rating for neurological conditions:

(Each step is elaborated in the following pages.)

STEP 1	Determine an impairment rating for functional loss from the accepted neurological condition, by applying Tables 5.1, 5.2, 5.3, 5.4, and 5.5, as applicable.	Page 86
STEP 2	Determine an impairment rating for functional loss from the accepted neurological condition, by applying other applicable chapters of this Guide.	Page 92
STEP 3	Determine a rating for Other Impairment from the accepted neurological condition, by applying Table 5.6 as applicable.	Page 93
STEP 4	(Omit this step if no rating was given in Step 3.) Combine the ratings obtained in Step 1 and Step 2, by applying Chapter 18 (Combined Values Chart). Compare the resultant combined rating with the rating obtained in Step 3. Take the higher rating.	Page 93

Step 1: Determine an impairment rating for functional loss from the accepted neurological condition, by applying Tables 5.1, 5.2, 5.3, 5.4, and 5.5, as applicable.

Cognitive function

“Cognition” means “the faculty of knowledge”. The cognitive function deals with such aspects of knowledge as acquisition (learning), retention and recall (memory), and use (reasoning and problem-solving).

Table 5.1 is applied only if an organic brain condition has been diagnosed. It is not to be applied to assess general mental capacity in a veteran with a condition of another body system unrelated to the brain condition. The impairment rating must relate only to cognitive deficits that were not present before the onset of the condition. Psychiatric conditions are to be assessed by applying Chapter 4 (Emotional and Behavioural).

Self-reports of deteriorating mental function must be interpreted with caution. Organic brain disease is often associated with a lack of insight or a tendency to deny failing abilities. Self-reported complaints about poor memory may be more closely related to depressive symptoms than to true memory deficits. If there is doubt about the nature or extent of the deficit, formal psychometric testing may be required.

Table 5.1 addresses memory and new learning ability as well as reasoning and problem-solving abilities. This requires:

adequate levels of motivation and attention;
restraint of impulsive tendencies;
ability to organise, categorise and shift responses;
use of feedback to modify behaviour; and
capacity to evaluate final performance.

The ratings reflect increasing grades of severity.

Functional Loss Table 5.1
LOSS OF NEUROLOGICAL FUNCTION: COGNITION
Impairment Ratings	Criteria
NIL	Negligible impairment: reasoning is comparable with that of peers.
	Memory similar to that of peers: written notes, etc., used in the manner of busy people of all ages.
TEN	Mild impairment: appropriate use is made of accumulated knowledge and reasonable judgement is shown in routine daily activities most of the time. Difficulties are apparent in new circumstances. Mild but demonstrable impairment of memory: misplaces objects, and has increased difficulty in remembering names and appointments. Can learn, although at a slower rate than previously. Impairment has little impact on everyday activity because of compensation through reliance on written notes, schedules, checklists and spouse.
TWENTY- FIVE	Moderate impairment of memory: has frequent difficulty in recalling details of recent experiences; frequently misplaces objects; fails to follow through with intentions or obligations; tends to get lost more easily in unfamiliar areas. Compensation through use of aids, eg. lists and diaries, is adequate. Moderate impairment of problem solving ability, relies on accumulated knowledge. Suffers significant disadvantage in circumstances requiring complex decision-making or non-routine activities, i.e. when past decision-making is not directly relevant. Has reduced initiative, spontaneity, and capacity for abstract thinking.
FORTY	Symptoms as above, but more frequent and severe. Is partially able to compensate, but unable to function with complete independence, and needs some supervision.
SIXTY	Severe impairment: has difficulty in carrying out basic activities such as sequencing the steps needed for dressing and for preparing meals. Planning/organisational ability is reduced. Is unable to function independently in new or complex situations. Shows markedly reduced initiative and spontaneity, and perseverative thinking. Severe memory deficiency: is unable to retain any information about recent experiences. New learning is not possible after attention has been directed elsewhere. Is unable to work or live independently, needing supervision to avoid harm, e.g. from fire caused by forgetting to put out cigarettes or to turn off appliances. Has extreme difficulty in keeping track of finances, scheduled activities, social relationships, etc.
SEVENTY	Gross impairment: is unable to initiate and sustain activities without supervision. Supervision and prompting are required for virtually all daily activity. Is unable to plan a course of action for the simplest activity. Gross amnesic syndrome: is unable to acquire or recall new information. Constant supervision and care are required. Unable to recognise family, own reflection in mirror, etc. Is disoriented in familiar surroundings.

No age adjustment permitted for this table

Communication

Communication has two elements: comprehension and expression. “Comprehension” means “understanding”. It includes understanding of speech and gestures, recognition of sights and sounds, spatial and temporal orientation. “Expression” is the capacity to convey the content of one’s mind to others.

Comprehension and expression are to be rated separately, by applying Tables 5.2 and 5.3 respectively. Impairment ratings from these tables are to be combined when criteria from both are applicable. Impairment ratings from these tables are not to include communication deficits that were present before the onset of the condition.

Tables 5.2 and 5.3 are to be applied to rate neurological or neuromuscular conditions as well as local lesions involving the mechanisms of speech production. Communication may also be restricted by vision loss, hearing loss, or loss of hand function. Ratings are then to be made from Chapter 8, Chapter 7, or Chapter 3 respectively, instead of Tables 5.2 and 5.3.

Comprehension

Table 5.2 is to be applied to rate limitation of auditory or visual comprehension. Only one impairment rating is to be given from this table. If more than one criterion is applicable that which results in the higher rating is to be chosen.

Expression

Table 5.3 is to be applied to rate limitation of speech production, as well as written and unspoken methods of expression. Only one impairment rating is to be made from this table. If more than one criterion is applicable, that which results in the higher rating is to be chosen.

Evaluation of speech production takes into account:

audibility: the ability to speak loudly enough to be heard;
intelligibility: the ability to articulate and to link phonetic units of speech with sufficient accuracy to be understood;
functional efficiency: the ability to speak quickly enough, and to sustain the rate for a period; and
retrieval and manipulation of language elements: expression of ideas.

Functional Loss Table 5.2
LOSS OF NEUROLOGICAL FUNCTION: COMPREHENSION
Impairment Ratings	Criteria
NIL	Normal or nearly normal comprehension.
FIVE	Can understand movies, radio programs or group discussions, but with some difficulty. Comprehension is good in most situations, but understanding is difficult in large groups, or when tired and upset. Has difficulty coping with rapid changes of topic.
TEN	Can understand speech face-to-face, but confusion or fatigue occurs rapidly in any group. Is unable to cope with rapid change in topic, or with complex topics: is able to grasp the meaning of TV serials, but not more complex ideas. Mild dyslexia: is able to grasp the meaning of basic newspaper and magazine articles, but has difficulty understanding details. Is unable to follow the storyline in books.
TWENTY- FIVE	Can understand only simple sentences, and follow simple conversion when some points are repeated Moderate dyslexia: reading comprehension is limited to sentences and short paragraphs. Can follow simple two-to-three line instructions, and cope with shopping (and other) lists, but nothing more complex.
FORTY	Can understand only single words. Shows some understanding of slowly-spoken simple sentences from context and gesture, although frequent repetition is needed. Severe dyslexia: is able to read single words, to match words to pictures and to read labels and signs, but is unable to read instructions.
FIFTY	Unable to understand simple instructions or yes/no questions, even with gesture. Unable to read single words, labels or signs.
	Ratings from one Functional Loss table may be combined with ratings from any other table for a different loss of function. Ratings from Functional Loss tables are not to be combined with ratings from Other Impairment tables for the same condition.

No age adjustment permitted for this table

Functional Loss Table 5.3
LOSS OF NEUROLOGICAL FUNCTION: EXPRESSION
Impairment Ratings	Criteria
NIL	Normal or nearly normal expression.
FIVE	Speech is of sufficient intensity and vocal quality for most everyday needs, eg:  normal speech, but unable to shout; or  needs to repeat self at times; or  is unable to produce some phonetic units; or  speech is sustained over a 10-minute period, but with difficulty that includes hesitation and word-retrieval problems; or  is permanently hoarse.
TEN	Speech is of sufficient intensity and vocal quality for many of the needs of everyday speech, eg:  is adequate with low background noise, but is heard with some difficulty in vehicles or public places; or  has many inaccuracies, but is easily understood by strangers; or  is slow or discontinuous, conveying the distinct impression of difficulty. Converses in simple sentences on familiar topics, although word-finding problems are frequent, and has difficulty in explaining long or complex ideas. Has mild dysgraphia: is unable to cope with more than short letters (about five lines) or postcards, which show both grammatical and spelling errors.
TWENTY	Speech is of sufficient intensity and vocal quality for some of the needs of everyday speech, eg:  is adequate under quiet conditions, but is heard with great difficulty against any background noise; voice fades rapidly; or  is understood by family and friends, but is difficult for strangers; or  needs frequent repetition; or  speech is sustained for short period only: fatigues rapidly. Has moderate dysgraphia: is unable to write more than short sentences which include frequent spelling errors, eg. has difficulty filling in bank forms.
THIRTY	Speech is of sufficient intensity and vocal quality for only a few of the needs of everyday speech, eg:  is reduced to a whisper at best: inaudible over the telephone; or  can produce only a few phonetic units approximating some words, but these are not intelligible if the context is unknown; or  can produce only short phrases or single words: speech flow is not maintained, or is too slow to be useful. Is unable to initiate conversation, but, with considerable effort, is able to respond in short simple sentences or phrases. Has severe dysgraphia: is able to write only some recognisable words, eg: items for a shopping list, or names of family.
FORTY	Has no speech production, but is able to use non-verbal means of expression. Is limited to single words or familiar social or stereotyped phrases requiring considerable listener inference. Has agraphia: no functional writing ability, although is able to copy or write much-practiced sequences, such as own name.
	Ratings from one Functional Loss table may be combined with ratings from any other table for a different loss of function. Ratings from Functional Loss tables are not to be combined with ratings from Other Impairment tables for the same condition.

No age adjustment permitted for this table

“Total Loss of Speech” is also mentioned in Table 24.1 (Degree of Incapacity for Specific Disabilities) in Chapter 24.

Sensory function

Table 5.4 is to be applied to rate sensory loss only. Lesions of nerves or nerve roots may also cause motor loss, which is to be rated independently by applying Chapter 3. Ratings may be made for sensory loss in the distribution of either a dermatome or a peripheral nerve, but not both for the same loss.

“Partial loss” refers either to a loss of less than the complete distribution of the nerve, or to altered sensation. Peripheral neuropathies with a “glove and stocking distribution” and “happy feet” are examples of this.

Functional Loss Table 5.4
LOSS OF NEUROLOGICAL FUNCTION: SENSORY NERVES
		Impairment Ratings
	Partial Unilateral Loss	Total Unilateral or Partial Bilateral Loss	Total Bilateral Loss
Dermatome
C2-3 (together)	0	5	10
C6&7 (together)	5	10	20
C8	0	5	10
L5&S1 (together)	0	5	10
S2&3&4 (together)	0	5	10
Hemianaesthesia (central)	15	30	—
Peripheral Nerve
Greater auricular	0	5	10
Median	5	10	20
Ulnar	0	5	10
Radial	0	0	0
Posterior femoral cutaneous	0	5	10
Sciatic	0	5	10
Tibial (medial popliteal)	0	5	10
Pudendal	0	5	10

Ratings from one Functional Loss table may be combined with ratings from any other table for a different loss of function. Ratings from Functional Loss tables are not to be combined with ratings from Other Impairment tables for the same condition.

No age adjustment permitted for this table

Cranial nerves

Although related anatomically, cranial nerves represent diverse functions which are to be rated elsewhere in most cases. Sometimes no alternative tables exist, and a rating relating to loss of motor or sensory function is given.

Ratings from Table 5.5 can be combined with ratings from other tables relating to neurological function, but not with ratings from Table 5.6 for the same condition. The ratings listed are for complete loss of function. If partial losses exist the ratings are to be reduced proportionately.

Functional Loss Table 5.5
LOSS OF NEUROLOGICAL FUNCTION: CRANIAL NERVES
Cranial Nerve	Function	Assessment to be made by application of:	Complete Unilateral Loss	Complete Bilateral Loss
I	Smell		0	5
II	Vision	Chapter 8
III, IV, VI	Eye movement	Chapter 8
V Trigeminal (sensory)	Ophthalmic
	division		5	10
	Maxillary
	division		5	10
	Mandibular
	division		5	10
	Chewing	Chapter 6
	Speech	Table 5.3
VII	Taste		0	5
	Facial expression		10	20
	Chewing	Chapter 6
	Speech	Table 5.3
VIII	Hearing	Chapter 7
	Balance	Chapters 15 or 16
IX, X, XI, XII	Swallowing	Chapter 6
	Speech	Table 5.3
XI	Shoulder Elevation		5	10

No age adjustment permitted for this table

Step 2: Determine an impairment rating for functional loss from the accepted neurological condition, by applying other applicable chapters of this Guide.

Assessment of conditions of the central and peripheral nervous system may require the application of tables from Chapter 3 (upper and lower limb function), Chapter 6 (eating and swallowing, faecal continence), Chapter 7 (hearing), Chapter 8 (vision), Chapter 9 (urinary continence), and Chapter 10 (sexual function). A neurological rating may involve the combination of multiple ratings, each relating to the loss of a different function. Cerebrovascular accidents, for example, may require ratings for hemiparesis of the upper limb, hemiparesis of the lower limb, hemianopia and dysphasia.

Step 3: Determine a rating for Other Impairment from the accepted neurological condition, by applying Table 5.6 as applicable.

Neurological Other Impairment

Most neurological conditions are associated with a readily identifiable functional deficit. Table 5.6 is to be applied to rate those conditions where such deficit is minimal, and yet a significant neurological condition exists. Many of the conditions referred to in Table 5.6 may result in significant loss of function. Ratings from Table 5.6 and the functional loss table are to be compared, and the higher rating is to be chosen.

Functional Loss Table 5.6
NEUROLOGICAL OTHER IMPAIRMENT
Impairment Ratings	Criteria
NIL	Headaches of any type, infrequent and easily controlled. History of epilepsy no longer necessitating medication.
FIVE	Documented cerebrovascular disease, eg. history of transient ischaemic attacks; cerebrovascular accident with good return of function; pathological narrowing of arteries demonstrated with Doppler studies or angiography (but not calcification shown on plain X-ray). Aneurysms (not surgically corrected). Tics, hemifacial spasm. Epilepsy requiring daily medication.
TEN	Progressively deteriorating neurological disorders associated with significantly reduced life expectancy, eg. multiple sclerosis, Alzheimer’s disease. Tic douloureux occurs intermittently.
TWENTY	Rapidly progressive neurological disorders associated with significantly reduced life expectancy, eg. motor neurone disease. Tic douloureux occurs frequently.
	Ratings from this table and the Functional Loss table are to be compared and the higher rating is to be chosen — see Step 4.

No age adjustment permitted for this table

Chapter 15 (Intermittent Impairment) may be applied to rate cases with more frequent or severe episodes.

Step 4: (Omit this step if no rating was given in Step 3.) Combine the ratings obtained in Steps 1 and 2, by applying Chapter 18 (Combined Values Chart). Compare the resultant rating with the rating obtained in Step 3. Take the higher. This is the final impairment rating for the accepted neurological condition.

CHAPTER 6

GASTROINTESTINAL IMPAIRMENT

This chapter consists of 2 parts:

Part 6.1 — Diseases of the digestive system

Part 6.2 — Abdominal wall hernias and obesity

PART 6.1: DISEASES OF THE DIGESTIVE SYSTEM

Diseases of the digestive system include conditions of the alimentary tract and of the accessory organs of digestion: liver, pancreas and gall bladder.

Loss of function (Tables 6.1.1, 6.1.2 and 6.1.3)

Gastrointestinal impairment is measured by loss of the abilities to ingest food, to maintain nutrition and to excrete the waste products of digestion. Impairment of these functions will be manifested by:

difficulty in chewing and swallowing;
nutritional deficiency and loss of weight; and
faecal incontinence or constipation.

Impairment of each function is to be rated independently of the others. Separate ratings are to be given for each affected function.

If the gastrointestinal loss of function is due to a malignant condition, the step-by-step instructions in Chapter 14 (Malignant Conditions) are to be followed.

If the gastrointestinal loss of function is intermittent in nature or has a significant intermittent component, Chapter 15 (Intermittent Impairment) is to be applied.

If the gastrointestinal loss of function is very severe or causes marked debility, Chapter 16 (Activities of Daily Living) is to be applied.

In particular, severely impaired liver function is to be rated by reference to Chapter 16 (Activities of Daily Living).

Other Impairment (Tables 6.1.4 to 6.1.12)

Tables 6.1.4 to 6.1.12 give specific impairment ratings for various gastrointestinal conditions, based largely on the presence of symptoms. Each of the nine tables refers to a different region or aspect of the gastrointestinal tract or to one of the associated organs of digestion. If, for the same gastro-intestinal condition, ratings can be given both from one of the Functional Loss tables and from a gastrointestinal Other Impairment table, the higher rating is to be chosen.

If multiple accepted conditions contribute to any of the ratings obtained from any of Tables 6.1.1, 6.1.2 or 6.1.3, Chapter 20 (Apportionment) is to be applied as required before making any comparison with a rating from one of the gastrointestinal Other Impairment tables.

Calculation of the impairment rating for gastrointestinal conditions

Follow the steps below to calculate the impairment due to accepted gastrointestinal conditions.

(Each step is elaborated in the following pages.)

STEP 1	Determine one or more ratings for loss of gastrointestinal function.	Page 95
STEP 2	Determine any Other Impairment ratings that are applicable.	Page 98
STEP 3	Compare the functional impairment rating with the relevant Other Impairment rating. Take the higher rating.	Page 102

Step 1: Determine one or more ratings for loss of gastrointestinal function.

There are three tables relating to gastrointestinal functional loss:

Table 6.1.1	Loss of gastrointestinal function: ingestion of food
Table 6.1.2	Loss of gastrointestinal function: maintenance of nutrition
Table 6.1.3	Loss of gastrointestinal function: faecal excretion

A gastrointestinal condition may cause a loss of function under more than one of the above tables. In that case a rating is to be selected from each applicable table.

If more than one condition is present, a rating is to be selected from each of the applicable tables. However, only one rating is to be selected from each table irrespective of the number of conditions that contribute to the functional impairment that is being assessed by applying that table.

If a non-accepted condition or non-accepted conditions contribute to the rating selected from a table, Chapter 19 (Partially Contributing Impairment) is to be applied.

Functional Loss Table 6.1.1
LOSS OF GASTROINTESTINAL FUNCTION: INGESTION OF FOOD
Impairment Ratings	Criteria
NIL	Some difficulty in chewing or swallowing, but only minor or occasional restriction of diet and there is no weight loss.
FIVE	Significant difficulty in chewing or swallowing, but diet is not grossly restricted and there is no weight loss.
TEN	Difficulty in chewing or swallowing that limits diet to soft or semi-solid foods. Constant dysphagia requiring dilation two or three times a year.
TWENTY	Diet limited to liquid or to pureed food because of difficulty in chewing or swallowing.
THIRTY	Constant dysphagia necessitating dilation six times or more a year.
	Only one rating is to be selected from this table for any condition or combination of conditions.

No age adjustment permitted for this table

To calculate the percentage loss of weight for the purposes of Table 6.1.2 follow the substeps below.

Substep 1A	Determine the veteran’s weight before the beginning of the gastro-intestinal condition (irrespective of when the condition was first diagnosed or accepted). This is the “premorbid weight”.
Substep 1B	Determine the veteran’s weight at the relevant time in the assessment period.
Substep 1C	If the weight obtained in substep 1B is equal to, or greater than, the premorbid weight, no impairment rating based on involuntary weight loss can be given from Table 6.1.2. If the weight obtained in substep 1B is less than the premorbid weight, express the difference as a percentage of the premorbid weight. The result is the “percentage loss of weight”.
Substep 1D	Determine whether the percentage loss of weight is due to the accepted gastrointestinal condition being assessed. If it is, then the percentage loss of weight may be used in applying Table 6.1.2. If the percentage loss of weight is not due to the accepted gastro-intestinal condition being assessed, then no impairment rating based on involuntary loss of weight can be given from Table 6.1.2.
Substep 1E	If non-accepted conditions contribute to the percentage loss of weight, Chapter 19 (Partially Contributing Impairment) is to be applied.

Functional Loss Table 6.1.2
LOSS OF GASTROINTESTINAL FUNCTION: MAINTENANCE OF NUTRITION
Impairment Ratings	Criteria
NIL	Minor or no modification to diet, eg. high fibre diet or necessity to avoid certain foodstuffs.
TWO	Malabsorption well controlled with appropriate replacement therapy.
FIVE	Prescribed exclusion diet or major dietary restrictions, eg. gluten-free diet. Laboratory evidence of malabsorption or nutritional deficiency despite therapy (including dietary restriction), but no signs or symptoms.
TEN	Laboratory evidence of malabsorption together with some signs or symptoms.
TWENTY	Involuntary weight loss of 10% or more with evidence of active disease and minor symptoms only.
THIRTY	Involuntary weight loss of 10% or more with evidence of active disease and associated with local symptoms or mild systemic symptoms.
FORTY	Involuntary weight loss of 20% or more with evidence of active disease. Ileostomy, jejunostomy, oesophagostomy or gastrostomy.
SIXTY	Involuntary weight loss of 20% or more with evidence of active disease and associated with severe, frequent local symptoms and systemic symptoms, eg. fever, malaise, anaemia.
	Only one rating is to be selected from this table for any condition or combination of conditions.

No age adjustment permitted for this table

Functional Loss Table 6.1.3
LOSS OF GASTROINTESTINAL FUNCTION: FAECAL EXCRETION
Impairment Ratings	Criteria
NIL	Intermittent constipation.
TWO	Persistent constipation.
FIVE	Minor faecal incontinence associated with occasional soiling.
TEN	Faecal soiling necessitating frequent changes of underwear, or a precautionary incontinence pad.
TWENTY	Faecal incontinence necessitating use of incontinence pads on most days.
THIRTY	Faecal incontinence necessitating several changes of incontinence pads on most days. Colostomy.
FIFTY	Complete faecal incontinence.
	Only one rating is to be selected from this table.

No age adjustment permitted for this table

Step 2: Determine any Other Impairment ratings that are applicable.

Determine which of the Other Impairment tables apply to the accepted gastrointestinal condition and select the appropriate impairment rating from each.

There are nine gastrointestinal Other Impairment tables:

Table 6.1.4	Oral cavity and oesophagus
Table 6.1.5	Non-ulcer dyspepsia, nausea and vomiting
Table 6.1.6	Peptic ulcers: duodenal or gastric ulcers
Table 6.1.7	Effects of past gastric surgery
Table 6.1.8	Disorders of the large and small bowel
Table 6.1.9	Disorders of the anus and rectum
Table 6.1.10	Liver
Table 6.1.11	Pancreas
Table 6.1.12	Gall bladder

A gastrointestinal condition may attract an Other Impairment rating under more than one of the above tables. In that case a rating is to be selected from each applicable table.

Only one impairment rating is to be selected from each of the gastrointestinal Other Impairment tables for each condition or combination of conditions. If more than one rating from any table is applicable, the higher or highest rating is to be selected.

Other Impairment Table 6.1.4
ORAL CAVITY AND OESOPHAGUS
Impairment Ratings	Criteria
NIL	Oral disorders causing no problems or minimal difficulties in chewing. Asymptomatic hiatus hernia. Halitosis.
TWO	Reflux, mild or occasional symptoms with or without prophylactic treatment.
FIVE	Reflux, with or without oesophagitis: frequent minor symptoms necessitating frequent use of antacids or use of H2 receptor antagonist medication.
TEN	Oesophagitis: active disease with moderate symptoms on most days, despite regular use of H2 receptor antagonist medication.
TWENTY	Oesophagitis, proven endoscopically: active disease with complications, eg. Barrett’s epithelium, blood loss, aspiration or stricture.
	Only one rating is to be selected from this table for any condition or combination of conditions. If more than one rating is applicable, the higher rating is to be selected.

No age adjustment permitted for this table

Other Impairment Table 6.1.5
NON-ULCER DYSPEPSIA, NAUSEA AND VOMITING
Impairment Ratings	Criteria
NIL	Non-ulcer dyspepsia, nausea or vomiting: infrequent and mild.
FIVE	Non-ulcer dyspepsia, nausea or vomiting: mild to moderate, necessitating some medication on most days.
TEN	Non-ulcer dyspepsia, nausea or vomiting: moderate symptoms, necessitating daily full-dose medication.
TWENTY	Non-ulcer dyspepsia or vomiting: severe, not controlled despite medication, and causing weight loss of 10% or more.
	Only one rating is to be selected from this table for any condition or combination of conditions. If more than one rating is applicable, the higher rating is to be selected.

No age adjustment permitted for this table

Other Impairment Table 6.1.6
PEPTIC ULCERS: DUODENAL OR GASTRIC ULCERS
Impairment Ratings	Criteria
NIL	Past history of peptic ulcer: currently inactive and asymptomatic, with or without maintenance treatment.
FIVE	Peptic ulcer: with intermittent symptoms necessitating ongoing maintenance treatment.
TEN	Peptic ulcer: active disease with moderate symptoms on most days, despite regular H2 receptor antagonist or proton pump inhibitor medication.
TWENTY	Peptic ulcer: proven endoscopically: active disease with complications and troublesome daily symptoms, eg. bleeding or outlet obstruction.
	Only one rating is to be selected from this table for any condition or combination of conditions. If more than one rating is applicable, the higher rating is to be selected.

No age adjustment permitted for this table

For a gastric ulcer that has been surgically removed apply Table 6.1.7.

Other Impairment Table 6.1.7
EFFECTS OF PAST GASTRIC SURGERY
Impairment Ratings	Criteria
NIL	Past gastric surgery, currently asymptomatic.
FIVE	Past gastric surgery with intermittent dyspepsia and/or mild dumping syndrome.
TEN	Past gastric surgery with frequent dyspepsia and/or dumping syndrome.
TWENTY	Past gastric surgery with severe dyspepsia and/or dumping syndrome on most days.
	Only one rating is to be selected from this table for any condition or combination of conditions. If more than one rating is applicable, the higher rating is to be selected.

No age adjustment permitted for this table

Severe cases of dumping syndrome may be rated by applying Chapter 15 (Intermittent Impairment).

Other Impairment Table 6.1.8
DISORDERS OF THE LARGE AND SMALL BOWEL
Impairment Ratings	Criteria
NIL	Bowel disorder, eg. irritable bowel, diverticulosis: infrequent and minor symptoms such as constipation, or intermittent diarrhoea and abdominal cramps which respond to dietary treatment.
FIVE	Bowel disorder: frequent moderate symptoms necessitating regular medication.
TEN	Bowel disorder: marked symptoms, such as regular diarrhoea and frequent abdominal pain, partially controlled by full-dose medication.
TWENTY	Bowel disorder: diarrhoea and abdominal pain on most days, with no response to medication and considerable interference with daily routine.
	Only one rating is to be selected from this table for any condition or combination of conditions. If more than one rating is applicable, the higher rating is to be selected.

No age adjustment permitted for this table

Other Impairment Table 6.1.9
DISORDERS OF THE ANUS AND RECTUM
Impairment Ratings	Criteria
NIL	Anal disorder: infrequent and minor symptoms, eg. haemorrhoids, anal fissures, controlled by medication. Mild to moderate pruritus ani.
FIVE	Anal disorder: moderate symptoms on most days, necessitating regular medication for control. Marked pruritus ani, with daily symptoms and evidence of excoriation.
TEN	Anal disorder: marked to severe symptoms despite regular treatment.
	Only one rating is to be selected from this table for any condition or combination of conditions. If more than one rating is applicable, the higher rating is to be selected.

No age adjustment permitted for this table

Other Impairment Table 6.1.10
LIVER
Impairment Ratings	Criteria
NIL	Abnormality of liver function tests, but otherwise asymptomatic. Acute hepatitis (resolved).
TWO	Chronic persistent hepatitis.
FIVE	Signs of chronic liver disease, but no evidence of portal hypertension.
TEN	Chronic liver disease with evidence of portal hypertension. Chronic active hepatitis.
TWENTY	Chronic liver disease with history of variceal bleeding or encephalopathy.
	Only one rating is to be selected from this table for any condition or combination of conditions. If more than one rating is applicable, the higher rating is to be selected.

No age adjustment permitted for this table

Other Impairment Table 6.1.11
PANCREAS
Impairment Ratings	Criteria
NIL	Pancreatic disease, with no symptoms.
TWO	Pancreatic disease, with mild infrequent symptoms.
TEN	Chronic pancreatitis with ongoing intermittent attacks of abdominal pain and/or steatorrhoea.
TWENTY	Chronic pancreatitis with frequent attacks of abdominal pain and steatorrhoea, or two or more admissions to hospital within the past year.

No age adjustment permitted for this table

More frequent exacerbations of pancreatic disease can be rated by applying Chapter 15 (Intermittent Impairment).

Other Impairment Table 6.1.12
GALL-BLADDER
Impairment Ratings	Criteria
NIL	Gall-bladder disease with no symptoms. Cholecystectomy currently asymptomatic.
TWO	Gall-bladder disease with mild infrequent symptoms.
FIVE	Post-cholecystectomy syndrome. Two or more attacks of gall-bladder disease necessitating hospital admission within the past year.
	Only one rating is to be selected from this table for any condition or combination of conditions. If more than one rating is applicable, the higher rating is to be selected.

No age adjustment permitted for this table

More frequent exacerbations of gall bladder disease can be rated by applying Chapter 15 (Intermittent Impairment).

Step 3: Compare the functional impairment rating with the relevant Other Impairment rating. Take the higher rating.

This step determines the final impairment rating for the gastrointestinal condition. Select one of the following substeps depending on the circumstances:

Substep 3A	If, for any condition, only one rating has been obtained in Step 1 and only one rating has been obtained in Step 2, compare the ratings. Take the higher rating. This is the final rating for that gastrointestinal condition.
Substep 3B	If, for any condition, only one rating has been obtained in Step 1 but more than one rating has been obtained in Step 2, combine the ratings for that condition obtained in Step 2 using Chapter 18 (Combined Values Chart). Compare the rating for that condition obtained in Step 1 with the combined value of the ratings for that condition obtained in Step 2. Take the higher rating. This is the final rating for that gastrointestinal condition. For the purpose of the final combining of all values, if the higher value is made up of a combination of ratings, then the component ratings are to be used.
Substep 3C	If, for any condition, more than one rating has been obtained in Step 1 but only one rating has been obtained in Step 2, combine the ratings for that condition obtained in Step 1 by applying Chapter 18 (Combined Values Chart). Compare the combined value of the ratings for that condition obtained in Step 1 with the rating obtained in Step 2. Take the higher rating. This is the final rating for that gastrointestinal condition. For the purpose of the final combining of all values, if the higher value is made up of a combination of ratings, then the component ratings are to be used.
Substep 3D	If, for any condition, more than one rating has been obtained in Step 1 and more than one rating has been obtained in Step 2, combine the ratings for that condition obtained in Step 1 by applying Chapter 18 (Combined Values Chart) and separately combine the ratings for that condition obtained in Step 2 by applying Chapter 18 (Combined Values Chart). Compare the combined value of the ratings for that condition obtained in Step 1 with the combined value of the ratings for that condition obtained in Step 2. Take the higher rating. This is the final rating for that gastrointestinal condition. For the purpose of the final combining of all values, if the higher value is made up of a combination of ratings, then the component ratings are to be applied.

PART 6.2: ABDOMINAL WALL HERNIAS AND OBESITY

Impairment ratings obtained from Tables 6.2.1 and 6.2.2 are not to be compared with any other tables but are to be included in the final combining of all ratings.

Functional Loss Table 6.2.1
ABDOMINAL WALL HERNIAS
Impairment Ratings	Criteria
NIL	Inguinal or ventral hernia surgically repaired.
TWO	Inguinal or ventral hernia easily reducible.
FIVE	Inguinal or ventral hernia not easily reduced and resulting in mild symptoms.
TEN	Large inguinal or ventral hernia resulting in frequent symptoms.
	An impairment rating is to be selected from this table for each accepted inguinal and ventral hernia.

No age adjustment permitted for this table

Functional Loss Table 6.2.2
OBESITY
Impairment Ratings	Criteria
NIL	Body mass index equal to or below 30.
FIVE	Body mass index above 30.

No age adjustment permitted for this table

Body mass index is given by the formula:

Body mass index

(weight in kg)

(height in m)2

Table 6.2.2 is to be applied only if obesity is an accepted condition or if obesity is an integral feature of an accepted condition.

INTRODUCTION

Somatic effects

Substance abuse

INTRODUCTION

Loss of function tables (Tables 5.1–5.5)

Other Impairment table (Table 5.6)

STEP 1

Cognitive function

Communication

Comprehension

Expression

Sensory function

Cranial nerves

Neurological Other Impairment

Part 6.2 — Abdominal wall hernias and obesity

Loss of function (Tables 6.1.1, 6.1.2 and 6.1.3)

Other Impairment (Tables 6.1.4 to 6.1.12)

STEP 1