MENTAL IMPAIRMENTSMENTAL IMPAIRMENTS

DOCUMENTATION & DOCUMENTATION & LISTINGSLISTINGS

“ “In most situations, the clinical diagnoses of a DSM-In most situations, the clinical diagnoses of a DSM-IV mental disorder are not sufficient to establish the IV mental disorder are not sufficient to establish the existence, for legal purposes, of a ‘mental disorder,’ existence, for legal purposes, of a ‘mental disorder,’

or ‘mental disability, ’‘mental disease’ or ‘mental or ‘mental disability, ’‘mental disease’ or ‘mental defect.’ It is precisely because impairments, abilities defect.’ It is precisely because impairments, abilities and disabilities vary widely within each diagnostic and disabilities vary widely within each diagnostic category that assignment of a particular diagnosis category that assignment of a particular diagnosis

does not imply a specific level of impairment or does not imply a specific level of impairment or disability.” (Reference: Diagnostic and Statistical disability.” (Reference: Diagnostic and Statistical Manual of Mental Disorders, Ed. Text revision p. Manual of Mental Disorders, Ed. Text revision p.

xxxii-xxxiii.)xxxii-xxxiii.)

12.00C ASSESSMENT OF 12.00C ASSESSMENT OF SEVERITYSEVERITY

• Severity is measured according to the functional limitations imposed by the MDI.

• 4 criteria – this is known as the “B” criteria– 1. ADL– 2. social functioning– 3. concentration, pace, persistence– 4. episodes of decompensation

A marked limitation arises when several activities or functions are impaired or even when only one is impaired, so long as the degree of limitation is such as to seriously interfere with the ability to function independently, appropriately, & effectively.

ADLsADLs• Quality of ADLs may be assessed by evaluating

adaptive activities by independence, appropriateness, & effectiveness.

• Necessary to define the extent to which the individual is capable of initiating & participating in activities independent of supervision or direction.

• A marked limitation is based on the overall degree of restriction or combo of restrictions.

– Examples: chores, public transporation, paying bills, grooming/hygiene, etc

SOCIAL FUNCTIONINGSOCIAL FUNCTIONING

• Quality of social functioning may be assessed by evaluating the individual’s capacity to interact appropriately & communicate effectively w/ others.– Example: ability to get along w/ others, including friends, family

members, authority figures

• A marked limitation is based on the overall degree of interference in a particular area of combo of areas of functioning.

CONC/PACE/PERSISTENCECONC/PACE/PERSISTENCE• Quality of c/p/p is assessed by the ability to sustain

focused attention & concentration sufficiently long to permit the timely & appropriate completion of tasks commonly found in work settings.

• This can often be assessed through psychiatric examination, psychological testing, & work evaluations/workshops.

– MSE: serial 7s, serial 3s– Psychological testing: Trails A&B– Work evaluation: in either real or simulated work tasks

• A marked limitation is based on the nature & overall degree of interference w/ function. An individual may be able to sustain attention & persist at simple tasks but may have difficulty w/ complicated tasks.

EPISODES OF EPISODES OF DECOMPENSATIONDECOMPENSATION

• Episodes of decompensation are exacerbations or temporary increases in sx or signs accompanied by a loss of adaptive functioning, as manifested by difficulties in performing ADLs, maintaining social relationships, or maintaining conc/pace/persistence.

• Episodes of decompensation may be demonstrated by an exacerbation in sx or signs that would ordinarily require increased treatment or a less stressful situation (or a combination of the two).

• Episodes of decompensation may be inferred from medical records showing significant alteration in medication; or documentation of the need for a more structured psychological support system (e.g., hospitalizations, placement in a halfway house, or a highly structured and directing household); or other relevant information in the record about the existence, severity, and duration of the episode.

REPEATED EPISODES…REPEATED EPISODES…

OF DECOMPENSATION, EACH OF EXTENDED DURATION– Three episodes w/in 1 year, or an average of once

every 4 months, each lasting for at least 2 weeks.– However, if more frequent episodes of shorter

duration or less frequent episodes of longer duration, judgment is used to determine if the duration and functional effects of the episodes are of equal severity and may be used to substitute for the listed finding in a determination of equivalence.

SOURCES OF FUNCTIONAL INFOSOURCES OF FUNCTIONAL INFO

• The treating physician (TP) is usually the best source of functional info however MER may not have the detailed functional info necessary to document the case.

• Info can also be obtained from “other sources” (ie social worker, therapist, job coaches, etc).

• Info is also obtained from the clmt & 3rd pty– Just be aware that the info rec’d fits the general

pattern of the illness as it has been described to the clinical sources so there is a clear picture of what the claimant can actually do.

EFFECTS OF STRUCTURED EFFECTS OF STRUCTURED SETTINGS, MEDS, TREATMENTSETTINGS, MEDS, TREATMENT

• STRUCTURED SETTINGS – may control or attenuate overt symptomatology. Consider the claimant’s ability to function outside of the structured setting.

• MEDICATION – some treatment may not affect all functional limitations. Attention must be focused on the functional limitations that persist. Consider side effects.

• TREATMENT – may or may not assist in the achievement of an adequate level of adaptation in the workplace.

GO OVER THE LISTINGSGO OVER THE LISTINGS