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Disability Eval. under Social Security PT 1
These are the rules SSDI uses to evaluate disabilities. This is the Listings of Impairments referred to in: What Parkinsonians Should Know About Social Security Disability Insurance.
Part 1 covers the basic rules and Neurological disorders. Part 2 covers Mental disorders.
PART II EVIDENTIARY REQUIREMENTS Medical Evidence
Under both the title II and title XVI programs, medical evidence is the cornerstone for the determination of disability.
Each person who files a disability claim is responsible for providing medical evidence showing that he or she has an Impairment(s) and how severe the impairment(s) is. However, SSA will help claimants get medical reports from their own medical sources when the claimants gives SSA permission to do so. This medical evidence generally comes from sources who have treated or evaluated the claimant for his or her impairment(s).
Acceptable Medical Sources
Documentation of the existence of a claimant's impairment must come from medical professionals defined by SSA's regulation as "acceptable medical sources." Once the existence of an impairment is established, all the medical and nonmedical evidence is considered in assessing impairment severity.
"Acceptable medical sources" generally include licensed physicians (including licensed osteopaths), licensed or certified psychologists, and licensed optometrists (for measurement of visual acuity and visual fields). Social Security also requests copies of medical evidence from hospitals, clinics, or other health facilities where a claimant has been treated. All medical reports received are considered during the disability determination process.
Medical Evidence From Treating Sources
Currently. many disability claims are decided on the basis of medical evidence from treating sources. SSA regulations place special emphasis on evidence from treating sources because they are likely to be the medical professionals most able to provide a detailed, longitudinal picture of the claimant's impairments and may bring a unique perspective to the medical evidence that cannot be obtained from the medical findings alone or from reports of individual examinations or brief hospitalizations. Therefore, timely, accurate, and adequate medical reports from treating sources accelerate the processing of the claim because they can greatly reduce or eliminate the need for additional medical evidence to complete the claim.
Other Evidence
Information from other sources may also help show the extent to which a person's impairment(s) affects his or her ability to function. Other sources include public and private social welfare agencies, non-medical sources such as teachers, day care providers, social workers and employers, and other practitioners such as naturopaths, chiropractors, audiologists, and speech and language pathologists.
Medical Reports
Physicians, psychologists, and other health professionals are frequently asked by SSA to submit reports about an individual's impairment. Therefore, it is important to know what evidence SSA needs. Medical reports should include:
* medical history; * clinical findings (such as the results of physical or mental status examinations); * laboratory findings (such as blood pressure, x-rays); * diagnosis; * treatment prescribed with response and prognosis; * a statement providing an opinion about what the claimant can still do despite his or her impairment(s), based on the medical source's on the above factors. This statement should describe, but is not limited to the individual's ability to perform work-related activities, such as sitting, standing, walking, lifting, carrying, handling objects, hearing ,speaking and traveling. In cases involving mental impairments, it should describe the individual's ability to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and work pressures in a work setting. For a child, the statement should describe the child's ability to function independently, appropriately, and effectively in an age-appropriate manner in the domains and behaviors appropriate for the child's age.
Consultative Examinations
If the evidence provided by the claimant's own medical sources is inadequate to determine if he or she is disabled, additional medical information may be sought by recontacting the treating source for additional information or clarification by arranging for a CE. The treating source is the preferred source for a CE if he or she is qualified, equipped, and willing to perform the examination for the authorized fee. Even if only a supplemental test is required, the treating source is ordinarily the preferred source for this service. However, SSA's rules provide for using an independent source (other than the treating source) for a diagnostic study if:
* the treating source prefers not to perform these examination; * the treating source does not have the equipment to provide the specific data needed; * there are conflicts or inconsistencies in the file that cannot be resolved by going back to the treating source; * the claimant prefers another source and has a good reason for doing so; * prior experience indicates that the treating source may not be a productive source.
Consultative Examination Report Content
A complete CE is one which involves all the elements of a standard examination in the applicable medical specialty. When the report of a complete consultative examination is involved, the report should include the following elements:
* the claimant's major or chief complaint(s); * a detailed description, within the area of specialty of the examination, of the history of the major complaint(s); * a description, and disposition, of pertinent "positive" and "negative" detailed findings based on the history, examination, and laboratory tests related to the major complaint(s), and any other abnormalities or lack thereof reported or found during examination or laboratory testing; * the results of laboratory and other tests (e.g., X-ray s) performed according to the requirements stated in the Listing of Impairments (see Part III); * the diagnosis and prognosis for the claimant's impairment(s); * a statement about what the claimant can still do despite his or her impairment(s), unless the claim is based on statutory blindness. This statement should describe the opinion of the consulting physician or psychologist about the claimant's ability, despite his or her impairment(s), to do work-related activities such as sitting, standing, walking, lifting carrying, handling objects, hearing, speaking, and traveling; and, in cases of mental impairment(s), the opinion of the physician or psychologist about the individual's ability to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and work pressures in a work setting; and * the consultative physician or psychologist will consider, and provide some explanation or comment on, the claimant's major complaint(s) and any other abnormalities found during the history and examination or reported from the laboratory tests. The history, examination, evaluation or laboratory test results, and the conclusions will represent the information provided by the physician or psychologist who signs the report.
Evidence Relating to Symptoms
In developing evidence of the effects of symptoms, such as pain, shortness of breath, or fatigue, on a claimant's ability to function, SSA investigates all avenues presented that relate to the complaints. These include information provided by treating and other sources regarding:
* the claimant's dally activities; * the location, duration, frequency, and intensity of the pain or other symptom; * precipitating and aggravating factors; * the type, dosage, effectiveness, and side effects of any medication; * treatments, other than medications, for the relief of pain or other symptoms; * any measures the claimant uses or has used to relieve pain or other symptoms; and * other factors concerning the claimant's functional limitations due to pain or other symptoms.
In assessing the claimant's pain or other symptoms, the decisionmaker(s) must give full consideration to all of the above-mentioned factors. It is important that medical sources address these factors in the reports they provide.
PART III LISTING OF IMPAIRMENTS
The Listing of Impairments describes, for each major body system, impairments which are considered severe enough to prevent a person from doing any gainful activity, (or in the case of children under age 18 applying for SSI, are comparable in severity to an impairment that would preclude an adult from engaging in any gainful activity). Most of the listed impairments are or expected to result in death, or a specific statement of duration is made. For all others, the evidence must show that the impairment has lasted or is expected to last for a continuous period of at least 12 months. The criteria in Listing of Impairments are applicable to evaluation of claims for disability benefits or payments under both the Social Security disability insurance and SSI.
Part A of the Listing of Impairments contains medical criteria that apply to adults age 18 and over. The medical criteria in part A may also be applied in evaluating impairments in persons under age 18 if the disease processes have similar effect on adults and younger persons.
Part B contains additional medical criteria that apply only to the evaluation of impairments of persons under age 18. Certain criteria in part A do not give appropriate consideration to the particular effects of the disease processes in childhood, i.e., when the disease process is generally found only in children or when the disease process differs in its effect on children and adults. Additional criteria are included in part B, and the impairment categories are, to the extent possible, numbered to maintain a relationship with their counterparts in part A. In evaluating disability for a person under age 18, part B will be used first. If the medical criteria in part B do not apply, then the medical criteria in part A will he used.
The criteria in the Listing of Impairments apply only to one step of the multi-step sequential evaluation process. At that step, the presence of an impairment that meets the criteria in the Listing of Impairments (or that is of equal severity) is usually sufficient to establish that an individual who is not working is disabled. However, the absence of a listing-level impairment does not mean the individual is not disabled. Rather, It merely requires the adjudicator to move on to the next step of the process and apply other rules in order to resolve the issue of disability.
11.01 Category Of Impairments, Neurological
11.02 Epilepsy - major motor seizures (grand mal or psychomotor), documented by EEG and by detailed description of a typical seizure pattern, including all associated phenomena; occurring more frequently than once a month, in spite of at least 3 months of prescribed treatment. With:
A. Daytime episodes (loss of Consciousness and convulsive seizures) or B. Nocturnal episodes manifesting residuals which interfere significantly with activity during the day.
11.03 Epilepsy - Minor motor seizures (petit mal or psychomotor), documented by EEG and by detailed description of a typical seizure pattern including all associated phenomena; occurring more frequently than once weekly in spite of at least 3 months of prescribed treatment. With alteration of awareness or loss of consciousness and transient postictal manifestations of unconventional behavior or significant interference with activity during the day.
11.04 Central nervous system vascular accident. With one of the following more than 3 months post-vascular accident:
A. Sensory or motor aphasia resulting in ineffective speech or communication; or B. Significant and persistent disorganization of motor function in two extremities, resulting in sustained disturbance of gross and dexterous movements, or gait and station (see 11.00C).
11.05 Brain tumors
A. Malignant gliomas (astrocytoma - grades III and IV, glioblastoma muitiforme), medulloblastoma, ependymoblastoma, or primary sarcoma; or B. Astrocytoma (grades I and II), meningioma, pituitary tumors, oligodendroglioma, ependymoma, clivus chordoma, and benign tumors, Evaluate under 11.02, 11.03, 11.04A, or B, or 12.02.
11.06 Parkinsonian syndrome. With the following signs: Significant rigidity, bradykinesia, or tremor in two extremities, which, singly or in combination, result in sustained disturbance of gross and dexterous movements, or gait and station.
11.07 Cerebral palsy. With:
A. IQ of 70 or less; or B. Abnormal behavior patterns, such as destructiveness or emotional instability; or C. Significant interference in communication due to speech, hearing, or visual defect; or D. Disorganization of motor function as described in 11.04B.
11.08 Spinal cord or nerve root lesions, due to any cause with disorganization of motor function as described in 11.04B.
11.09 Multiple sclerosis. With:
A. Disorganization of motor function as described in 11.04B; or B. Visual or mental impairment as described under the criteria in 2.02, 2.03, 2.04, or 12.02; or C. Significant, reproducible fatigue of motor function with substantial muscle weakness on repetitive activity, demonstrated on physical examination, resulting from neurological dysfunction in areas of the central nervous system known to be pathologically involved by the multiple sclerosis process.
11.10 Amyotrophic lateral sclerosis. With:
A. Significant bulbar signs: or B. Disorganization of motor function as described in 1l.04B.
11.11 Anterior poliomyelitis. With:
A. Persistent difficulty with swallowing or breathing; or B. Unintelligible speech; or C. Disorganization of motor function as described in 11.04B.
11.12 Myasthenia gravis. With:
A. Significant difficulty with speaking, swallowing, or breathing while on prescribed therapy; or B. Significant motor weakness of muscles of extremities on repetitive activity against resistance while on prescribed therapy.
11.13 Muscular dystrophy with disorganization of motor function as described in 11.04B.
11.14 Peripheral neuropathies. With disorganization of motor function as described in 11.04B, in spite of prescribed treatment.
11.15 Tabes dorsalis. With:
A. Tabetic crises occurring more frequently than once monthly; or B. Unsteady, broad-based or ataxic gait causing significant restriction of mobility substantiated by appropriate posterior column signs.
11.16 Subacute combined cord degeneration (pernicious anemia) with disorganization of motor function as described in 11.04B or 11.15B, not significantly improved by prescribed treatment.
11.17 Degenerative disease not listed elsewhere, such as Huntington's chorea, Friedreich's ataxia, and spino-cerebellar degeneration. With:
A. Disorganization of motor function as described in 11.04B or 11.15B; B. Chronic brain syndrome. Evaluate under 12.02.
11.18 Cerebral trauma:
Evaluate under the provisions of 11.02,11.03,11.04, and 12.02, as applicable.
11.19 Syringomyelia. With:
A. Significant bulbar signs; or B. Disorganization of motor function as described in 11.04B.
Disability Eval. under Social Security PT 2
These are the rules SSDI uses to evaluate disabilities. This is the Listings of Impairments referred to in: What Parkinsonians Should Know About Social Security Disability Insurance.
Part 1 covers the basic rules and Neurological disorders. Part 2 covers Mental disorders. 12.00 Mental Disorders
A. Introduction: The evaluation of disability on the basis of mental disorders requires the documentation of a medically determinable impairment(s) as well as consideration of the degree of limitation such impairment(s) may impose on the individual's ability to work and whether these limitations have lasted or are expected to last for a continuous period of at least 12 months. The listings for mental disorders are arranged in eight diagnostic categories: organic mental disorders (12.02); schizophrenic, paranoid and other psychotic disorders (12.03); affective disorders (12.04); mental retardation and autism (12.05 anxiety related disorders (12.06); somatoform disorders (12.07); personality disorders (12.08); and substance addiction disorders (12.09). Each diagnostic group except listings 12.05 and 12.09, consists of a set of clinical findings (paragraph A criteria), one or more of which must be met, and which, if met lead to a test of functional restrictions (paragraph B criteria), two or three of which must also be met. There are additional considerations (paragraph C criteria) in listings 12.03 and 12.06, discussed therein.
The purpose of including the criteria in paragraph A of the listings for mental disorders is to medically substantiate the presence of a mental disorder. Specific signs and symptoms under any of the listings 12.02 through 12.09 cannot he considered in isolation from the description of the mental disorder contained at the beginning of each listing category. Impairments should be analyzed or reviewed under the mental category(ies) which is supported by the individual's clinical findings.
The purpose of including the criteria in paragraphs B and C of the listings for mental disorders is to describe those functional limitations associated with mental disorders which are incompatible with the ability to work. The restrictions listed in paragraphs B and C must be the results of the mental disorder which is manifested by the clinical findings outlined in paragraph A. The criteria included in paragraphs B and C of the listings for mental disorders have been chosen because they represent functional areas deemed essential to work. An individual who is severely limited in these areas as the result of an impairment identified in paragraph A is presumed to be unable to work.
The structure of the listing for substance addiction disorders, listing 12.09, is different from that for the other mental disorder listings. Listing 12.09 is structured as a reference listing; that is, it will only serve to indicate which of the other listed mental or physical impairments must be used to evaluate the behavioral or physical changes resulting from regular use of addictive substances.
The listings for mental disorders are so constructed that an individual meeting or equaling the criteria could not reasonably be expected to engage in gainful work activity.
Individuals who have an impairment with a level of severity which does meet the criteria of the listings for mental disorders may or may not have the residual functional capacity (RFC) which would enable them to engage substantial gainful work activity. The determination of mental RFC is crucial to the evaluation of an individual's capacity to engage in substantial gainful work activity when the criteria of the listings for mental disorders are not met or equaled but the impairment is nevertheless severe.
RFC may be defined as a multidimensional description of the work-related abilities which an individual retains in spite of medical impairments. RFC complements the criteria in paragraphs A and C of the listings for mental disorders by requiring consideration of an expanded list of work-related capacities which may be impaired by mental disorder when the impairment is severe but does not meet or equal a listed mental disorder.
B. Need for Medical Evidence: The existence of a medically determinable impairment of the required duration must be established by medical evidence consisting of clinical signs, symptoms and/or laboratory or psychological test findings. These findings may be intermittent or persistent depending on the nature of the disorder. Clinical signs are medically demonstrable phenomena which reflect specific abnormalities of behavior, affect, thought, memory, orientation, or contact with reality. These signs are typically assessed by a psychiatrist or psychologist and/or documented by psychological tests. Symptoms are complaints presented by the individual. Signs and symptoms generally cluster together to constitute recognizable clinical syndromes (mental disorders). Both symptoms and signs which are part of the diagnosed mental disorder must be considered in evaluating severity.
C. Assessment of Severity: For mental disorders, severity is assessed in terms of the functional limitations imposed by the impairment. Functional limitations are assessed using the criteria in paragraph B or the listings for mental disorders (descriptions of restrictions of activities of daily living; social functioning; concentration, persistence, or pace: and ability to tolerate increased mental demands associated with competitive work). Where "marked" is used as a standard for measuring the degree of limitation, it means more than moderate but less than extreme. A marked limitation may arise 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 and effectively. Four areas are considered.
1. Activities of daily living include adaptive activities such as cleaning, shopping, cooking, taking public transportation, paying bills, maintaining a residence, caring appropriately for one's grooming and hygiene, using telephones and directories, using a post office, etc. In the context of the individual's overall situation, the quality of these activities is judged by their independence, appropriateness and effectiveness. It is necessary to define the extent to which the individual is capable of initiating and participating in activities independent of supervision or direction.
"Marked" is not the number of activities which are restricted but the overall degree of restriction or combination of restrictions which must be judged. For example, a person who is able to cook and clean might still have marked restrictions of daily activities if the person were too fearful to leave the immediate environment of home and neighborhood, hampering the persons ability to obtain treatment or to travel away from the immediate living environment.
2. Social functioning refers to an individual's capacity to interact appropriately and communicate effectively with other individuals. Social functioning includes the ability to get along with others, e.g., family members, friends, neighbors, grocery clerks, landlords, bus drivers, etc. Impaired social functioning may be demonstrated by a history of altercations, evictions, firings, fear of strangers, avoidance of interpersonal relationships, social isolation, etc. Strength in social functioning may be documented by an individual's ability to initiate social contacts with others, communicate clearly with others, interact and actively participate in group activities, etc. Cooperative behaviors, consideration for others, awareness of others' feelings, and social maturity also need to be considered. Social functioning in work situations may involve interactions with the public, responding appropriately to persons in authority, e.g., supervisors, or cooperative behaviors involving coworkers.
"Marked" is not the number of areas in which social functioning is impaired but the overall degree of interference in a particular area or combination of areas of functioning. For example, a person who is highly antagonistic, uncooperative, hostile but is tolerated by local storekeepers may nevertheless have marked restrictions in social functioning because that behavior is not acceptable in social contexts.
3. Concentration, persistence and pace refer to the ability to sustain focused attention sufficiently long to permit the timely completion of tasks commonly found is work settings. In activities of daily living, concentration may be reflected in terms of ability to complete tasks in everyday household routines. Deficiencies in concentration, persistence and pace are best observed in work and work-like settings. Major impairment in this area can often be assessed through direct psychiatric examination and for psychological testing, although mental status examination or psychological test data alone should not be used to accurately describe concentration and sustained ability to adequately perform work-like tasks. On mental status examinations, concentration is assessed by tasks such as having the individual subtract serial sevens from 100. In psychological tests of intelligence or memory, concentration is assessed through tasks that must be completed within established time limits. In work evaluation, concentration, persistence, and pace are assessed through such tasks as filing index cards, locating telephone numbers, or disassembling and reassembling objects. Strengths and weaknesses in areas of concentration can be discussed in terms of frequency of errors, time it takes to complete the task, and extent to which assistance is required to complete the task.
4. Deterioration or decompensation in work or work-like settings refers to repeated failure to adapt to stressful circumstances which cause the individual either to withdraw from that situation or to experience exacerbation of signs and symptoms (i.e., decompensation) with an accompanying difficulty in maintaining activities of daily living. social relationships, and/or maintaining concentration, persistence, or pace (i.e., deterioration which may include deterioration of adaptive behaviors). Stresses common to the work environment include decisions, attendance. schedules, completing tasks, interacting with supervisors, interactions with peers, etc.
D. Documentation: The presence of a mental disorder should he documented primarily on the basis of reports from individual providers, such as psychiatrists and psychologists, and facilities such as hospitals and clinics. Adequate descriptions of functional limitations must he obtained from these or other sources which may include programs and facilities where the individual has been observed over a considerable period of time.
Information from both medical and nonmedical sources may be used to obtain detailed descriptions of the individual's activities of daily living; social functioning; concentration, persistence, and pace; or ability to tolerate increased mental demands (stress). This information can be provided by programs such as community mental health centers, day care centers, sheltered workshops, etc. It can also be provided by others including family members, who have knowledge of the individual's functioning. In some cases descriptions of activities of daily living or social functioning given by individuals or treating sources may be insufficiently detailed and/or may be in conflict with the clinical picture otherwise observed or described in the examinations or reports. It is necessary to resolve any inconsistencies or gaps that may exist in order to obtain a proper understanding of the individual's functional restrictions.
An individual's level of functioning may vary considerably over time. The level of functioning at a specific time may seem relatively adequate or, conversely, rather poor. Proper evaluation of the impairment must take any variations in level of functioning into account in arriving at a determination of impairment severity over time. Thus, it is vital to obtain evidence from relevant sources over a sufficiently long period prior to the date of adjudication in order to establish the individual's impairment severity. This evidence should include treatment notes, hospital discharge summaries, and work evaluation or rehabilitation progress notes if these are available.
Some individuals may have attempted to work or may actually have worked during the period of time pertinent to the determination of disability. This may have been an independent attempt at work, or it may have been in conjunction with a community mental health or other sheltered program which may have been of either short or long duration. Information concerning the individual's behavior during any attempt to work and the circumstances surrounding termination of the work effort are particularly useful in determining individual's ability or inability to function in a work setting.
The results of well-standardized psychological tests such as the Wechsler Adult Intelligence Scale (WAIS), the Minnesota Multiphasic Personality Inventory (MMPI), the Rorschach, and the Thematic Apperception Test (TAT), may be useful in establishing the existence of a mental disorder. For example, the WAIS is useful in establishing mental retardation, and the MMPI, Rorschach, and TAT may provide data supporting several other diagnoses. Broad-based neuropsychological assessments using, for example, the Halstead-Reitan or the Luria-Nebraska batteries may be useful in determining brain function
deficiencies, particularly in cases involving subtle findings such as may be seen in traumatic brain injury. In addition, the process of taking a standardized test requires concentration, persistence, and pace; performance on such tests may provide useful data. Test results should, therefore, include both the objective data and a narrative description of clinical findings. Narrative reports of intellectual assessment should include a discussion of whether or not obtained IQ scores are considered valid and consistent with the individual's developmental history and degree of functional restriction.
In cases involving impaired intellectual functioning, a standardized intelligence test, e.g., the WAIS, should be administered and interpreted by a psychologist, or psychiatrist qualified by training and experience to perform such an evaluation. In special circumstances, nonverbal measures, such as the Raven Progressive Matrices, the Lieter international scale, or the Arthur adaption of the Lieter may be substituted.
Identical IQ scores obtained from different tests do not always reflect a similar degree of intellectual functioning. In this connection, it must be noted that on the WAIS, for example, IQs of 70 and below are characteristic of approximately the lowest 2 percent of the general population. In instances where other administered, it would be necessary to convert the IQ to the corresponding percentile rank in the general population in order to determine the actual degree of impairment reflected by those IQ scores.
In cases where more than one IQ is customarily derived from the test administered, i.e., where verbal, performance, and full-scale IQs are provided as on the WAIS, the lowest of these is used in conjunction with listing 12.05.
In cases where the nature of the individual's intellectual impairment test as described above, are precluded, medical reports specifically describing the level of intellectual, social, and physical function should be obtained. Actual observations by Social Security administration or State agency personnel, reports from educational institutions and information furnished by public welfare agencies or other reliable objective sources should be considered as additional evidence.
E. Chronic Mental Impairments: Particular problems are often involved in evaluating mental impairments in individuals who have long histories of repeated hospitalizations or prolonged outpatient care with supportive therapy and medication. Individuals with chronic psychotic disorders commonly have their lives structured in such a way as to minimize stress and reduce their signs and symptoms. Such individuals may be much more impaired for work than their signs and symptoms would indicate. The results of a single examination may not adequately describe these individuals' sustained ability to function. It is, therefore, vital to review all pertinent information relative to the individual's condition, especially at times of increased stress. It is mandatory to attempt to obtain adequate descriptive information from all sources which have treated the individual either currently or in the time period relevant to the decision.
F. Effects of Structured Settings: Particularly in cases involving chronic mental disorders, overt symptomatology may be controlled or attenuated by psychosocial factors such as placement in a hospital, board and care facility, or other environment that provides similar structure. Highly structured and supportive settings may greatly reduce the mental demands placed on an individual. With lowered mental demands, overt signs and symptoms of the underlying mental disorder may be minimized. At the same time, however, the individual's ability to function outside of such a structured and/or supportive setting may not have changed. An evaluation of individuals whose symptomatology is controlled or attenuated by psychosocial factors must consider the ability of the individual to function outside of such highly structured settings. (For these reasons the paragraph C criteria were added to Listings 12.03 and 12.06.)
G. Effects of Medication: Attention must be given to the effect of medication on the individual's signs, symptoms and ability to function. While psychotropic medications may control certain primary manifestations of a mental disorder, e.g., hallucinations, such treatment may or may not affect the functional limitations imposed by the mental disorder. In cases where overt symptomatology is attenuated by the psychotropic medications, particular attention must be focused on the functional restrictions which may persist. These functional restrictions are also to be used as the measure of impairment severity. (see the paragraph C criteria in Listings 12.03 and 12.06.)
Neuroleptics, the medicines used in the treatment of some mental illnesses, may cause drowsiness, blunted effect or other side effects involving other body systems. Such side effects must be considered in evaluating overall impairment severity. Where adverse effects of medications contribute to the impairment severity and the impairment does not meet or equal the listings but is nonetheless severe, such adverse effects must be considered in the assessment of the mental residual functional capacity.
H. Effect of Treatment: It must be remembered that with adequate treatment some individuals suffering with chronic mental disorders not only have their symptoms and signs ameliorated but also return to a level of function close to that of their premorbid status. Our discussion here in 12.00H has been designed to reflect the fact that present day treatment of a mentally impaired individual may or may not assist in the achievement of an adequate level of adaption required in the work place. (See the paragraph C criteria in Listings 12.03 and 12.06.)
I. Technique for Reviewing the Evidence in Mental Disorders Claims to Determine Level of impairment Severity. A special technique has been developed to ensure that all evidence needed for the evaluation of impairment severity in claims involving mental impairment is obtained, considered and properly evaluated. This technique, which is used in connection with the sequential evaluation process is explained in 404.l520a and ' 416.920a.
12.01 Category of Impairments - Mental
12.02 Organic Mental Disorders: Psychological or behavioral abnormalities associated with a dysfunction of the brain. History and physical examination or laboratory tests demonstrate the presence of a specific organic factor judged to be etiologically related to the abnormal mental state and loss of previously acquired functional abilities.
The required level of severity for these disorders is met when the requirements in both A and B are satisfied.
A. Demonstration of a loss of specific cognitive abilities or affective changes and the medically documented persistence of at least one of the following: 1. Disorientation to time and place; or 2. Memory impairment, either short-term (inability to learn new information), intermediate, or long-term (inability to remember information that was known sometime in the past); or 3. Perceptual or thinking disturbances (e.g., hallucinations, delusions); or 4. Change in personality; or 5. Disturbance in mood; or 6. Emotional lability (e.g., explosive temper outbursts, sudden crying, and impairment in impulse control; or 7. Loss of measured intellectual ability of at least 15 I.Q. points from premorbid levels or overall impairment index clearly within the severely impaired range on neuropsychological testing, e.g., the Luria-Nebraska, Halstead-Reitan, etc; AND
B. Resulting in at least two of the following: 1. Marked restriction in activities of daily living; or 2. Marked difficulties in maintaining social functioning; or 3. Deficiencies of concentration, persistence or pace resulting in frequent failure to complete tasks in a timely manner (in work settings or elsewhere); or 4. Repeated episodes of deterioration or decompensation in work or work-like settings which cause the individual to withdraw from that situation or to experience exacerbation of signs and symptoms (which may include deterioration of adaptive behavior).
12.03 Schizophrenic, Paranoid and Other Psychotic Disorders: Characterized by the onset of psychotic features with deterioration from a previous level of functioning.
The required level of severity for these disorders is met when the requires in both A and B are satisfied, or when the requirements in C are satisfied.
A. Medically documented persistence, either continuous or intermittent, or more of the following: 1. Delusions or hallucinations: or 2. Catatonic or other grossly disorganized behavior, or 3. Incoherence, loosening of associations, illogical thinking, or poverty of content of speech if associated with one of the following:
a. Blunt affect: or b. Flat affect; or c. Inappropriate affect;
Or
4. Emotional withdrawal and/or isolation:
AND
B. Resulting in at least two of the following: 1. Marked restriction in activities of daily living; or 2. Marked difficulties in maintaining social functioning;
OR
3. Deficiencies of concentration, persistence or pace resulting in frequent failure to complete tasks in a timely manner (in work settings or elsewhere); or 4. Repeated episodes of deterioration or decompensation in work or work-like settings which cause the individual to withdraw from that situation or to experience exacerbation of signs and symptoms (which may include deterioration of adaptive behavior).
OR
C. Medically documented history of one or more episodes of acute symptoms, signs, and functional limitations which at the time met the requirements in A and B of this listing, although these symptoms or signs are currently attenuated by medication or psychosocial support, and one of the following:
1. Repeated episodes of deterioration or decompensation in situations which cause the individual to withdraw from that situation or to experience exacerbation of signs or symptoms (which may include deterioration of adaptive behaviors); or 2. Documented current history of two or more years of inability to function outside of a highly supportive living situation.
12.04 Affective Disorders: Characterized by a disturbance of mood, accompanied by a full or partial manic or depressive syndrome. Mood refers to a prolonged emotion that colors the whole psychic life; it generally involves either depression or elation
The required level of severity for these disorders is met when the requirements in both A and B are satisfied.
A. Medically documented persistence, either continuous or intermittent of one of the following;
1. Depressive syndrome characterized by at least four of the following;
a. Anhedonia or pervasive loss of interest in almost all activities; or b. Appetite disturbance with change in weight; or c. Sleep disturbance; or d. Psychomotor agitation or retardation; or e. Decreased energy; or f. Feelings of guilt or worthlessness; or g. Difficulty concentrating or thinking; or h. Thoughts of suicide; or i. Hallucinations, delusions or paranoid thinking; or
2. Manic syndrome characterized by at least three of the following:
a. Hyperactivity; or b. Pressure of speech; or c. Flight of ideas; or d. Inflated self-esteem; or e. Decreased need for sleep; or f. Easy distractibility; or g. Involvement in activities that have a high probability of painful consequences which are not recognized; or h. Hallucinations, delusions or paranoid thinking;
OR
3. Bipolar syndrome with a history of episodic periods manifested by the full symptomatic picture of both manic and depressive syndromes (and currently characterized by either or both syndromes);
And
B. Resulting in at least two of the following:
1. Marked restriction in activities of daily living; or 2. Marked difficulties in maintaining social functioning; or
Deficiencies of concentration, persistence or pace resulting in frequent failure to complete tasks in a timely manner (in work settings or elsewhere); or
4. Repeated episodes of deterioration or decompensation in work or work-like settings which cause the individual to withdraw from that situation or to experience exacerbation of signs and symptoms (which may include deterioration of adaptive behaviors).
12.05 Mental Retardation and Autism: Mental retardation refers to a significantly subaverage general intellectual functioning with deficits in adaptive behavior initially manifested during the developmental period (before age 22), (Note: The scores specified below refer to those obtained on the WAIS, and are used only for reference purposes. Scores obtained on other standardized and individual administered tests arc acceptable, but the numerical values obtained must indicate a similar level of intellectual functioning.) Autism is a pervasive developmental disorder characterized by social and significant deficits originating in the developmental period.
The required level of severity for this disorder is met when the requirements of A, B, C, or D are satisfied.
A. Mental incapacity evidenced by dependence upon others for personal (e.g., toileting, eating, dressing, or bathing) and inability to follow directions, such that the use of standardized measures of intellectual functioning is precluded;
OR
B. A valid verbal, performance, or full scale IQ of 59 or less; Or
C. A valid, verbal, performance, or full scale IQ of 60 through 70 and a physical or other mental impairment imposing additional and significant work-related limitation of function;
OR
D. A valid verbal, performance, or full scale IQ of 60 through 70, or in the case of autism, gross deficits of social and communicative skills, with either conditions resulting in two of the following:
1. Marked restriction of activities of daily living; or 2. Marked difficulties in maintaining social functioning; or 3. Deficiencies of concentration, persistence or pace resulting in frequent failure to complete tasks in a timely manner (in work settings or elsewhere); or 4. Repeated episodes of deterioration or decompensation in work or work-like settings which cause the individual to withdraw from that situation or to experience exacerbation of signs or symptoms (which may include deterioration of adaptive behaviors).
12.06 Anxiety related disorders: In these disorders anxiety is either the predominant disturbance or it is experienced if the individual attempts to master symptoms; for example, confronting the dreaded object or situation in a phobic disorder or resisting the obsessions or compulsions in obsessive compulsive disorders.
The required level of severity for these disorders is met when the requirements in both A and B are satisfied, or when the requirements in both A and C are satisfied.
A. Medically documented findings of at least one of the following:
1. Generalized persistent anxiety accompanied by three out of four of following signs or symptoms:
a. Motor tension; or b. Autonomic hyperactivity; or c. Apprehensive expectation; or d. Vigilance and scanning; or
2. A persistent irrational fear of a specific object, activity, or situation which results in a compelling desire to avoid the dreaded object, activity, or situation, or
3. Recurrent severe panic attacks manifested by a sudden unpredictable onset of intense apprehension, fear, terror and sense of impending doom occurring on the average of at least once a week; or
4. Recurrent obsessions or compulsions which are a source of marked distress; or
5. Recurrent and intrusive recollection of a traumatic experience, which are a source of marked distress
AND
B. Resulting in at least two of the following:
1. Marked restriction in activities of daily living; or 2. Marked difficulties m maintaining social functioning; or 3. Deficiencies of concentration, persistence or pace resulting in frequent failure to complete tasks in a timely manner (in work settings or elsewhere); or 4. Repeated episodes of deterioration or decompensation in work or work-like settings which cause the individual to withdraw from that situation or to experience exacerbation of signs and symptoms (which may include deterioration of adaptive behaviors).
OR
C. Resulting in complete inability to function independently outside the area of one's home.
12.07 Somatoform Disorders: Physical symptoms for which there are no demonstrable organic findings or known physiological mechanisms.
The required level of severity for these disorders is met when the requirements in both A and B are satisfied.
A. Medically documented by evidence of one of the following:
1. A history of multiple physical symptoms of several years duration beginning before age 30, that have caused the individual to take medicine frequently, see a physician often and alter life patterns significantly; or
2. Persistent nonorganic disturbance of one of the following:
a. Vision; or b. Speech; or c. Hearing; or d. Use of a limb; or e. Movement and its control (e.g. coordination disturbances, psychogenic seizures, akinesia, dyskinesia); or f. Sensation (e.g., diminished or heightened); or
3. Unrealistic interpretation of physical signs or sensations associated with the preoccupation or belief that one has a serious disease or injury.
AND
B. Resulting in at least two of the following;
1. Marked restriction in activities of daily living: or 2. Marked difficulties in maintaining social functioning; or 3. Deficiencies of concentration, persistence or pace resulting in frequent failure to complete tasks in a timely manner (in work settings or elsewhere); or 4. Repeated episodes of deterioration or decompensation in work or work-like settings which cause the individual to withdraw from that situation or to experience exacerbation of signs and symptoms (which may include deterioration of adaptive behavior).
12.08 Personality Disorders: A personality disorder exists when personality traits are inflexible and maladaptive and cause either significant impairment in social or occupational functioning or subjective distress. Characteristic features are typical of the individual's long-term functioning and are not limited to discrete episodes of illness.
The required level of severity for these disorders is met when the requirements in both A and B are satisfied.
A. Deeply ingrained, maladaptive patterns of behavior associated with one of the following:
1. Seclusiveness or autistic thinking; or 2. Pathologically inappropriate suspiciousness or hostility; or 3. Oddities of thought, perception, speech and behavior; or 4. Persistent disturbances of mood or affect; or 5. Pathological dependence, passivity, or aggressivity; or 6. Intense and unstable interpersonal relationships and impulsive and damaging behavior:
AND
B. Resulting in at least two of the following:
1. Marked restriction in activities of daily living; or 2. Marked difficulties in maintaining social functioning; or 3. Deficiencies of concentration, persistence or pace resulting in frequent failure to complete tasks in a timely manner (in work settings or elsewhere); or 4. Repeated episodes of deterioration or decompensation in work or work-like settings which cause the individual to withdraw from that situation or to experience exacerbation of signs and symptoms (which may include deterioration of adaptive behaviors).
12.09 Substance Addiction Disorders: Behavioral changes or physical changes associated with the regular use of substances that affect the central nervous system.
The required level of severity for these disorders is met when the requirements in any of the following (A through I) are satisfied.
A. Organic mental disorders. Evaluate under 12.02 B. Depressive Syndrome. Evaluate under 12.04 C. Anxiety Disorders. Evaluate under 12.06 D. Personality disorders. Evaluate under 12.08 E. Peripheral neuropathies. Evaluate under 11.14 F. Liver Damage. Evaluate under 5.05 G. Gastritis. Evaluate under 5.04 H. Pancreatitis. Evaluate under 5.08 L. Seizures. Evaluate under 11.02 or 11.03.
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