DI 22511.003 Documenting the Existence of a Medically Determinable Mental Impairment
The existence of a medically determinable mental impairment must be established by objective medical evidence consisting of signs, laboratory findings (including psychological tests), or both. 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). The mental status examination and psychiatric history will ordinarily provide the needed information to document the existence of a mental disorder.
Upon review of the medical evidence, it must be determined if the existence of a mental disorder(s) is supported by the findings. If a mental disorder(s) exists, its presence is documented in one of the eleven categories contained in the section of the Psychiatric Review Technique Form (PRTF) entitled “Documentation of Factors that Evidence the Disorder.” These eleven categories correspond to the eleven listed mental impairments contained in the “Mental Disorders” section of the Listing of Impairments DI 34001.032.