DI 22511.005 Documenting the Impact of a Medically Determinable Mental Impairment on an Individual's Ability to Work
Regulations No. 4, Sec. 404.1508 and Regulations No. 16, Sec. 416.908
Regulations No. 4, Sec. 404.1520a and Regulations No. 16, Sec. 416.920a
Part 404, Subpart P, Appendix 1, Part A, Section 12.00
The first step in evaluating disability on the basis of a mental disorder is the need to establish the existence of a medically determinable mental impairment (see DI 22511.003). The next step is to determine how the impairment impacts on the individual's ability to work. This is done by examining functional areas which are deemed essential to work. These functional areas are described in the paragraph B and C criteria contained in the Mental Disorders section of the Listing of Impairments DI 34001.032 and the section of the PRTF entitled “Rating of Functional Limitations” OS 15020.325.
For a mental disorder, functional limitations imposed by the disorder are used to assess impairment severity. It must be kept in mind that for purposes of assessing impairment severity, the limitation must result from the mental disorder.
B. Functional Areas Deemed Essential to Work
The functional areas deemed essential to work are: (1) Activities of daily living (ADL's), (2) social functioning, (3) concentration, persistence or pace, and (4) the ability to tolerate increased mental demands associated with competitive work. Alternative functional areas to these exist and are used in special circumstances. The alternative criteria are discussed in DI 22511.005E.
To permit proper assessment of these functional areas, certain contexts or parameters about them must be addressed.
C. ADL's and Social Functioning
ADL's (i.e., the B1 criterion) 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. Social functioning (i.e., the B2 criterion) refers to an individual's capacity to interact appropriately and communicate effectively with other individuals.
For ADL's and socialization, documentation must be sufficient to permit an assessment of those functions within five general parameters or contexts: (1) Appropriateness, (2) independence, (3) sustainability, (4) quality, and (5) effectiveness. Each of these parameters is further described as follows:
Appropriateness means the individual performs his/her daily activities and engages in social relations in a suitable and/or compatible fashion with the environmental set.
Independence means that the individual performs daily activities and engages in social relations on an autonomous or self-directed or self-generated basis and without direct step-by-step supervision and direction to ensure adequate participation.
Sustainability means that the individual performs his/her daily activities and engages in social relations on a sustained basis (e.g., throughout an average day and week without undue interruptions or distractions).
4. QUALITY AND EFFECTIVENESS
Quality and effectiveness mean that the individual can perform daily activities and engage in social relations on a consistent, useful, routine basis.
D. Concentration, Persistence or Pace and Deterioration and Decompensation in Work or Work-like Settings
Concentration, persistence or pace (i.e., the B3 criterion) refers to the ability to sustain focused attention sufficiently long to permit the timely completion of tasks commonly found in work settings. For example, concentration may be reflected in terms of ability to complete tasks in everyday household routines. Deficiencies in concentration, persistence or pace are best observed in work and work-like settings. Major deficits in this area can often be assessed through direct psychiatric examination and/or psychological testing, although mental status examination or psychological test data alone should not be used to 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 requiring short-term memory or through tasks that must be completed within established time limits. In work evaluations, concentration, persistence, or 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, the time it takes to complete the task, and extent to which assistance is required to complete the task.
Deterioration or decompensation in work or work-like settings (i.e., the B4 criterion) refers to failure to adapt to stressful circumstances which cause the individual either to withdraw from that situation or to experience exacerbation of signs and symptoms or experience deterioration in previously attained adaptive skills. Stresses common to the work environment include decisions, attendance, schedules, completing tasks, interaction with supervisors, interaction with peers, etc.
Great care should be exercised in making assumptions about the inability to sustain attention or pace under the stress of competitive employment for a normal workday or workweek based on short term mental status or psychological testing by a clinician. The ability to sustain activity over the workweek must be assessed by evaluating all the evidence with emphasis on past work attempts, workshop or rehabilitation reports, if available, and the current functioning of the individual at home and in other social or educational activities performed over a sustained period.
Individuals may be able to sustain attention and persist at simple tasks but may have difficulty with complicated tasks. Deficiencies of concentration, task persistence, or pace which are apparent only in performing complex procedures or tasks would not satisfy the intent of the “B3” criterion. Even when these deficiencies are seen in combination with another “B” criterion the individual could not be reliably considered unable to engage in substantial gainful activity.
The “B4” criterion is derived from the longitudinal history of the disorder. To satisfy the criterion it must be shown that the individual experienced an exacerbation in signs and symptoms of sufficient duration and intensity which would ordinarily require increased treatment and/or a less stressful situation. Increases in signs and symptoms and their effect on function may be demonstrated by significant alterations in medication or the need for a more structured psychological support system (e.g., hospitalization, placement in a halfway house or a highly structured and directing household, etc.). The key here is that we are measuring the significance of episodes of deterioration and decompensation, as shown by the increase in symptoms or signs and the need to seek new or additional treatment or withdraw from the stress-provoking environment. Generally, to fulfill this criterion, the file should document the three significant episodes of deterioration or decompensation, each of which is at least 2 weeks or longer, during the most recent adjudicative year.
In circumstances in which the individual has more frequent but less marked (in terms of duration and effect) episodes of decompensation or deterioration, medical judgment must be used to determine if the duration and effect are equivalent to that described above. If so, the portion of the listing will be considered to be fulfilled. The listing could also be fulfilled if fewer than 3 significant episodes have occurred and the episodes have been of longer than 2 weeks duration.
For the B3 criterion (deficiencies in concentration, persistence, or pace) and B4 criterion (episodes of deterioration or decompensation), documentation must be sufficient to permit an assessment of their frequency, duration, and effect on the claimant's function. If such documentation cannot be derived from recent work history or work attempts (i.e., the individual has never worked or does not have any recent work attempts), these criteria should be developed and evaluated based upon the individual's ability to function within situations simulating work-like tasks, e.g., hobbies, day-care settings, etc.
E. Alternative Functional Criteria for the Assessment of Impairment Severity
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 psychiatric disorders commonly have their lives structured in such a way to minimize stress to 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.
Additionally, 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.
The paragraph C criteria are similar to the paragraph B criteria in that they describe those functional limitations associated with mental disorders which are incompatible with the ability to work. The “C” criteria relate to whether an individual requires a supportive stress-reducing or anxiety-avoidant environment.
1. “C” CRITERIA IN LISTINGS 12.02, 12.03, AND 12.04
To satisfy the “C” criteria in Listings 12.02, 12.03, and 12.04 documentation must be sufficient to establish a medically documented history of one or more episodes of acute symptoms, signs and functional limitations which met the requirements in paragraph A and B of the listing in the past for at least 6 months, although the symptoms or signs are currently attenuated by medication or psychosocial support. Documentation must also be sufficient to establish either:
Repeated episodes of deterioration or decompensation 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
Documented current history of one or more years of inability to function outside of a highly supportive living arrangement with an indication of continued need for such an arrangement.
Concerning repeated episodes of deterioration or decompensation, this criterion is satisfied only if the episodes are substantially as described for the “B4” criterion, or if the residual disease process has resulted in such marginal adjustment that any increase in mental demands or change in the environment would be predicted to cause such deterioration or decompensation.
2. “C” CRITERIA IN LISTING 12.06
To satisfy the “C” criterion in Listing 12.06, documentation must establish a medically determinable mental impairment which has resulted in the individual's complete inability to function independently outside the area of his/her home.