Basic Skills Workshop

AOOP 2002 Annual Meeting

Friday Jan. 18, 2002

AOOP

“Social Security Disability Evaluations”

C. Donald Williams, MD CGP  

Author's note: Names and locations have been changed for confidentiality reasons; nevertheless, this material is intended for professional use only, and is copyright, C. Donald Williams MD, 2002

Table of Contents

1.        Background, outline of evaluation, “listings requirements” and “B” and “C” criteria, conduct of the evaluation, summary

The social security examiner may request this form, as may a hearings judge, or an attorney representing the applicant at the hearings stage of the appeal process.

Conduct of the evaluation

The purpose of the psychiatric evaluation should be explained to the claimant.  The examinee should be advised of the limitations on confidentiality associated with their status as an applicant for SSDI.  They should be advised that the interview is for evaluation purposes only, and that it is not for treatment. They should be informed that a copy of the evaluation would be provided to the Social Security Administration. My practice is to suggest that the applicants themselves directly request that the SSA provide copies of the evaluation to any other parties they wish to receive the report.  This avoids the possibility of violating confidentiality guidelines or overlooking the obtaining of release of information forms. As a matter of policy, the physician evaluator is allowed to directly furnish a copy of the evaluation to a treating physician. Nevertheless I prefer to have the patient assume responsibility for requesting the report be sent from the SSA to other parties.

Although in the past the SSA provided phone-in transcription service to an 800 number, in Washington State psychiatrists have been required to provide their own transcription for the last several years because of funding constraints, making on-site transcription services an economic necessity if any significant work volume is undertaken .  This varies from state to state; many states still provide dictation/transcription services.

Conduct the examination according to a standard format provided by the DDS.  I find it helpful to use a form I have developed with my word processor, as that speeds the transcription process and helps me to remember all necessary areas of inquiry.  I have included a copy of my headings in the handouts.

Record primary data, including liberal use of quotes, accumulated during the evaluation.  State the specific findings on the mental status examination directly.  Avoid statements such as “concentration and memory are grossly normal” in favor of facts.  As an example: “The patient was able to recall three out of three dissimilar objects at 5 minutes and was able to repeat 7 digits forward and 5 digits backward”.  I utilize a prepared evaluation format, which helps to avoid omissions. The evaluation should be dictated, as it is possible to produce a meaningful 4-6-page report within 5 or 10 minutes given sufficient practice and experience.  For transcription purposes, I developed a formatted word processing file that contains relevant headings and saves a significant amount of typist time.  One proofreading is all that should be necessary. This makes it possible to conduct the evaluation and issue a report within 24 hours.  The SSA appreciates timeliness, and I find that I am more efficient when the material is fresh in my mind.  I make it a practice to dictate all social security evaluations within 24 hours of the interview.  Usually they are completed during breaks between patients within an hour or two of seeing the patient, markedly reducing the subjective sense of being burdened.  In other words, don’t let dictation pile up.

Finally, a Social Security Disability Psychiatric Evaluation must offer diagnoses utilizing the DSM-IV format, and comment on the degree and duration of functional limitation resulting from the diagnosed condition. These requests are made explicit in the evaluation request.  Avoid offering diagnoses of mental retardation in the absence of formal psychological testing, and if you correctly place such diagnoses on Axis II. 

Provide an evaluation of the claimant’s ability to manage his or her own funds, as this will determine whether or not a representative payee is named if benefits are awarded.  Include an opinion regarding the prognosis of the condition with treatment, and an opinion concerning the necessary length of psychiatric treatment.

Summary of Main Points:

1.   Obtain Informed consent; explain the purpose of the evaluation, and how the information will be distributed.  Treat claimants courteously. You are a neutral professional, and you are not an adjudicator.

2.   Conduct a standard psychiatric evaluation utilizing the DDS guidelines.  Record the primary data you obtain in the evaluation, not just your conclusions.  Your opinion must be supported by facts and evidence to be given weight by the examiner or by an ALJ.

3.   Employ DSM-IV diagnostic criteria in your diagnosis section.

4.   Specifically answer the examiner’s questions regarding the claimant’s prognosis with treatment, and the ability to manage his/her own funds. 

                5.   Provide your report promptly to DDS. 

6.   If you for any reason feel that it would be unsafe for you to begin or continue an evaluation, cancel it, and notify DDS of your reasons.  It may be necessary for the evaluation to take place within a secure facility.

Acknowledgement:  Leann Amstutz, Professional Relations Specialist, Washington Disability Determination Services, Olympia, WA kindly reviewed this presentation and offered valuable corrections as well as a national perspective.  All errors and omissions are of course my responsibility. 

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Adult Social Security Disability Eval Example—No Diagnoses—V71.09

KYLENE M. BARGE

SSN: xxx-xx-xxxx

D.O.B.: 03/14/1978

Identifying Data:

The claimant is a 22-year old single Caucasian female who lives with her fiancé.

Statement of Non-Confidentiality:  

The claimant was advised that this interview was for evaluation purposes only and that a copy of the evaluation report would be provided to the Social Security Administration.  The claimant was further advised that no doctor-patient relationship was established and claimant agreed to continue with this evaluation with that understanding.

Chief Complaint:

“My pain.”  

Records Reviewed:

A referral consultation by Dr. Grissom, Pain Management Center in Lewiston, Idaho, was reviewed.  He presents a history of a motor vehicle accident and care subsequent to that accident.  He essentially notes the development of pain cycles lasting about eight weeks.  Mood fluctuations associated with pain are noted.  Fluctuations in sleep patterns and relationships with relatives and co-workers are noted.  Fibromyalgia was noted as the primary diagnosis and was apparently documented through a workup at the University of Washington.

History of Current Situation:

The claimant stated that her pain began subsequent to a motor vehicle accident that occurred in about October 1996.  She was leaving school, driving down the street, stopped for a car that slammed on its brakes in front of her, and was rear-ended by a car following her.  She was taken to the hospital by ambulance, placed in a neck collar for about one week and then saw numerous physicians, as outlined in Dr. Grissom’s referral.  She has received numerous medications and has also received physical therapy.  She stated that she has had difficulty holding down a job.  However, she was able to hold a job as a bank teller from January 1998 through May 1999, about 18 months.  She attributes her longevity at that position to her ability to move around, sit and stand, and not have to remain in one position.

Other jobs as a cashier and a secretarial position lasted for briefer periods of time because of the inability to shift and change positions.

Over the past three months she has done “nothing”.  “I’ve just been hanging out – developing a plan for school”.  She stated that she plans on completing her schooling and receiving an AA degree and then going to work in criminal justice.

Her sleep continues to be disrupted, depending on the stage of her pain cycle noted above.  She falls asleep anywhere between 9:00 p.m. and 5:00 a.m. and arises anywhere between 5:00 a.m. and 10:00 p.m.  Her energy level is low.  She has rare crying spells.  Her temper is good.  Her concentration is excellent as is her memory.  She does not think of death.  Her appetite is within normal limits.  She gained 35 pounds while taking Amitriptyline last fall.  She has resumed exercising, walks every day, and notes that she feels better since having done that.

She receives no financial benefits.

Employment History:

She worked most recently as a cashier for four weeks and prior to that she worked as a secretary for about three months.  Prior to that time she worked for 18 months as a teller at Seafirst Bank.  That was her best job.

Current Medications:

1)       Vicodin

2)       Flexeril

3)       Ambien

She noted that she was taking Effexor and Nortriptyline, but ran out of these medications and since having instituted exercise, is now feeling better without them 

Past Personal Psychiatric History:

Hospitalizations:  She was hospitalized in 1993 at about the age of 13 when her parents were going through a divorce.  This was an overnight hospitalization only and she reports that she had been having suicidal thoughts.  She had some follow-up counseling, which was helpful.  She stated that that had resolved the matter.

Psychiatric Outpatient Treatment:  Currently she and her fiancé are receiving premarital counseling through her pastor.  Outpatient counseling received prior to that time – at the time of her parents’ divorce was helpful.

Family Psychiatric History:

A grandfather has a history of depression and another grandfather has a problem with alcohol.

Past Medical History:

Fibromyalgia

Developmental History:

She was born and raised in Walla Walla, Washington.  Her father worked as a trucker and her mother works as an RN.  Her parents divorced when she was 13-years old.  She has a good relationship with both her mother and father, by her report.

She has one older brother.

She stated that she was rebellious when starting high school and instead went to Running Start, a program through the local community college.  She ultimately attained her diploma.  She began very successfully academically, then began to fail classes but has now improved her GPA to 3.2. 

She has best friends and sees them.

Her hobbies include riding horses and crocheting.

There is no history of military service.

Typical Day:

Her day follows a variable schedule as noted above in the earlier portion of the evaluation.

She prepares occasional meals, does much of the laundry and housecleaning, and shares financial management responsibilities with her fiancé.

Alcohol and Substance Use:

She states that she consumes one beer per week, does not smoke cigarettes, and does not use street drugs.  She has used marijuana in the past to assist with pain relief, according the medical reports.  This is a relatively well-known phenomenon and appears credible.

Legal:

She was arrested for shoplifting at age 18.  This matter is now resolved.

Mental Status Examination:

The claimant presented as an overweight but friendly woman who was neatly attired and cooperative throughout the evaluation.  Her vocabulary and grammatical structure was about average.  She stated that she had no suicidal ideation and there was no evidence of homicidal ideation.

There was no evidence of psychotic thought processes and she specifically denied auditory and visual hallucinations and denied possessing special powers or abilities as well as denying paranoid ideation.

She was oriented to the date and knew the name of the last two Presidents.  She was quickly and correctly able to perform serial three subtractions and subtract $.45 from $1.  She was able to recall three out of three dissimilar objects at five minutes. 

Her fund of knowledge was good for a person of her education and background; she knew the names of the south and east bordering states as well as the largest city and the capital city of the state of Washington.  She was able to quickly and correctly spell the word “world” forward and backward and was likewise capable of simple abstraction.  The proverb “spilled milk” revealing “don’t dwell on your mistakes”.  If she were to find a stamped and addressed envelope on a sidewalk, she would take it to the post office, revealing intact judgment in simple non-emotionally loaded situations.  She was also able to easily and correctly repeat seven digits forward, a good performance.

Summary and Discussion:

This individual presents with a prior history of depression, motor vehicle accident, and a diagnosis of fibromyalgia.  However, she does not currently appear to be depressed, although unquestionably at times of markedly increased pain, she would suffer from a mood disturbance.

It is to be noted that she has worked for periods as long as 18 months in positions that allowed for reasonable accommodation.

Her activities during a typical day are only mildly restricted and she appears to have a normal range of interests.  Her ability to relate to other people is unimpaired.  Her ability to care for her personal needs and manage her own funds is quite intact.

The pastoral counseling she is receiving on a premarital basis is certainly appropriate but is unrelated to her fibromyalgia or history of depression. 

I do not currently note the presence of any psychiatric diagnosis.  It is extremely encouraging that she does not appear to have any of the cognitive problems typically associated with fibromyalgia, as that reflects a very favorable prognosis for her, both with regard to her schooling and her longer-term employment.

Diagnoses:

AXIS I:             No diagnosis V71.09

AXIS II:             No diagnosis V71.09

AXIS III:           Fibromyalgia

AXIS IV:           PSYCHOSOCIAL AND ENVIRONMENTAL FACTORS: chronic

                          medical condition

AXIS V:            GAF – 70

Child Social Security Disability Evaluation Example

A Psychiatric Evaluation

RODNEY HARRIS

SSN:xxx-xx-xxxx

D.O.B.: 02/10/xx

Identifying Data:

Rodney is an 8-year old boy who lives with his grandmother.  His 7-year old sister also lives at the same residence.  He attends Barge Elementary School.  He has lived with his grandmother for about five years.

Statement of Non-Confidentiality:

The claimant was advised that this interview was for evaluation purposes only and that a copy of the evaluation report would be provided to the Social Security Administration.  The claimant was further advised that no doctor-patient relationship was established and claimant agreed to continue with this evaluation with that understanding.

Chief Complaint:

“My father – I just don’t like him because of his past.”

Records Reviewed:

A Psychiatric Evaluation conducted by this evaluator on this same boy dated August 13, 1997 was reviewed.  At that time I diagnosed an Attention Deficit Hyperactivity Disorder, predominantly hyperactive impulsive type, on Axis I, along with Conduct Disorders.  I assigned a GAF of 35-40 at that time.  I noted that he had come from a very abusive situation and that he seemed to be functioning at a significantly deficient level.  A history of extremely serious physical abuse and neglect was also noted.

History of Current Situation:

The entire interview was conducted was conducted with Rodney and his grandmother present.

Rodney and his grandmother stated that he was a student at Barge Elementary School.  His teacher is a Ms. Glaspy.  Rodney then volunteered “I don’t like my father – he has a very bad past – I like living at my grandmother’s.”  He stated that his father was living with his grandfather.  Rodney’s grandmother stated that his father had been released from jail in about July of this year following six years of incarceration.

Initially, Rodney stated that he had only one contact with his father but his grandmother stated “honesty – more than that Rodney”.  He then reviewed some of his other contacts, 2-3 in number, including Halloween and visiting with him briefly at a soccer game.

Regarding his relationship with his teacher and authority figures, he stated that his teacher was “very nice – very disciplined too”.  He volunteered that there were 24 students in the class.  He stated that he got along with his sister “like a brother and sister."

He stated that presently he had no real problems except “nobody gives me trouble, except when I whine”.  His grandmother took some issue with that.  She noted that, although he had improved considerably in his behavior since he first moved with her, that there continued to be arguments with his sister, problems with his temper, and when he is visiting cousins “they are at each other’s throat."

Rodney sleeps about 8-9 hours per night.  His appetite is good.  He is having considerable success remaining on task.  He described his grandmother as “my best friend”.  They were physically close throughout the evaluation and she frequently touched him in an affectionate manner.

There have been no fights at school since the beginning of the second grade, a little more than one year ago.  His energy level is satisfactory.  He has only a few friends, and only very occasionally will see them outside of school.

Rodney has no contact with his mother who has effectively abandoned him.  She is still using alcohol and drugs.

Employment History:

Not applicable.

Current Medications:

Rodney is taking no medication.

Past Personal Psychiatric History:

Hospitalizations:  None

Psychiatric Outpatient Treatment: Rodney has been meeting with the same therapist at Central Washington Comprehensive Mental Health every two weeks since about age 4, four or more years ago.  This has been very helpful.

Family Psychiatric History:

Rodney’s father is a convicted pedophile.  He was jailed for six years.  He was recently released.

Both Rodney’s parents have had alcohol and drug problems.  According to Rodney’s grandmother, to the best of her knowledge Rodney’s father is now clean and sober.

Past Medical History:

Rodney has a congenital hip dysplasia problem.  He has recently had to resume exercises for his hips because they have started to give him trouble again.  He has problems with wheezing; there is a possibility of asthma.  He will be going to Shriner’s Hospital in Spokane to be fitted for a brace.  His grandmother noted that he was born with Cerebral Palsy.

Developmental History:

Rodney was born and raised in Yakima.  He was raised in an extremely abusive and neglectful environment for the first four years of his life.  He has lived with his grandmother for about the last five years. 

His grandmother stated that since the time of the prior evaluation, she has been involved in some legal battle with the mother regarding custody.  However, she stated that when she agreed to drop her requirement for child support, that his mother dropped the case.  It is her conclusion that the mother was concerned only for financial reasons. 

Rodney’s father has a paternal right to see Rodney and this represents a concern to the grandmother.  Rodney is uncomfortable with his father.

Rodney is in a regular classroom.  Rodney and his grandmother both describe him as being a very good reader and satisfactory in math.

Typical Day:

Rodney gets up at 7:30 and goes to school.  He is responsible for showering, brushing his teeth, and getting dressed.  He does this essentially without prompting and is able to do so in a timely fashion.  He has some household chore responsibilities, including taking care of the dog, taking out the garbage, and helping with yard work. 

His social functioning is generally pretty good with teachers and other adults.  It is more mixed with family and peers, although Rodney gets along very well with his grandmother.  Rodney has recently become involved in a church group.  This appears to be a serious undertaking for him as he talked about it at some length.  He has no sports activities.

Rodney is able to concentrate for long periods of time on the computer.  He likes to read.  He is able to finish his tasks in a timely manner.

Alcohol and Substance Use:

None.

Legal:

None.

Mental Status Examination:

Rodney presented as a friendly and forthcoming boy who appeared rather anxious.  His vocabulary and grammatical structure were about average.  He was a bit stiff.  There was some spontaneity.

There is no evidence of suicidal ideation.  He used to have visions of dead people, but he describes them as good people, “not like ghosts, more like angels”.  He views these visitations as coming from God.

He states that even now on trips, he will imagine spirits or angels traveling with him.  This helps to pass the time.  He talked about feeling like they touched him and he touched them.

He was well groomed.  He was wearing appropriate clothing for the weather.  He had a normal gait, and his general motor movements were certainly within normal limits.  He was somewhat more active than normal, but this appeared to be more anxiety.  He was cooperative, made eye contact, and although anxious regarding his contact with me, was able to be adequately responsive.

His mood is best described as anxious.  There was nor particular evidence of depression.  He got up and looked out the window on several occasions, although far less frequently than at the time of my evaluation three years ago.

He has imaginary friends, including Pokemon characters.  There also appear to be angels that he views as imaginary and intentional friends. 

Both his expressive and receptive language were within normal limits.  The complexity was age-appropriate.  All of his speech was intelligible and he demonstrated good articulation.  There was no evidence of hearing or listening problems.

He was oriented to the date.  He knew the name of the current and preceding President, rather remarkable for his age. 

He had difficulty with counting backward by threes from 10.  10-6-3-0.  He had to think for some time to make this response.  He was able to follow a two-step command.  He had no difficulty following conversation.  He was able to volunteer information when I was speaking with his grandmother.  He displayed mild distractibility.  His length of attention on specific tasks in the interview was about 3-4 minutes duration but he would come back to the task without nearly the degree of intervention that was required previously.  His judgment is quite limited but probably within normal limits for a child of his age.

Summary and Discussion:

This boy has fortunately made considerable improvement since the date of my prior evaluation.  He continues to have considerable anxiety and certainly was very traumatized by his developmental history. 

Continued therapy through the mental health center is absolutely critical to his continued progress.

His ability to concentrate, persist in a task, and maintain pace with work has certainly improved since the time of the prior evaluation, although it is still less than desirable.  He remains very vulnerable to relapse.

Diagnoses:

AXIS I:             1)  Attention Deficit Hyperactivity Disorder DSM IV 314.01 – resolved

2)       Dysthymic Disorder DSM IV 300.4, childhood onset type

AXIS II:            No diagnosis V71.09

AXIS III:           Orthopedic deformity

AXIS IV:           PSYCHOSOCIAL AND ENVIRONMENTAL FACTORS:  separation

                        from parents

AXIS V:          GAF – 65

  ******************************************************************************************************************************************

Social Security Disability Evaluation—Private Attorney Request

Tom Gerard, Attorney

 Gerard Law Offices

P.O. Box 2730

Bellingham, Washington  9------

RE:      MILDRED CLINTON

            Date of Evaluation: 06/12/00

            SSN: xxx-xx-xxxx

            D.O.B.: 8/5/67

Dear Mr. Gerard:

Thank you for allowing me the opportunity to perform a psychiatric evaluation on Mildred Clinton.  The text of the psychiatric evaluation follows.

Identifying Data:

Ms. Clinton is a 32-year old married Caucasian female who lives with her spouse and 14-year old daughter; they currently reside in a motel, having recently had to move from their residence.

Statement of Non-Confidentiality:

Ms. Clinton was informed that this evaluation was being conducted at the request of her attorney, Mr. Thomas Gerard and that a copy of the evaluation would be furnished to him.  She agreed to proceed with the evaluation with this understanding.  She was further advised that this was for evaluation purposes only and that no doctor-patient relationship was established.

Chief Complaint:

“I am still battling my depression – I have two weeks of really bad attitude – just craziness – throwing things – and packing my things – I didn’t know where I was going.”  

Records Reviewed:

1)      A 02/28/98 brief Adult Intake Evaluation from Western Washington Comprehensive Mental Health was reviewed.  This handwritten evaluation noted impaired memory, suicidal thoughts, a diagnosis of Bi-Polar Disorder, depressed type, and a deferred diagnosis on Axis II.  A GAF of 45 was awarded.  It was noted in the evaluation that bi-polar episodes had occurred since age 15-16.

2)       A 03/02/98 Psychiatric Evaluation by Dr. Ackerly, psychiatrist at Western Washington Comprehensive Mental Health is noted.  Dr. Ackerly notes a history of her having been treated for her bi-polar disorder with Lithium, Prozac, and other medications.  Again psychological problems are noted since her teenage years.  Running away from home and a teenage pregnancy are noted, along with drug use between ages 16-19.  Drug abuse included LSD, marijuana, speed, crank, and alcohol.  A pattern of rapid mood swings lasting 2-5 hours interspersed with suicide attempts, including wrist slashing and overdosing in response to life stressors, are noted.  An episode of sexual abuse is noted at age 5-6 and a rape episode at age 18.  Problems in school are noted.  In the Summary and Discussion portion of the evaluation, Dr. Ackerly noted multiple substance abuse, and a possible history of borderline personality disorder, and posttraumatic stress disorder.  Episodes of depression are noted.  He stated that she did not present any family history of psychiatric illness (in contrast to the history presented to this evaluator).

3)       A 04/19/98 Discharge Summary from Bellingham Valley Memorial Hospital, Inpatient Psychiatric Unit, is noted wherein diagnoses of Major Depression, Polysubstance Abuse, and Personality Disorder are given.  Admission diagnoses from the same date are the same.

4)       An ITA Evaluation dated 06/14/98 is reviewed.  The basis for the evaluation was danger to self, and suicidal ideation of overdosing or “cutting on herself”.  A diagnosis of Bi-Polar I Disorder, most recent episode depressed, without psychotic features was noted.

5)       A 06/14/98 Discharge Summary from Bellingham Valley Memorial Hospital, Adult Inpatient Psychiatric Unit, is reviewed.  Diagnoses of Bi-Polar Disorder, depressed and Cannabis Abuse are noted on Axis I.  A Personality Disorder, Not Otherwise Specified with Cluster B Traits is noted on Axis II.  The admission diagnoses of the same date are the same.

6)       A 02/08/99 Intake Evaluation by Western Washington Comprehensive Mental Health, handwritten, is noted.  Diagnoses of Depressive Disorder, NOS, and Rule Out Bi-Polar Disorder, Mixed, along with Borderline Personality Traits, are noted.  A GAF of 50 is noted.

7)       A Psychiatric Evaluation conducted by ************, M.D., psychiatrist, dated 03/18/99 for the Disability Determination Services is reviewed.  A history of alcohol and substance abuse is noted.  A paternal history of mood swing problems is noted.  By this time 8-9 psychiatric hospitalizations had occurred.  Sporadic employment is noted.  Suicidal ideation is noted.  In the Summary and Discussion portion of the evaluation, it was noted that the presence of a pervasive personality disorder with dependent and borderline traits was present.  An ongoing pattern of marijuana and alcohol abuse appeared to be present.  A lack of motivation to improve was commented upon.

8)       A Psychiatric Evaluation conducted by Charter Behavioral Health Systems, dated 08/27/99 by Dominic Smith, M.D., psychiatrist, is noted.  This evaluation was occasioned by an intention to jump off the Forest Hill Bridge in Roseville, CA.  Several family traumas were noted, including disrupted marriage, mood swings, and behavioral instability.  In this evaluation, she apparently gave a negative drug and alcohol history.  A type II Bi-Polar Mood Disorder was diagnosed on Axis I and a Borderline Personality Disorder was diagnosed on Axis II with a GAF of 40.  A Discharge Summary likewise noted a Bi-Polar Affective Disorder, Type II, and a Borderline Personality Disorder, “considered to be primary diagnosis”.

9)       A 02/07/2000, Adult Intake Evaluation by Western Washington Comprehensive Mental Health is noted.  Diagnoses of Bi-Polar I Disorder on Axis I is noted with a Deferred Diagnosis but Borderline Traits on Axis II.  A GAF of approximately 50 is noted.

10)   A 05/15/2000 Psychiatric Evaluation by psychiatrist, Jan James, M.D., is noted.  Dr. James diagnosed a Recurrent Major Depression, Polysubstance Dependence in remission on Axis I, and a Personality Disorder, NOS on Axis II.  He awarded a GAF of 40-45.  Mood stabilizing medications and antidepressant medications were prescribed.

History of Current Situation:

“I first began to have problems at age 16, with crying bouts and depression.  I had a foster parent and she didn’t know what was going on with me.  I told her I needed to see a doctor – that it wasn’t normal crying.”  She stated that she met with a doctor on one occasion but then was moved to a different county and did not receive further medical care.

She identifies some consequences of her mood disturbance.  She stated that she did drugs, beginning at about age 14 ½.  She had difficulty forming relationships with people, never having more than one friend at school.  Because she had difficulty getting along with people at school, she was home schooled.  She also noted that she did not like going out and described what sounded like agoraphobia.  She stated “I can’t relax in public”. 

She complains of mood swings, which she reports happening every day.  She states that she has “highs” which consist of high levels of energy lasting for a few hours at most, occurring at a frequency of one time per week or less.  Her “lows” however, last for “days and days”.

Frequently she cut on herself, the most recent episode occurring about six weeks ago.  She showed me her wrists and there appeared to be some very well healed lacerations on her upper forearm.

Her life has been somewhat chaotic over the past year.  She was hospitalized some time in the early part of 1999 at Bellingham Valley Memorial Hospital.  Subsequent to that she left for California in the summer of 1999, “leaving my husband”.  For a while she lived with another man’s family but described the experience as “terrible”.  She stated that “he gave my 16-year old daughter drugs and talked nasty to her – he went to jail."  She said she moved there because “that was home to me – my mom was there."

She returned from California to the Bellingham area in December 1999 and pleaded with her spouse, who had a girlfriend by that time, to take her back.  He did so and they are now reunited.

Currently she describes erratic sleeping, typically occurring between the hours of 10:00 p.m. and noon or 2:00 p.m.  She has crying spells twice weekly, decreased in frequency since she began her medication.  She described her mood as “bitchy” and characterized by “irateness”.  Her energy level is satisfactory.  She has a terrible temper and breaks things.  The most recent such episode occurred about ten days ago.  I observed her to have poor concentration and poor immediate recall.  She frequently thinks of death and suicide as well.  She has specific plans, including “driving my car and crashing it”.  Her weight has fluctuated widely, losing between 60-70 pounds over a 10-month period and then regaining 15 pounds over the last two months.  She also noted that because of her thoughts of suicide and behavior, “my husband hid all the sharp instruments in the house.  Now when I get out of control, he just tells me to ‘chill out’.”

Her husband is currently unemployed.

Employment History:

She worked most recently as a housekeeper in California for slightly more than one month following her discharge from a psychiatric hospital facility in California last summer.  She stated that she undertook this work because it was a requirement of a local child protection agency that she be employed in order to have continued contact with her daughter.  However, she stated that she was unable to maintain that job and quit it because she was not able to handle the stress.  This has apparently been true of other housekeeping jobs she has held within the last year or two.

Current Medications:

1)      Remeron, 45-mg. qd.

2)      Lithium, 1,500 mg. per day in divided doses

3)      Serzone, 100-150 mg. qd.

4)      Klonopin

Past Personal Psychiatric History:

Hospitalizations: Her most recent hospitalizations occurred in 1999, the first being in the early part of that year at Bellingham Valley Memorial Hospital.  She was hospitalized at that time because of suicidal plans.  Her most recent hospitalization occurred in August 1999 in California, for a period of six days by her report; she mentioned that the paperwork indicated that the hospitalization was for three days.  She stated that she had suicidal plans at that time and had cut on herself.

She reports a total of 11 psychiatric hospitalizations over the course of her life.

Psychiatric Outpatient Treatment: She is not currently involved in psychiatric outpatient care.  She has apparently just resumed pharmacologic management through Western Washington Comprehensive Mental Health, with Dr. James.  Prior to that time her psychotropic medications were being managed by her family physician.

Family Psychiatric History:

She reports that her mother has a mood disorder and that her daughter began to develop problems with depression in early adolescence.  She also noted that her daughter had cut on her wrists as well.  Her daughter currently resides in a group home and the claimant describes her as “very happy”.  She stated that her father had been diagnosed as having a bi-polar mood disorder.  She stated that her brother recently informed her that he had been struggling with suicidal thoughts.

Past Medical History:

She reports having intermittent problems with an ulcer, migraine headaches for which she receives injections, and “a bad knee”.

Developmental History:

She was born in Lancaster, California, and raised in California.  She was in foster care from age 14 on.  Her parents separated when she was 2-3 years old.  She stated that the reason for being placed in foster care was that her mother became involved in a very rigid church and would not let the children do anything outside the church.  When she rebelled, she stated her mother told the State “take her – I don’t want her”.  She attended school through the 11^th grade.  While home schooled she earned B’s and C’s, better grades than previously.

Discipline was physical and she reports that her mother spanked her with a belt.  She stated there was one episode of sexual abuse that occurred at about age 5, which involved fondling but not intercourse.  This was perpetrated by a friend or acquaintance of the family.

She has been married twice.  She was first married at age 21 for a period of 4 ½ years.  There were no children by that marriage.  Her spouse left her because “he thought I had an affair”.  Her second marriage began at age 30, about four years ago.  They remain together but have had a rocky relationship.

She has two children, one age 14 with whom she currently resides.  The other daughter, age 17, lives in a California group home as noted above.

There is no history of military service.

Typical Day:

She arises between 12:00 noon and 2:00 p.m.  She prepares less than half the meals.  Her spouse does most of the laundry.  She does minimal housecleaning.  Her spouse manages the family finances.

Alcohol and Substance Use:

She stated that she has consumed no alcohol for somewhat more than one year.  She stated that she has used no marijuana for 1½ years.  She denied use of other street drugs for more than 18 years.  She smokes about ½ pack of cigarettes per day or perhaps a bit less.

Legal:

She was pulled over once under suspicion of driving under the influence but was found not to be intoxicated, and was released.

Mental Status Examination:

The claimant presented as an overweight woman whose speech was somewhat thick.  She was cooperative.  At times she seemed to have trouble understanding my questions.

She acknowledges specific suicidal ideation and specific homicidal ideation.  Regarding the homicidal ideation, she states that she has misgivings because “then I knew I’d have to kill myself afterwards and I’d still have my daughter so I couldn’t do it.”

She claims she sees shadows and thinks of them as ghosts.  She wonders whether they are good or bad; she tries to find their source.  Regarding special powers or abilities, she states “I have a hell of a woman’s intuition – I’m always right”.  She had difficulty accounting for the fact that her judgment was so impaired in light of this claimed ability.

She was not oriented to the date, incorrectly describing the date as June 7 rather than June 12.  She knew the year.  She knew the name of the current President but not the preceding President.  She was able to recall only one out of three dissimilar objects at five minutes.  She performed serial three subtractions to 85 slowly.  She was not capable of subtracting $.45 from $1 accurately.  She knew the names of the south and east bordering states as well as the largest city of the state of Washington.  She did not know the name of the capital city of the state of Washington.

She was able to abstract, the proverb “spilled milk” revealing “don’t make a big thing out of something that small”.  If she were to find a stamped and addressed envelope on a sidewalk, she would put it in a mailbox.  She was able to spell the word “world” forward but not backward.  She was able to repeat six digits forward.

Summary and Discussion:

Based on both my current evaluation and my review of the additional medical records provided, which are cited in the Records Review portion of this evaluation, it is my conclusion that Ms. Clinton meets the listed requirements for 12.04 Affective Disorders and 12.08 Personality Disorders. 

Under 12.04 Affective Disorders, the following symptoms are present:

1)      Appetite disturbance with change in weight;

2)      Sleep disturbance;

3)      Psychomotor agitations;

4)      Decreased energy;

5)      Difficulty concentrating or thinking;

6)      Thoughts of suicide.

A review of Section 12.08, Personality Disorders, reveals qualifying symptoms, specifically, inflexible and maladaptive personality traits which cause either significant impairment in social, occupational, or subjective distress as evidenced by the following:

1)      Persistent disturbances of mood or affect;

2)      Pathological dependence, passivity, or aggressivity;

3)      Intense and unstable interpersonal relationships and impulsive and damaging behavior.

With regard to the rating of impairment severity, the claimant displays a marked restriction of activities of daily living, extreme difficulties in maintaining social functioning, constant deficiencies in concentration, persistence, or pace, resulting in failure to complete tasks in a timely manner; and repeated episodes of deterioration or decompensation in work or work-like settings, which cause the individual to withdraw from that situation or experience exacerbation of signs or symptoms.

Based on the above, she displays four functional impairments that satisfy the listings.

With regard to the mental residual functional capacity assessment, she displays a moderately limited ability to remember locations and work-like procedure; a markedly limited ability to remember short and simple instructions; a markedly limited ability to understand and remember detailed instructions.

Under sustained concentration and persistence criteria, she displays a moderately limited ability to carry out very short and simple instructions; a markedly limited ability to carry out detailed instructions; a markedly limited ability to maintain attention and concentration for extended periods; a markedly limited ability to perform activities within a schedule, maintain regular attendance, be punctual within customary tolerances; a markedly limited ability to sustain an ordinary routine without special supervision; a markedly limited ability to work in coordination and proximity without being distracted by them; and a markedly limited ability to make simple work-related decisions.  She also displays a markedly limited ability to complete a normal workday and workweek without interruptions from psychologically based symptoms.

It is my impression that under social interaction criteria, she displays markedly limited impairments for all criteria except for the ability to ask simple questions or request assistance, for which she displays no significant limitations.

Under adaptation, she displays markedly limited abilities with regard to all four criteria under that category.

I should state that I was initially of the opinion that this claimant’s Borderline Personality Disorder was the primary diagnosis.  However, I must modify my original opinion because of evidence that there is a history of prominent mood instability, beginning in early to mid-adolescence, at about the time affective disorders are known to become initially manifest.  There is a complex interplay between her very severe Borderline Personality Disorder and her Affective Disorder.  Her history of substance abuse is seen as related to her personality disorder.  The history provided by the patient as well as an examination of the available medical records suggests rapid cycling, although it is very difficult to distinguish between a rapid cycling bi-polar disorder and the mood instability manifested by patients with borderline personality organization.  The two are not necessarily mutually exclusive.

It would be reassuring to have in hand a drug of abuse screen that was negative for illegal substances.  Her marginal performance on the mental status examination and her even more impaired interview responses may be explainable solely on the basis of her mood disorder, the psychological disorientation accompanying her borderline personality disorder, and her currently prescribed medications, but a drug abuse screen for illegal substances would confirm that.

Her prognosis for improvement is poor.  The severity and duration of her psychiatric disorders, as evidenced by her eleven or more psychiatric hospitalizations reflect a functionally psychotic level of functioning, which is to say no ability to manage her feelings and behavior in accord with reality.

Diagnoses:

AXIS I:             1)         Bi-Polar II Disorder, most recent episode depressed DSM IV

                                    296.5

                        2)         History of Polysubstance Abuse, reportedly in sustained

            complete remission

AXIS II:            Borderline Personality Disorder DSM IV 301.83

AXIS III:           History of ulcer; migraine headaches; orthopedic knee problem

AXIS IV:           PSYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS:

                        unemployment; disrupted familial relationships; living in

                        temporary housing

AXIS V:            40-45 current, and probably highest during past 12 months.

Please contact me if you have any questions.

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"Consultative Examiners Roles and Responsibilities"

(Washington State DDS published guidelines)