Sep 27, 2016

New PTSD Listing

     From Social Security's new mental impairment Listings effective January 17, 2017:
12.15 Trauma-and [so in the original] stressor-related  disorders (see 12.00B11), satisfied by A and B, or A and C:
     A. Medical documentation of all of the following:
          1. Exposure to actual or threatened death, serious injury, or violence;
        2. Subsequent involuntary re-experiencing of the traumatic event (for example, intrusive memories, dreams, or flashbacks);
          3. Avoidance of external reminders of the event;
          4. Disturbance in mood and behavior; and
        5. Increases in arousal and reactivity (for example, exaggerated startle response, sleep disturbance).
AND
     B. Extreme limitation of one, or marked limitation of two, of the following areas of mental functioning (see 12.00F):
          1. Understand, remember, or apply information (see 12.00E1).
          2. Interact with others (see 12.00E2).
          3. Concentrate, persist, or maintain pace (see 12.00E3).
          4. Adapt or manage oneself (see 12.00E4).
OR
     C. Your mental disorder in this listing category is “serious and persistent;” that is, you have a medically documented history of the existence of the disorder over a period of at least 2 years, and there is evidence of both
     1. Medical treatment, mental health therapy, psychosocial support(s), or a highly structured setting(s) that is ongoing and that diminishes the symptoms and signs of your mental disorder (see 12.00G2b); and
    2. Marginal adjustment, that is, you have minimal capacity to adapt to changes in your environment or to demands that are not already part of your daily life (see 12.00G2c).

13 comments:

Anonymous said...

That is a huge change. People can have PTSD from trauma other than "Exposure to actual or threatened death, serious injury, or violence" especially when they have other mental illnesses. The whole issue for some people is that they don't experience reality the way others do--so something can be traumatic to them that others would be able to handle in a more resilient way.

Just like what constitutes a "low-stress" work environment is different for different people, what constitutes a trauma that causes a PTSD diagnosis and symptoms can be different for different people.

Plus, what if the ALJ agrees the person has the symptoms but can't verify the trauma that caused it? Is this going to be like refugee and asylee cases where the violence needs to be documented and the claimant needs to testify about what they experienced and there's a credibility (whoops we don't call it that anymore) assessment?

Anonymous said...

Good points. Policy guidance is needed for this new listing.

Anonymous said...

@ 4:51 pm. Actually, you're wrong. The DSM criteria for a PTSD diagnosis requires "exposure to actual or threatened death, serious injury or sexual violation".

http://www.dsm5.org/Documents/PTSD%20Fact%20Sheet.pdf

So while we often see PTSD diagnoses for other things, these are not correct per the DSM.

Anonymous said...

I have concerns about PTSD diagnosis narrowed to such an extent on physical violence, sexual assault, or threat of death. Where does this leave the millions of PTSD sufferers whose PTSD stems not so much from physical violence, but exposure to severe and pervasive psychological or verbal abuse, not to mention persistent harassment, stalking, terrorizing acts, intimidation, etc., with the specific intent designed to instill fear and perceived threat to someone. This is often seen in domestic violence cases and among crime victims. Also, what about a PTSD sufferer who was not involved in combat, or the target of a crime, but witnessed the event(s); lost a loved one to a heinous act, such as a beheading or a mass shooting captured on video. I find this definition of PTSD too narrow, ill defined, and poorly worded and written. In my opinion, this is in serious need of further work and expert input, and should NOT be implemented as is.

Anonymous said...

@ 11:21...this is not an SSA definition of PTSD. This is the definition set forth in the DSM (Diagnostic and Statistical Manual of Mental Disorders) that is published by the APA (American Psychiatric Association). It has undergone thorough peer review and comment, including expert input, and is currently implemented (hopefully) by all practicing psychiatrists.

Dan Smith said...

The B and C criteria for these conditions appear to be identical. In my experience, if you're struggling to make a case for the A criteria, you have no shot at the necessary B or C criteria anyway. Different opinions/experiences?

Anonymous said...

Thanks 1:17PM - My mistake, 11:21PM.

That being said, I do think Policy Guidance, as 4:49AM suggested, is needed, specifically as to what constitutes "violence." Is it exclusively physical violence, or can/does it include PERVASIVE psychological and verbal abuse, harassment, terrorizing, stalking, intimidation, etc. My inclination is yes, it can/does include these other forms of "violence," but the emphasis will be placed on the pervasive, repeated, and persistent nature of said acts, and whether a reasonable person under such circumstances could interpret the level of fear/threat as potentially life threatening.

Anonymous said...

I agree with the first comment. Whenever I have a PTSD allegaton at a hearing, I don't get into the causes. It's like someone broke a limb : who cares how? As long as there is a diagnosis from an acceptable medical source, I look at the residual symptoms and functional limits. Now this listing is making the ALJ make a medical determination: Is the source of the PTSD sufficient to result in the alleged symptoms?

Anonymous said...

I think one could quite easily characterize the DV-related stalking, harassment, intimidation, etc. mentioned a few times (in a way that worried they wouldn't qualify as the precipitating cause of PTSD) under "threats of..."

It's most definitely good and everything that yall are looking out for your clients, but sometimes you are just so quick to throw SSA under the bus and light us up for doing something boneheaded that your reasoning capacity goes out the window.

Anonymous said...

@Dan

I am assuming you are limiting your question to the current 12.04 language?

In my experience, the A criteria is easy to establish in most cases where a claimant suffers from relevant mental impairments. If directly asked, treating physicians will generally agree with the B criteria. The C criteria is extremely rare in my experience as inpatient treatment is nonexistant in my state, or at least it certainly is for the lower and middle-class individual's my firm generally represents. We have quite a few world-renowned inpatient high-end facilities. I can think of a single case where a claimant was hospitalized for inpatient treatment of a long duration. The ALJ ignored this hospitalization saying it was outside the relevant time period...despite it occurring fully within the relevant time period as it postdated the application, and predated the hearing.

The issue is, a patient's ability to engage in activities of daily living and social functioning is not generally what physicians look at. Also, decompensation is a poorly defined concept and a term I rarely see in medical records even if the claimant is comatose staring into space for weeks on end.

In any event, the A criteria generally result in the B criteria but only if you directly provide the B criteria definitions and ask the treating physicians if they agree with the definitions.

Anonymous said...

@9:12, I agree that reasonable people would find that stalking is a threat of violence, but if you get the ALJ who says "so what, that guy kept showing up at your work? maybe he just likes eating at wendy's every day. during your shift. and staring at you. and telling you how he can't wait to get you alone" then it doesn't matter what a reasonable person would do. because an unreasonable person is deciding whether you have enough money to keep your house.

also, what if the ALJ would agree that something would be a threat of violence if the claimant had proof of it, but the claimant doesn't? Let's say a 50 year old claimant whose mom was repeatedly beaten by her alcoholic boyfriend. This all happened in the 1970s and mom never called the cops--or did, and the arrest records are in another state and probably long since gone anyway.

It's just one more thing for a claimant (who, let's remember, has PTSD and probably not a lot of money or coping skills) and rep to have to prove.

Anonymous said...

BRAVO, 12:29PM!

Anonymous said...

what sux is --- what constitutes medical documentation of the violent event...When my ex twisted my arm and I went to the ER the dr called em a liar because she liked my husband....When I was raped my dr said "alleged rape"...There was no rape kit...What is evidence