Rating Schedule

INTRODUCTION

Three principles are central to assessing mental impairment:

1. Diagnosis is among the factors to be considered in assessing the severity and possible duration of the impairment, but it is by no means the sole criterion.

2. Motivation for improvement may be a key factor in the outcome of impairment.

3. A complete assessment requires a longitudinal history of the impairment, its treatment, and attempts at rehabilitation.

DIAGNOSIS AND IMPAIRMENT

The Diagnostic and Statistical Manual of Mental Disorders (3rd. ed., revised in 1987), commonly known as DSM (current edition), is a widely accepted classification system for mental disorders. It is similar to another system, the International Classification of Diseases (ICD), also in widespread use. The criteria for mental disorders include a wide range of signs, symptoms and impairments. Most mental disorders are characterized by one or more impairments. An individual may have a mental or behavioral impairment, however, without meeting the criteria for one of the mental disorders specified in the DSM (current edition) or the ICD.

DSM (current edition) calls for a multiaxial evaluation. Each of five axes refers to a different class of information. The first three constitute the official diagnostic evaluation, including the clinical syndromes and conditions that are the focus of treatment (Axis I), personality and developmental disorders (Axis II), and physical disorders and conditions that may be relevant to understanding and managing the care of the individual (Axis III). Axis IV (specifying and rating psychosocial stressors) and Axis V (rating adaptive functioning) may be particularly important for assessing severity of impairment.

Specific impairments: The degree of impairment may vary considerably among patients, and the severity of the impairment is not necessarily related to the diagnosis. Indeed, diagnosis alone is of limited relevance to the objective assessment of psychiatric impairment because it does not permit sufficient insight into the nature of the impairment.

EVIDENCE OF MENTAL IMPAIRMENT

The presence of a mental disorder should be documented primarily on the basis of reports from individual providers, such as psychiatrists, psychologists, and other state licensed mental health professionals, and facilities, such as hospitals and clinics. Adequate descriptions of functional limitations must be obtained from these or other sources, which may include programs and facilities where the individual has been observed over a considerable period of time. Longitudinal data are particularly useful.

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, or 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 function.

An individual’s level of functioning may vary considerably over time. Proper evaluation of the impairment must take any variations in level of functioning into account in arriving at a determination of severity of impairment over time. 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 the individual’s ability or inability to function in a work setting. Results of work evaluations and rehabilitation programs can be significant sources of relevant data in regard to vocational and related impairments.

The results of well-standardized psychological tests and other projective techniques may be useful in establishing the existence of a mental disorder. For example, intelligence tests are useful in establishing mental retardation, and projective techniques may provide useful data in supporting diagnoses of other mental disorders. Broad-based neuropsychological assessments may be useful in determining brainfunction 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. 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 obtained IQ scores are considered valid and consistent with the individual’s developmental history and degree of functional restriction.

SPECIAL CONSIDERATIONS

Particular problems often are 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. The results of a single examination may not adequately describe these individuals’ sustained ability to function. It is, therefore, vital to review pertinent information relative to the individual’s condition, especially at times of increased stress.

Effects of structured settings: An evaluation of individuals whose symptoms are controlled or attenuated by psychosocial factors must consider the ability of the individual to function outside such highly structured settings.

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, such as hallucinations, such treatment may or may not affect the functional limitations imposed by the mental disorder. Neuroleptics, the medicines necessary to control signs of an “amotivational” like syndrome, used in the treatment of some mental illnesses, may cause drowsiness, blunted affect, or other side effects involving other body systems. Such side effects must be considered in evaluating overall severity of impairment as well as the patient’s functional capacity.

Pain: The assessment of impairment due to the perception of pain, especially in circumstances in which the complaint exceeds what is expected based on physical findings, is complex and controversial. The perception of pain may be distorted by mental disorders. Pain may be an element in a somatic delusion in a patient with a Major Depression or Psychotic Disorder. It may become the object of an obsessive preoccupation or a chief complaint in a Conversion Disorder. The latter has been called “Psychogenic Pain Disorder” or “Idiopathic Pain Disorder,” but these terms often are used more loosely to describe any complaint of pain that is greater than the physician expects for the “normal” patient with the same physical findings. The more specific disorders with impairments are somewhat easier to evaluate than cases in which the perception of pain is said to have a “psychogenic component.” Such cases require specialized assessment, perhaps using a multidisciplinary, multispeciality approach.

ASSESSING IMPAIRMENT SEVERITY

A method of evaluating psychiatric impairment: Solutions to the many dilemmas encountered in determining the degree of impairment resulting from a psychiatric illness can only be sought through the application of consistent and observable criteria that must be considered in relation to one another.

The table that follows, when used according to the best clinical judgment of the evaluator, will aid in the evaluation of an individual, and it should be used after all diagnostic, clinical, treatment and rehabilitation factors have been explored.

An example that follows the table gives the overall rating of a patient based upon the mental status and upon the current condition as observed by the calculator. The rating is based upon observed attributes and phenomena that are somewhat interrelated, and it necessarily must be considered to be somewhat subjective. Reduced ability to deal with activities of daily living and treatment potential may be considered in determining the severity of mental status.

Reference

1. Social Security Administration: Federal Old-Age, Survivors and Disability Insurance; Listing of Impairments, Medical Disorders; Final Rule. Fed. Reg. 20 CFR par 404 (Reg No A) 50 (167), 35038-35070, 1985