"Residual Functional Capacity Form - Personality Mental Disorder"

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THESE ARE THE FORMS I USE – THIS IS NOT LEGAL ADVICE AND INTENDED TO
SUPPLEMENT YOUR PARTICULAR FACTUAL SITUATION ONLY – It is crucial you educate
yourself on the Social Security Regulations that define and govern impairments prior to preparing this
form for review. These forms are used to enhance the provider’s understanding of the purpose of the
assessment and the impact of their evaluation. It includes SSA definitions while combining the
traditional SSA standard form.
Affective Disorders most often should be viewed in conjunction with other physical and mental
impairments.
As an attorney or an individual representing yourself it is important to combine multiple diagnoses in
your RFC, if they are present and diagnosed. The Surgeon General estimated that about one half of
those who have a primary diagnosis of major depression also have an anxiety disorder. Comorbidities
of multiple mental diagnoses and combined physical diagnoses are common. Mental diagnoses
include substance abuse, mood disorder and personality disorders, and often combined with physical
illnesses. A federal district court has recognized the mental health disease of schizoaffective disorder
as a combination of schizophrenia and bipolar disorder, resulting in severe changes in mood and some
of the psychotic symptoms of schizophrenia, such as hallucinations, delusions, and disorganized
thinking.
Lee Ann Torrans
RESIDUAL FUNCTIONAL CAPACITY – PERSONALITY MENTAL DISORDER
Name:
SSN:
DOB:
Health Care Provider Name:
Health Care Provider Relationship to Patient:
When First Treated Patient:
How Often Sees Patient:
Primary Diagnosis:
Date of Onset*:
Secondary Diagnosis:
Date of Onset:
Other Impairments:
Date of Onset:
Date of Onset is defined as the first day the claimant meets the definition of disability as defined in the Act and regulations.
Purpose of Medical Evidence and of RFC:
(1) Establish the presence of a medically determinable mental impairment(s),
(2) Assess the degree of functional limitation the impairment(s) imposes, and
(3) Project the probable duration of the impairment(s).
Page 1 of 8
THESE ARE THE FORMS I USE – THIS IS NOT LEGAL ADVICE AND INTENDED TO
SUPPLEMENT YOUR PARTICULAR FACTUAL SITUATION ONLY – It is crucial you educate
yourself on the Social Security Regulations that define and govern impairments prior to preparing this
form for review. These forms are used to enhance the provider’s understanding of the purpose of the
assessment and the impact of their evaluation. It includes SSA definitions while combining the
traditional SSA standard form.
Affective Disorders most often should be viewed in conjunction with other physical and mental
impairments.
As an attorney or an individual representing yourself it is important to combine multiple diagnoses in
your RFC, if they are present and diagnosed. The Surgeon General estimated that about one half of
those who have a primary diagnosis of major depression also have an anxiety disorder. Comorbidities
of multiple mental diagnoses and combined physical diagnoses are common. Mental diagnoses
include substance abuse, mood disorder and personality disorders, and often combined with physical
illnesses. A federal district court has recognized the mental health disease of schizoaffective disorder
as a combination of schizophrenia and bipolar disorder, resulting in severe changes in mood and some
of the psychotic symptoms of schizophrenia, such as hallucinations, delusions, and disorganized
thinking.
Lee Ann Torrans
RESIDUAL FUNCTIONAL CAPACITY – PERSONALITY MENTAL DISORDER
Name:
SSN:
DOB:
Health Care Provider Name:
Health Care Provider Relationship to Patient:
When First Treated Patient:
How Often Sees Patient:
Primary Diagnosis:
Date of Onset*:
Secondary Diagnosis:
Date of Onset:
Other Impairments:
Date of Onset:
Date of Onset is defined as the first day the claimant meets the definition of disability as defined in the Act and regulations.
Purpose of Medical Evidence and of RFC:
(1) Establish the presence of a medically determinable mental impairment(s),
(2) Assess the degree of functional limitation the impairment(s) imposes, and
(3) Project the probable duration of the impairment(s).
Page 1 of 8
RFC is based upon:
1. A comprehensive mental status examination which generally includes a narrative description of
appearance, behavior, and speech; thought process (e.g., loosening of associations); thought content
(e.g., delusions); perceptual abnormalities (e.g., hallucinations); mood and affect (e.g., depression,
mania); sensorium and cognition (e.g., orientation, recall, memory, concentration, fund of information,
and intelligence); and judgment and insight. The individual case facts determine the specific areas of
mental status that need to be emphasized during the examination.
2. Psychological testing. Reference to a "standardized psychological test" indicates the use of a
psychological test measure that has appropriate validity, reliability, and norms, and is individually
administered by a qualified specialist. "Qualified" is defined as a specialist currently licensed or
certified in the State to administer, score, and interpret psychological tests and have the training and
experience to perform the test.
Psychological tests should the specialist's observations regarding the patient’s ability to sustain
attention and concentration, relate appropriately to the specialist, and perform tasks independently
(without prompts or reminders). The test results should include both the objective data and any clinical
observations.
Neuropsychological assessments. Comprehensive neuropsychological examinations may be used to
establish the existence and extent of compromise of brain function, particularly in cases involving
organic mental disorders. Normally, these examinations include assessment of cerebral dominance,
basic sensation and perception, motor speed and coordination, attention and concentration, visual-
motor function, memory across verbal and visual modalities, receptive and expressive speech, higher-
order linguistic operations, problem-solving, abstraction ability, and general intelligence.
In addition, there should be a clinical interview geared toward evaluating pathological features known
to occur frequently in neurological disease and trauma; e.g., emotional lability, abnormality of mood,
impaired impulse control, passivity and apathy, or inappropriate social behavior. The specialist
performing the examination may administer one of the commercially available comprehensive
neuropsychological batteries, such as the Luria-Nebraska or the Halstead-Reitan, or a battery of tests
selected as relevant to the suspected brain dysfunction. The specialist performing the examination must
be properly trained in this area of neuroscience.
Considerations of Mitigating Factors
Chronic mental impairments. 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. If the patient’s life structured in such a way to minimize
stress and reduce symptoms and signs this should be noted. The patient may be more impaired for
work symptoms and signs would indicate.
Effects of structured settings. Chronic mental disorders, overt symptomatology may be controlled or
attenuated by psychosocial factors such as placement in a hospital, halfway house, board and care
facility. Highly structured and supportive settings may also be found at home. Mental demands from
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these environments may reduce overt symptoms and signs of the underlying mental disorder while the
ability to function outside of such a structured or supportive setting may not have changed. The
symptomatology may be controlled or attenuated by psychosocial factors.
Effects of medication. The functional limitations in assessing impairment severity and the effects of
medication on symptoms, signs, and ability to function are considered. Drugs used to modify
psychological functions and mental states may control certain primary manifestations of a mental
disorder, e.g., hallucinations, impaired attention, restlessness, or hyperactivity, such treatment may not
affect all functional limitations imposed by the mental disorder.
In cases where overt symptomatology is attenuated by the use of such drugs, particular attention must
be focused on the functional limitations that may persist.
_________________________________________
Affective Disorders – Circle those symptoms present in patient as indicated below:
12.04 Affective disorders: Characterized by a disturbance of mood, accompanied by a full or partial
manic or depressive syndrome. Mood refers to a prolonged emotion that colors the whole psychic life;
it generally involves either depression or elation.
The required level of severity for these disorders is met when the requirements in both A and B are
satisfied, or when the requirements in C are satisfied.
A. Medically documented persistence, either continuous or intermittent, of one of the
following:
1. Depressive syndrome characterized by at least four of the following:
a. Anhedonia or pervasive loss of interest in almost all activities; or
b. Appetite disturbance with change in weight; or
c. Sleep disturbance; or
d. Psychomotor agitation or retardation; or
e. Decreased energy; or
f. Feelings of guilt or worthlessness; or
g. Difficulty concentrating or thinking; or
h. Thoughts of suicide; or
i. Hallucinations, delusions, or paranoid thinking; or
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2. Manic syndrome characterized by at least three of the following:
a. Hyperactivity; or
b. Pressure of speech; or
c. Flight of ideas; or
d. Inflated self-esteem; or
e. Decreased need for sleep; or
f. Easy distractibility; or
g. Involvement in activities that have a high probability of painful consequences which
are not recognized; or
h. Hallucinations, delusions or paranoid thinking; or
3. Bipolar syndrome with a history of episodic periods manifested by the full
symptomatic picture of both manic and depressive syndromes (and currently
characterized by either or both syndromes);
AND
B. Resulting in at least two of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Marked difficulties in maintaining concentration, persistence, or pace; or
4. Repeated episodes of decompensation, each of extended duration;
OR
C. Medically documented history of a chronic affective disorder of at least 2 years' duration
that has caused more than a minimal limitation of ability to do basic work activities, with
symptoms or signs currently attenuated by medication or psychosocial support, and one of the
following:
1. Repeated episodes of decompensation, each of extended duration; or
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2. A residual disease process that has resulted in such marginal adjustment that even a
minimal increase in mental demands or change in the environment would be predicted
to cause the individual to decompensate; or
3. Current history of 1 or more years' inability to function outside a highly supportive
living arrangement, with an indication of continued need for such an arrangement.
"
Marked" is defined as a standard for measuring the degree of limitation, it means more than
moderate but less than extreme. A marked limitation may arise when several activities or functions
are impaired, or even when only one is impaired, as long as the degree of limitation is such as to
interfere seriously with ability to function independently, appropriately, effectively, and on a
sustained basis. See §§ 404.1520a and 416.920a.
Impairment Definitions:
(1) No impairment
(2) Mild impairment: No significant interference with the ability to perform basic work-related
activities
(3) Moderate impairment: Significant interference with the ability to perform one or more basic
work-related activities
(4) Marked impairment: Very significant interference with the ability to perform one or more
basic work-related activities
(5) Severe impairment: Inability to perform one or more basic work-related activities.
Mental Abilities of Patient
UNDERSTANDING, CARRYING OUT, AND REMEMBERING SIMPLE INSTRUCTIONS
Mild
Moderate
Marked
Severe
No
Impairment
Impairment
Impairment
Impairment
Impairment
The ability to remember locations
and work-like procedures.
The ability to understand and
remember very short and simple
instructions.
The ability to carry out very short
and simple instructions.
The ability to maintain concentration
and attention for extended periods
(the approximately 2-hour segments
between arrival and first break,
lunch, second break, and departure).
The ability to perform activities
within a schedule, maintain regular
attendance, and be punctual within
customary tolerances.
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