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 overtime. 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 brain-function 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 articular 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.