Many of the symptoms of post-traumatic conditions that produce functional limitations and behaviors are severe but intermittent. For that reason it is critical for adjudicators to consider evidence from non-professional sources in conjunction with evidence from professional sources. It is consistent with the nature of the post-traumatic impairments that particular symptoms might not be consistently present and observable during treatment sessions and/or mental examinations. Nevertheless they can still occur often enough to be severely limiting in employment situations. Examples include intrusive memories, panic attacks, flashbacks, and behavioral disturbances.
Given the presentation of post-traumatic impairments, If adjudicators fail to give serious consideration to evidence from non-professional sources they will likely not have all the information necessary to make accurate findings on the frequency, nature and duration of symptoms as required by 20 C.F.R. 404.1529 and 416.929. Failing to capture accurate symptom information leads to erroneous residual functional capacity determinations, which can in turn result in erroneous decisions.
Example: A person diagnosed with post-traumatic stress disorder experiences flashbacks twice a week and panic attacks once per week on average, which are often witnessed by family members. The professional source who treated the claimant twelve times in the past year has only witnessed the claimant actually having a panic attack or flashback twice during that time.
In that example, an adjudicator should not automatically find that the claimant only has panic attacks or flashbacks twice a year because those are the only ones that a professional source witnessed and reported in the medical record. Guidance should point out that depending on frequency of treatment, it is likely that most such episodes will take place outside of the presence of a professional medical source. Also, people with chronic post-traumatic symptoms manage some of them without going to the hospital or immediately consulting a medical source.
Thus, the adjudicator should carefully consider available testimony from the claimant, family members and friends before making findings regarding the frequency, nature and duration of the symptoms which are related to a post-traumatic impairment. Adjudicators can then consider and determine the extent to which that testimony is supported by and consistent with the evidence as required by SSR 16-3p, always considering the expectedly intermittent nature of such symptoms.
Most behaviors and functional deficits caused by post-traumatic impairments are readily observable and capable of some description by lay persons. A third party might observe that a person having a panic attack was shouting, hyperventilating, or sweating. A person with a flashback might be observed to be non-responsive or reacting to internal stimuli that are not present. A spouse might observe a person with post-traumatic impairment being unable to sleep, or disturbed by nightmares. A friend or family member may observe that a person is often forgetful or distracted.
In children’s cases there are special considerations. For example, symptoms associated with reactive attachment disorder (e.g. rarely seeking comfort when distressed and rarely respond to comfort) may only be available through reports from parents or guardians. In our experience, adjudicators sometimes dismiss or discount allegations of symptoms, even if documented by a medical source, if the allegations are based solely on the reports of parents or guardians. Information about a child’s “failing to seek comfort when distressed” may only be available from a parent or guardian, particularly if a child is not in a school setting. Guidance is needed to stress that any documentation by a medical source of symptoms, even if those symptoms come solely from a parent or guardian, can be sufficient to satisfy a listing or functional equivalence finding in situations where they are the only ones likely to witness the symptom.
Guidance should stress that there are multiple situations in which medical records alone do not adequately capture information relevant to trauma and stressor-related impairments, and information from non-professional sources should be carefully considered.
-Comments from experts at the Institute of Medicine were clear that many treating sources and clinics do not adequately screen for trauma and stressor related disorders.
-Trauma victims are often reluctant to report their trauma especially in cases involving child abuse, domestic violence, and sexual trauma due to fear, perceived stigma and/or feelings of shame.
-There is sometimes a delay in onset of symptoms following trauma
-There are often delays in seeking treatment due to symptoms of the impairment such as dissociation, need to avoid triggers for severe symptoms, lack of control, inability to trust people, and social isolation.
-High comorbidity with other illnesses complicates diagnosis, causes misdiagnosis, and can cause an inconsistent presentation that distracts health care providers and adjudicators.
-Many people with such impairments are impoverished people with limited access to treatment, and it is difficult for them to find evidence-based treatment for these conditions.
-Failure to report trauma or delayed reporting of trauma is also prevalent in child-trauma cases, where there can be a delay or dearth of reporting because it is the parent that has to initiate treatment.
Mental health providers do not often document exactly how often their patients have intermittent symptoms in their medical records. Carefully tracking such things in records is often not considered especially relevant to the treatment of the post-traumatic impairment. For instance, it is rare for a mental health provider to document that a “patient had ten panic attacks since the last visit.” Rather, the record will typically say something like “patient reports panic attacks.” Nevertheless, adjudicators must make a finding of the frequency, intensity and duration of such symptoms in order to properly assess claims and to make accurate residual functional capacity determinations. Given that reality, reports from non-professionals on frequency, intensity and duration of symptoms play a crucial role in providing information upon which adjudicators can make a sound decision. It is important for adjudicators to understand that there is no requirement for treating source records to indicate exactly how often intermittent symptoms occur in order to find a claimant or other non-professional person’s evidence regarding that frequency reasonably supported.