Evaluation of Posttraumatic Stress Disorder

More on Lesser Known Symptoms

What lesser-known symptoms of PTSD might be helpful for adjudicators to know about, and what professional sources support this information?

 

a. Chronic sleep deprivation

Chronic partial sleep deprivation is a known symptom of trauma or stressor related disorders. In our experience adjudicators often misunderstand its effects perhaps due to not fully understanding the impact it can have on function. When we mention chronic partial sleep deprivation, we don’t refer to the infrequent instances of less than adequate sleep that most people have experienced at some point, but rather to situations in which a person frequently experiences a sleep deficit due to a medical impairment without an opportunity to “catch up” on their sleep. This is a common problem in post-traumatic impairments due to chronic nightmares, anxiety, racing thoughts and other causes.

 

Peer reviewed studies show that people with chronic sleep deficits suffer considerably in their ability to maintain attention and concentration and they make significantly more errors on even simple tasks. I have provided SSA with a summary of some major studies documenting the effects of such sleep deficits. Chronic partial sleep deprivation can also reduce physical stamina, pace of work, memory, and other abilities important to maintaining a full-time work schedule. Policy guidance should advise adjudicators of the evidence-based association between trauma and stressor related disorders and chronic sleep deficit, and that it is associated with diminished function in the categories mentioned above. Guidance would assist adjudicators in properly considering such issues when the evidence establishes chronic partial sleep deprivation due to medically determinable impairments.

 

b. Structuring daily activities to avoid stressors and triggers

SSA has issued some guidance on how people with mental illness sometimes structure their daily lives to avoid stressors that might exacerbate symptoms and specific triggers that might bring on particular symptoms. I would urge additional guidance to adjudicators on how that would apply in claims involving post-traumatic impairments.

 

This can be particularly difficult for adjudicators because some people with post-traumatic impairments may function well in a highly structured environment that could not be reproduced in a competitive work situation without substantial disability accommodations. Without guidance, some adjudicators may overlook the highly structured environment and only see that the person is functioning well. Once that occurs, erroneous findings are likely to result at multiple stages of the sequential evaluation process.

 

People with post-traumatic impairments often structure their activities to carefully avoid specific things that remind them of their trauma. Those things can be very particular (a color, being in a room with the door closed, being in a car, etc.). If they are unable to avoid them then debilitating symptoms like flashbacks, panic episodes and behavioral extremes can result. In our experience handling these cases we find that some adjudicators fail to understand that such cases require a highly individualized analysis to accurately determine a claimant’s residual functional capacity. Questions that adjudicators should consider include:

 

-What kind of structured environment (if any) would this person require in order to avoid debilitating symptoms?

-What specific things would trigger severe symptoms, or exacerbate existing symptoms in this case?

 

Residual functional capacity findings should incorporate the answers to those questions. One common problem we see is that adjudicators try to mold what should be very particular individualized limitations into broad, ill-defined categories that do a poor job of depicting the claimant’s actual abilities and limitations.

 

For example, consider a person with a post-traumatic impairment who would immediately experience debilitating panic and/or flashback if left in a room alone with another person, or in a room with all the doors closed. Any residual functional capacity determination that does not incorporate that specific information fails to accurately depict the reality of the claimant’s abilities and limitations. What we find in such cases is that some adjudicators try to mold that kind of information into categories like “only occasional contact with co-workers” and a “low-stress work environment” which are overly broad and vague, and which do not accurately depict the claimant’s abilities and limitations. It would be more accurate to acknowledge that such a claimant could not be in a room alone with another person, or in a room with closed doors, without experiencing extreme mental limitations in attention and concentration, etc.

 

Thank you for the opportunity to comment. Please feel free to contact me if you have any questions.

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Idea No. 205