Dear Social Security Administration:
Thank you for the opportunity to provide comments on the following three questions about evaluating Post-traumatic Stress Disorder and other trauma and stressor disorders. CLS agrees with the comments offered by Kevin Liebkemann and Emilia Sicilia.
1. How should we consider evidence about a claimant’s behavior and functioning from non-professional sources, such as parents or friends?
Adjudicators should be instructed to seek out and seriously consider functional evidence from non-professional sources for claimants who are diagnosed with trauma and stressor related disorders in conjunction with evidence from professional sources.
There can be many impediments to getting sufficient evidence of trauma based impairments due to the nature of those impairments. Many of the symptoms of trauma and stressor related disorders are intermittent. Moreover, is well documented that many who suffer from trauma and stressor related disorders are reluctant to report about their traumatic experiences and may experience innate terror associated with even discussing the traumatic experience, limiting self-revelation.
Because medical professionals frequently rely on self-reports, there may not be professional sources that have observed or documented all of the trauma symptoms a particular claim. In those circumstances, reports from observant others can be extremely useful. In order to get a complete picture of the nature or duration of trauma symptoms, it is important that information from non-professional sources be sought out and seriously considered in order to allow adjudicators to have all the information available to make accurate determinations about the nature of a claimant’s symptoms.
The need to look to non-professional sources may be particularly important in children’s cases. Symptoms of trauma-based impairments, like reactive detachment disorder, may only be available from reports from parents or other care givers. A good best practice would be for adjudicators to seek out reports about functioning from those who have the most interactions with a child including teachers, parents and other care givers.
In our experience, adjudicators sometimes dismiss or discount allegations of symptoms, even if accepted and documented by a medical source, if the allegations are based solely on reports by a parent, guardian or other family member. Those medical sources frequently base their diagnosis and evaluation on the observations of those who know a child best, namely parents/guardians. Guidance should stress that any documentation by a medical source of symptoms, even if that documentation is based on a report from a parent/guardian/family member or the claimant can be sufficient to satisfy a listing or functional equivalence finding. It certainly should not be dismissed merely because the medical source has followed the norms of the profession in reaching an opinion.
2. What lesser-known symptoms of PTSD might be helpful for adjudicators to know about, and what professional sources support this information?
1. Chronic Sleep Deprivation
Many individuals who suffer from trauma-based impairments have chronic partial sleep deprivation. In our experience, adjudicators often misunderstand and minimize the effect that chronic sleep deprivation can have on overall function. Chronic partial sleep deprivation can significantly impair functionality: limiting someone’s ability to maintain attention and concentration, reduce physical stamina, cause them to be irritable and anti-social, reduce their ability to persist in working, especially for a full eight hour day and reduce pace of work. Guidance should educate adjudicators about the association between chronic partial sleep deprivation, trauma, and impaired functionality.
2. Avoidance of triggering circumstances
The DSM-V instructs that “[s]timuli associated with the trauma are persistently (e.g., always or almost always) avoided. The individual commonly makes deliberate efforts to avoid thoughts, memories, feelings to talking about the traumatic events . . . and to avoid activities, objects, situations, or people who arouse recollections of it.” AM. PSYCHIATRIC ASSN., DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 275 (5th Ed. 2013). In our experience, consistent with the DSM-V, many individuals with trauma or stressor related impairments structure their lives in order to avoid situations that will trigger their symptoms. But it can be hard to detect how someone is structuring their life to avoid trauma symptoms, without deep inquiry. Accordingly, it is important for adjudicators to realize that the absence of serious trauma related symptoms does not mean that someone is not seriously limited by a trauma or stressor related impairment – but merely means the symptomology is different. For example, instead of experiencing flashbacks, a claimant may be unable to get their own groceries in a store. Guidance should instruct adjudicators to inquire deeply into what a claimant can or cannot do because the functional limitations of their disorder (i.e., not being able to go to a doctor, not using an oven, avoidance of loud noises, large numbers of people or people of a particular kind (such as males in the case of rape victims), refusing to leave the house and covering the windows with trash bags) in order to evaluate all the relevant symptoms. Moreover adjudicators should be aware that some of these avoidances can be quite debilitating – a rape victim, for example who cannot interact with males may go to unusual means to avoid even the possibility of encountering someone who reminds her of her rapist, even if she might be able to avoid such encounters most of the time.
3. Dissociative symptoms
Individuals with trauma and stressor related disorders frequently experience dissociative symptoms that make it difficult to recall/report a trauma. AM. PSYCHIATRIC ASSN., DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 275 (5th Ed. 2013). As a result, some will avoid reporting the trauma completely, or provide inconsistent accounts of the trauma. Although such symptoms are widely acknowledged, in our experience adjudicators do not recognize or understand such symptoms. For example, a person who suffered a trauma or complex trauma may delay in reporting that trauma and then when they do report that trauma, may report slight differing stories on different days, or to different providers. In our experience, adjudicators frequently find that inconsistent retellings of a trauma undermines the claimant’s credibility instead of acknowledging that such inconsistencies are actually a symptom of the impairment. Guidance should educate adjudicators about dissociative symptoms to ensure they are being properly evaluated.
Adjudicators should also realize the shame that many victims experience. Many victims are reluctant to talk about their experience and are ashamed that they did not immediately put a stop to their abuse, especially if it began in childhood. The fact that such abuse was not reported at first or even for quite a long time is not probative. Failure to report abuse to a doctor on the first encounter is not surprising and should not be relied upon as evidence that such experience of trauma or traumatic symptoms did not take place.
4. Early substance abuse
In our experience, in keeping with the DSM-V, many trauma victims, particularly those who were subjected to abuse as children, self-medicate and engage in substance abuse at an early age. Some of these individuals experienced the trauma before they were old enough to properly label it as such – and have a hard time acknowledging it. Accordingly, early substance abuse should be viewed as a red flag for a possible trauma or stressor related impairment. It should never be considered as causing the stress related disorder, even though it might adversely affect overall function.
5. Distracting nature of flashbacks
Auditory pseudo-hallucinations, or flashbacks, are a symptom of trauma or stressor based disorders. AM. PSYCHIATRIC ASSN., DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 276 (5th Ed. 2013). Flashbacks can be terrifying when they occur, but also cause persistent agitation after they have passed, sometimes even after the person as “calmed” down. The flashbacks can also cause residual terror anticipating that they will return unexpectedly, causing hypervigilance. This residual terror can cause additional avoidance, leading to a cyclical decrease in concentration, followed by hyper-awareness, which can make routine tasks difficult.
In our experience, although adjudicators and vocational experts acknowledge that some claimants have such symptoms, they do not fully appreciate how distracting a flashback can be. For example, some adjudicators will find that a claimant is only limited by a flashback or hallucination for the period of time the hallucination lasts. Thus, if a person claims to have a daily flashback that lasts around five minutes, some adjudicators will evaluate this symptom is a minor distraction. It is important that guidance educate adjudicators that the functional limitations caused by a flashback or hallucination may last much longer than the flashback itself.
3. What indicators can be used to rule out PTSD as an impairment, and what professional sources support this information?
Because intermittent symptoms and delayed reporting can make it harder to assess the existence of a PTSD, it may also be harder to rule it out. Notably, even when someone does not meet a PTSD diagnosis, they may have similar symptoms related to another trauma or stressor related disorder. We recommend that the Social Security administration develop and promulgate Medical Report form, similar to the Medical Adult with Allegations of Human Immunodeficiency Virus form to assist Social Security Administration staff and medical providers in soliciting information about all the relevant symptoms. Such a form may also assist in ruling out PTSD.