Health and Psychology

Head injuries are classified as mild, moderate, or severe based on length of loss of consciousness.  There is no concussive injury that should not be taken seriously.  So the attorney that asked me in court "Your injury was only mild right?" didn't seem to understand that even a so-called "mild" head injury can produce significant and life-altering symptoms.  

The Center for Disease Control uses this definition:

• A case of mild traumatic brain injury is an occurrence of injury to the head resulting from blunt trauma or acceleration or deceleration forces with one or more of the following conditions attributable to the head injury during the surveillance period:
• Any period of observed or self-reported transient confusion, disorientation, or impaired consciousness;
• Any period of observed or self-reported dysfunction of memory (amnesia) around the time of injury;
• Observed signs of other neurological or neuropsychological dysfunction, such as—
• Seizures acutely following head injury;
• Among infants and very young children: irritability, lethargy, or vomiting following head injury;
• Symptoms among older children and adults such as headache, dizziness, irritability, fatigue, or poor concentration, when identified soon after injury, can be used to support the diagnosis of mild TBI, but cannot be used to make the diagnosis in the absence of loss of consciousness or altered consciousness. Further research may provide additional guidance in this area.
• Any period of observed or self-reported loss of consciousness lasting 30 minutes or less.

The definition focuses on the actual injury or symptoms, not the possible consequences. For many people, there are challenges in getting an accurate diagnosis and treatment, especially when there is no documented or observed loss of consciousness. There does not need to be a loss of consciousness for a brain injury to occur.

Severity of Brain Injury

Emergency personnel typically determine the severity of a brain injury by using an assessment called the Glasgow Coma Scale (GCS). The terms Mild Brain Injury, Moderate Brain Injury, and Severe Brain Injury are used to describe the level of initial injury in relation to the neurological severity caused to the brain. There may be no correlation between the initial Glasgow Coma Scale score and the initial level of brain injury and a person’s short or long term recovery, or functional abilities. Keep in mind that there is nothing “Mild” about a brain injury—the term “Mild” Brain injury is used to describe a level of neurological injury. Any injury to the brain is a real and serious medical condition. There is additional information about mild brain injury on our mild brain injury page

Glasgow Coma Scale (GCS)

The scale comprises three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person). A GCS score of 13-15 is considered a "mild" injury; a score of 9-12 is considered a moderate injury; and 8 or below is considered a severe brain injury.

Mild Traumatic Brain Injury (GCS of 13-15)

Some symptoms of mild TBI include:

• Headache
• Fatigue
• Sleep disturbance
• Irritability
• Sensitivity to noise or light
• Balance problems
• Decreased concentration and attention span
• Decreased speed of thinking
• Memory problems
• Nausea
• Depression and anxiety
• Emotional mood swings 

Moderate Brain Injury (GCS of 8-12)

A moderate TBI occurs when there is a loss of consciousness that lasts from a few minutes to a few hours, when confusion lasts from days to weeks, or when physical, cognitive, and/or behavioral impairments last for months or are permanent. Persons with moderate TBI generally can make a good recovery with treatment and successfully learn to compensate for their deficits. 

Severe Brain Injury (GCS Below

Severe brain injury occurs when a prolonged unconscious state or coma lasts days, weeks, or months. Severe brain injury is further categorized into subgroups with separate features:

• Coma
• Vegetative State
• Persistent Vegetative State
• Minimally Responsive State
• Akinetic Mutism
• Locked-in Syndrome

Following a concussive injury the person remains at risk for seizure for a period of 18 months.  To lessen risk of seizure or a second head injury the following are recommended:.  

1. No alcohol use for the 18 month period post injury  
2. No activities that increase the risk of a second injury --horseback riding, motor cycle riding, roller coaster riding, sledding, skiing, etc. 
3. Limit use of caffeine.  
4. No return to contact sports until all symptoms of post-concussion have resolved 
5. No activities at height-standing on ladder or chair.

Post Concussive Headaches 

These headaches are of migraine intensity, but are not vascular (the hands do not get cold).  There is no effective treatment.  These occur as a result of sheering injuries and tearing of nerves and nerve fibers.  Many people notice improved functioning following these headaches.

Memory Loss and Paranoia

Memory loss produces a sense of helplessness and confusion.  Sometimes when people do not realize they have a brain injury, they believe other people are hiding their things, lying to them, or trying to make them feel confused.  Labeling items and where they go, having a routine, using a system to track items, and assistance with evaluating thinking like Cognitive Behavioral Therapy, can help people manage memory difficulties.

Depression and Anxiety

In right handed people left hemisphere injuries tend to produce depression, while right hemisphere injuries tend to produce anxiety.  Most right handed people with left hemisphere injuries know something is wrong and may complain of forgetting things, being emotional, having difficulty with speaking, writing or understanding people.  This sense of something being wrong, knowing it is, and feeling helpless can lead to feelings of depression.

In right handed people right hemisphere injuries tend to produce anxiety.  These people may not recognize any changes following the injury but are not able to do things they once were able to do.  Since the difficulties are not as easily recognized there is a vague sense of something being wrong, but no clear idea of what it may be.  It' only when they attempt to do a task they used to be able to do and can't that they get upset. Mindfullness, meditation, or returning to an easier and well matered task may lessen anxious symptoms.  

Long term changes

In severe or moderate head injuries, or multiple mild head injuries there may be changes that occur with blood pressure, blood sugar, and hormonal changes.  It's not unusual to find heart attacks or strokes following severe or moderate brain injuries.  The development or worsening of diabetes, thyroid or immune problems are also noted.  Seizures may be a complication of head injury.  

Improvement

Most brain injuries improve significantly over the first several years.  While the person may not get back to who they were and how they functioned prior to their injury or accident, they improve significantly from the initial days after the injury.  

Cognitive rehabilitation can be extremely helpful in recovery.  Psychological counseling and interacting with other people with head injury can also be helpful.

I do a lot of psychological and neuropsychological testing.  I'm often asked to do screenings instead of psychological evaluation.  In many cases that's adequate.  But in other cases it leads to an inadequate and incorrect diagnosis.  

Schools, psychiatrists, general medical doctors, and pediatricians do a lot of screening measures.  These are often checklists, questionnaires, and other self-report measures that people complete themselves or on behalf of someone else.   These are great as an initial step in trying to figure out how to appropriately diagnose and treat someone.  The problem comes when these are used as stand alone evaluations, and the person is not responding to the "appropriate" treatment.  The problem is often that these measures are inadequate and another condition is causing the problems.

Because I see people that are either not diagnosed or not responding to treatment, the first thing I do is start an evaluation with a history, laboratory reports, review of any testing that has actually been done, and a review of any checklists that have been completed.  Often I can compile enough information to document what is going on and then do a specific test to rule in or out a condition.  In other cases I have to do a battery of tests to make that determination.

Let me provide two cases:

Johnny is not focusing or paying attention in school.  The teacher suggests an evaluation and treatment for ADHD.  A pediatrician sends home a Connor's checklist for the parent and teacher to complete.  It comes back positive for ADHD and a medication is prescribed.  Two weeks later, the child is now more irritaable, not sleeping, losing weight, crying often, and still not paying attention.  Rather than revisit the evaluation, the doctor either adds a new medication, or increases the dose of the original.   Behavior problems continue and eventually the child gets an adequate evaluation.

The first thing I'm going to do with Johnny is to take a history.  This will include information on the pregnancy, birth and delivery.  I'm going to take a history of attention difficulties and when they started.  I'm going to attempt to confirm the ADHD diagnosis with a continuous performance test-either a Connor's CPT or a TOVA CPT.  These are computer based tests that measure reaction times.  If that comes out positive I'm going to review the diet and the response to medication.  I'll give information back to the prescribing doctor about more effective methods to help Johnny attend in school.  I may also suggest things like preferential seatig, a study space free of distractions, extra time on assignemnts and tests, a more organized space to study, and a plan for managing homework.  

If it comes out negative then I'm going to do more testing.  The Wechsler Intelligence Scale for Children 5th Edition will allow me to look at cognitive functioning in several domains.  If that shows significant scatter I may do some more testing or I may refer out for a neurological work-up.  

So in several cases as mistaken ADHD diagnoses what came up on testing?

• Parietal lobe disorders from birth trauma or head injury.
• Depression
• Seizure disorders
• Malnutrition
• Sleep disorders
• Medical conditions
• Genetic disorders

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Apart from the topics of sex, religion, politics, or money, nothing generates more controversy than food.  At this time of year lots of people have food "issues."  I visited in-laws for the annual Christmas party, with the vegan, vegetarian, gluten free, raw, non-dairy, plant only, fruit only, nut free, chocolate heavy, alcohol free, alcohol included, the e-cig and "I can't eat anything post bariatric surgery" group of relatives gathered.  The difference between the success of this get-together, is a simple rule:  If you have the need to have a special food, bring it.  Make enough to share with the group if you'd like.  There was enough to go around for everyone.  

There were two people who were new to the group.  They were friends of relatives.  So when one of my cousins started munching on chocolate spoons designed to be used to flavor hot chocolate or coffee, one of these friends explained she "shouldn't just eat it."  Certainly not before dinner, and not without stirring it in some hot liquid. And this being California, and our group knowing the rules, said "It's hers.  She gets to do whatever she wants with it."  

For those of you wanting to attempt to accommodate people coming to eat who may have diatary rules or "food issues"  Here are some ideas:

1. Ask if anyone has a serious health allergy than can produce difficulty breathing.  Ensure than any food containing a potential allergen is labelled.  If you are the person with a severe allergy, bring your own food.  Shellfish and nut allergies are common so for hlidays you may want to skip those ingredients.
2. Bring your own special food.  You already know what you can and can't eat.  Bring the things you can eat to the party.
3. Gluten Free:  These are people for dietary reasons or medical conditions like Celiac or Hartnup disorder need to avoid foods containing gluten.  This includes foods with wheat, oat, rye, or barley.  But wheat is used as a thickener in things like salad dressing, frozen hash browns, and soy sauce.  Foods labelled Gluten Free have no gluten.  
4. Vegan:  Vegans do not eat meat, fish, or poultry, or any animal derived products.  Someone in my family said, "If it has a face now or ever I'm not eating it."
5. Vegetarian:  There is a range of people who call themselves vegetarian.  Some people are essentially vegans and add dairy products and eggs.  A few add fish and poultry.  All have a heavy plant based diet including foods like tofu.  If someone tells you they are vegetarian they certainly do not eat meat.  The rest of the food groups are optional depending on the type of vegetarian.
6. Paleo Diet:  Whole unprocessed foods that look like they do in nature. They eat: Meat, fish, eggs, vegetables, fruits, nuts, seeds, herbs, spices, healthy fats and oils. They avoid: Processed foods, sugar, soft drinks, grains, most dairy products, legumes, artificial sweeteners, vegetable oils, margarine and trans fats.
7. Post-Bariatric Surgery Diet:  Phase One: 2-3 ounces of broth, strained soup, unsweetened juice, sugar free gelatin.  Phase Two: Pureed foods.  Phase Three: Soft solid foods.  Phase Four: solid food avoiding: Nuts and seeds, popcorn, dried fruits, sodas and carbonated beverages, granola, stringy or fibrous vegetables, such as celery, broccoli, corn or cabbage, tough meats or meats with gristle, or breads.
8. Raw Food: Foods generally eaten raw or cooked at temperatures below 118 degrees.  Some foods need to be soaked or sprouted to make them safer to eat.  A raw food diet requires a lot of meal preparation unless it's mainly nuts, seeds, and fruits.  Kidney beans, fava beans and soy beans are considered unsafe to eat raw.
9. If you are eating out at a restaurant, you may want to call ahead and ensure that the chef can manage any special dietary needs you may have.  In California these requests are very common.  Not so much in other states.

There are moments in history were you realize that something important is taking place. A woman being knocked unconscious and dragged out of an elevator. A football player beating his 4 year old with a switch. And now with the backdrop of 15 women indicating they had been drugged and raped by Bill Cosby in the 1980’s, and the abduction, rape and murder of Hannah Graham, the Rolling Stone article on rape on college campuses Rolling Stone article, http://www.rollingstone.com/culture/features/a-rape-on-campus-20141119 highlighting acquaintance rape and what actually happens with post-traumatic stress disorder is one of those important moments. While the article is about UVA, there are lots of college campuses where acquaintance rape is a common occurrence. Perceptions about rape trauma are changing. Just last year US News questioned whether rape was that big of a deal on college campuses. http://www.usnews.com/opinion/blogs/economic-intelligence/2013/10/24/statistics-don't-back-up-claims-about-rape-culture. This is very similar to the 1980’s where child abuse cases were actually starting to be prosecuted and people started to understand that beating a child was wrong.

The Rolling Stone article is unflinching in the description of the horror, the complicity of large groups of people who do not want to believe this happens, and in accounts of the re-victimization of the women involved.

The new DSM-5 has downgraded the diagnosis of Post-Traumatic Stress Disorder to make it not survival of a life-threatening event such as rape, or the witnessing of a horrific event such as someone burning to death, but now includes hearing about such an event. So if someone says they read about an event and it bothered him or her, they can now be diagnosed with Post-Traumatic Stress Disorder. This downgrading of trauma minimizes actual life-threatening trauma.

I sit in my office evaluating a woman who has a tattoo of a bracelet on her wrist, except it’s too low for where a bracelet would be worn. As I look at it I realize it covers ligature marks. There’s a history of drug and alcohol abuse, but in more recent years she’s gotten sober. She now works with women trying to get sober in a residential treatment facility. She didn’t mention child abuse or rape trauma. But I know to ask.

I’m evaluating a man who looks much younger than he actually is. He’s my age. Child abuse laws weren’t on the books in California until 1974. He left home at 17. He has trouble getting along with anyone in authority. He’s had a history of broken bones-“from fights.” He had no medical treatment. He would have been 8 or 9 years old. I just ask if it was from his father or mother. “My father” he says. He’s had years of therapy, 3 failed marriages, countless jobs that ended in him being fired. But I’m the first person who asked, so the first person he’s told.

My own history of child abuse at the hands of my adoptive mother has been described as child torture by a couple of therapists. I’ve had decades of therapy and have written an unpublished memoir about it. I’ve spoken publicly about my acquaintance rape back in the 1980’s. I knew him in high school. We were dating. We’d had consensual sex. There was a rumor he had raped someone he was dating, but I didn’t believe the rumor. He’d never do anything like that, I thought. But he did. And I came to find out I was his fourth victim. I was lucky. My injuries weren’t severe. He and I discussed what happened with me holding a knife for my protection. He agreed never to see me ever again. I agreed not to hunt him down. I’d already talked to a friend who was a police officer and a friend who was an attorney. “These kinds of cases do not hold up well in court,” they told me. I know why people don’t report. I’ve never seen him again.

One of my psychological assistants and I were talking about the Bill Cosby situation. At 6 or 7 women, I’d be prepared to say it might not have happened. But at now 16 there are simply too many. http://www.washingtonpost.com/lifestyle/style/bill-cosbys-legacy-recast-accusers-speak-in-detail-about-sexual-assault-allegations/2014/11/22/d7074938-718e-11e4-8808-afaa1e3a33ef_story.html The statute of limitations has run out. There’s nothing to gain by them coming forward. The stories are fairly similar. http://www.washingtonpost.com/wp-srv/lifestyle/bill-cosby-timeline/ So yes I believe it happened.

The second abduction and murder at UVA brought the gang rapes at the fraternities to a tipping point. False reports of rape are not uncommon, but false accusations of rape are relatively rare. An average rapist is an acquaintance rapist and has about 6 victims. Some, obviously have many more.

"Can you test me?"  I get this question often.  It comes in a variety of forms.  "Can you test me for _____?"  and "Can you test my child for _____?"

The short answer is yes probably.  The longer answer is "Then what?"  And it's the answer to that question that tells me what to do.

I literally have hundreds of tests, measurements, screening items, and questionnaires.  Literally.  I bought new file cabinets to hold them all and will probably need to buy more.  Online I have access to thousands.  So knowing these tests I have to select the correct test or tests to measure the correct things in the best way possible.  

Let me give an example:

Example 1:  "Can you test my child for ADD/ADHD?"

Yes, probably then what?  If you now know your child has ADD/ADHD then what happens?

"Oh I want them to get special accommodations for school."  

Oh okay.  That's a 40 to 60 page forensic report designed to go to an Administrative Law Judge who specializes in Special Education law and Disability Law under the Americans with Disabilities Act.  It's a 10 hour evaluation documenting the need for special accommodations and what happens if accommodations are not provided. It's set up as a repeaed measures experiment with a single subject under accommodating and non-accommodating conditions.

Example 2:  "Can you test my child for ADD/ADHD?"

Yes, probably then what?  If you know your child has ADD/ADHD then what happens?

"Oh, I'll take them to a psychiatrist for medication."

Oh Okay.  I have a continuous performance test that will do that.  It's about an hour.  I can give you a rating form for your child's teacher to complete so the psychiatrist can track the response to medication.  We can also retest your child under medication to ensure that inattention is eliminated with medication.

Example 3.  "Can you test my child for ADD/ADHD?"

Yes, probably then what?  If you know your child has ADD/ADHD then what happens?

I want to make sure they have it.  I want to know what it's doing to them.  I'm not looking for medication, but maybe some form of rehabilitation to help them.  

Oh okay.  I have a continuous performance test that can tell me within a great deal of certainty if your child has an attention difficulty.  I can do an cognitive test that will tell me if their working memory is impacted as I would expect it to be in an attention disorder.  I can also do some testing of executive dysfunction.  I'll need a copy of their last complete physical with standard complete blood count laboratory results and metabolic panel. I also want their oxygen saturation level documented.  That will allow me to rule out most medical conditions that can contribute to inattention.  It will take 3-4 hours, and wil include a 10 to 12 page report.  I can then talk with you about rehabilitation and various options available.

So all three start off with the exact same question.  But they want different things after the question is answered.  Knowing what they want next changes what I do to address those issues.

Here's a final example:  "Can you test my child for ADD/ADHD?"

 Yes, probably then what?  If you know your child has ADD/ADHD then what happens?

I'd like early intervention.  Right now my child is 6 months old.  

ADD/ADHD doesn't get diagnosed at this age in children.  I can evaluate cognitive, language and motor skills in very young children, down to preterm infants in a neonatal intensive care unit.  So I can tell you how your child is doing compared to other children at 6 months.  Early intervention services are generally done for cognitive delay or deficits in language skills or motor skills.  The evaluation will take about an hour or so.  I need birth records and recent laboratory records. If there is an issue at this age with alertness, visual tracking, attending to the environment, or motor movements, your child may qualify for services by Regional Center.  My report can help to document any delays your child may have.  

If you are interested in an assessment, feel free to contact our office. 

DSM 5 the Psychiatric Diagnostic and Statistical Manual of Mental Disorders is out and updates are available online.  The problem is that it's moving away from research based epidemiological discussions about diagnoses and moving more into checklist based diagnoses, based on rating scales and observations of "people who know the individual, or the individual themselves."  

So what's the problem?

Here are case examples from just the last couple of weeks (some details are changed to maintain privacy).  

• A child with a known brain injury is misdiagnosed with ADHD.  They have a known parietal lobe injury.  Medication, especially stimulant medication, is likely to have a negative effect. They have no executive dysfunction.  It certainly won't contribute to rehabilitation, and the trials of medication and side-effects will post-pone or neglect rehabilitation efforts.
• A child is diagnosed with Autistic Spectrum Disorder (ASD) based on a rating scale.  On formal evaluation, the child has evidence of a brain injury (TBI).  The prognosis and the impact of cognitive rehabilitation are very different between TBI and ASD.
• A child is diagnosed with Autistic Spectrum Disorder.  What they actually have are absence seizures.
• An adult is diagnosed with bipolar disorder.  What they actually have is a personality disorder-borderline personality disorder.  Medication may keep some symptoms in check, but it won't change core personality structure like several forms of evidenced based psychotherapy will. 
• An adult is diagnosed with schizophrenia.  What they actually have is post-traumatic stress disorder. (It would be nice if some physicians actually understood hallucinations, flashbacks, symptoms from sleep disturbance, and medical conditions and took an adequate history).
• An individual diagnosed with depression actually has a rapidly growing brain tumor.  This is potentially a fatal misdiagnosis.
• An individual diagnosed with a personality disorder actually has thyroid cancer.  This is a potentially fatal misdiagnosis.
• An individual diagnosed with depression actually has a massive septic infection. This is potentially a fatal misdiagnosis.
• An individual diagnosed with anxiety and depression actually has obstructive sleep apnea.  Medication for anxiety and depression will not help until the oxygen levels are improved.

So I was on a social networking site for mental health professionals and a colleague mentioned he just got iPads for testing and wondered what was available.  So here goes.

Let me start with simple things that don't require an iPad and can work on an iPhone.  They may be on Google or Android as well but I don't have those.

1.  PAR Toolkit.  This includes the Normal Curve, a Conversion Chart, an Age Calculator, a Stop Watch, a Compliancy Calculator, a QR Code Scanner.  It includes a link to assessments for purchase.

2.  MMSE-and MMSE-2 Also by PAR.  These are mental status examinations.

3.  BRIEF-also by PAR-a rating of executive Function with a conversion to convert raw scores into scaled scores

4. NEO-also by PAR-a personality inventory

5.  The PAI also by PAR also for personality.

6.  What U see-by Baltronic a measure of visual acuity

7.  What U hear-by Baltronic-a measure of auditory acuity

8. SCAT-2-Standardized Assessment of Concussion and Maddocks questions for sideline concussion assessment.

9.PAR-CARR-Concussion Recognition and Response

10.  CCT-CoOccurring Conditions for TBI. This is a great little appication to help people with traumatic brain injury ensure other conditions aren't missed. it's by DCoETBI it links to medications, patient education, provider websites and DSM-IV-TR.

11. Novopsych-application for testing.  These are generally public domain tests all together in a single application.

12. Pearson-Q-interactive.  Requires two iPads.  I tried this, but it felt too excessive for working with an SSD population.  I have it for my office, but if the internet isn't working you still need paper.

13. OSMO-this is a game that uses the ipad and regular paper or a table, that allows the person to be able to manipulate things in front of the iPad like Tangrams, drawing, and words.  Nice for rehabilitation and to describe what difficulties some people have.

14. Personality Types by Radiance House-16 personality type assessment for helping with team building or career counseling.

15.  TOMS-Therapy Outcome Management System, a pre and post measure of how treatment is going session by session.

All reports written by a psychologist are NOT psychological evaluations.  The vast majority of evaluations are brief, question specific evaluations that are extremely limited in scope.  Many of these reports state in the opening paragaph that they are not to be misunderstood as a psychological evaluation.  These kinds of reports include things like evaluations for employment or appeals of psychological evluations done for employment, specific test result reports, single issue reports and something referred to as a consultative examination for social security disability.

I spend a couple days a week working for a company doing social security disability evaluations.  I also spend time in my clinical practice doing psychological and forensic evaluations.  My main forensic reports have to do with school and test accommodations for disability (forensic means law) and the reports can eventually go to an administrative law judge.  My psychological evaluation reports generally go to a treating therapist or physician.  Consultative Examinations performed by a psychologist for the Disability Determination Service are very different from other types of evaluation.  They are very brief, and are focused on functional impairment for the purpose of employment.  They are simply one piece of documentation used by a Disability Analyst to make a determination of disability.

My Consultative Examinations involve administering psychological tests provided to me by the Disability Analyst.  I do NOT choose the tests.  so if you ask me why I'm doing a specific test, my answer is "Because it's on the list."  I have limited to no records about a person I'm evaluating for SSD.  

The people I evaluate are not clients or patients.  I refer to them as claimants.  I usually ask a claimant to complete a four page intake form that gives me some basis for attempting to understand test scores on which to base recommendations about functional limitations to work.  I'm also not allowed to get information from other sources, because that information isn't mine to evaluate.  That information is to be sent to the Disability Analyst so they can evaluate it and consider it in their determination.   Unless the Disability Analyst has sent the information to me, I'm not supposed to consider it in my evaluation.

The issue of fraud, faking symptoms, exaggerating symptoms, or just magnifying symptoms is a HUGE issue that makes everyone involved in Social Security Disability very frustrated.  Estimates on the degree of obvious fraud range from 2% to upwards of 50% of disability applicants.  I the 5 clinics I work at currently, the average is 20%.  So about 1 in 5 applicants is reporting symptoms that are so significantly exaggerated that I suggest the Fraud Unit of social security investigate the claim.  A much larger percentage are putting forth a very poor effort.  An unusual problem also exists where people do not believe they are disabled and try to perform better than they should.  This appears to happen for a couple of reasons.  First, they were talked into applying for Social Security Disability and thought they'd automatically be denied and now are going through an evaluation.  Second, they've had SSD as children and are now adults trying to show they don't need to have a payee for benefits.  Third, they are recently diagnosed and are cognitively impaired and didn't really understand there was a problem.  These people can fall apart during testing as they come to realize they can't do some tasks.  What I advise everyone applying for disbility is to simply do their best on the evaluations.  Exaggerating or fabricating symptoms just limits how much self-report information from the claimant can be used or relied on.

My average forensic report for disability accommodations for a school or a test runs 50 pages or so and has a table of contents and an executive summary.  My average SSD Consultative Examination report runs 6 pages.  There's quite a difference.  My intake form for a disability accommodation report is 11-21 pages, not the 4 page form for SSD.   It's a very brief history.  

The questions for Social Security are the following:

• Can this person follow simple instructions?
• Can they follow detailed instructions?
• Can they pay attention and concentrate?
• Can they follow safety rules?
• Can they show up to work and remain at work for a work-day?
• Can they get along with other people?
• Can they manage their benefits?
• Is the person compliant with treatment and/or medication?
• If their symptoms are due to a drug or alcohol problem will they improve if they stop abusing substances?

All reports written by a psychologist are NOT psychological evaluations.  The vast majority of evaluations are brief, question specific evaluations that are extremely limited in scope.  Many of these reports state in the opening paragaph that they are not to be misunderstood as a psychological evaluation.  These kinds of reports include things like evaluations for employment or appeals of psychological evluations done for employment, specific test result reports, single issue reports and something referred to as a consultative examination for social security disability.

I spend a couple days a week working for a company doing social security disability evaluations.  I also spend time in my clinical practice doing psychological and forensic evaluations.  My main forensic reports have to do with school and test accommodations for disability (forensic means law) and the reports can eventually go to an administrative law judge.  My psychological evaluation reports generally go to a treating therapist or physician.  Consultative Examiinations performed by a psychologist for the Disability Determination Service are very different from other types of evaluation.  They are very brief, and are focused on functional impairment for the purpose of employment.  They are simply one piece of documentation used by a Disability Analyst to make a determination of disability.

My Consultative Examinations involve administering psychological tests provided to me by the Disability Analyst.  I do NOT choose the tests.  so if you ask me why I'm doing a specific test, my answer is "Because it's on the list."  I have limited to no records about a person I'm evaluating for SSD.  

The people I evaluate are not clients or patients.  I refer to them as claimants.  I usually ask a claimant to complete a four page intake form that gives me some basis for attempting to understand test scores on which to base recommendations about functional limitations to work.  I'm also not allowed to get information from other sources, because that information isn't mine to evaluate.  That information is to be sent to the Disability Analyst so they can evaluate it and consider it in their determination.   Unless the Disability Analyst has sent the information to me, I'm not supposed to consider it in my evaluation.

The issue of fraud, faking symptoms, exaggerating symptoms, or just magnifying symptoms is a HUGE issue that makes everyone involved in Social Security Disability very frustrated.  Estimates on the degree of obvious fraud range from 2% to upwards of 50% of disability applicants.  I the 5 clinics I work at currently, the average is 20%.  So about 1 in 5 applicants is reporting symptoms that are so significantly exaggerated that I suggest the Fraud Unit of social security investigate the claim.  A much larger percentage are putting forth a very poor effort.  An unusual problem also exists where people do not believe they are disabled and try to perform better than they should.  This appears to happen for a couple of reasons.  First, they were talked into applying for Social Security Disability and thought they'd automatically be denied and now are going through an evaluation.  Second, they've had SSD as children and are now adults trying to show they don't need to have a payee for benefits.  Third, they are recently diagnosed and are cognitively impaired and didn't really understand there was a problem.  These people can fall apart during testing as they come to realize they can't do some tasks.  What I advise everyone applying for disbility is to simply do their best on the evaluations.  Exaggerating or fabricating symptoms just limits how much self-report information from the claimant can be used or relied on.

My average forensic report for disability accommodations for a school or a test runs 50 pages or so and has a table of contents and an executive summary.  My average SSD Consultative Examination report runs 6 pages.  There's quite a difference.  My intake form for a disability accommodation report is 11-21 pages, not the 4 page form for SSD.   It's a very brief history.  

The questions for Social Security are the following:

• Can this person follow simple instructions?
• Can they follow detailed instructions?
• Can they pay attention and concentrate?
• Can they follow safety rules?
• Can they show up to work and remain at work for a work-day?
• Can they get along with other people?
• Can they manage their benefits?
• Is the person compliant with treatment and/or medication?
• If their symptoms are due to a drug or alcohol problem will they improve if they stop abusing substances?