2015 Newsletter

DR. MASON TALKS ABOUT ADHD  

Oren Mason, MD, gave a lively presentation on ADHD, especially as it relates to adults.  Having the condition himself, he is a great source of information on this topic.  Dr. Mason explains that it is actually a myth that people grow out of ADHD as they become adults.  As patients mature, the symptoms take on a different form as the patient learns to cope with the condition.  He explained that adults with ADHD fail to use the most effective pathway to process information when in an attention-based task.  Scientific evidence shows that there is decreased blood flow in the part of the brain called the anterior cingulate and a likewise increased blood flow in the frontal portion of the brain.  The condition of ADHD is more of a disability than a disease.  It affects the networking in the brain, or neural pathways.  Dr. Mason explained that patients with ADHD have a lot less “crosstalk” going on in their brain.   

He showed an interesting chart that demonstrates how ADHD evolves from childhood to adolescence:  

    CHILD  to ADULT                                                          

  • Hyperactivity Turns Into Restlessness
  • Impulsivity Turns Into History of Poor Choices
  • Inattention Turns Into History of Failure in Meeting Life’s Demands  

Approximately 5 percent of the population has ADHD, but only 10 percent are actually being treated.  The doctor explained that the large gap in absence of treatment leads to a lot of social consequences, which include higher rate of suicide, unemployment and, more importantly, criminal activity.  He indicated that approximately 50 percent of all inmates incarcerated have a form of ADHD.  They have a higher rate of unemployment and divorce.  Fewer graduate from college.  Patients with ADHD have a lower lifetime income.  Dr. Mason summarized that ADHD takes a little bit out of all of the person’s life.  It’s a burden on everything they do.  

Dr. Mason talked about the two types of attention, which are cognitive and emotional attention, and the interplay between both types.  Cognitive attention is the ability to manage time, the ability to be cooperative, socially conscious and easily trainable.  Emotional attention is an all-or-nothing response.  It’s spontaneous, self-protective, somewhat irrational at times, and comes as easily as it goes.  There is no “why” to emotional attention.   Unfortunately, patients with ADHD lack cognitive attention and deal with everything in life via emotional attention, which makes life much more difficult.  Giving some real-life examples, Dr. Mason explained that patients with ADHD actively use emotional attention to get things done, i.e., they do things at the last minute – they are procrastinators.  Conversely, people with cognitive attention have the ability to start projects much earlier and do not tend to be procrastinators.   

Dr. Mason explained that patients with ADHD use anxiety and urgency to get things done, i.e., by kicking their own butts.  They deride themselves to get things done.  They tend to be perfectionists.  They tend to have overriding guilt for not meeting their goals.  They have problems cleaning up a mess after a project – they just move on to the next project.  They basically swim upstream for everything they encounter.

To their credit, ADHD patients excel when they are interested and engaged.  Therefore, they need to find what they are passionate about and run with it.

Dr. Mason indicated that no matter how excited a patient with ADHD is about a project or their work, the work cannot be static or the ADHD patient will begin to become bored and eventually underperform.

Regarding treatment, Dr. Mason reiterated many times throughout the presentation that medication is by far the best treatment there is.  In fact, he indicated that brain MRIs of patients affected by ADHD improved in size and function just taking medication.

The second best treatment is cognitive behavior therapy.  Also very helpful are meditation, mindfulness training (living in the moment) and exercise.

Dr. Mason indicated that by treating with medications, patients will find a 100 percent increase in safer driving, i.e., 100 percent fewer accidents and a 100 percent increase in successful weight loss.  Their self-esteem increases 85 percent, social functioning increases 80 percent and drug addiction is reduced by 65 percent.  Patients treated with medication alone have a 54 percent increase in meeting outcome-objective goals.  When combined with therapy, such as cognitive behavioral therapy, that figure increases to a 74 percent favorable outcome.

Lewis M. Seward (2015 Newsletter)

Editor 

Schizophrenia: Your Questions Answered

SCHIZOPHRENIA:  EVERYTHING YOU WANTED TO KNOW BUT WERE AFRAID TO ASK   Dr. Wallace is a hospital-based practicing physician at Pine Rest Christian Mental Health Services in Grand Rapids.  She has a very easy-to-understand presentation style and did a very good job of explaining the intricate nature of Schizophrenia.  One percent of the general population suffers from this condition.  The onset for males occurs in their late teens to early 20s, while females exhibit the traits in their 20s or 30s.  It is rarely found in children and rarely diagnosed for the first time in patients over 40 unless it’s undiagnosed.  

She discussed an interesting correlation between smoking and mental illness.  She explained that the medicines used to treat Schizophrenia try to suppress the dopamine level in the body.  Cigarettes actually increase dopamine, which is why clients with fairly serious emotional problems tell you that they cannot give up smoking.  

Nearly 50 percent of patients diagnosed with some form of Schizophrenia also have comorbid substance abuse.  Patients with Schizophrenia also have a 10 percent suicide rate and a 20 percent shorter life expectancy.  

Schizophrenia is very prevalent genetically.  In identical twins, if one is diagnosed, the other twin has a 35 to 60 percent chance of also being affected.  Fraternal twins range from 10 to 30 percent.  If one sibling has been diagnosed, there is a 10 percent chance the other sibling will have the same affliction.  

Dr. Wallace spent a good deal of time talking about the signs and symptoms.  She explained that people with Schizophrenia have impaired reality, where they cling to a distorted view of events.  Most have periods of active hallucinations, such as voices commenting or arguing.  She said that the voices tend to be familiar and are usually consistent with some delusion they are having.  They can also be demonic voices or voices that are derogatory in nature.   

Interestingly, she also said that if the hallucinations are not bothering the patient, the doctor may decline to give medications to treat the condition because of the side effects of these fairly potent medications.  

A person with Schizophrenia may dress in inappropriate attire for the season.  The Editor recalls a client who was dressed in a mink coat pushing her baby in a stroller in 90-degree heat.  They may collect objects they believe to have magical powers.  They may have ideas of reference which are messages on the television or radio that they believe are directed to them.  

Schizophrenic patients usually have a thought disorder.  These are thoughts that appear unrelated to another idea – in other words, talking about two different unrelated subjects.  She also indicated that some patients also suffer from “word salad,” which means they will speak in sentences that sometimes do not make sense.  

Dr. Wallace talked about negative symptoms, which are more difficult to respond to treatment.  Those include a flat or blunted affect with little or no range of emotion.  It could also be poverty of speech or thought, such as limited response to questions or a significant lapse between asking a question and answering it.  She said that this in particular is a sign of poor prognosis.  It demonstrates that the patient has a slower processing ability that greatly affects concentration, persistence and pace.  

Patients afflicted with Schizophrenia also have Anhedonia, which is a lack of interest in doing things they used to enjoy.  They may be socially withdrawn with no desire to be around people and/or an inability to have a meaningful interaction with others.  

Patients with Schizophrenia tend to lack motivation to care for their basic needs such as dressing, eating, paying bills, taking medication or having poor hygiene.  They generally also have slowed thinking, i.e., psychomotor slowing.  

Interestingly, patients with long-term Schizophrenia will have brain atrophy in the form of large ventricles.  Dr. Wallace showed a side-by-side comparison of a long-term schizophrenic patient compared to a normal brain, and the contrast was significant.  This atrophy contributes to cognitive dulling that happens gradually over time to these patients.  

There are two types of medications to treat Schizophrenia.  One is a dopamine antagonist, i.e., suppresses dopamine, and the other is a neurotransmitter, i.e., serotonin.  If a patient complies with medical management, 70 percent can achieve remission in three to four years, although they generally will need to take the medications throughout their lifetime.  Obviously, successful treatment means that the patient’s risk of suicide and overall life expectancy will be markedly reduced, which also benefits members of the family in dealing with a loved one with this condition. 

As you have seen in your own practice, compliance to medication is always difficult with these claimants.  The medications in fact usually work very well.  Eventually, they may get to a point where they feel that they do not need to take the medication anymore.  It may take only a few weeks or a few months, but the wheels will start spinning off and may culminate in a psychotic break, which may necessitate a trip to the emergency room and psych unit.  

Dr. Wallace also discussed how substance abuse  can have a counteracting effect on the medications, causing the patient’s judgment and insight to be impaired, leading to poor symptom control.  Contributing to non-compliance or a poor prognosis would be a dysfunctional family or lack of adequate support system.  Males tend to have a poorer prognosis than females.   

Dr. Wallace also talked about personality disorders, which are pervasive patterns of mental illness over time that interfere with social and occupational functioning.  Cluster A symptoms, also called Schizoid Personality, tend to have strange or bizarre behavior.  This behavior effectively excludes them from the social world, and that is usually fine with Cluster A patients because they do not want friends in the first place.  They may also have magical thinking, be able to read people’s minds or predict events in the future.    

The other general category of personality disorder is Cluster B patients.  This is the patient with Paranoid Personality traits.  They are difficult to treat because they don’t respond well to anti-psychotic medication. 

Another type of Schizophrenia is called Schizoaffective Disorder, which is a combination of psychosis or delusions and depression with a little mania thrown in for good measure.  These patients can also be very difficult to treat due to the wide range of symptoms.

In closing, when answering questions from the audience, Dr. Wallace explained why patients should avoid any form of non-prescribed drug.  She said that cocaine and marijuana can make the psychosis worse.  She related that patients have told her that they only use “natural drugs,” i.e., marijuana, but the doctor reminds them that cocaine and opium are also “natural” drugs which have mind-altering effects that make it difficult to treat the underlying condition.

Lewis M. Seward (2015 Newsletter)

Editor

 

New Evidence Regulations

NEW ALL-EVIDENCE REGULATIONS  

We were pleased to have Cliff Farrell, from Columbus, Ohio, give a presentation on this new law.  Cliff is an Ohio-certified specialist in Social Security Disability law and a member of the Board of Directors of NOSSCR.  The new Rule requires you to submit all records that even remotely address your client’s medical condition.  Even records that appear to be duplicates have to be submitted if they are not exact duplicates, such as a lab report that has a doctor’s initials on it.  Mr. Farrell indicated you should submit all records now that the standard in the new Regulation has deleted the term relevant records with a broader standard of relating to the claimant’s disability.  This means records that pertain to your client’s Worker’s Comp claim, Personal Injury and State Disability (SDA), to name a few.  

With electronic records for hospital admissions, you may request the history, physical and discharge summary if applicable.  However, the record copy service may send the entire chart because that is usually easier than isolating the relevant records requested.  So, if that 500-page hospital stay is sent to you, you are obligated to forward that on because it is relevant to your client’s medical condition. 

The most important aspect of this Regulation is that you must either inform Social Security or submit the records if they are not in your possession or your client’s possession – all evidence known to you.  Therefore, any records that are in your possession or your client’s possession and any evidence known to you or your client must be submitted or disclosed to SSA.  

The Regulations give rise to more questions than answers.  Therefore, Cliff advised to err on the side of caution and submit anything, even if you don’t believe it relates to your client’s disability to be on the safe side.  As Cliff explains, the Regulations are designed that they don’t want us to use independent judgment – SSA wants everything.  

Even after the hearing, it is your duty to either inform Social Security or obtain the records for post-hearing medical care either at the hearing or via correspondence after the hearing.  

Cliff prepared some excellent materials, pulling together the Regulations and some sample cover letters relating to this new Regulation.  NOSSCR also published an excellent article by Eric Snauffer in the March 2015 Newsletter.  

Your duty is ongoing up to and including the Appeals Council.  If evidence relates to the period on or before the date of the hearing, it must be either submitted if it’s in your possession or the Appeals Council must be informed.   Cliff prepared a handy summary of the law. 

You must inform us about or submit:                   

  • All evidence known to you or the claimant
  • That relates to whether or not claimant is blind or disabled
  • When you submit evidence received from another source, you must submit that evidence in its entirety unless you previously submitted the same evidence [exact duplicate] to us or we instruct you otherwise

 If we ask you, you must inform us about the claimant’s:

  •  Medical source(s)
  • Age
  • Education and training
  • Work experience
  • Daily activities both before and after the day you say you became disabled
  • Efforts to work
  • Any other factors showing how the impairment affects your ability to work

Treating Source Statements – the good, the bad and the ugly – must be submitted.  Sometimes the form by a PA or NP is not completed or reviewed and signed by the treating supervising physician.  Cliff advises to send whatever you receive and then resubmit it once you obtain the supervising physician’s review and approval.

Under 20 CFR 404.1512 and 416.912, exceptions to the All-Evidence Rule include oral or written communication between you and the claimant that is subject to the attorney-client privilege, including the attorney’s analysis of the client’s claim.  However, regarding treating source opinions, the attorney work product doctrine would not protect the treating source’s opinions on a completed form, regardless of whether or not the representative used a form in his or her analysis of the claim or made hand-written notes on the face of the report.

The new Rules are found under the following sections: 20 CFR 404.1512 and 416.912; and 404.1740(b)(2) and 416.1540(b)(2).

There are also corresponding hearing office Regulations under the HALLEX:

  • I-2-1-5 – Pre-Hearing Analysis and Case Work
  • I-2-5-1 – Obtaining Evidence
  • I-2-5-2 – Pre-Hearing Case Review by the ALJ
  • I-2-5-13 – Claimant Informs Hearing Office of Additional Evidence
  • I-2-5-14 – Obtaining Medical Evidence from a Medical Source
  • I-2-6-78 – Closing the Hearing
  • I-2-7-1 – Post-Hearing Action
  • I-3-2-15 – General Work-Up and Analysis Procedures at the Appeals Council

 Lewis M. Seward (2015 Newsletter)

Editor

SSA ISSUES A NEW RULING FOR EVALUATING INTERSTITIAL CYSTITIS (IC)

This is the only new Ruling this year so far.  This new Ruling under SSR 15-1p replaces SSR 02-2p.  This new Ruling was drafted to clarify SSA’s policy on evidence in establishing Interstitial Cystitis (IC) and how this condition is evaluated in adjudicating disability claims, as well as CDRs.

The Ruling does a good job discussing the criteria when evaluating evidence of IC.  Information was gathered from the American Urological Association and National Institute of Diabetes and Digestive and Kidney Diseases and took considerations from both to develop criteria for a medically determinable impairment of IC.  The Ruling also discusses related symptoms such as Sleep Dysfunction, Sexual Dysfunction and Chronic Fatigue or Tiredness.  The symptoms must be more than six weeks in duration in the absence of infection or other identifiable cause and discusses common symptoms such as urinary frequency, bladder pain and pelvic pain.  The Ruling also talks about treatment for IC as well.

The Ruling discusses the medical signs that support the diagnosis of IC which must be established by a licensed physician, such as Fibrosis (bladder-walls stiffening); Diffuse Glomerulations (pinpoint bleeding of the bladder wall); and broken patches of skin on the bladder wall.

The Ruling also has a section acknowledging patients with mental conditions such as Anxiety or Depression associated with IC symptoms such as chronic bladder and pelvic pain.

The Ruling goes through in fair detail the five steps of the Sequential Evaluation Process.  Although there is no listing for IC at Step Three, the Ruling indicates that SSA will compare the specific findings in each case to any pertinent listing to determine whether medical equivalence may exist. 

Lewis M. Seward

Editor

STATUS OF DISABILITY INSURANCE TRUST FUND

As you are aware, there is a lot of misinformation out there regarding news articles that the Disability Trust Fund will run out of money in the year 2016.  On July 22, 2015, the Social Security Board of Trustees for the Disability Trust Fund sent a press release indicating the Trust reserve gained one year for projected depletion date.  Despite the dire headline, the press release explains that at the current funding rate, the Trust Fund for Disability will be depleted in 2034, one year later than projected last year.  Next year, in 2016, if nothing is done, 81 percent of benefits will be payable.

In the 2015 Annual Report to Congress, the Trustees announced that the combined trust fund reserves are still growing and will continue to do so through 2019.  However, beginning in 2020 the cost of the program is projected to exceed income.  Acting Commissioner Carolyn W. Colvin indicated that Congress must take action to allocate a portion of the payroll tax rate between the trust funds.  This is to avoid deep and abrupt cuts or delays in benefits for individuals with disabilities who paid into the system while they worked and now need the benefits they earned to support themselves and their families.  In the year 2014, the combined trust funds earned $98 billion in interest.  During 2014, an estimated 166 million people had earnings covered by Social Security and paid payroll taxes.  The combined trust fund asset reserves earned an interest rate at an effective annual rate of 3.6 percent in 2014. 

Without getting into the actual political wrangling, while the Retirement and Disability Trust Funds are separate, they have borrowed funds from each trust 11 times in the past.  The President has proposed a reallocation of retirement trust funds into the Disability program, which is only a temporary five-year fix.  Another proposal is to combine both trust funds into one trust fund and then look at various increases in funding in order to strengthen both programs.

Lewis M. Seward (2015 Newsletter)

Editor

Words from The Honorable Paul W. Jones

THE HONORABLE PAUL W. JONES – A PERSONAL VIEW 

We saved the best for last by having the Honorable Paul Jones speak to our group, not in his official capacity for SSA, but rather sharing his personal views as an ordinary citizen who happens to also be an Administrative Law Judge.  He is still in the Navy Reserves keeping our country safe.  

On the topic of Pre-Hearing Memorandums, he does not require them, although he would like to have a Pre-Hearing Memorandum if you have a Step Three case.  Regarding on-the-record requests, he said the earlier the better.  If you make an on-the-record request after the hearing is set, you probably won’t save any time.   

Regarding dismissals, 60 days is a very generous time frame to appeal, and on top of that, you get an additional five days for mailing.  

One very helpful reminder to practitioners, not just before Judge Jones but all ALJs, is the fact that they have a very busy case load.  A successful judge must be well organized.  Therefore, many judges like Judge Jones prepare for their cases a week in advance.  What this means in plain English is that if you submit probative evidence less than a week before the hearing, or a Pre-Hearing Memorandum, you may be losing that persuasive edge.  

Judge Jones schedules his cases every other week, using the weeks in between to review cases.  When the Editor asked what about clients bringing in evidence at the day of the hearing, such as printouts from their doctor’s visit a week earlier, or a recent x-ray result, he had no problem with that.  However, he has a major problem with someone bringing in a hundred plus pages of records a few days before the hearing.  Because of the strict time schedule of 45 minutes between hearings, the unlucky soul who brings in 200 pages just before the hearing may have to wait until the last hearing of the day to be heard.  

He also does not like duplicate records, which of course presents a dilemma with the new All-Evidence Rule, unless they are exact duplicates.  If the duplicate has a physician’s initial on it or a date stamp, they are not considered an exact duplicate, so both must be submitted.  

Judge Jones also gave some valuable insight into cross-examining the vocational expert.  Although this is very basic knowledge, he made some excellent points.  He likes the practitioner to use specific functional limitations.  Those are: constant, frequent, occasional and never.  He doesn’t like warm and fuzzy limitations such as very little, superficial, avoid.  In some instances, terms such as “less than frequent” or “less than constant” can be okay as long as the VE and the representative are on the same page and can understand the limitation.  He also said to minimize the introduction of your hypothetical, i.e., due to a claimant who has Neuropathy and unrelenting pain, .... The “due to” portion of the hypothetical is not particularly relevant.  

Lastly, Judge Jones also talked about credibility.  He is troubled by claimants who calmly testify that their pain level is a 10, and when the Judge makes sure they know the definition of a level 10 pain factor, he wonders why 911 isn’t called to take the patient to the hospital.  Although he is correct,  this occurs to many of our claimants.  It is basically how some people are hardwired.  They just don’t get it, and unfortunately they shoot themselves in the foot no matter what legal forum they are in front of.

Lewis M. Seward (2015 Newsletter)

Editor

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Seward, Tally & Piggott, P.C.

1009 Washington Ave.

Bay City, MI 48708

Phone: 989-892-6551

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We are located across the street from the Post Office and Court House.