Psychiatric Review Technique

PSYCHIATRIC REVIEW TECHNIQUE

Form Approved
OMB No. 0960-0413

Name     SSN

NH (If different from above)     SSN

I. MEDICAL SUMMARY

A. Assessment is from: to

B. Medical Disposition(s):

1. No Medically Determinable Impairment

2. Impairment(s) Not Severe

3. Impairment(s) Severe But Not Expected to Last 12 Months

4. Meets Listing (Cite Listing)

5. Equals Listing (Cite Listing)

6. RFC Assessment Necessary

7. Coexisting Nonmental Impairment(s) that Requires Referral to Another Medical Specialty

8. Insufficient Evidence

C. Category(ies) Upon Which the Medical Disposition is Based:

1. 12.02 Organic Mental Disorders

2. 12.03 Schizophrenic, Paranoid and Other Psychotic Disorders

3. 12.04 Affective Disorders

4. 12.05 Mental Retardation

5. 12.06 Anxiety-Related Disorders

6. 12.07 Somatoform Disorders

7. 12.08 Personality Disorders

8. 12.09 Substance Addiction Disorders

9. 12.10 Autism and Other Pervasive Developmental Disorders

These findings complete the medical portion of the disability determination.

II. DOCUMENTATION OF FACTORS THAT EVIDENCE THE DISORDER

A. 12.02 Organic Mental Disorders

Psychological or behavioral abnormalities associated with a dysfunction of the brain…as evidenced by at least one of the following:

1. Disorientation to time and place

2. Memory impairment

3. Perceptual or thinking disturbances

4. Change in personality

5. Disturbance in mood

6. Emotional lability and impairment in impulse control

7. Loss of measured intellectual ability...

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of the impairment:

Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes).

B. 12.03 Schizophrenic, Paranoid and Other Psychotic Disorders

Psychotic features and deterioration that are persistent (continuous or intermittent), as evidenced by at least one of the following:

1. Delusions or hallucinations

2. Catatonic or other grossly disorganized behavior

3. Incoherence, loosening of associations, illogical thinking, or poverty of content of speech

a. Blunt affect, or

b. Flat affect, or

c. Inappropriate affect

4. Emotional withdrawal and/or isolation

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of this impairment:

Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes).

C. 12.04 Affective Disorders

Disturbance of mood, accompanied by a full or partial manic or depressive syndrome, as evidenced by at least one of the following:

1. Depressive syndrome characterized by at least four of the following:

a. Anhedonia or pervasive loss of interest in almost all activities, or

b. Appetite disturbance with change in weight, or

c. Sleep disturbance, or

d. Psychomotor agitation or retardation, or

e. Decreased energy, or

f. Feelings of guilt or worthlessness, or

g. Difficulty concentrating or thinking, or

h. Thoughts of suicide, or

i. Hallucinations, delusions or paranoid thinking

2. Manic syndrome characterized by at least three of the following:

a. Hyperactivity, or

b. Pressures of speech, or

c. Flight of ideas, or

d. Inflated self-esteem, or

e. Decreased need for sleep, or

f. Easy distractibility, or

g. Involvement in activities that have a high probability of painful consequences which are not recognized, or

h. Hallucinations, delusions or paranoid thinking

3. Bipolar syndrome with a history of episodic periods manifested by the full symptomatic picture of both manic and depressive syndromes (and currently characterized by either or both syndromes)

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of this impairment (explain in Part IV, Consultant’s Notes, if necessary):

Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes).

D. 12.05 Mental Retardation

Significantly subaverage general intellectual functioning with deficits in adaptive functioning initially manifested during the developmental period; i.e., the evidence demonstrates or supports onset of the impairment before age 22, with one of the following:

1. Mental incapacity evidenced by dependence upon others for personal needs and inability to follow instructions such that the use of standardized measures of intellectual functioning is precluded

2. A valid verbal, performance, or full scale IQ of 59 or less

3. A valid verbal, performance, or full scale IQ of 60 through 70 and a physical or other mental impairment imposing an additional and significant work-related limitation of function

4. A valid verbal, performance, or full scale IQ of 60 through 70

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of this impairment.

Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes).

E. 12.06 Anxiety-Related Disorders

Anxiety as the predominant disturbance or anxiety experienced in the attempt to master symptoms, as evidenced by at least one of the following:

1. Generalized persistent anxiety accompanied by three of the following:

a. Motor tension, or

b. Autonomic hyperactivity, or

c. Apprehensive expectation, or

d. Vigilance and scanning

2. A persistent irrational fear of a specific object, activity or situation which results in a compelling desire to avoid the dreaded object, activity, or situation

3. Recurrent severe panic attacks manifested by a sudden unpredictable onset of intense apprehension, fear, terror, and sense of impending doom occurring on the average of at least once a week

4. Recurrent obsessions or compulsions which are a source of marked distress

5. Recurrent and intrusive recollections of a traumatic experience, which are a source of marked distress

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of this impairment:

Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes).

F. 12.07 Somatoform Disorders

Physical symptoms for which there are no demonstrable organic findings or known physiological mechanisms, as evidenced by at least one of the following:

1. A history of multiple physical symptoms of several years duration beginning before age 30, that have caused the individual to take medicine frequently, see a physician often and alter life patterns significantly

2. Persistent nonorganic disturbance of one of the following:

a. Vision, or

b. Speech, or

c. Hearing, or

d. Use of a limb, or

e. Movement and its control (e.g., coordination disturbances, psychogenic seizures, akinesia, dyskinesia), or

f. Sensation (e.g., diminished or heightened)

3. Unrealistic interpretation of physical signs or sensations associated with the preoccupation or belief that one has a serious disease or injury

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of this impairment:

Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes).

G. 12.08 Personality Disorders

Inflexible and maladaptive personality traits which cause either significant impairment in social or occupational functioning or subjective distress, as evidenced by at least one of the following:

1. Seclusiveness or autistic thinking

2. Pathologically inappropriate suspiciousness or hostility

3. Oddities of thought, perception, speech and behavior

4. Persistent disturbances of mood or affect

5. Pathological dependence, passivity, or aggressivity

6. Intense and unstable interpersonal relationships and impulsive and damaging behavior

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of this impairment:

Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes).

H. 12.09 Substance Addiction Disorders

Behavioral changes or physical changes associated with the regular use of substances that affect the central nervous system.

If present, evaluate under one or more of the most closely applicable listings:

1. Listing 12.02—Organic mental disorders

2. Listing 12.04—Affective disorders

3. Listing 12.06—Anxiety-related disorders

4. Listing 12.08—Personality disorders

5. Listing 11.14—Peripheral neuropathies

6. Listing 5.05—Liver damage

7. Listing 5.04—Gastritis

8. Listing 5.08—Pancreatitis

9. Listing 11.02 or 11.03—Seizures

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of this impairment:

Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes).

I. 12.10 Autistic Disorder and Other Pervasive Developmental Disorders

Qualitative deficits in the development of reciprocal social interaction, in the development of verbal and nonverbal communication skills, and in imaginative activity. Often there is a markedly restricted repertoire of activities and interests, which frequently are stereotyped and repetitive.

1. Autistic disorder, with medically documented findings of all of the following:

a. Qualitative deficits in reciprocal social interaction

b. Qualitative deficits in verbal and nonverbal communication and in imaginative activity

c. Markedly restricted repertoire of activities and interests

2. Other pervasive developmental disorders, with medically documented findings of both of the following:

a. Qualitative deficits in reciprocal social interaction

b. Qualitative deficits in verbal and nonverbal communication and in imaginative activity

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of this impairment:

Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes).

III. RATING OF FUNCTIONAL LIMITATIONS

A. “B” Criteria of the Listings

Specify the listing(s) (i.e., 12.02 through 12.10) under which the items below are being rated

B. “C” Criteria of the Listings

1. Complete this section if 12.02, 12.03, or 12.04 applies and the paragraph B requirements are not satisfied.

Medically documented history of a chronic organic mental, schizophrenic, etc., or affective disorder of at least 2 years’ duration...

1. Repeated episodes of decompensation, each of extended duration

2. A residual disease process that has resulted in such marginal adjustment...

3. Current history of 1 or more years’ inability to function outside a highly supportive living arrangement...

Evidence does not establish the presence of the “C” criteria

Insufficient evidence to establish the presence of the “C” criteria (explain in Part IV, Consultant’s Notes).

2. Complete this section if 12.06 applies and the paragraph B requirements are not satisfied.

Complete inability to function independently outside the area of one’s home

Evidence does not establish the presence of the “C” criteria

Insufficient evidence to establish the presence of the “C” criterion (explain in Part IV, Consultant’s Notes).

IV. CONSULTANT’S NOTES

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