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Social Security Disability Application

The following is an example of an application for social security disability. For any questions, contact the webmaster.

[Author chooses to retain anonymity]

Greetings,

You will find here a copy of my social security disability application (from 1990). [I have been back at work since mid 1991]

I had heard many stories of pwc's applications for disability being denied and sent into the appeals process.

Consequently, along with filling out the requisite forms (with the help of the first social security administrator of my case), taking care to fill in all spaces, to cross every "T" and dot every "i," I spent weeks (often 5 minutes a day, the extent of my stamina at that time) working on a background statement (to show my former level of functioning intellectually, physically, academically, socially, emotionally, etc.). As you'll see, this is followed by a listing of my illness at that point in time. (Go for a multi-system approach, missing nothing and telling only the truth). I made it a point after listing each illness/condition to then list the symptomology (including specific examples of each).

I listed my medical history of physicians and other health care practitioners seen.

I included my resume to show my former level of functioning as a reference point for the evaluators.

I had a colleague administer the WAIS-R (adult IQ test) to me and the test results confirmed my drop in IQ/CFIDS dementia at that time. We followed Dr. Sheila Bastien's "Sample Guide for Disability Report" that was printed in the summer/fall 1989 CFIDS Chronicle. I played an important part in the report writing in terms of assessing myself and my functioning/coping/defense mechanisms accurately at that point in time.

A very important part of my application was including letters from colleagues, friends, family, etc. who wrote about their perceptions/observations of my former level of functioning, the decline they saw, and their perceptions/observations and feelings about my deterioration physically, cognitively, etc.

I took everything in to the intake worker (who was terrifically professional and exceedingly helpful and caring) who then went over the forms (actually filling out most of them with the information I gave him as I lay with my head in my arms on his desk). When he saw the extra information I had brought in (apart from the requisite forms), he said "This is the most complete application I have ever seen. There won't be any problems with this."

I then called my congressperson's office to let them know about my concern about the seemingly routine rejection of PWC's applications and asked him to follow my file. They did.

I had my social security benefits (with back payments) before 3 months had passed.

When I went back to work, this was considered to be a "trial period" by the social administration, during which time I was still paid benefits. I was told/written that at any point I felt I could not work, that time would not be counted as part of my trial period. After the trial period lapsed (several months at that time!), benefits were rightfully discontinued. I made sure to keep them appraised (they sent forms regularly to get updates on work hours and pay during the trial period) of my progress and let them know I was ready to discontinue benefits.

In retrospect, I was overly optimistic about my level of functioning when I returned to work for the "trial work period" and went back about 6-8 months too soon. The work set me back healthwise as a result.

I am happy to report that I work 4 days a week, seeing at least 20 patients weekly. On top of that, there is much paperwork which often gets me out of the office around 8 P.M. I'm doing fine at work, making sure to chart in detail so nothing falls through the cracks memory wise. On my bad days (fortunately now few and far between), I pull the plug and do not work.

Since I've been back at work, I have coached many people in obtaining social security disability benefits, utilizing my format (and that of Dr. Bastien's). All have been successful.

Please feel free to utilize this "recipe" for your own use if needed and to share it with others in need of disability benefits.

I wish all of you good health.

Best,

Just One Patient with CFIDS

Page 1

Telephone

Social Security Disability Application for:

Disabilities:

  1. Chronic Fatigue and Immune Dysfunction Syndrome
  2. Interstitial Cystitis
  3. Candidiasis
  4. Hashimoto's Thyroiditis
  5. Organic Mental Disorder
Background :

Before I got sick, I was always a high achiever and had lots of stamina, verve, activities, and physical energy. I graduated from High School in 2 1/2 years in December of 1969; from City College in 1 1/2 years; and finished my B.A. in Psychology at University of California ********* in 1 1/2 years with high evaluations in June 1974. I completed my Masters degree in Psychology from ***** State University ***** with a high g.p.a. in 1975., then taught at three Community Colleges in the ***** area, commuting 500 miles a week for 3 years and facilitated groups before going on to a Ph.D. program in Psychology.

I earned my doctorate from ***** University in 3 years (finishing in 1981) with a 3.79 g.p.a. At the same time, I was taking classes, teaching at 3 local community colleges, facilitated groups, worked on my dissertation and completed my clinical internship while maintaining an active life. I did an additional internship and continued teaching and started a private practice for 2 more years, worked out daily at a local gym, ran several miles daily, took ice skating lessons and enjoyed a very active social life.

In 1983, I moved to *****, I knew no one, had a place to housesit for 2 months and came with boundless optimism, my skills, and faith in myself that I would create a successful business and social life for myself. Within 2 years, I had one of the most successful clinical practices [in *****], enjoyed a good professional reputation, worked out regularly and made friends. By 1985, I was married (and still am) to a wonderful man and in 1986 we were able to buy a house here [in *****]. I have always felt fortunate to live here, do work I love, to have friends who mean something to me, and to have enjoyed good physical health.

In 1986, I developed a painful and debilitating physical disease (recently reported by a Scripps Clinic research study as an autoimmune problem) called Interstitial Cystitis, an inflammatory condition of the bladder lining with all of the symptomatology of a bladder infection in the absence of any bacterial infection. Despite the agonizing physical pain and resultant exhaustion of the first year, I continued my active clinical practice (a big part of my identity), resting nights and weekends. With the help of my continual international and national computer searches in the medical literature, I was able to find an article in the British Journal of Urology on the use of Chromalyn Sodium instilled into the bladder. At my request, my urologist taught me how to self-catheterize and the drug abated my pain by about 40-50%, allowing me to on some days reactivate my physical work-out schedule of about 1/2 hour an evening including nautilus equipment, treadmill work and an occasional pool exercise class. I adjusted to the diminishment of my health and still called my life successful due to my optimistic outlook, persistence to get better and my love of my career.

My clinical practice provided my happiest times of all. Aside from my practice (seeing up to 40 patients a week), my ***** classes and ***** Trainings that I did as a public service at the three community colleges in our area were (according to the Directors of the Community Education programs) the most highly rated there. I was also the only therapist to ever be called in to do stress training talks (to 1500-1700 ***** and staff) at ***** and have a standing offer to return. In addition, I was actively sought out by my city's police department to be their consulting therapist and trauma debriefer. I'm a hard worker and love work and activity.

In my first year with Interstitial Cystitis, I complained of tiredness because of pain and sleep deprivation related to pain and extremely frequent trips to the bathroom. Once I stabilized to some degree with the chromalyn (meaning I was not feeling each drop of urine against my unprotected bladder wall 30 times a minute as a battery acid burn), I adjusted to the best of my ability to the tiredness and adapted to the somewhat decreased pain and discomfort with as active a lifestyle as possible. I started piano lessons, gardened, enjoyed my marriage, traveled, went to the movies and theatre, read, socialized, and went to cultural events.

Then, in December of 1988, I got the flu. It was the sickest I had ever been in my life and I wasn't out of bed for approximately 10 days. Afterward, I began calling my family practice physician to complain of incapacitating exhaustion and malaise. This, I was told, was a common post-viral complaint and that it would just take time to recoup my strength -- a normal expectation on both my part and that of my physician's. A couple of months later, still debilitated by exhaustion, I was prescribed iron supplements with the supposition that I was anemic. Outside of work, I spent my time resting in bed every evening, on Fridays and every weekend. Sometime during the year, I started feeling a little better and resumed a partial work-out schedule (on the treadmill) and an occasional pool exercise class, all the while maintaining my full clinical practice.

In August of 1989, my husband and I joyfully went to the *****, an event we look forward to each year with great anticipation. After walking about one/eighth of a mile, I suddenly felt exhausted, dizzy, faint, and drained of all energy. I had to sit down in ***** for over half an hour in order to walk slowly back to the car and back home to bed. These episodes became more frequent, with me intermittently experiencing marked post-exertional malaise. Around October, before a piano lesson and feeling good energy-wise that morning, I asked my piano teacher to wait a moment while I transferred some laundry from the washing machine to the dryer. I almost fainted and the lesson was cancelled while I had to lie down for the rest of the day.

Tiredness became a way of life while I kept adjusting my life in pain and exhaustion downward, maintaining a 40 hour a week work schedule and nothing else. In retrospect, there was a tremendous amount of denial on my part of how debilitatingly, abnormally exhausted I was along with the bladder pain. I would tell myself I just needed to rest more on weekends and that I'd catch up on my rest over a 2 week Christmas vacation in bed. I was barely making it through the day at work, often during sessions reclining on the sofa or chair with my legs up. I have never experienced my work as depressing or stressful and have always felt fortunate to do what I do for a living-- helping people make positive differences in their lives. This has always been a tremendous source of satisfaction for me. I love my work.

I am neither stressed nor burned out from my work or lifestyle.

By this time, my clients and associates were remarking with growing concern on my pallor and thinness. I kept trying to overcome the overwhelming incapacitating fatigue and didn't even realize that for months I hadn't even gotten any reports or billings out totaling about 1/4 of my yearly income. I, in retrospect, was on automatic pilot, trying to get my body through the day as best I could.

In November, one day while sitting at my office desk, my brain suddenly felt like it was trying to come out of general anesthesia: "fogged out" and druggy, in the absence of drugs. Around the same period of time, I took a ***** seminar in ***** and couldn't even focus enough to take notes or concentrate on what was being said; this after being at the top of my doctoral-level classes.

In November, I was diagnosed by a hematologist as having Chronic Fatigue Syndrome. In early December, this was confirmed by my family practice physician and an infectious disease specialist. Since then, I have received the same diagnosis from my immunologist and by an oncologist (seen by order of my insurance company). This is on top of my diagnosis of Interstitial Cystitis and, since then, Hashimoto's Thyroiditis, Candidiasis, and Organic Mental Disorder.

By December 15th, 1989, I couldn't concentrate, could barely sit up, felt "foggy" mentally all the time, clammy, was soaking the sheets with my nightsweats and couldn't retain my immediate or short-term memory skills. For example, my clients would tell me things and I would ask them the same thing they had just told me; I would ask my husband several times within a minute what time it was, not remembering that I had just asked him. I felt as if I'd been hit by a truck and was extremely weak and overwhelmingly, debilitatingly exhausted, beyond anything I'd ever experienced. I was showering on the shower floor and dragging myself back to bed, shaking from fatigue and malaise. I still am.

Since then, my life has been a living hell. I haven't (on orders of my physician and my body) been to work since December 15, 1989. I miss it terribly but can't concentrate or get energy or stay physically stable enough to go. My bladder is in pain and for at least 10 days out of the month the vaginal burning is agonizing related to Interstitial Cystitis. I don't socialize (except on rare occasions when someone will come over for a brief visit or during short telephone conversations) because it's too debilitating and tiring. Any exercise is exhausting (this includes being exhausted by my daily shower). Whereas before, I worked out all the time, 99 percent of the time I don't have the energy to go out for a "ride" on the electric mobility cart loaned to me by the Easter Seal Society.

I spend 90 percent my time resting in bed. I wake up exhausted and achey and stay that way. Sometimes, I feel better by 11:00 PM. after resting all day, but I haven't figured out how to run a practice between my "energy time" of 11:00-11:30 P.M., or a normal social life for that reason.

When I saw a recent study of 26 Chronic Fatigue and Immune Dysfunction (CFIDS) patients and 26 person control group that said 42 percent of the CFIDS patients were depressed, I had to laugh. Take away someone's health, add flu-like and Alzheimer-like symptoms, dis-enable them from working at the job they've worked all their life to get and love so much, take away most of their social life (because it's exhausting, their health situation is unstable, they can't usually honor plans, plus most people can't handle illness and disappear after awhile), take away activities they love (theatre, movies, gardening, piano lessons, physical activity, walks, cultural events, etc.) because it sends them back to bed feeling as if they've been hit by a 10-ton truck and muddles their brain; and then wonder why only 42 percent have gotten depressed. I not only can't engage in the employment that means so much to me, I can't even get the energy to dust the house or water a plant.

I am not psychoneurotic. I have no psychiatric history. My ego strength is remarkably healthy, especially given all I've lost and the uncertainty of my prognosis. I would say that I'm depressed or discouraged about 10-15 percent of the time. I do my best to see every day as a new day, with tomorrow being one day closer to good health and getting my life and work back. There is no secondary gain to my being sick.

I am applying for social security disability benefits because my private insurance disability will soon run out, we've exhausted all the savings we worked for, and I'm brutally ill. Please help me. I am 100 percent disabled for work and normal daily activities.

Current Diagnoses:

  1. Chronic Fatigue and Immune Dysfunction Syndrome
  2. Interstitial Cystitis
  3. Candidiasis
  4. Hashimoto's Thyroiditis
  5. Organic Mental Disorder
My symptomatology touches several areas or my life and body:

CHRONIC FATIGUE SYMPTOMS

I. Abnormal, Debilitating, Incapacitating Exhaustion
Examples:
  1. Taking a shower sends me back to bed.

  2. I wake up exhausted, not refreshed, as if I've run a marathon.

  3. Walking from the bedroom (a few feet away) to the bathroom can and often does exhaust me.

  4. One night, after resting in bed and sleeping for 5 days, I had a little energy. I pulled on a pair of pants and a sweater. My husband and I drove to a restaurant 2 miles away. The act of walking from the curb to the restaurant door knocked me for a loop. I was able to set a small salad down (with my head and body resting against the wall) before I had to leave so I could lie down and rest.

  5. Last month, I tried going to a stationary store. I had to lie on the floor there. This is a common occurrence.

  6. I can't stand longer than a few seconds without leaning on something, then I need to sit and then lie down.

These are a few of hundreds of examples of the last 8 months.

II. Debilitating Weakness
Examples:

  1. Lifting my arms to wash my hair, it feels like my arms weigh 100 lbs. I shower on the shower floor.

  2. When I've tried to carry a small wallet, it's too heavy.

  3. Getting dressed takes all my energy and turns me pale.

  4. I can't lift a small dinner tray. At times, a spoon is heavy.

  5. Most of the time, I can't stand for longer than a few seconds and sitting up is tiring. Before the flu, I could leg press 60 lbs. and arm press 40 lbs.

  6. I can do no housework including dusting because I don't have the strength.

  7. I had to give up piano lessons because of not being able to sit up on the bench (or concentrate).

These are just a few of hundreds of examples and, just like all the rest of my symptoms, wax and wane in severity.

III. Myalgia
Examples:

  1. My muscles feel like I have the flu. My arms, legs, hands and feet are the worst of all. Grasping with my hands hurts.

  2. There are days I don't have the strength to towel dry myself after a shower.

  3. I had to give up watering my previously well-tended and cherished garden because I am too achey to stand or to hold the garden hose.

  4. There are times I'm too achey to lift my hand to eat.

  5. Most days, I have to nap for several hours.

These are just a few of hundreds of examples.

IV. Arthralgia
Examples:

  1. My bones in my fingers hurt, especially around the joints.

  2. My knees are arthritic without being swollen.

  3. The bones in my feet hurt.

The pain is fluctuating in terms of sites.

V. Gastrointestinal Disorders
Examples:

  1. I have become extremely food sensitive (previously, I had no food sensitivities). My abdomen is extremely tender.

  2. I suffer from daily bouts of diarrhea up to 2-4 times daily. This chronic diarrhea is debilitating and exhausting.

  3. I suffer from continual nausea, only partially helped by taking a prescription anti-emetic 4x daily.

VI. Incapacitating Headaches

Previous to the flu and the onset of CFIDS, I had had perhaps 3 or 4 headaches in an acute illness. The headaches are now daily, usually in the temples and forehead. The headaches are painful, incapacitating, debilitating, and only go away after napping for several hours in the afternoon, or after a night's sleep. In addition, because of bladder pain, I clench my jaw at night and my jaw aches for hours every day, causing neck pain and further worsening my headaches.

VII. Sleep Disorder
Examples:

  1. I wake up several times a night to urinate.

  2. Sleep is not refreshing; it's exhausting. I now sleep at least 10 hours a night. I usually still am so exhausted (just resting) during the day that I go down for a several hour nap sometime during the day. It takes me about 2 hours to fully wake up after the nap but I have to nap because at some point during the day I just can't function. I am overcome with incapacitating exhaustion where my body feels like it's been hit by a ton of bricks and my brain gets muddled and feels drugged.

  3. I wake exhausted, not restored, as if I've run a marathon while sleeping. Previously I had boundless energy.

VIII. Fevers/Temperature Regulation Problems
Examples:

  1. I run low-grade fevers on occasion but feel feverish virtually all the time as if I'm running a high temperature with the flu.

  2. I suffer from intermittent chills.

  3. Periodically, I suffer from night sweats (including during the day).

  4. My temperature regulator is out of whack with wide fluctuations between hot and cold.

IX. Post-Exertional Malaise
Examples:

  1. It exhausts me to stand or to sit.

  2. Walking more than a few steps, my heart races and I often feel like I'm on an endurance walk. Previously, exercise always gave me energy, not took it away. Activity debilitates me.

  3. If I go outside my home and try to engage in activity like a brief lunch with my husband or a ride of more than a few minutes on my electric mobility cart, it exhausts me. I want to go out; I get cabin fever but I inevitably pay for the outing in spades, winding up back in bed drained.

  4. Concentrating is exhausting. This report, with the help of others, has taken weeks.

  5. I spend over 90 percent of my time in bed because most other activities can drain me of energy without warning. The exhaustion will unexpectedly hit like a ton of bricks, without rhyme or reason.

X. Dizziness and Motion Sickness
Examples:

  1. I've lost approximately 8 pounds (from 98 lbs. down to 90 lbs.) because I'm so frequently nauseated even with the use of Tigan (I can't take other anti-nausea drugs because of extrapyramidal effects).

  2. If I take an antibiotic (to prevent a bladder infection) when I catheterize, I'm overcome with nausea and cannot sleep and stay clammy and stay nauseous for hours. Yet, I need the antibiotic.

  3. Movement is often nauseating to me as is suddenly turning my head. It is impossible for me to now be a passenger in a car because of motion sickness but compounding this problem is that I'm often too mentally confused to drive.

XII. Photosensitivity.

If I go outside, I have to wear sunglasses. I often have to keep the blinds drawn in my bedroom. I keep lights low because my eyes hurt in normal light.

XIII. Cognitive Impairment

  1. Immediate and short-term memory is markedly impaired. I often have a hard time holding onto a thought. I ask people to repeat the beginning of sentences because I forget. I read the paper and don't remember what I've read.

  2. Two recent bad examples: I can't file because I can't figure out which date comes before another one. One time, I couldn't remember how to unlock the car door from the inside.

  3. I have to work off a list to try to stay focused because of impaired concentration.

  4. My organizational abilities, including the ability to get started on a task is severely impaired.

  5. I forget basic words. I can stare at a can of soda and not know what to call it. Other times, my cognitions are pure and focused. The more tired I become, the worse my cognitive impairment, continuity of thinking skills, focus and organization of thinking becomes. I become increasingly more confused and forgetful the more tired I become. I forget the names of people I've known for years.

  6. I get confused very easily and can only work on 1 task at a time (example: a friend is on the phone, the electricians are at the door and I get confused and forget the phone and then have a hard time following through with the door). This type of confusion happens too often and capriciously. I often feel as if I have Alzheimers disease.

  7. I can get confused about the day, year and the month. For someone who used to give mental status exams, it's shocking for me to now flunk them.

  8. I was recently tested by 2 psychologist for my I.Q. to see how this illness has affected my brain. It has: my I.Q. has dropped over 20 points. (Please see enclosed psychological report on the I.Q. test and organic brain problems.)

  9. My visual-spatial skills are impaired and I get disoriented. On occasion when I've driven the car, I've gotten confused about which way the road is going. Similarly, in the neighborhood where I have been living for 5 years, I get confused about which way to turn and where I am. It is as if, at times, my visual-spatial map has been erased.

  10. I have a hard time following a lot of dialogue in that my brain is working slower than the person talking. I feel like a lip-reader who only gets about 40-50 percent of what's being said. This leads to problems retaining instructions or conversations as well as to further mental confusion about what just happened.

Before I got sick with CFIDS, I had tremendous mental clarity and a steel trap memory for detail. When you've had this, it's painfully noticeable (by myself and others) when it's gone.

XIV. Opportunistic Infection Susceptibility

Invariably, when I am exposed to anyone outside my household realm, I'm extremely susceptible to any germs they may be carrying. Subsequently, I have suffered from an almost continual array of viruses over the course of this last year.

Interstitial Cystitis Symptomatology:

My health began its downward spiral in 1986 with the onset of Interstitial Cystitis. My current symptoms include the following:

I. Supra-pubic Pressure -- feeling as if I have a telephone book pressing on my abdomen.

II. Urethral Burning -- My urethra at least 60 percent of the time feels like it's on fire, causing extreme pain. If I take a pain pill, it exacerbates my CFIDS symptoms and makes me feel as if I've been hit by a 10-ton truck, lasting 3-5 days.

III. Frequent Urination -- I urinate at least once hourly during the day. Nighttime is the worst -- it takes a long time to get to sleep because of constant urgency and pressure and burning when I lie down to sleep. I am awakened by my bladder to urinate several times a night, adding to my exhaustion. When I experience a bladder flare-up, I have to void several times an hour because of the burning pain in my bladder and urethra.

IV. Bladder burning -- As a few drops of urine accumulate in my bladder, I'm in pain and have to void. I urinate at least once an hour during the day unless I've recently catheterized and instilled Chromalyn (again, facing the agony or the pain pill-CFIDS problem).

I can't have sex because within a day after intercourse, I am in vaginal and bladder agony with agonizing pain, burning and frequency. Similarly, when my progesterone level is low (for the several days preceding my period, during my period, and for a few days afterward) I am in agonizing pain. I have to lay down and keep Marcaine-soaked cotton balls on the labial area, on the urethral opening and inside the vagina.

Candidiasis Symptomatology:

These include:
  1. Exhaustion.

  2. Mental "fogginess."

  3. Continual vaginal yeast infections which cause agonizing burning on top of the Interstitial Cystitis. I have now been on Ketoconazal (Nizoral) for 7 months, a strong drug that helps this but can cause liver damage over extended periods of time. Topical treatments (Monistat, etc.) don't help. When I'm off the Nizoral, the vaginal yeast infection returns.

  4. I have had continual skin rashes for the past year, varying over different parts of my body but predominately centering around my chest and back.

Hashimoto's Thyroiditis Symptomatology:

Hashimoto's Thyroiditis is a "putative autoimmune disorder with cell-mediated and humoral thyroid cytotoxicity" (according to Merck's Manual, 15th edition).
  1. Enlarged and inflamed thyroid.

  2. Extremely high microsomal anti-bodies of 1:1600. I cannot take steroids for this because of my compromised immunity.

Organic Mental Disorder Symptomatology:

  1. Disorientation.

  2. Memory Impairment.

  3. Significant I.Q. loss.

  4. Marked reduction in lifestyle.

  5. Problems concentrating.

(Please see enclosed report documenting I.Q. deficits, cognitive functioning and motor impairment correlating with this disability).

Enclosures:

  1. Resume showing previous level of functioning.

  2. Letters from colleagues, friends and family regarding my past and current level of functioning.

  3. Psychologist's Report (***** ,Ph.D.) regarding Social Security listing 12.02, Organic Mental Disorders.

  4. Social Security Application, including listing of additional physicians seen.

Addendum for Social Security Disability for:

  1. Chronic Fatigue and Immune Dysfunction Syndrome

  2. Interstitial Cystitis

  3. Hashimoto's Thyroiditis

  4. Candidiasis

  5. Organic Mental Disorder

List of Physicians and Health Care Providers Seen:

  1. *******M.D. specialty: Immunology
    ******, California
    Date of 1st visit: Jan. 22, 1990
    Most recent visit: Aug. 10, 1990 plus ongoing telephone consults.

    Treatment for: CFIDS, Interstitial Cystitis, Hashimoto's
    Thyroiditis, Candidiasis.

  2. *******M.D. specialty: Family Practice
    *******, California
    Date of 1st visit: September 23, 1988
    Most recent visit: July 25, 1990 plus ongoing telephone consults.

    Treatment for: CFIDS, Interstitial Cystitis, on-going viral
    infections, bladder infections, chronic diarrhea and nausea.

  3. **********M.D. specialty: Infectious Diseases
    ********, California
    Date of 1st visit: Dec. 1, 1989
    Most recent visit: Feb. 9, 1990 plus ongoing consults to Dr. on my ongoing treatment.

    Treatment for: Chronic Fatigue and Immune Dysfunction Syndrome (diagnostic, symptomatic).

  4. *************M.D. specialty: Urology
    *************, California
    Date of 1st visit: July 16, 1987
    Most recent visit: Dec. 28, 1988 plus ongoing telephone consults due to my sickness and geographic distance.

    Treatment for: Interstitial Cystitis and cystitis infections.

  5. **********, M.D. specialty: Gynecology
    ********, California
    Date of 1st visit: Feb. 26, 1990
    Most recent visit: May 30, 1990 plus ongoing telephone consults.

    Treatment for: Vaginal/Urethral/Bladder pain related to Interstitial Cystitis, yeast infections, chemical sensitivity reactions.

  6. *********, M.D. specialty: Hematology
    *********, California
    Date of 1st visit: Nov. 2, 1989
    Most recent visit: Nov. 13, 1989

    Treatment for: Diagnosis of CFIDS and blood tests.

  7. *********, M.D. specialty: Oncology, Hematology,
    *********, California
    Date of Visit: March 26, 1990
    Reason for Visit: By order of my health insurance company to confirm CFIDS diagnosis.

    Treatment: Diagnosis Confirmed

  8. ********, M.D. specialty: Urology
    ********, California
    Date of 1st visit: March 30, 1987
    Most recent visit: April 2, 1987(?)

    Treatment: Cystoscopy, Diagnosis of Interstitial Cystitis at Century City Hospital. Told I have a 300 cc capacity under general anaesthesia and that there was scarring as the base of my bladder.

  9. *******M.D. specialty: Urologist
    *********, California
    Date of 1st visit: Feb. 19, 1985
    Date of last visit: Sept. 25, 1987

    Treatment: DMSO, Heparin, and prescription from office for Elmiron.

  10. ************, D.C., specialty: Chiropractor
    *********, California
    Date of 1st visit: Oct. 18, 1986
    Most recent visit: July 13, 1990

    Treatment: Symptomatic treatment for pain of Interstitial Cystitis, Arthralgia, and Myalgia.

  11. ************, Ph.D. specialty: Clinical Psychology and Psychodiagnostic testing.
    Outpatient Mental Health
    **********, California
    Date seen: July 19, 1990

    Treatment: Psychodiagnostic Testing (Wechsler Adult Intelligence Scale -Revised): I.Q. test and to determine presence of Organic Mental Disorder (confirmed)

Authorization For Source To Release Information To The Social Security Administration (SSA).

General and Special Authorization To Release Medical and Other Information In Accordance With The Provisions Of The Social Security Laws, The Public Health Service Act, Sections 523, and 527, and Title 38 U.S.C. Veterans Benefits, Section 4132.

I hereby authorize all of the above health care providers to release or disclose to the Social Security Administration or State Agency the following information for the periods identified above:

  1. All medical records or other information regarding my treatment, hospitalization, and/or outpatient care for my condition, including psychological or psychiatric impairment, drug abuse and/or alcoholism, or sickle cell anemia.

  2. Information about how my impairment affects my ability to complete tasks and activities of daily living.

  3. Information about how my condition affected my ability to work.

I understand this authorization, except for action already taken, may be voided by me at anytime. If I do not void this authorization, it will automatically end when a final decision is made on my claim. If I am already receiving benefits, the authorization will end when a final decision is made as to whether I can continue to receive benefits.

Signature of Claimant/Beneficiary or person Authorized to Act in Her Behalf

Relationship to Claimant: Self

Date: August 10, 1990

Address: *********; ( home)
        *********, California

Signature and address of a person who either knows the person signing this form or is satisfied as to that person's identity.

Signature of Witness:
Date: August 10, 1990
Address:

Enclosed Psychological Report

Community Hospital
Outpatient Mental Health Dept.

Re:

To whom it may concern:

August 1, 1900

I had the opportunity to interview ****** July 19, 1990 and at that time to administer to her the Wechsler Adult Intelligence Scale-Revised (I.Q. test). In addition, I have known ******** for over five years as a professional colleague both by reputation and professional interactions. I have had the experience of watching her deteriorate physically (since 1986 from the pain of bladder disease) and most recently, since late 1988 from the physical and cognitive effects of Chronic Fatigue Syndrome. Previous to this time, I have found her to be high functioning both physically and cognitively, maintaining a full-time clinical practice and enjoying an excellent reputation for her clinical expertise, teaching skills, lectures and work with the police department.

It is my opinion that ********** meets the Social Security listing 12.02 Organic Mental Disorders of the Social Security Guidelines, demonstrating:

A) A loss of specific cognitive abilities and affective changes, with medically documented persistence/symptoms in the following areas:

  1. Disorientation to time and place: ****** gets confused about the month, date, season and current year. In addition, there are times she without warning becomes spatially disoriented: this includes becoming confused about the location of places previously well-known to her during the seven years she has lived here on the *****, as well as incidents (she has described and her husband has witnessed) whereby she'll be driving her car and becomes confused about which way the road is going or where to turn on previously well-known streets;

  2. Memory Impairment: ******* suffers from noticeable and frequently severe immediate and short-term memory impairment. For example, she'll forget whether a question has been asked or answered, who just called her on the phone, why she walked into a particular room, common words, whether an event has occurred (such as whether her husband is going to walk the dog or has just come back from walking the dog). It is not uncommon now for her to have to ask an individual to repeat the beginning of their sentence or even to have difficulty in following through on her own train of thought. For an individual who has made her living in a very successful clinical practice with a full client load by having a retentive memory, continuity of thinking skills, and an ability to connect one event to another, her cognitive losses are all the more significant and noticeable;

  3. Perceptual disturbances: ********could complete only five of the nine Block Designs on the WAIS-R, becoming perceptibly confused when more than 4 blocks were presented. Again, she becomes confused about the sequencing of events or whether events have taken place. She was able to complete only two of the four Object Assembly designs, especially becoming confused and disoriented on the proper assembly of the elephant (she finally recognized it as being an elephant but could not put the pieces together to coherently resemble an elephant);

  4. Change in personality. This patient has changed from being even-tempered to being easily frustrated and irritable. While previously having a lifestyle that was multi-faceted and integrated new activities, she now has a very difficult time with change and becomes easily confused. While having a low-frustration tolerance for changes in her environment or daily routine, conversely, there are times she manifests a higher degree of impulsivity, which was not the case before. When she wants something done, she wants it done now (I believe as a defense against possible ensuing confusion or forgetfulness). This impulsiveness is a result of organic mental disorder;

  5. Disturbance in Mood: This patient is now given to periodic anxiety and depression over her current circumstances and fate, and social withdrawal. The social withdrawal can be seen in large measure related to her palpable physical exhaustion, but also in part to her discouragement and embarrassment over her physical and cognitive deterioration in a community where she has been so well known in her respected professional capacity. The patient has tried a variety of anti-anxiety/ anti-depressants, by prescription, since the onset of her current illness but had to discontinue usage each time due to extreme chemical over-sensitivity and reactions to the drugs. [She] does take, by prescription, Klonopin (3/4 mg. nightly) "to help reserve nor-epinephrine and to help clear the brain";

  6. Impairment in impulse control: This is demonstrated in her cognitive testing. The patient did relatively poorly on the Comprehension sub-test of the WAIS-R; in particular, on question seven ("What should you do if you were the first person in a movie theatre to see smoke and fire?") she spoke about trying to walk to the door to try to get away. Similarly, she fell completely apart on question ten regarding what to do about finding her way out if lost in a forest, stating that she'd "just stay there." These answers, along with her Verbal, Performance and Full Scale I.Q. score is not commensurate with her previously high level of cognitive functioning and common sense;

  7. Loss of I.Q. points: Her loss is well in excess of 20 points, measuring a Verbal score of 101, a very low Performance score of 89 and a Full Scale score of 96. It is common with Organic Mental Disorder patients to measure a drop of 15-30 I.Q. points. Again, ********* scores are not commensurate with her past high academic performance, her previous level of professional functioning and many varied accomplishments. She is able to some small degree compensate for the loss of I.Q. by the use of some humor and re-directing of a topic to one that she feels she has a better handle on;

  8. Resulting in all of the following, of which one needs only two to qualify:
  1. ******** manifests a marked restriction of daily activities. This is shown in the patient's inability to engage in clinical practice (due to exhaustion and mental confusion), to dress up, to engage in all but minimal correspondence (as she finds this confusing), household tasks such as laundry, cooking, dusting, etc.

  2. Marked difficulties in maintaining social functioning. This patient has become socially withdrawn due to poor physical health, the exertion that it takes to look presentable and to interact and embarrassment at being seen in her present condition. She has confusion about the sequencing of social events.

  3. Deficiencies of concentration, with problems in persistence, pace and initiation of activities. For instance, her husband has to handle her correspondence, left-over paperwork from her clinical practice (which she was forced to cease in December of 1989). She becomes confused over the filling out of forms and, confused, cannot follow-through on all but the simplest of tasks undertakes. ******** is not able to complete tasks in a timely manner because of confusion and concentration problems.

  4. This patient is likely to have repeated episodes of deterioration and decompensation in her work setting for she can no longer calculate in a way adequate to perform her work. It is hoped that with the resolution of her illnesses her cognitive functioning will improve. At this time, her prognosis remains very uncertain.
In addition, ******* would qualify under Social Security Guidelines 12.04 Affective Disorders. There is a secondary affective disorder as a result of this disease.

A) There is medically documented persistence of the following. (One needs only one of the following to qualify for Social Security disability and *********** has many):

a. Appetite disturbance (the patient has lost 10 lbs. over the course of her illness, bringing her down to a weight of 90 lbs.);

b. Sleep disturbance (the patient sleeps over 10 hours a night; is awakened several times a night to urinate due to her bladder disease and reduced bladder capacity; frequently has to nap several hours a day; and wakes up exhausted from her sleep);

c. Psychomotor retardation (the patient performed her Performance sub-tests slowly and showed marked deterioration of psycho-motor skills on Digit Symbol, Block Design, and Object Assembly); in addition, she visibly moves slowly, especially in comparison to her previous high rate of functioning);

d. Decreased energy (the patient is visibly exhausted from any exertion sustained over more than a few minutes. Her appearance is wan and pale and she has medical documentation of Chronic Fatigue Syndrome. The patient reports showering and dressing as exhausting and physical energy is enervating for her. In watching her, mental activity requiring concentration is equally debilitating;

e. Feelings of worthlessness and decreased self-esteem (this patient has lost her professional identity, experiences a loss of self-esteem over her emaciated appearance and is clearly searching for ways to make her days meaningful). These feelings are interspersed with optimism that she can return to her previous high state of functioning.

f. Difficulty in concentrating or thinking (as stated above, this patient evidences confusion in her thinking, has problems holding her train of thought, has deductive reasoning problems. Her arithmetic skills at this point are all but non-existent. She describes herself as feeling "foggy brained." The severity of her cognitive impairment waxes and wanes from what she describes as 10-60% functioning. Her immediate and short-term memory deficits are marked.

B) This results in the following restrictions, of which two are necessary to qualify:
1. Marked restriction in daily activities of living; and

2. Marked difficulties in maintaining social functioning; and

3 Deficiencies of concentration, persistence and pace; and .

4. Repeated episodes of deterioration or decompensation in work/work-like settings, social settings which cause her to withdraw from those situations (for both physical and cognitive reasons) or to experience exacerbations of signs and symptoms.

In summary, it is my opinion that completely disabled from any gainful employment at present, and this is based on multiple areas of disability. There are multiple organs and systems involved and multiple cognitive deficits, as well as emotionally related disabilities, including a periodic depressive and agitative syndrome related to her physical and cognitive impairments.

******* Ph.D.
Clinical Psychologist

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