All in your head: a comprehensive approach to somatoform disorders in adult disability claims.

• Author: Flatt, Gregory C.

1. THE CONFUSION SURROUNDING SOMATOFORM DISORDERS--A HYPOTHETICAL (1)

   1. The Patient

      The Patient is a married woman in her late twenties. She has a diagnosed history of depression, anxiety, post-traumatic stress disorder, and high blood pressure, and she was sexually abused as a child. In recent years, she has suffered seizures that occur as frequently as several in a single day and as rarely as two in a month. Because of the frequency and severity of the seizures, the Patient finds it impossible to hold a steady job, has difficulty with complex tasks, and is embarrassed to leave her house without her husband. She has been hospitalized several times for the seizures and has been examined by many physicians. To her dismay, no physiological cause for her seizures has been diagnosed. Electroencephalogram (EEG) tests, (2) generally helpful in identifying epileptic seizures, (3) have produced no evidence of epileptic seizure activity in the brain, despite the fact that family, friends, and medical personnel have all observed the effects of the seizures firsthand. Doctors have prescribed numerous medications for her and she has undergone psychotherapy, but neither option has resulted in a demonstrable change in her condition. She feels that because of her debilitating condition, and its effect on her social, physical, and occupational well-being, she has no choice but to file for disability with the social security Administration (SSA). (4)

      Her condition was examined by her own physicians, as well as those employed as a part of the SSA's disability evaluation process. (5) However, because there is no demonstrable physiological cause for her condition, no medically generated evidence that it exists, and no methodological evaluation or test which can attest to how her condition actually affects her (beyond what she claims is happening to her), the SSA denied her request for disability. (6) Her application was again denied after she requested reconsideration, and she was subsequently granted an appeal hearing before an Administrative Law Judge (ALJ) to make a more formal evaluative determination. (7) But how can she demonstrate to the ALJ that she has a debilitating condition when even her physicians can offer no physiological evidence of its cause and no physical evidence to substantiate its effects?

   2. The Lawyer

      The Lawyer has taken up the case of the Patient, which is set to go before the ALJ. He has spoken with the Patient's friends, family, and treating physician, who have convinced the Lawyer that the Patient's condition is sufficiently serious to prohibit work, and the Lawyer has observed the patient firsthand during seizure activity. The bulk of medical diagnoses certainly suggest that medical personnel who have treated the Patient have determined that she has a substantially limiting condition.

      However, even as the effects of the condition appear clearly disabling, providing convincing proof of that condition is problematic. Physicians are doubtful that the seizures are a result of an epileptic condition and have most frequently diagnosed the Patient as having "pseudoseizures," (8) indicating that the seizures represent physical symptoms which genuinely manifest themselves without a demonstrable physiological cause. one treating physician documented skepticism about the legitimacy of the Patient's condition and noted that the condition may be primarily malingering (9) or otherwise fraudulent. No drugs seem to counteract the condition, and no treatment seems to affect it in any significant way. The only one who can attest to the actual effects of the condition is the Patient. How does the Lawyer go about proving that the Patient hasn't simply fabricated the condition as a means of receiving disability benefits?

   3. The Administrative Law Judge

      The ALJ is hearing the case of the Patient on appeal. She has read the accounts of the Patient's friends, family, and treating physician, testifying to the significantly limiting effects of the claimed condition. She has read the medical reports of physicians, which are unable to tie the Patient's symptoms to any specified malady beyond a diagnosis of pseudoseizures. No tests indicate the presence of a seizure disorder, either at rest or during one of the Patient's seizures. several medications have been prescribed in an attempt to alleviate the seizures, but medicine seems to have little to no lasting effect on the Patient. The ALJ has consulted a report from the state's office of Disability Determination Services (DDS), (10) which has concluded, on the basis of the medical documentation, that no significant barrier exists to prevent the Patient from work beyond some minor environmental limitations. The ALJ talks to the Patient, who seems genuine in her account of her claimed disability. However, the ALJ has seen many people appear before her who have tried to fake a disability to receive benefits, and she has been instructed by the SSA to be alert for false or malingering claims. (11) How does she go about making a decision that balances the apparently genuine limiting effects of the Patient's condition with the lack of medical evidence and an interest in discouraging malingering or fraudulent disability claims?

2. THE NECESSITY OF REEVALUATING SOMATOFORM DISORDERS IN THE DISABILITY DETERMINATION PROCESS

   Somatoform disorders, (12) including the aforementioned pseudoseizures, present a unique and challenging problem at all phases of disability determinations. Characterized by physical symptoms or complaints that cannot be substantiated by medical examination or treatment, (13) somatoform disorders force evaluators to confront difficult questions about the existence of a condition that all too often only the claimant is able to appreciate with any certainty and can seem to both the lay person and the medical evaluator to be "all in one's head." (14) As much as somatoform disorders are gaining understanding, recognition, and acceptance in the medical industry, (15) the law is still struggling to catch up. (16)

   This tension between the legal analysis of somatoform disorders and medical understanding of the conditions is perhaps best demonstrated within the disability determination context. (17) The purpose of the SSA's disability determination process is to "assure a minimum level of income for people who are age 65 or over, or who are blind or disabled and who do not have sufficient income and resources to maintain a standard of living at the established Federal minimum income level." (18) When a claim is made pursuant to disability, the claimant's impairments must be compared with the corresponding statutory requirements. (19) The imperfect nature of comparing a specific claimant's impairments to comparable listings in the Code of Federal Regulations, and the potential economic impact the determination's outcome presents to the claimant, indicate that "for all [benefit] programs[,] disability stands out as the most important and most difficult issue to resolve, both at the initial decision-making level and on appeal." (20)

   As a result, while several existing statutes can be utilized effectively to handle somatoform disorders, (21) confusion about the medical nature of the disorders, lack of uniformity in applying the relevant statute, and the tendency to cling to traditional notions of disabling conditions have dulled efficient use of those statutes and hindered effective analysis of somatoform disorders presented for disability determination. Therefore, this Note will demonstrate that the issues of identification, understanding, and resolution within the present system at every level prevent somatoform disorders from receiving adequate adjudication.

   in response, i will present a comprehensive approach to somatoform disorders in disability claims, which can be followed to ensure that claims are appropriately examined at all levels of evaluation. in Part iii, i will explain the medical aspects of somatoform disorders, including their diagnosis, prevalence, and acceptance in the medical community. i will then turn, in Part iv, to an examination of the disability process, including the sequential analysis used to determine if disability status should be awarded, relevant statutes that are useful when dealing with somatoform disorders, and available methods for meeting the statutory qualifications. (22) in Part v, i will discuss the aspects of somatoform disorder terminology, acceptance, and assessment that prevent somatoform disorder determinations from being efficiently and consistently made when examined within the framework of current disability determination protocol. Accordingly, Part vi will offer an appropriate and comprehensive approach to somatoform disorders to counteract or eliminate these systemic problems and to ensure that those impairments that suggest a somatoform diagnosis are properly reviewed. Finally, Part vii will address potential complications with my proposal and explain why those complications do not overwhelm the systemic advantages of the process i propose.

3. THE MEDICAL ASPECTS OF SOMATOFORM DISORDERS

   Discussion of somatoform disorders is inherently difficult because analysis of the problem requires the evaluator, whether conducting a medical review or a legal review, to attempt to "bridge the gap" between medicine and psychiatry. (23) As noted above, somatoform disorders are essentially psychiatric problems that manifest themselves in physical symptoms. (24) This tension can often lead to misdiagnosis (25) and confusion (26) on the part of the treating physicians.

   Effective diagnosis and identification of somatoform disorders are further complicated by the fact that conditions with somatoform aspects can be referred to by several different names, (27) which may or may not suggest to others the somatoform component. Beyond "somatoform disorder," the medical terms with somatoform components include, but are by no means limited to...