Understanding CD4 Count in HIV Cases

CD4 Count: What Does It Mean?

CD4 cells are a type of white blood cell that fights infection. Another name for them is T-helper cells. CD4 cells are made in the spleen, lymph nodes, and thymus gland, which are part of the lymph or infection-fighting system. CD4 cells move throughout your body, helping to identify and destroy germs such as bacteria and viruses.

The CD4 count measures the number of CD4 cells in a sample of your blood drawn by a needle from a vein in your arm. Along with other tests, the CD4 count helps tell how strong your immune system is, indicates the stage of your HIV disease, guides treatment, and predicts how your disease may progress. Keeping your CD4 count high can reduce complications of HIV disease and extend your life.

How HIV Affects CD4 Cells

HIV targets CD4 cells by:

• Binding to the surface of CD4 cells
• Entering CD4 cells and becoming a part of them. As CD4 cells multiply to fight infection, they also make more copies of HIV
• Continuing to replicate, leading to a gradual decline of CD4 cells

HIV can destroy entire "families" of CD4 cells. Then the diseases these "families" were designed to fight can easily take over. That's when opportunistic infections are likely to develop.

When to Have a CD4 Count Test

Your doctor will recommend a CD4 count test:

• When you're first diagnosed with HIV. This is called a baseline measurement. It allows you to compare against future measurements.
• About 2 to 8 weeks after starting or changing treatment.
• Every 3 to 6 months after that (is a reasonable time interval).

What the CD4 Count Test Results Mean

CD4 counts are reported as the number of cells in a cubic millimeter of blood. A normal CD4 count is from 500 to 1,500 cells per cubic millimeter of blood. It is more important to pay attention to the pattern of results than to any one test result.

In general, HIV disease is progressing if the CD4 count is going down. This means the immune system is getting weaker and you are more likely to get sick. In some people, CD4 counts can drop dramatically, even going down to zero.

The test does not always correspond with how well you are feeling. For example, some people can have high CD4 counts and do poorly. Others can have low CD4 counts and have few complications.

If your CD4 count goes down over several months, your doctor may recommend:

• Beginning or changing antiretroviral therapy.
• Starting preventive treatment for opportunistic infections.

Public health guidelines recommend starting on preventive antiretroviral therapy if CD4 counts are under 200, whether or not you have symptoms. This is a later stage of HIV infection called AIDS (acquired immunodeficiency syndrome). Some doctors start therapy earlier, when the CD4 count reaches 350. If therapy is effective, your CD4 count should go up or become stable.

Most doctors recommend starting medication for opportunistic infections at these levels:

• Less than 200: pneumocystis pneumonia (PCP).
• Less than 100: toxoplasmosis and cryptococcal meningitis.
• Less than 75: mycobacterium avium complex (MAC).

Factors That Can Affect Your CD4 Count

You should know that other factors can influence how high or low your CD4 count is.

• CD4 counts tend to be lower in the morning and higher in the evening.
• Acute illnesses such as pneumonia, influenza, or herpes simplex virus infection can cause CD4 counts to go down for a while.
• If you have a vaccination or when your body starts to fight an infection, your CD4 counts can go up.
• Cancer chemotherapy can cause CD4 counts to go way down.
• Fatigue and stress can also affect test results.

For these reasons:

• Try to use the same lab each time.
• Have your tests done at the same time of day each time.
• Wait for at least a couple of weeks after an infection or vaccination before getting a CD count test.

WebMD Medical Reference

View Article Sources

SOURCES: Lab Tests Online: "CD4 Count." New Mexico AIDS InfoNet: "CD4 Cell Tests."

Reviewed by Daniel Perlman, MD

© 2007 WebMD, Inc. All rights reserved.

©2005-2007 WebMD, Inc. All rights reserved.
WebMD does not provide medical advice, diagnosis or treatment.

My Notes:

Woman indicted after allegedly lying to Social Security about illnesses

by Matthew Perenchio | Editor

.

A federal grant jury indicted a Black River Falls woman last week after she allegedly told the Social Security Administration she had a number of illnesses and up to a year to live in order to collect disability benefits.

Lisa Marie Miller, 32, was charged June 3 with two counts of making false statements to the Social Security Administration. A federal grand jury in the Western District of Wisconsin sitting in Madison returned the indictment.

If convicted, Miller faces a maximum penalty of 10 years in federal prison.

According to the indictment, Miller applied for Social Security disability benefits online on Oct. 30, 2008, and falsely stated she suffered from breast cancer, diabetes, kidney disease and post-traumatic stress disorder.

Four days later, as part of the process to complete her Supplemental Security Income application, Miller reportedly stated her doctors told her she only had eight months to a year to live.

The charges against Miller were the result of an investigation conducted by the Social Security Administration.

The case has been assigned to Assistant U.S. Attorney John W. Vaudreuil.

.

Surgical Compared with Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis

Background: The management of degenerative spondylolisthesis associated with spinal stenosis remains controversial. Surgery is widely used and has recently been shown to be more effective than nonoperative treatment when the results were followed over two years. Questions remain regarding the long-term effects of surgical treatment compared with those of nonoperative treatment.

Methods: Surgical candidates from thirteen centers with symptoms of at least twelve weeks' duration as well as confirmatory imaging showing degenerative spondylolisthesis with spinal stenosis were offered enrollment in a randomized cohort or observational cohort. Treatment consisted of standard decompressive laminectomy (with or without fusion) or usual nonoperative care. Primary outcome measures were the Short Form-36 (SF-36) bodily pain and physical function scores and the modified Oswestry Disability Index at six weeks, three months, six months, and yearly up to four years.

Results: In the randomized cohort (304 patients enrolled), 66% of those randomized to receive surgery received it by four years whereas 54% of those randomized to receive nonoperative care received surgery by four years. In the observational cohort (303 patients enrolled), 97% of those who chose surgery received it whereas 33% of those who chose nonoperative care eventually received surgery. The intent-to-treat analysis of the randomized cohort, which was limited by nonadherence to the assigned treatment, showed no significant differences in treatment outcomes between the operative and nonoperative groups at three or four years. An as-treated analysis combining the randomized and observational cohorts that adjusted for potential confounders demonstrated that the clinically relevant advantages of surgery that had been previously reported through two years were maintained at four years, with treatment effects of 15.3 (95% confidence interval, 11 to 19.7) for bodily pain, 18.9 (95% confidence interval, 14.8 to 23) for physical function, and –14.3 (95% confidence interval, –17.5 to –11.1) for the Oswestry Disability Index. Early advantages (at two years) of surgical treatment in terms of the secondary measures of bothersomeness of back and leg symptoms, overall satisfaction with current symptoms, and self-rated progress were also maintained at four years.

Conclusions: Compared with patients who are treated nonoperatively, patients in whom degenerative spondylolisthesis and associated spinal stenosis are treated surgically maintain substantially greater pain relief and improvement in function for four years.

Md. researchers joining major study on causes of autism

By Kelly Brewington | kelly.brewington@baltsun.com

June 10, 2009

Researchers at Johns Hopkins and the Kennedy Krieger Institute are joining in what is being called one of the largest studies to examine early causes of autism.

Medical experts have been trying for years to unravel why children develop autism. Is it genes? Could it be their environment? While other studies have focused on one or the other, the four-year investigation announced yesterday will examine both questions about the puzzling neurobiological disorder that affects about 1 in 150 children nationwide.

The Baltimore investigators will join experts at four research centers in Philadelphia and Northern California to recruit 1,200 pregnant women who already have a child with autism and study them throughout pregnancy and their baby's first three years.

"This is a great opportunity to put gene and environmental hypotheses together," said Daniele Fallin, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health and one of the study's principal investigators. "The great thing about this new study is we are able to do things in real time."

Fallin expects to spend the next four years recruiting about 250 women from the Baltimore area and the Washington suburbs for the Early Autism Risk Longitudinal Investigation. The study is spearheaded by the National Institutes of Health with funding from the institute and Autism Speaks, a national advocacy group.

Scientists will closely monitor the women, taking blood and urine samples during their pregnancy and breast milk samples after they deliver. The women will be asked to keep a diary of their eating habits and lifestyle, fill out questionnaires and participate in interviews about their health, their jobs and their lives before their babies' conception. Fathers will be asked questions about chemicals they might have been exposed to and to give blood samples.

Researchers will collect dust samples from the couples' homes and examine common household chemicals, including cleaning solutions, pesticides and flame retardants used in mattresses and sofas.

Researchers will gather similar biological samples from the babies and follow them closely for any early signs of autism, such as regressions in development.

Children found at risk for developing autism will be referred for treatment, even if doing so means skewing the study's results, said Dr. Rebecca Landa, director of the Center for Autism and Related Disorders at Kennedy Krieger.

"This is a risk to the interpretation of the data that one takes for ethical reasons," she said.

The wide range of disabilities known as autism spectrum disorders is marked by impaired communication and social interaction. There is no cure for the disorder, and the factors that cause it remain a mystery.

Still, researchers have unlocked clues to possible genetic causes of the disorder. For instance, the likelihood of a child being born with autism is less than 1 percent. But for couples with one autistic child, Fallin said, the risk of having a second child with the disorder rises to between 5 percent and 20 percent.

In addition, researchers at UCLA recently found an autism-risk gene that is more common in boys than girls, which they think helps explain why the disorder is four times more common in boys. Dr. Stanley Nelson, a professor of human genetics at the David Geffen School of Medicine at UCLA, believes that research ultimately will link many genes to the disorder.

For now, he said, the genetics remain murky. Several people with autism have been found to share the same genetic mutations, but the disorder differs in each: Some develop severe autism, some develop mild cases and others do not develop the disorder at all.

Nelson, who is not connected with the study announced yesterday, said that beginning the research during pregnancy is worthwhile but he wonders if the scope is too broad.

"My concern would be, we don't know that much about the genetics yet," he said. "Trying to study genetics, with a complex process such as pregnancy and ... combining them, they may not have enough compelling data one way or the other."

Possible environmental causes of autism are even trickier to understand. There is little hard evidence that chemicals or lifestyle cause autism, said Dr. Irva Hertz-Picciotto, of the University of California, Davis School of Medicine, who is also involved in the study. But researchers think there may be a link between environment and genetic susceptibility.

While the researchers acknowledge that their study is broad, they say it will provide a critical opportunity to study autism's causes in real time - as a baby develops from fetus to toddler.

"Many studies rely on identifying children with autism spectrum disorders and a group without, and making families recall what exposures they had early in pregnancy," said Lisa A. Croen, an epidemiologist with Kaiser Permanente and a partner in the study. "You can't get that from a study that collects data after the fact."

A small but vocal minority of parents believes that childhood vaccinations can cause autism, leading some to refuse to inoculate their children against common diseases. Studies have shown no credible link between vaccinations and autism, and research shows that individuals who miss inoculations put larger populations at risk of contracting preventable diseases.

For other families coping with autistic children, the research announced yesterday offers hope, said Peter Waldron of Lutherville, whose son Frankie, 5, has received speech and occupational therapy at Kennedy Krieger since being diagnosed with autism at 16 months. Frankie was talking when he turned 1, but several months later Waldron and his wife, Julie, noticed that Frankie had stopped saying mommy and daddy.

"Studies like this are incredibly important and in dire need," said Waldron, whose daughters, Lila, 2, and Millie, 3, took part in a study at Kennedy Krieger for siblings of children with autism. They have not been diagnosed with the disorder.

"It's very important for families to participate in these studies to help unlock some of the questions and provide some answers to what is happening," he said. "And, hopefully, answer why."

More information on the study is available at www.earlistudy.org or by calling 443-287-4768 or 877-868-8014

Discussion on Autism

Autism starts in childhood and abnormalities continue into adulthood. A seamless discussion must include infants and children under this section, although they could be evaluated under listing 112.10.

Autism is a brain disorder that typically affects a person’s ability to communicate, form relationships with others, and respond appropriately to the environment. Some people with autism are relatively high-functioning, with speech and intelligence intact. Others are mentally retarded, mute, or have serious language delays. For some, autism makes them seem closed off and shut down; others seem locked into repetitive behaviors and rigid patterns of thinking.

Although people with autism do not have exactly the same symptoms and deficits, they tend to share certain social, communication, motor, and sensory problems that affect their behavior in predictable ways.

Isolated in worlds of their own, people with autism appear indifferent and remote and are unable to form emotional bonds with others. Although people with this baffling brain disorder can display a wide range of symptoms and disability, many are incapable of understanding other people’s thoughts, feelings, and needs. Often, language and intelligence fail to develop fully, making communication and social relationships difficult. Many people with autism engage in repetitive activities, like rocking or banging their heads, or rigidly following familiar patterns in their everyday routines. Some are painfully sensitive to sound, touch, sight, or smell.

Children with autism do not follow the typical patterns of child development. In some children, hints of future problems may be apparent from birth. In most cases, the problems become more noticeable as the child slips farther behind other children the same age. Other children start off well enough. But between 18 and 36 months old, they suddenly reject people, act strangely, and lose language and social skills they had already acquired.

Listing 112.10 Autistic Disorder and Other Pervasive Developmental Disorders

Listing 112.10 Autistic Disorder and Other Pervasive Developmental Disorders: Characterized by 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.



The required level of severity for these disorders is met when the requirements in both A and B are satisfied.



A. Medically documented findings of the following:



1. For autistic disorder, all of the following:

a. Qualitative deficits in the development of reciprocal social interaction; and

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

c. Markedly restricted repertoire of activities and interests;



OR



2. For other pervasive developmental disorders, both of the following:

a. Qualitative deficits in the development of reciprocal social interaction; and

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



AND



B. For older infants and toddlers (age 1 to attainment of age 3), resulting in at least one of the appropriate age-group criteria in paragraph B1 of listing 112.02; or, for children (age 3 to attainment of age 18), resulting in at least two of the appropriate age-group criteria in paragraphs B2 of listing 112.02.

Psychiatric Disability: A Step-by-Step Guide to Assessment and Determination Tips on a Complex and Challenging Role for Consulting Psychiatrists

Samuel O. Okpaku MD, PhD
Nashville, Tenn.

Dr Okpaku is clinical professor of psychiatry at the Vanderbilt University School of Medicine and executive director of the Center for Health Culture and Society in Nashville, Tenn. The author reports no conflicts on interest concerning the subject matter of this article.

Acknowledgment—The author is grateful for the helpful assistance of Tamara Smith and staff, Betty Hood, Ann Benes, Dr Tommie Slayden, Jeffrey Eddie, and the staff at the Tennessee DDS.

The epidemiology and management of psychiatric disability have gained increased attention for a variety of reasons in the past 3 decades. There are issues of empowerment, advocacy, and reduction of stigma. There are also concerns about cost containment as well as reliability, validity, and efficacy of the determination process.

About 20% of adults who receive Social Security disability benefits have psychiatric disability. Psychiatric disability accounts for a significant proportion of private long-term disability claims and payments.1,2 Advances in technology that have had an impact on physical disabilities have not had a corresponding effect on psychiatric disability.

This article is based on the United States Social Security Administration (SSA) model of disability assessments for psychiatric impairment. Since its inception in 1935, there have been several amendments and rul-ings that have attempted to expand and refine the Disability Act. Despite these efforts, the reliability and validity of the disability determination process have been impaired by several factors:

• The inherent difficulty of objectifying psychiatric signs and symptoms

• The fluctuating nature of psychiatric disorders

• Problems with language and communication (central to the collection of data from patients), which may be compromised by the disease process

In addition, many individuals who apply for disability on the basis of physical illness also have comorbid mental disorders. Hence, psychiatrists may be called on as treating physicians, consultative examiners, and expert witnesses to provide disability reports.

Defining disability

The SSA defines disability as “the inability to engage in any substantial gainful activity by reason of medically determinable physical or mental impairments which can be expected to result in death or which has lasted, or can be expected to last, for a continuous period of not less than 12 months.”3 SSA disability is regarded as permanent, although the disability is subject to periodic review.

Keep in mind that diagnosis of a mental illness is not necessarily equivalent to disability or functional impairment. An individual who has major depressive disorder is not legally disabled if he or she can engage in “substantive gainful activity.” Substantive gainful activity refers to a level of activity that SSA uses to establish disability. As a rule of thumb, a disabled individual should not be able to participate actively in the national economy. For example, if an attorney has a mental disorder (and therefore cannot effectively practice law) but he can work as a waiter, he is then not legally disabled according to the SSA. In assessing disability, psychiatrists should be aware of opportunities for vocational rehabilitation and work incentives as well as treatment opportunities.

The application process

The application for Social Security disability benefits is initiated by a claimant who completes a form at the local SSA field office, or by mail or telephone.3 The information obtained at the field office includes background and demographics, such as age, marital status, employment, Social Security coverage, and contact information. Information on the nature of the impairment(s) and other pertinent information relative to the potential disability are obtained. If the claimant’s information passes the initial disability requirements, his file is transmitted to a Disability Determination Service (DDS) team that consists of a disability analyst and a psychiatrist or psychologist. The analyst gets as much information as possible from treating physicians, hospitals, clinics, and other relevant sources.

Once the analyst has gathered relevant information to complete the medical evidence, the file is passed on to the DDS psychiatrist or psychologist who reviews the documentation and adjudges whether the patient’s condition:

• Meets or equals the (listed) criteria of mental impairments

• Does not meet the listed criteria

• Falls between meeting and not meeting the criteria

For patients who fall within the third category, the psychiatrist or psychologist completes a Residual Functioning Capacity (RFC) form. At this time, a consultation with a vocational analyst may be requested. The disability analyst then makes a determination as to the legal eligibility of the claimant and a decision is made to approve or deny the claim.

The appeal process

There are 4 steps in the appeal process. If the claim is denied, the claimant can apply for reconsideration. It is important for the claimant to ensure that all relevant information from doctors, hospitals, clinics, and other treatment sources are submitted to the DDS. For the reconsideration process, the case is assigned to a different DDS team. If this reconsideration fails, the claimant can appeal to the next level, which is a hearing before an administrative judge. At this appeal level, the claimant may be represented by an attorney; witnesses and new evidence may be presented, and the claimant may appear in person. The next level for appeal is the SSA appeals court in Baltimore; ultimately, the appeal may be made to a federal court.

The medical evidence

Generally, individual psychiatrists may contract with their local DDS to provide consultative examinations. There are some key issues in conducting a consultative examination and completing the report. The claimants can request to have the consultative examination carried out by their own treating psychiatrists.3 The psychiatrist should be familiar with the Psychiatric Review Technique form and the Residual Functioning Capacity form used by the DDS.4,5 All available records should be reviewed before the examination to ascertain the specific reasons for the consultative examination.

The psychiatrist should specify his role in conducting the examination to dispel the myth that approval for disability is given by the physician. The provision of adequate and comprehensive information that enables the DDS team to make a reasonable, prompt, and fair determination is a sine qua non and is dependent on the accuracy and completeness of patient records.

The SSA uses “listings” to approve or deny applications for disability. There are 9 categories under the mental disorder listings used in making such decisions. Each category refers to a disease process or disorder. Using the model of disease → impairment → disability, impairment refers to the signs and symptoms of the disorder that provides medical determination of the condition (criteria A). Disability refers to the severity of restrictions and limitations of functioning (criteria B) that are directly related to criteria A.

The 9 diagnostic categories for mental impairments are:

• Organic mental disorders

• Schizophrenic, paranoid, and other psychotic disorders

• Affective disorders

• Mental retardation

• Anxiety-related disorders

• Somatoform disorders

• Personality disorders

• Substance disorders

• Autistic and other pervasive developmental disorders

Each listing is further qualified by criteria A and B. For organic mental disorders, schizophrenic, paranoia, and affective disorders, or other psychotic and anxiety-related disorders, an additional set of criteria (criteria C) may be used to meet the diagnostic and impairment-related restriction of functioning requirements. Disability is therefore met when criteria A and B are met, or when criteria C is met.

The report should be typewritten (not handwritten). DDS jurisdictions usually provide dictations by phone. Again, the report should provide a longitudinal and current assessment of the case. The pathogenesis of the disease is helpful in establishing the nature and duration of illness. General observations of the patient, his history, and any additional information required for that listing of diagnoses are other essential elements of the report. If there is a comorbidity, this should be stated. This is especially important for the claimant who has several minor disabilities which, when taken together, may affect his ability to work.

In addition, for consultative examinations, the number of appointments the patient has canceled and difficulties in keeping appointments may point to a diagnosis of an anxiety-related condition. Prolonged treatment by a primary care physician may be a clue to chronic treatment-resistant depression. The report must record the patient’s education or employment and rehabilitation history.

In preparing the report, the psychiatrist should be aware of how, in which manner, and to what extent the mental impairment limits the patient’s functionality.6

Items from criteria A are delusions/hallucinations, catatonic behavior, and incoherence. For criteria B, items are selected from 4 domains:

• Activities of daily living (eg, grocery shopping, doing laundry)

• Social functioning (eg, ability to interact socially with other people at home or in a public setting)

• Concentration, persistence, and pace (eg, inability to complete a task in the given time)

• Deterioration or decompensation in work or worklike setting (eg, panic attacks, psychotic decompensations, and crying)

For these domains, the documentation must be sufficiently descriptive and explicit to permit an assessment of the appropriateness, independence, sustainability, quality, and effectiveness of these functions over long periods. The examples of deficits in those domains must be tied directly to the mental disorder, rather than to circumstantial factors. For example, a statement that “the patient does not do any grocery shopping, laundry, or cooking” or a statement that the patient cannot complete a task will be inadequate without specifically saying that these examples are caused by the clinical manifestations of the mental disorder and not by circumstantial factors.

CASE VIGNETTE

Tony is 32 years old. He has been ill since age 22, when he was a second-year law student. He came home and informed his parents that poisonous gases were being pumped into his room. He dropped out of school and made attempts to return to school but failed. He has remained paranoid; he keeps to himself and has been hospitalized 5 times. He was hospitalized 6 months ago when he became belligerent at work. He believed his supervisors were out to get him. He has been on a combination of several antipsychotics to help reduce his hallucinations and delusions. His longest period of employment in 10 years was 3 months. He has never earned more than $300 per month.

By meeting 1 item from criteria A and 2 items from criteria B, Tony meets (at least superficially) the requirement for disability under the listing of schizophrenia. Alternatively, criteria C may be used. The psychiatric report to DDS should include the date, time, and place of the assessment. It should conclude with a 5-axis diagnosis as well as a statement of daily activities. The report should not make any recommendation as to whether the application should be approved or denied. This is a function for DDS. The report should be signed and dated.

DDS evaluation forms

The use of and familiarity with the Psychiatric Review Technique form and the Residual Functioning Capacity form can greatly enhance the quality of the medical evidence. The concepts and terms in these forms are those generally used by DDS and administrative judges. Attorneys who represent mentally ill claimants frequently attempt to bolster their cases by having the treating psychiatrist complete these forms. The emphasis in completing these forms is to continuously link the signs, symptoms, and diagnosis to the restrictions and limitations of functioning.

The Psychiatric Review Technique form is completed by a DDS psychologist or psychiatrist for all claims that involve mental illness. That form should include a summary of what mental impairments are present and the degree of functional loss in criteria B and C. In activities of daily living and social functioning the functional loss ratings are none, slight, moderate, marked, extreme restrictions, and insufficient evidence. In the domains of deficiencies and concentration, persistence, or pace, the ratings are never, seldom, often, frequent, and constant. For episodes of deterioration or decompensation in work or worklike settings, the ratings range from never, or once or twice, to repeated (3 or more times), and continual. The emphasis is on how specific symptoms and signs from the Psychiatric Review Technique Form impair work-related activities in the Residual Functioning Capacity assessment.

When the medical evidence shows that the level of severity of impairment falls between “meets or equals” the listed mental criteria or “does not significantly affect work-related capacities” DDS psychiatrists or psychologists usually complete the residual capacity and assessment form. This procedure attempts to gauge what the claimant may do despite his limitations. It assesses the claimant’s impairment, related functioning limitations, the degree, severity, and frequency of the limitations, as well as the claimant’s ability to sustain work-related activities in the face of restricted functioning during a normal work day or week. The form contains examples of mental activities that are grouped under 4 headings:

• Understanding, comprehension, and memory (eg, ability to remember locations and worklike procedures)

• Sustaining concentration and persistence, ability to perform activities within a schedule (eg, attendance and punctuality)

• Social interaction (eg, ability to sustain socially appropriate behavior and to maintain a reasonable standard of neatness and cleanliness)

• Adaptation (eg, ability to respond adequately and appropriately to the work environment)

The RFC items are rated as not significantly limited, moderately limited, markedly limited, no evidence of limitation, or not rateable based on available evidence.

Special considerations

Some patients such as infants, children, and adolescents have special needs. In this setting, only psychiatrists who have clinical experience working with children and adolescents should agree to do consultative examinations for children under the age of 18. The listings for children are similar to those for adults, but they take into consideration age-appropriate and developmental factors, the unique presentation of certain diagnostic categories in this age group, the impact of schooling, and the need for corroborative evidence.

School teachers, social workers, and foster care parents may provide information that is essential for making appropriate decisions. Appropriate psychological tests may contribute to a more informative report. In fact, for children, the use of psychological tests may be more critical than for adults.

Another class of claimants are those with multiple minor impairments. Each condition with its concomitant restrictions and functions should be well described. Also, the needs of veterans have taken center stage: practitioners should be familiar with the subtleties of posttraumatic stress disorder.






References
1. Leo RJ. Social Security disability and the mentally ill: changes in the adjudicatory process and treatment source information requirements. Psychiatr Ann. 2002;32:284-292.
2. MacDonald-Wilson K, Rogers ES, Anthony WA. Unique issues in assessing work function among individuals with psychiatric disabilities. J Occup Rehabil. 2001;11:217-232.
3. Social Security Administration. Disability Evaluation Under Social Security, January 2005. http://www.socialsecurity.gov. Accessed November 25, 2008.
4. Psychiatric Review Technique form. http://www.fedforms.gov/bgfPortal/docDetails.do?dId=13996. Accessed December 8, 2008.
5. The Residual Functioning Capacity form. http://ssaconnect.com/tfiles/SSA-4734-F4.sup.pdf. Accessed December 8, 2008.
6. Okpaku SO. The psychiatrist and the Social Security Disability and Supplemental Security Income programs. Hosp Community Psychiatry. 1988;39:879-881.

Evidence-Based References
Disability determination for adults with mental disorders: Social Security Administration vs independent judgments. Am J Public Health. 1994;84:1791-1795.
Okpaku SO, Anderson KH, Sibulkin AE, et al. The effectiveness of a multidisciplinary case management intervention on the employment of SSDI applicants and beneficiaries. Psychiatr Rehab J. 1997;20(3).

DON'T BE SURPRISED IF, WHEN SOCIAL SECURITY DENIES YOUR CLAIM.

Question: Does Social Security pay you if you become disabled?

Answer: Sometimes. But they aren't afraid to say no.

According to a 2004 General Accounting Office, Social Security Administration report, 60 percent of all first initial claims for Social Security disability benefits were rejected.

Your most valuable asset is your human capital — your ability to create value in the marketplace and, thereby, earn an income. Yet most people who wouldn't think of leaving their home or auto uninsured (what if there was a fire?) leave their most valuable asset completely unprotected against loss.

If you earn $50,000 a year and have 30 years to go in your working life, you stand to earn $1.5 million over that period of time. Let's assume you get a raise or two along the way (averaging 3 percent per year), you would earn about $2.5 million over that period.

If you owned a $2.5 million house, would you sleep well at night knowing that a fire might send your wealth up in smoke?

Life insurance is pretty straightforward — you're either dead or you're not. Disability insurance isn't quite so simple.

For example, what does it mean to be disabled?

According to Social Security, you are "disabled" when you have a medical problem that will either kill you or keep you out of work for a year. Also, you must be unable to engage in any "substantial gainful activity." And you get no benefits for short-term or partial disability. And benefits are very limited.

That's a pretty narrow definition that leaves a lot of folks out.

It would be like buying a homeowners insurance policy that says the house has to completely burn to the ground before your claim gets accepted, and what you get is only enough to rebuild a much smaller house.

Clearly, Social Security disability coverage is meant only as a social safety net. A middle class or higher wage earner counting on Social Security to preserve their financial life in the event of a disability is likely to be very disappointed.

Speak to your agent about individual, private disability insurance.

Ask him about a policy with a definition of disability that takes into account your education, training and experience. You may even be able to get a policy that defines disability in terms of your specific occupation (often referred to as "Own Occ" coverage).

Inquire about coverage that pays you even if you are not totally disabled. Why have an incentive not to return to work? That could be the effect of a total-disability-or-nothing policy.

Because the cost of living is unlikely to stay level, your benefits should also be able to rise with inflation. Ask about any cost-of-living-adjustment (COLA) features that may be available in any disability income insurance policy you are considering.

When will you benefits start? And how long do you want your benefits to last? A month? A year? Until you retire?

If you became disabled, your ability to save and invest for a future retirement would be severely compromised. You may wish to consider coverage that pays benefits for life.

Nobody wants to think about being disabled. But it can happen to anyone.

If you become disabled, Social Security may or may not pay you a benefit — it will depend on a lot of circumstance. Individual disability insurance can make sure that if a disability means you are out of work, it doesn't also mean you're out of luck.

Fibromyalgia: Patients say many doctors don't take them seriously

By Sam McManis
smcmanis@sacbee.com
Published: Sunday, May. 31, 2009 - 12:00 am | Page 2I

Asked to describe the seemingly indescribable, to make real the manifestations of a medical condition that some still doubt even exists, fibromyalgia patients often rely on similes of the most wince-inducing sort.

• "I felt like acid was going through my veins."

• "It was like a steamroller ran over me."

• "Fatigue like someone's pulled out your battery pack."

• "… as if someone pinged me with a hammer all over my body."

• "Your (brain) feels like a pinball machine. You're trying to come up with the word, and the ball bounces around until it finally falls on your tongue."

• "It feels like death, only worse."

Can there be any doubt that these people truly are suffering from diffuse, widespread chronic pain with multiple tender spots, enervating fatigue and a host of symptoms that include restless legs, impaired memory and depression?

Well, yes.

Despite being recognized as a diagnosable disease by the American College of Rheumatology, the Food and Drug Administration and most insurers, fibromyalgia has not completely shed the stigma of being dismissed as "psychosomatic" by some in the medical establishment.

Controversy swirls even as new FDA-approved medications have shown promise and recent brain imaging research has shown central nervous system changes in those afflicted. The National Fibromyalgia Association, a patient advocacy group, estimates that 10 million Americans suffer from one or more of the multifarious manifestations of the condition.

It is this array of symptoms not linked to specific cause and effect – as opposed to how rheumatoid arthritis can ravage a patient's joints – that keeps skeptics in mainstream medicine from validating fibromyalgia as a legitimate disease.

Where, exactly, is this deep muscular aching? What's the cause of that nebulous numbness and dizziness? Why won't painkillers help? Where are the lab tests that can prove it exists?

Those are the questions that still dog fibromyalgia patients.

"They make you think you're a hypochondriac or something," says Jennifer Filbeck, 36, a former restaurant manager from Fairfield who's been unable to work since 2006. "Doctors treat you like you're crazy."

Not crazy per se, critics of the existence of fibromyalgia claim. Their argument: These people suffer from psychological conditions that manifest themselves in vague and hard-to-define physical maladies.

Dr. Frederick Wolfe, who wrote the landmark 1990 paper that first created diagnostic guidelines for fibromyalgia, recently told the New York Times that he now considers it merely a byproduct of depression, stress and social anxiety. Wolfe, head of the National Databank of Rheumatic Diseases, told the paper, "Some of us in those days thought that we had actually identified a disease, which clearly this is not. To make people ill, to give them an illness, was the wrong thing."

That view is supported by Dr. Nortin Hadler, a rheumatologist and professor at the University of North Carolina. Writing in the Journal of Rheumatology, Hadler states bluntly that fibromyalgia is all in the mind.

"I am suggesting that chronic persistent pain is an ideation, a somatization if you will, that some are inclined toward as a response to living life under a pall, and not vice versa," he writes. "I am further suggesting that these people choose to be patients because they have exhausted their wherewithal to cope."

Medical literature has been slow to publish data on fibromyalgia. Recent studies have gone a long way in disputing the claims of Wolfe and Hadler, though researchers still have yet to pinpoint a cause.

A 2008 University of Michigan study showed that fibromyalgia patients exhibited central nervous system abnormalities that resulted in elevated sensitivity to pain and stimuli. The study, however, tested only 31 subjects.

Other research using functional MRI brain scans show increased activity in pain receptors for even minor discomfort among fibromyalgia patients.

Fibromyalgia: Patients say many doctors don't take them seriously - Sacramento Living - Sacramento Food and Wine, Home, Health | Sacramento Bee

Fibromyalgia: Patients say many doctors don't take them seriously - Sacramento Living - Sacramento Food and Wine, Home, Health | Sacramento Bee

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