1. Timothy Harlan
Timothy Cuddigan
NOSSCR
Spring 2012
Bipolar Disorder: How to
Recognize Symptoms, Interview Client/Family,
Request the RFC, Present the Case at a
Hearing, and Be Prepared for Oral Argument

2. May lack insight into illness
May not be compliant with medication or
treatment
May have substance abuse problems
May be difficult to represent
Challenges of Representing Clients with
Bipolar Disorder

3.  The average onset age
for bipolar disorder is
late teens to early 20s1
 Individuals living with
chronic mental illness
have a life expectancy
that is 25 years less
than the rest of the
population
Demographics
1 Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence,
severity, and comorbidity of twelve-month DSM-IV disorders in
the National Comorbidity Survey Replication (NCS-R). Archives
of General Psychiatry, 2005 Jun;62(6):617-27.

4.  Mental illness is the
leading cause of
disability in the US2
 2.2% of the US adult
population live with
“severe” bipolar
disorder.3
Prevalence
2 World Health Organization
3 Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence,
severity, and comorbidity of twelve-month DSM-IV disorders in
the National Comorbidity Survey Replication (NCS-R). Archives
of General Psychiatry, 2005 Jun;62(6):617-27.

5.  MANIA: mental illness marked by periods of great
excitement, euphoria, delusions, and over activity.
 HYPOMANIA: a mild form of mania, marked by elation
and hyperactivity.
 DELUSIONS: an idiosyncratic belief or impression that
is firmly maintained despite being contradicted by
what is generally accepted as reality or rational
argument.
 EUPHORIA: a feeling or state of intense excitement
and happiness.
Definitions

6. Symptoms of Mania or Manic Episodes
 Mood Changes
 A long period of feeling “high,” or an overly happy or
outgoing mood
 Extremely irritable mood, agitation, feeling “jumpy” or
“wired”
Symptoms of Bipolar Disorder

7.  Behavioral Changes
 Talking very fast, jumping from one idea to another,
having racing thoughts
 Being easily distracted
 Increasing goal-directed activities, such as taking on new
projects
 Being restless
 Sleeping little
 Having an unrealistic belief in one’s abilities
 Behaving impulsively and taking part in a lot of
pleasurable, high-risk behaviors, such as spending sprees,
impulsive sex, and impulsive business investments
Symptoms of Bipolar Disorder
Symptoms of Mania or Manic Episodes

8. Symptoms of Depression or Depressive Episodes
 Mood Changes
 A long period of feeling worried or empty
 Loss of interest in activities once enjoyed, including sex
Symptoms of Bipolar Disorder

9.  Behavioral Changes
 Feeling tired or “slowed down”
 Having problems concentrating, remembering, and
making decisions
 Being restless or irritable
 Changing eating, sleeping, or other habits
 Thinking of death or suicide, or attempting suicide
Symptoms of Bipolar Disorder
Symptoms of Depression or Depressive Episodes
http://www.nimh.nih.gov/health/publications/
bipolar-disorder/complete-index.shtml

10. The Initial Interview

11. When were you diagnosed with
bipolar disorder?
Who made that diagnosis?
What events led up to the
diagnosis?
What medications do you take?
Initial
Interview

12. What is it like when you are
depressed?
Possible answers:
I can’t concentrate on anything*
I don’t want to leave the house
I wake up early in the morning for
no reason
I have no short-term memory
I feel like I’m a failure*
I eat too much (or I don’t eat)*
I gain/lose a lot of weight*
Initial
Interview
* Listing Issue

13. What is it like when you are
depressed?
Possible answers:
I don’t like to go to the store,
everybody is watching me*
I don’t move very fast, I’m in slow
motion5*
I get fired because I just can’t get up
and I’m ashamed to call in
I drink until I feel numb
I lie in bed all day looking at the
ceiling
I sleep 20 hours a day or I can’t
sleep*
I don’t take a shower for a week
Initial
Interview
* Listing Issue
5Family members may
point out, claimant
doesn’t usually notice

14. What is it like when you are
depressed?
Possible answers:
I have to be told to brush my hair or
brush my teeth
I don’t answer the telephone
I cry a lot, and/or I cry for no
reason
I have suicidal thoughts*
I wish I wasn’t here any more
(different than suicidal thoughts)
I don’t care about doing things I
would usually enjoy*
Initial
Interview
* Listing Issue

15. What is it like when you are
manic?
Possibilities are:
I can’t sleep for days, or I only
sleep an hour or two
My mind is going 100 miles an
hour
I talk too fast, I jump from one
thing to another*
I move too fast, I jump around*
I don’t have time to stop and eat
I make lots of lists
Initial
Interview
* Listing Issue

16. What is it like when you are
manic?
Possibilities are:
I scrub the floor at 2 a.m.
I wash clean clothes
I try to do 3 different things at once
I spend money I don’t have
I love going to the casino
I buy things that I have no use for
at all
I am sexually inappropriate
I have big plans to move to another
state or start a business
Initial
Interview
* Listing Issue

17. What is it like when you are
manic?
Possibilities are:
I am on Facebook all night
I work in the yard all night
I feel like I’m on top of the world
I am irritable and mad at everybody
I’ve been fired from lots of jobs, I
tell off my boss – regularly
I never do what I’m told, I can find a
better way to do the job
I drink until I don’t feel so jumpy
any more
Initial
Interview
* Listing Issue

18. Treatment Questions
Who diagnosed you? When?
What events led up to your
diagnosis?
Who do you see for treatment?
What medications do you
take?
Initial
Interview

19. Do you ever…
Stay in bed for a day? How
often?
Spend extravagantly?
Feel overwhelmed?
Get into major arguments with
friends or family?
Initial
Interview

20. Have you ever…
Had credit problems from
spending sprees?
Had a gambling problem?
Lost a job, told off an employer,
or walked off a job?
Gotten so out of hand that the
police were called?
Been hospitalized because of
mental illness?
Had problems with substance
abuse?
Experienced psychosis?
Had problems with anxiety? Been
diagnosed with an anxiety
disorder?
Initial
Interview

21. Depression related questions:
How sad do you get and for how
long?
Do you feel hopeless or helpless?
How do you feel about death and
dying?
Do you think about killing yourself?
Have you ever tried to kill yourself?
Do you ever enjoy things any more?
Can you concentrate?
Are you tired all the time?
Initial
Interview

22. Mania related questions:
How happy or angry do you get
and for how long?
Do you have periods of high
energy and productivity?
Have you gotten in trouble during
those times by spending money,
having an affair, or having
trouble with an employer?
Do you have times when you feel
like you are the best at
everything?
Initial
Interview

23. General questions about
thought process:
How is your thinking?
Do your thoughts feel slow or
hyperactive?
Do you feel as though you can’t
think clearly?
Does your brain ever play tricks
on you, hearing voices, believing
you have magical powers, or
thinking people want to hurt
you?
Initial
Interview

24. Anxiety and compulsive
behavior questions:
How much do you worry about
things?
Do you have unwanted thoughts
that won’t go away or illogical
behaviors you can’t stop doing?
Do you freeze in social situations
or avoid them altogether?
Initial
Interview

25. Medications

26. Questions to ask your client:
Have you stopped any medications because you were
feeling better and did not think they were necessary?
Have you stopped any medications because they
weren’t effective or caused side effects that were too
severe?
What side effects do you experience from the
medications you take?
Medication Questions

27. Questions to ask your client:
Have you stopped any medications because you
can’t afford them?
Have you had a prescription lapse and had trouble
getting it renewed?
Medication Questions

28. The medications your client is taking may
tell you about the severity of their illness
or suggest questions you should ask
about their symptoms, treatment trials
and side effects.
Medication Types

29. Mood stabilizers:
Lithium
Divaloprex (Depakote)
Lamotrigine (Lamictal)
Medication Types
Atypical antipsychotic:
Quetiapine (Seroquel)
Risperdone (Risperdal)
Aripoprazole (Abilify)
Olanapine (Zyprexa)

30. Antidepressants:
Fluoxetine (Prozac)
Sertraline (Zoloft)
Paroxetine (Paxil)
Citalopram (Celexa)
Bupropion (Wellbutrin)
Antianxiety:
Clonazepam (Klonipin)
Lorazepam (Ativan)
Medication Types
Be sure to review listed side
effects at www.medlineplus.gov,
especially significant weight
gain that is caused by some of
the antipsychotics.

31. Consider the
following two
situations
Interview
The client interview is perhaps the
hardest and the most important
part of case preparation. Important
because the representative can’t
simply rely on the fact that the
mental health professional has
asked all the hard questions, or if
they have, made note of the
answers. Hardest because, by
definition, it is hard to ask such
personal questions, particularly for
someone who does not have a
counseling psychology degree!

32. You have not asked your client if they
have suicidal thoughts, were sexually
abused as a child, specifics about
their alcohol abuse or if they fail to
bathe regularly, sometimes for a week
at a time. You don’t ask because you
assume that the treating psychologist
has already asked these questions
and it really isn’t necessary for you to
put yourself and your client through
such a difficult interview. If it isn’t
covered in the clinic notes it must not
be a problem. Right? Not at all. It is
possible that the clinician didn’t ask
your client any of these things for a
variety of reasons. Or your client may
have been afraid to admit problems.
Situation
One

33. Situation
One
True question: “Have you told your
doctor these things?”
True Answer: “No, if I did they might
put me in the hospital.”

34. Since you’ve skipped these
hard and uncomfortable
questions, you have no idea
what your client’s answers
might be. Now, in the
middle of the hearing, you
hear the ALJ asking the hard
questions that you skipped.
Could the hearing have gone
better if you had prepared
your client?
Situation
One

35. You took a Statement from your client
about mental health symptoms and how
they deal with the problems. The
Statement is in the exhibit file, the ALJ
has read it, and you know what your
client’s answers will be. You know that
your client hasn’t had a drink in 10
months and that they attend AA twice a
week. You know that they don’t shower
for 3-4 days at a time when they are in
a depressive mode. And you have
already established the bare bones
about the sexual abuse at age 11 from
an uncle and you have assured the
client that your question will be, “I’m
not going to ask you about this now, but
in your Statement you mentioned […]
Can you tell the judge whether that still
bothers you and if so how?”
Situation
Two

36. Which situation might make
you feel more confident
about the case and which
might make your client more
at ease before the hearing?

37. Regular treatment by prescriber and therapist
Therapy vs. just medication checks
Length and frequency of visits
Explanation for gaps in treatment
Legibility of provider’s notes
Reviewing the File

38. Changes in condition or medication
Compliance with medication
Detailed description of symptoms in visit notes
Internal consistency between symptoms and GAF
scores
Drug and alcohol use
Action required for suicide attempts
Reviewing the File

39. Look at the work history form and DEQY
Large number of jobs
Frequent job changes
Do you want to get a work performance
assessment?
Did they have behavioral problems in school? Get
school records.
Reviewing the file

40. Analyze the longitudinal record
Periods of exacerbation or lessening symptoms
Periods of non-compliance with medications or
treatment
Hospitalizations or emergency room visits
Reviewing the file

41. Do they need to have a psychological evaluation?
What do you need from the treating medical
provider RFC or report?
Prepare statement of the claimant
Developing the Record

42. Do you use a form RFC?
How do you address special issues: non-
compliance with medications, drug and alcohol
abuse, and the need for a regular shift schedule.
Asking the Medical Provider for an
Opinion

43. Diagnosis
When were you diagnosed with bipolar?
What provider diagnosed you?
What problems were you having when you were
diagnosed?
Did it take a while for you to get properly
diagnosed?
Direct Exam of the Claimant

44. Treatment
Who prescribes your medications? How often do
you see this person? What side effects do you
have? How many medication changes or
adjustments have you had? Why were your
medications changed?
Do you receive therapy? Has therapy been
recommended? Are you able to obtain or afford
therapy?
Direct Exam of the Claimant

45. Mood Swings
Do you have mood swings? What do you mean by
mood swings?
Mania
Do you have periods of mania? How often do they
occur? How long do they last? Describe an episode
of mania that you have had and what you did when
you were manic.
How does this mood (mania) affect your ability to
work? Have you ever lost a job because you were
manic? What behavior were you exhibiting?
Direct Exam of the Claimant

46. Depression
Do you have depressive moods? What do you mean
by a depressive mood? Describe a depressive
episode. How often do they occur? How long does
the depressive mood last?
How does this affect your ability to work? Have you
ever lost a job because you were depressive? What
behavior were you exhibiting?
Direct Exam of the Claimant

47. Recognizing Changes
Are you able to recognize the signs that your mood
is changing and adapt your behavior?
What do you do to prevent a full blown depressive or
manic episode?
 How do these health prevention measures either
interfere with your employment or cause you to lose
your job?
Direct Exam of the Claimant

48. Interfere with Work
How does your illness interfere with your ability to
work?
How has your illness caused you to lose jobs in the
past?
Do you continue to have the problems that caused
you to lose work in the past?
Are you able to do shift work?
What problems do you have working around others?
Working with the public?
Direct Exam of the Claimant

49.  Numerous jobs
 Walking off the job
 Difficulty getting along with coworkers and
supervisors
 Need for regular sleep and inability to do shift work
 Problems maintaining employment
SPECIAL VOCATIONAL ISSUES

50.  Your theory of the case
 Claimant’s vocationally significant testimony
 Medical expert’s vocationally significant testimony
 Gems from the consultative exam
 ALJ’s terms used to describe mental limitations (e.g.,
superficial contact)
Cross Exam of Vocational Expert

51.  Limitations if any from the PRTF section IV
 Treating physician limitations
 VE testimony about acceptable number of absences
from work
 VE testimony about contact with public, coworkers
and supervisors
 VE testimony about simple, repetitive tasks and
production quotas
Cross Exam of Vocational Expert

52. What goals do you want to accomplish?
Do you want to confirm the diagnosis?
Do you need to deal with the argument that the
condition worsened because of non-compliance?
Cross Exam of Medical Expert

53.  Kangail v. Barnhart, 454 F.3d 627 (7th Cir. 2006)
But that leaves the remainder of the three-year period
during which she was not abusing alcohol or drugs. She
held a total of 10 jobs during the three years, and her
testimony, backed up by medical evidence, was that she left
all but the first (the telemarketing job) either because
of “blowing up,” racing thoughts, confrontations with
customers and supervisors, or other manic activity; or
because of insomnia, inability to concentrate, feeling
overwhelmed, or other symptoms of depression; or because
of “disappearing,” confusion, or other symptoms of either
pole.
Caselaw Involving Bipolar Claimants

54.  Bauer v. Astrue, 532 F.3d 606 (7th Cir. 2008)
“What seems to have made the biggest impression
on the administrative law judge, but suggests a lack
of understanding of bipolar disorder, was that Dr.
Caspary’s treatment notes, which back up the report
in which she concludes that the plaintiff cannot work
full time, contain a number of hopeful remarks.”
Caselaw Involving Bipolar Claimants

55. Pate-Fires v. Astrue, 564 F. 3d 935 (8th Cir. 2009)
 Doctor’s silence on ability to work is not substantial
evidence.
 Discussion of GAF Scores
 Disability related to nature of illness and side effects
of medications
 Noncompliance was attributable to her mental
illness.”
Case law Involving Bipolar Claimants

56. National Alliance on Mental Illness
www.nami.org
http://www.nami.org/Template.cfm?Section=By_Illness&Templa
te=/TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID
=23037
Depression and Bipolar Support Alliance
www.dbsalliance.org
http://www.dbsalliance.org/site/PageServer?pagename=about_
MDOverview
National Institute of Mental Health
http://www.nimh.nih.gov/health/topics/bipolar-
disorder/index.shtml
*contains downloadable information booklet
References