January 2, 2011
How Does the SSA Evaluate Mental Impairments?
Our clients often cite mental disorders in Social Security disability cases. And many of their physical impairments include hidden psychological issues. Chronic physical problems take a psychological toll. A number of these cases are denied and ultimately go to hearings.
For the Social Security Administration to evaluate your mental disorder, it requires documentation of a medically determinable impairment (discussed further below), consideration of the degree to which your mental disorder impairs your ability to work, and consideration of whether such limitation on your ability to work has lasted or is expected last for a continuous period of at least 12 months.
The Social Security Administration’s rules for assessing whether an applicant for disability benefits qualifies due to a mental disorder are complex. Here is an overview.
What Different Types of Mental Disorders Are Recognized by the Social Security Administration in Social Security Disability Cases?
The Social Security Administration’s listings for mental disorders are arranged in nine diagnostic categories, which are as follows:
- 12.02 Organic Mental Disorders. Psychological or behavioral abnormalities associated with a dysfunction of the brain. History and physical examination or laboratory tests demonstrate the presence of a specific organic factor judged to be etiologically related to the abnormal mental state and loss of previously acquired functional abilities.
- 12.03 Schizophrenic, Paranoid and Other Psychotic Disorders. Characterized by the onset of psychotic features with deterioration from a previous level of functioning.
- 12.04 Affective Disorders. Characterized by a disturbance of mood, accompanied by a full or partial manic or depressive syndrome. Mood refers to a prolonged emotion that colors the whole psychic life; it generally involves either depression or elation.
- 12.05 Mental Retardation. Refers to significantly sub-average general intellectual functioning with deficits in adaptive functioning initially manifested during the developmental period (i.e., the evidence demonstrates or supports onset of the impairment before age 22).
- 12.06 Anxiety-Related Disorders. For these disorders, anxiety is either the predominant disturbance or it is experienced if the individual attempts to master symptoms. For example, confronting the dreaded object or situation in a phobic disorder or resisting the obsessions or compulsions in obsessive compulsive disorders.
- 12.07 Somatoform Disorders. Physical symptoms for which there are no demonstrable organic findings or known physiological mechanisms.
- 12.08 Personality Disorders. Exist when personality traits are inflexible and maladaptive and cause either significant impairment in social or occupational functioning or subjective distress. Characteristic features are typical of the individual’s long-term functioning and are not limited to discrete episodes of illness.
- 12.09 Substance Addiction Disorders. Behavioral changes or physical changes associated with the regular use of substances that affect the central nervous system.
- 12.10 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.
Do You Have a Medically Determinable Mental Impairment?
The A criteria
The first step the Social Security Administration takes in evaluating your mental impairment is to determine that you, in fact, have a medically determinable mental impairment. This is done by deciding whether diagnostic criteria in the Listings of Mental Impairments, known as the A criteria, are met. Each of the nine Listings of Mental Impairments has its own separate A criteria. The A criteria substantiate medically the presence of a certain mental disorder.
Is Your Mental Impairment Severe?
The B Criteria
If the A criteria are met, the Social Security Administration moves on to the B and, in some cases, the C criteria, which are used to assess the degree of your impairment.
The B and C criteria describe impairment-related functional limitations that are incompatible with the ability to do any gainful activity. The functional limitations set forth in the B and C criteria must be the result of the mental disorder (described in the diagnostic description as set forth above), and as manifested by the A criteria’s medical findings.
Under the B criteria, your functional limitations are evaluated in four areas:
1. Activities of daily living – Examples include shopping, cooking, taking public transportation, paying bills, maintaining a residence, and caring appropriately for your grooming and hygiene.
2. Social functioning – Your capacity to interact independently, appropriately, effectively, and on a sustained basis with other individuals.
3. Concentration, persistence, or pace – Your ability to sustain focused attention and concentration long enough to permit the timely and appropriate completion of tasks commonly found in work settings.
4. Episodes of decompensation – Exacerbations or temporary increases in symptoms or signs accompanied by a loss of adaptive functioning, as manifested by difficulties in performing activities of daily living, maintaining social relationships, or maintaining concentration, persistence, or pace.
Your functional limitations in each of the first three areas are rated as “none,” “slight,” “moderate,” “marked,” and “extreme.” The scale is “never,” “one or two,” “three,” and “four or more” for the fourth area (episodes of decompensation).
A rating of “none” or “mild” indicates a degree of limitation that is generally not considered severe by the Social Security Administration, unless the evidence otherwise indicates there is more than a minimal limitation of your ability to do basic work activities.
Are You Disabled Under the B Criteria Listing?
If you meet the A criteria, you will meet the listing for a mental disorder and be considered disabled if:
- Two of the B criteria are rated “marked” and, in the case of episodes of decompensation, three episodes of decompensation have occurred; or
- Any one of the B criteria is rated “extreme” (a degree of limitation that is incompatible with the ability to do any gainful activity).
A rating of “moderate” indicates a severe impairment, but one that does not meet or equal a listed impairment and therefore requires a “residual functional capacity” assessment. For more information regarding residual functional capacity, see below.
Establishing That You Meet the B Criteria for Social Security Disability Benefits
We tell our disability clients that the best sources of information and testimony about the “B criteria” are usually your family, friends, and neighbors. Sometimes you may be able to provide useful information, but often in mental impairment cases, claimants have insufficient insight into their limitations. Your views of your mental disorder and those of people who know you well may diverge widely. This problem in itself can turn out to be a major issue in a mental impairment case.
Sometimes denial decisions in mental impairment cases are based on little more than the Social Security Administration’s uncritical acceptance of a claimant’s statements about daily activities, social functioning, and ability to get things done on time. Mental disorders frequently rob claimants of the ability to realistically assess their limitations. In these cases, it is extremely important to have a competent disability attorney who can look beyond what the claimant says about level of functioning.
If You Do Not Meet the B Criteria, Move on to the C Criteria
If you do not meet the B criteria, the Social Security Administration moves on to evaluate the C criteria when your impairment is one of the following:
- An organic mental disorder,
- A schizophrenic, paranoid, or other psychotic disorder,
- An affective disorder, or
- An anxiety-related disorder.
The C criteria for organic disorders, psychotic disorders, and affective disorders are identical. They require a two-year history of a chronic mental impairment with more than minimal limitation in the ability to do basic work activities. In addition, the criteria require at least one of the following:
- A current history of one or more years’ inability to function outside a highly supportive living arrangement, with an indication of continued need for such an arrangement.
- Repeated episodes of decompensation, each of extended duration.
- A residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause the individual to decompensate.
The single C criterion for anxiety-related disorders is an anxiety disorder resulting in complete inability to function independently outside the area of one’s home.
As a rule, the C criteria must be assessed when you appear to function too well to meet the B criteria.
Establishing That Your Impairment Meets the C Criteria
More than the B criteria, deciding whether your impairment meets the C criteria may depend on expert opinion, particularly from your treating doctors. A single mental status examination may be insufficient. Claimants with long histories of repeated hospitalizations or prolonged outpatient care with supportive therapy and medication often have structured their lives to minimize stress and reduce symptoms. These claimants may be much more impaired for work than their symptoms and signs would indicate.
If You Meet the B or C Criteria, But Not the A Criteria
According to the Social Security Administration, the A criteria of the mental disorders listings “are only examples of common mental disorders that are considered severe enough to prevent an individual from doing any gainful activity. When [a claimant has] a medically determinable severe mental impairment that does not satisfy the diagnostic description or the requirements of the paragraph A criteria of the relevant listing, the assessment of the paragraph B and C criteria is critical to a determination of equivalence.” This means that a claimant who meets the B or C criteria, but not the A criteria may nonetheless be considered disabled.
Residual Functional Capacity Assessment
If your mental disorder causes only moderate functional limitations (i.e., the B or C criteria are not met), you may or may not have the residual functional capacity to do substantial gainful activity. The Social Security Administration must do a residual functional capacity assessment – it will determine whether you can do skilled, semiskilled, or unskilled work in spite of impairments, or whether you cannot even do unskilled work. Claimants with a marked impairment in any of the abilities required for unskilled work will be awarded disability benefits even in the absence of any physical impairment.
This assessment of mental residual functional capacity is crucial when your impairment does not meet the B or C criteria, but is nevertheless severe.
The Social Security Administration requires a lot of information to make an accurate residual functional capacity assessment. This is another important area in which information from others about how you behave at home, work, and in social situations can help.
Assistance Available for Mental Disorder Disability Claims
Cases involving mental disorders can be challenging. I am experienced in helping Social Security disability claimants through this process.
If you have such a case and are not already represented by a Social Security disability attorney and want my evaluation, click here, then give me a brief description of your claim using the form to the right.