People whose ability to work is impaired by mental illness or a psychiatric disorder may be entitled to Social Security Disability Insurance (SSDI) benefits, if the condition makes them totally disabled from working. SSDI benefits can be awarded to those suffering illnesses such as anxiety, depression, bipolar disorder (manic-depressive disorder), schizophrenia, agoraphobia (fear of public or open places), or post-traumatic stress disorder (PTSD), among others.
One common problem with proving total disability based on mental disorders is the up and down nature of some illnesses, which may not appear at first to prevent working, because a person may function relatively well for periods of time or in lower-stress situations. However, the SSA recognizes that these same individuals can experience sudden, extreme downturns known as “decompensation episodes,” which make it impossible for them to maintain employment.
“Decompensation” is a term used by mental health professionals to refer to episodes during which a person’s existing mental-health or psychiatric disorder deteriorates, for a time, to include symptoms that are unusually severe. Crippling panic attacks are a common example, but decompensation symptoms vary for different mental disorders.
Mental Illness Disability and Decompensation
The SSA defines disability as a proven medical condition that is expected to last a year or more (or result in death) and that prevents the sufferer from engaging in “substantial gainful activity” (currently, this means working enough to earn a little over $1,000/month). When the claimant has a mental illness or psychiatric disorder with symptoms that fluctuate in severity, proving the existence of decompensation episodes can be crucial to winning disability benefits.
While a sufferer might not seem fully disabled from working during better periods, the fact that decompensation episodes can produce sudden and marked changes in ability can provide additional proof necessary to show that a claimant meets the SSA’s definition of disability.
SSA Rules on Decompensation Episodes
To help prove SSDI disability, the medical records of treatment for decompensation episodes must include the kind of evidence that the SSA considers important. When the SSA considers an SSDI application based on mental disorder, it first looks to see whether a claimant is diagnosed with an illness contained in SSA’s list of disabling conditions (often called the “blue book”) or equal in severity to one that is on the list, which includes 9 categories:
• 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 category is divided into parts (usually Parts A, B, and sometimes C or D) that describe what must be proven if a claimant is to be found legally disabled for SSDI purposes, including (1) the symptoms that must be present for diagnosis of the illness; and (2) the disabling results, or functional limitations, that the illness must cause, in order to be considered legally disabling for purposes of SSDI.
In many of the SSA mental disorder listings, “repeated episodes of decompensation, each of extended duration” is one factor that can be used to show evidence of disability. To qualify for SSDI on this basis, the claimant’s evidence usually must show the SSA that decompensation episodes:
• Occur at least 3 times within a year (or an average of once every 4 months) and last at least 2 weeks each time; and
• Limit functional abilities in these areas:
o Daily living activities;
o Social activities; or
o Activities that require concentration, persistence, or pace.
However, a claimant might be able to show a condition “as severe as” one on the list, with evidence of decompensation episodes that happen more often, but endure for shorter periods of time, or vice-versa. There are also other ways that decompensation episodes can be used to help prove total disability in SSDI cases.
Proving Decompensation Episodes
The claimant must be sure to seek the right kind of medical help and provide the right details to doctors or psychiatrists. Claimants or family members should give medical providers detailed descriptions of how often the episodes occur, how long they last, and the types and degree of limitation that they place on the claimant’s ability to function.
Seeking treatment during decompensation episodes can be crucial to an SSDI benefits claim. In SSDI cases, the key to proving the existence and impact of decompensation episodes is to compile detailed medical records. To get medical records with the right kind of detail, the claimant must get proper treatment during these downturns.
For many people seeking SSDI benefits based on a mental or emotional disability, it can be difficult to seek medical attention during periods when symptoms suddenly worsen. In fact, decompensation can often make it hard for sufferers to cope with the prospect of a trip to the doctor, causing them to cancel or reschedule appointments; but making it to the doctor can be critical to a disability case for SSDI benefits.
Proving decompensation episodes to get SSDI benefits can be a complex process. Other evidence, combined with good medical records, can also demonstrate the impact that decompensation episodes have on a person’s life. These include disability journals, which record the details of episodes as they happen, and testimony from family members, co-workers, and friends with first-hand knowledge of the limits that a mental illness places on the claimant. Every case is different, and an experienced Social Security Disability Attorney can help assess an individual case and determine the best methods of proving disability in each one.
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