How Does the Social Security Administration Decide if I Qualify for Disability Benefits for Schizophrenia?
If you have schizophrenia, Social Security disability benefits may be available. To determine whether you are disabled by schizophrenia, the Social Security Administration first considers whether the schizophrenia is severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process. See Winning Social Security Disability Benefits for Schizophrenia by Meeting a Listing. If your schizophrenia is not severe enough to equal or meet a listing, the Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite schizophrenia), to determine whether you qualify for disability benefits at Step 4 and Step 5 of the Sequential Evaluation Process. See Residual Functional Capacity Assessment for Schizophrenia.
About Schizophrenia and Disability
What Is Schizophrenia?
Schizophrenia is a serious mental disorder for which there is no cure. Schizophrenia affects about 1% of the adult population. There are various types of schizophrenia, i.e., disorganized, catatonic, residual, undifferentiated, and paranoid. Any of these forms of schizophrenia may entitle a person to disability benefits.
Schizophrenia appears before age 45, usually in the adolescent or young adult. The person exhibits a definite deterioration from a previous level of functioning in social, work, and personal life. Psychological abnormalities are diverse, affecting:
- Emotion (affect).
- Ability to plan and carry out purposeful activity.
- Cognition (ability to think, learn, and understand).
- Sociability. The person may experience a tendency to withdraw from the outside world and a preoccupation with illogical ideas, fantasies, or delusions.
- Movement. The person may exhibit a decrease, increase, or bizarreness of movements or postures.
The prevailing view of schizophrenia has been that the psychotic features are the most important and that cognitive deficits are secondary. However, the latest research suggests that the cognitive deficits, which arise from various brain abnormalities, are the more fundamental cause of mental abnormalities in schizophrenia. In fact, there is reason to think that subtle brain abnormalities appear before a child is born and gradually increase in severity.
Causes of Schizophrenia
The disorder involves biochemical dysfunction in the brain, but no one can as yet describe the mechanisms involved. Numerous abnormalities are found in the brains of those with schizophrenia (see Figures 2 and 4 below).
There is also a complex genetic predisposition that no one is close to understanding. It is thought that about 40% of cases of schizophrenia are inherited, and 60% occur spontaneously. Recent research suggests that schizophrenia may result from a large number of genetic abnormalities (see Figures 1 and 3 below). Consequently, there is no chance of a single cause and cure for schizophrenia.
Figure 1: A so-called “linkage study,” showing a number of places in the human genome where pieces of DNA are inherited along with risk for the illness. It shows one of each of the 23 pairs of chromosomes, and the red dots indicate regions where a piece of DNA has been shown to be inherited along with the risk for schizophrenia in certain families and certain studies.
Figure 2: MRI scans of identical twins. The twin on the right has schizophrenia; the twin on the left is healthy. Even to the unprofessional eye, there are obvious differences, a systematic and consistent variation between the affected and the unaffected twin in the gross anatomy of the brain. Red arrows point to enlarged ventricles in the affected twin.
Figure 3: Each white dot represents cells in a particular part of the brain. A patient with schizophrenia is compared to an individual with another psychiatric illness, bipolar disorder, and to a normal subject. The white dots show the turning-on of a gene that is the blueprint for a protein related to the process by which cells adapt themselves to a changing environment. I–VI represent layers of the cerebral cortex.
Figure 4: PET scans of five normal individuals (left); each row is one person, and each image is a slice from five different levels of the person’s brain. The red areas show regions of the brain that are activated when a person performs a memory task. In PET scans of five individuals with schizophrenia (right), each row represents a different person, with comparable slices. Clearly, the patients with schizophrenia do not generate the dramatic brain activity in the circuits of the brain critical to the memory task.
Phases of Schizophrenia
Schizophrenia usually has 3 phases.
- First, there is the prodromal phase. The duration of this phase is variable. The person shows a clear deterioration from the previous level of functioning in multiple areas of life—mental, occupational, personal, and social. The “change in personality” is often noticed by friends and relatives, as the person withdraws from usual activities, engages in less effective and increasingly strange behavior and experiences difficulty with clear and logical communication with others.
- Next is the active or progressive phase. In this phase, overt psychotic symptoms become obvious. The impairments present in the prodromal phase become more severe. The individual increasingly withdraws. Strange behavior may become bizarre or completely disorganized, and odd perceptions and thought develop into hallucinations and delusions. Abnormalities in the form and content of thought produce further confusion and difficulty communicating with others. Transition from the prodromal to the active phase is often triggered by stress that the person cannot cope with. For example, such a stressor might be a serious physical illness or change in an important relationship with another person. Or it might be something that a normal person would consider trivial.
- A residual phase follows the active phase. Psychotic symptoms persist to some degree, but the accompanying emotions are not as intense. (The residual phase should not be confused with the residual type of schizophrenia, so-called because an active, florid phase of the illness is missing.) Unfortunately, normal emotional responsiveness tends to be subdued also. Residual functional impairment may remain severe.
The majority of claimants seeking disability benefits for schizophrenia are in the residual phase, and in some degree of remission on neuroleptic drugs which must be taken indefinitely. However, schizophrenia almost never goes into complete remission.
Cognitive Impairment With Schizophrenia
It is very important for the Social Security Administration to pay attention to cognitive dysfunction when assessing whether a person with schizophrenia is disabled. The Social Security Administration and many psychiatrists and psychologists still emphasize the psychotic features (hallucination, delusions) of the disease. So if a claimant’s psychotic features are controlled by medication, the Social Security Administration is not likely to test memory or other cognitive functions. Fewer than 10% of patients with schizophrenia ever get a regular job or live independently. At least 90% of people with schizophrenia are apparently incapable of working on any sustained basis.
The drugs taken to lessen the symptoms of schizophrenia can cause side effects. The severity varies from person to person. In the early phase of drug therapy, symptoms may include muscle spasms, tremors, dry mouth, drowsiness, blurry vision, and restlessness. Changing the type of medication or the dosage can help control these symptoms.
Older medications were associated with a risk of the patient developing tardive dyskinesia—a disorder characterized by involuntary movements, especially of the lips, tongue, and mouth. Newer medications, such as clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel) and resperidone (Resperdal) are associated with other risks. For example, clozapine can cause a decrease in white blood cells and greatly weaken the body’s defense against dangerous infections. Clozapine can also cause seizures, inflammation of the heart (myocarditis), low blood pressure (hypotension), and other side effects. Olanzapine (Zyprexa) can cause weight gain and Parkinsonian movement disorders. Anyone taking antipsychotic medications must be monitored by a doctor.
If the claimant is having medication side-effects, a Social Security Administration psychiatrist or other medical doctor, rather than a Social Security Administration psychologist, should evaluate at least that part of the claim.
Information from Family and Friends Is Crucial to Disability Determination
Claimants with chronic schizophrenia living with family members are most likely to be improperly denied Social Security disability benefits. It is critically important for family members or other caregivers to provide the Social Security Administration with as detailed information as possible about specific tasks the claimant can or cannot do.
Mental health clinics will often refuse to provide the Social Security Administration with clinical records that are useful in evaluating how a mental disorder has developed over time. They might simply write a letter summarizing what they think they Social Security Administration needs to know. In some instances, the Social Security Administration is forced to fall back on purchasing a consultative mental status examination in which the examining psychiatrist or psychologist has limited time to determine the details of daily functional capacity. The Social Security Administration should ask the treating psychiatrist (or psychologist) about work-related abilities for at least unskilled work and how these conclusions match with the corresponding limiting mental symptom.
If the claimant is receiving medication, information about side-effects must come from a medical doctor, because a psychologist is not competent to evaluate that matter. However, it is also important for the same kind of information and opinions to be obtained from family or other caregivers, to make sure that nothing is missed. The caregivers live with the claimant; they may have noticed important facts that can be brought to the treating psychiatrist’s attention and to the Social Security Administration.
Winning Social Security Disability Benefits for Schizophrenia by Meeting a Listing
To determine whether you are disabled at Step 3 of the Sequential Evaluation Process, the Social Security Administration will consider whether your schizophrenia is severe enough to meet or equal the schizophrenia listing. The Social Security Administration has developed rules called Listing of Impairments for most common impairments. The listing for a particular impairment describes a degree of severity that Social Security Administration presumes would prevent a person from performing substantial work. If your schizophrenia is severe enough to meet or equal the listing, you will be considered disabled.
The Listing for schizophrenia is 12.03. It has 3 parts: A, B, and C. To meet the listing, you must satisfy both parts A and B or just part C alone. You do not have to be in the active phase of psychosis to qualify under this listing.
Meeting Social Security Administration Listing 12.03A for Schizophrenia
To meet part A of the schizophrenia listing, you must have medically documented persistence, either continuous or intermittent, of one or more of the following:
1. Delusions or hallucinations; or
2. Catatonic or other grossly disorganized behavior; or
3. Incoherence, loosening of associations, illogical thinking, or poverty of content of speech if associated with one of the following:
a. Blunt affect; or
b. Flat affect; or
c. Inappropriate affect;
4. Emotional withdrawal and/or isolation.
Part A requires persistent abnormalities. Persistent does not mean that the abnormality has to be present all the time. Intermittent presence of the abnormality is sufficient, as specific abnormalities may be present in greater or lesser degree depending on the phase of the illness (see Phases of Schizophrenia), partial suppression by medications (see Side Effects of Schizophrenia Medications), and the severity of psychosocial stressors.
Part A.1 Hallucinations or Delusions
Part A.1 requires hallucinations or delusions. A hallucination is a false sensory perception; it is a sensory experience generated within the brain itself, rather than as a result of input from the stimulation of a sensory organ. Hallucinations may be experienced as inside or outside of the body. Any of the senses may be involved, e.g., visual, auditory, gustatory (taste), olfactory (smell), tactile, or somatic (apparent sensations from inside the body). A person having a hallucination may or may not recognize its unreality. Auditory hallucinations (e.g., hearing voices) are most common in schizophrenia.
A hallucination is not the same thing as an illusion. An illusion, rather than a hallucination, occurs if a person misunderstands or misperceives an actual sensory stimulus. Perceptions experienced while falling asleep, dreaming, or in the process of awakening are not considered hallucinations. A hallucination alone does not mean the person has a mental disorder. A person may experience hallucinations without being mentally ill.
A delusion is an abnormality of thought content; it is a false belief that is maintained despite clear evidence to the contrary. The most common delusions in schizophrenia involve various beliefs that one’s thoughts are broadcast so that they can be heard by others; that one is being persecuted by others in some special personal way; that thoughts can be removed from one’s head by other people; or that one is controlled by some outside agency acting upon one’s mind directly and by force. However, the delusions may be of any type.
Part A.2 Catatonic or Other Grossly Disorganized Behavior
Part A.2 is fulfilled by “catatonic or other grossly disorganized behavior.” Catatonia is an extreme example of disorganized behavior, ranging from excited purposeless activity to a stuporous state. Catatonia may involve rigid or bizarre posturing of the body. Catatonia is not the only form of disorganized behavior that qualifies. If a person’s behavior is so disorganized that rational, goal-directed activity is missing, then that is also sufficient to fulfill part A.2.
Part A.3 Incoherence, Loosening of Associations, Illogical Thinking, or Poverty of Speech Content
Part A.3 describes a number of abnormalities. Any one of these in conjunction with one of the subparts (a) (blunt affect), (b) (flat affect), or (c) (inappropriate affect) is sufficient.
- Incoherence is a defect in communication characterized by speech that cannot be understood in a rational way. The pattern of meaning found in rational speech is lacking, and even the rules of grammar may be distorted.
- Loosening of associations is a thought defect, in which ideas shift inappropriately from one subject to another, showing a lack of rational connectedness of which the person is unaware. Incoherence represents an even more severe defect in the form of thought.
- Illogical thinking is a defect in the content of thought in which clearly erroneous conclusions are reached from given presumptions or data, and can be closely linked to a delusional system.
- Poverty of content of speech represents an abnormality in the content of thought, in that very little information with meaningful content can be gained from listening to such speech. (Poverty of the content and quality of speech is known as alogia.)
In blunt affect, emotional responsiveness is decreased. In flat affect, emotional responsiveness is absent. In inappropriate affect, emotional responsiveness is present but not rationally connected to a person’s speech or thoughts.
Part A.4 Emotional Withdrawal or Isolation
Part A.4 requires emotional withdrawal or isolation. Isolation and withdrawal are frequent features of schizophrenia. In the extreme condition, the person may become autistic with a seemingly complete lack of awareness of his or her environment. Many severe abnormalities of perception and thinking in schizophrenia produce confusion in self-identity and relationship to the outside world. Reality-testing breaks down, and disorganiz ed behavior replaces purposeful activity and/or the purpose has an illogical or delusional basis.
Emotional withdrawal and isolation follow in response to an incomprehensible world and self. Or another way of looking at things is that the physiological processes of the brain are too disrupted to allow a normal level of interaction with the world. Suspiciousness and delusions tend to produce isolation and withdrawal also, as this may decrease the feeling of vulnerability the person feels.
Meeting Social Security Administration Listing 12.03B for Schizophrenia
To meet the schizophrenia listing, you must satisfy the requirements of part A and, as a result of those impairments have at least two of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Marked difficulties in maintaining concentration, persistence, or pace; or
4. Repeated episodes of decompensation, each of extended duration.
Information Needed to Assess Part B
Here is what Social Security Administration says about the information needed to assess whether part B of the listing is met:
Assessment of Severity: We measure severity according to the functional limitations imposed by your medically determinable mental impairment(s). We assess functional limitations using the four criteria in paragraph B of the listings: activities of daily living; social functioning; concentration, persistence, or pace; and episodes of decompensation. Where we use “marked” as a standard for measuring the degree of limitation, it means more than moderate but less than extreme. A marked limitation may arise when several activities or functions are impaired, or even when only one is impaired, as long as the degree of limitation is such as to interfere seriously with your ability to function independently, appropriately, effectively, and on a sustained basis. See §§404.1520a and 416.920a.
1. Activities of daily living include adaptive activities such as cleaning, shopping, cooking, taking public transportation, paying bills, maintaining a residence, caring appropriately for your grooming and hygiene, using telephones and directories, and using a post office. In the context of your overall situation, we assess the quality of these activities by their independence, appropriateness, effectiveness, and sustainability. We will determine the extent to which you are capable of initiating and participating in activities independent of supervision or direction.
We do not define “marked” by a specific number of activities of daily living in which functioning is impaired, but by the nature and overall degree of interference with function. For example, if you do a wide range of activities of daily living, we may still find that you have a marked limitation in your daily activities if you have serious difficulty performing them without direct supervision, or in a suitable manner, or on a consistent, useful, routine basis, or without undue interruptions or distractions.
2. Social functioning refers to your capacity to interact independently, appropriately, effectively, and on a sustained basis with other individuals. Social functioning includes the ability to get along with others, such as family members, friends, neighbors, grocery clerks, landlords, or bus drivers. You may demonstrate impaired social functioning by, for example, a history of altercations, evictions, firings, fear of strangers, avoidance of interpersonal relationships, or social isolation. You may exhibit strength in social functioning by such things as your ability to initiate social contacts with others, communicate clearly with others, or interact and actively participate in group activities. We also need to consider cooperative behaviors, consideration for others, awareness of others’ feelings, and social maturity. Social functioning in work situations may involve interactions with the public, responding appropriately to persons in authority (e.g., supervisors), or cooperative behaviors involving coworkers.
We do not define “marked” by a specific number of different behaviors in which social functioning is impaired, but by the nature and overall degree of interference with function. For example, if you are highly antagonistic, uncooperative, or hostile but are tolerated by local storekeepers, we may nevertheless find that you have a marked limitation in social functioning because that behavior is not acceptable in other social contexts.
3. Concentration, persistence and pace refer to the ability to sustain focused attention and concentration long enough to permit the timely and appropriate completion of tasks commonly found in work settings. Limitations in concentration, persistence, or pace are best observed in work settings, but may also be reflected by limitations in other settings. In addition, major limitations in this area can often be assessed through clinical examination or psychological testing. Wherever possible, however, a mental status examination or psychological test data should be supplemented by other available evidence.
On mental status examinations, concentration is assessed by tasks such as having you subtract serial sevens or serial threes from 100. In psychological tests of intelligence or memory, concentration is assessed through tasks requiring short-term memory or through tasks that must be completed within established time limits.
In work evaluations, concentration, persistence, or pace is assessed by testing your ability to sustain work using appropriate production standards, in either real or simulated work tasks (e.g., filing index cards, locating telephone numbers, or disassembling and reassembling objects). Strengths and weaknesses in areas of concentration and attention can be discussed in terms of your ability to work at a consistent pace for acceptable periods of time and until a task is completed, and your ability to repeat sequences of action to achieve a goal or an objective.
We must exercise great care in reaching conclusions about your ability or inability to complete tasks under the stresses of employment during a normal workday or workweek based on a time-limited mental status examination or psychological testing by a clinician, or based on your ability to complete tasks in other settings that are less demanding, highly structured, or more supportive. We must assess your ability to complete tasks by evaluating all the evidence, with an emphasis on how independently, appropriately, and effectively you are able to complete tasks on a sustained basis.
We do not define “marked” by a specific number of tasks that you are unable to complete, but by the nature and overall degree of interference with function. You may be able to sustain attention and persist at simple tasks but may still have difficulty with complicated tasks. Deficiencies that are apparent only in performing complex procedures or tasks would not satisfy the intent of this paragraph B criterion. However, if you can complete many simple tasks, we may nevertheless find that you have a marked limitation in concentration, persistence, or pace if you cannot complete these tasks without extra supervision or assistance, or in accordance with quality and accuracy standards, or at a consistent pace without an unreasonable number and length of rest periods, or without undue interruptions or distractions.
4. Episodes of decompensation are 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. Episodes of decompensation may be demonstrated by an exacerbation in symptoms or signs that would ordinarily require increased treatment or a less stressful situation (or a combination of the two). Episodes of decompensation may be inferred from medical records showing significant alteration in medication; or documentation of the need for a more structured psychological support system (e.g., hospitalizations, placement in a halfway house, or a highly structured and directing household); or other relevant information in the record about the existence, severity, and duration of the episode.
The term repeated episodes of decompensation, each of extended durationin these listings means three episodes within 1 year, or an average of once every 4 months, each lasting for at least 2 weeks. If you have experienced more frequent episodes of shorter duration or less frequent episodes of longer duration, we must use judgment to determine if the duration and functional effects of the episodes are of equal severity and may be used to substitute for the listed finding in a determination of equivalence.
It is not easy for the Social Security Administration adjudicator to obtain quality, detailed information for use in part B of the listing. Treating psychiatrists often will not provide actual treatment records and when they do, the records often lack the detail needed to make an accurate determination regarding daily activities, social functioning, or concentration, persistence or pace. Medical records are more likely to document part B.4 (repeated episodes of decompensation), because treatment notes or hospitalization records will record a change in the claimant’s condition.
The best evidence of functional ability comes from the claimant’s family or other caregivers, because they actually observe the claimant’s limitations and abilities, unlike the treating doctor. The doctor often merely guesses based on the claimant’s clinical condition.
Most psychiatrists and psychologists have only a general knowledge of their patient’s functional activities. But the treating doctor’s answers to questions about functional limitations may not always help the claimant. For example the doctor may be asked whether a claimant is limited in ability to perform a particular activity like take public transportation. If the doctor answers “Not that I know of,” this answer indicates ignorance and should not be taken as evidence of ability. But if the doctor answers, “I know of no mental limitation that would restrict the claimant’s ability to take public transportation,” then that informs Social Security Administration that the doctor thinks the claimant has the ability, even though the doctor may have no direct information to that effect.
Often, the Social Security Administration adjudicator will try to use daily activity, social information, etc., from a mental status consultative examination. This information often lacks enough detail for good disability determination.
It is important for the adjudicator to try to obtain a detailed specific description of daily activities, social functioning, task completion (concentration, persistence, or pace) and the circumstances surrounding episodes of decompensation. This means documentation of as many specific examples as possible; generalizations such as “He cannot do anything” are worthless. The daily activity forms that claimants or their caregivers complete are rarely specific enough to be of much use. To get high-quality information, the adjudicator must often contact the claimant or caregivers. This is a grueling, time-consuming job that requires an hour or more of communication. Furthermore, disability examiners have no skills in psychiatric interviewing even when they do attempt to get detailed information regarding part B, so that is an additional source of error. Therefore, inadequate development of part B information by the Social Security Administration in mental disorder claims is a weak spot and one reason by a claimant may be denied disability benefits.
Meeting Social Security Administration Listing 12.03C for Schizophrenia
If you do not meet parts A and B of the listing, you will be disabled if you meet part C. Part C requires a medically documented history of a chronic schizophrenic, paranoid, or other psychotic disorder of at least 2 years’ duration that has caused more than a minimal limitation of your ability to do basic work activities, with symptoms or signs currently attenuated (lessened) by medication or psychosocial support, and one of the following:
1. Repeated episodes of decompensation, each of extended duration; or
2. 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; or
3. Current history of 1 or more years’ inability to function outside a highly supportive living arrangement, with an indication of continued need for such an arrangement.
Proper evaluation under part C of the listing can require a lot of time and effort by the Social Security Administration adjudicator. For the same reasons as given in the discussion of part B, underdevelopment of evidence for part C is something that your Social Security disability attorney should always consider if your application for disability benefits is denied. See Providing the Social Security Administration With Adequate Information.
Part C.1 Decompensation Episodes
Part C.1 requires medical records—records from a medical care facility or from the treating physician that document repeated episodes of significant clinical worsening (decompensation). Worsening could be in any of the areas described under part B of the listing.
Part C.2 Deterioration in Minimally Stressful Conditions
Part C.2 requires deterioration under conditions that would be minimally stressful for a normal person. While medical records documenting the claimant’s decompensation with a minimal change in environment are desirable, family members, friends, and caregivers can be sources of evidence. In fact, statements in a claimant’s medical records about decompensation are probably based on information given to the treating physician by family members. However, the testimony of family and friends is more believable if decompensation was documented in the claimant’s medical records before he or she applied for disability benefits. Then any question about the testimony being self-serving is removed.
There are many possible ways in which change in environment can satisfy part C.2. For example, the claimant might exhibit:
- Increased withdrawal when guests other than family members come to dinner,
- Emotional outbursts when not permitted to watch a favorite TV show,
- Increased confusion when some routine of life is interrupted,
- Increased irritability when having to travel outside of the house such as a trip to the dentist, or
- Undue frustration and sadness when unable to accomplish some new task.
Part C.3 Need for Highly Supportive Living Arrangement
In part C.3, the “highly supportive living arrangement” could be the claimant living with family members, or living in some other kind of arrangement where there is close supervision. In these instances, the Social Security Administration needs to obtain evidence from the treating physician and other health providers (e.g., nurses), and family member statements that shows t he claimant needs a highly-supervised lifestyle despite only moderate severity in the areas described in part A of the listing.
The easiest way to accomplish this task is to look at the evidence over time to document why such a highly supportive living arrangement became necessary. Typically, family members will describe behavioral events that made the claimant unmanageable outside of a closely supervised environment. For example, the claimant may have attempted to stay with family members only to continually wander off and get lost, or have uncontrollable emotional outbursts of anger, or otherwise be unable to cope. While a home environment is acceptable for purposes of part C.3, some families simply do not have the resources and time to adequately care for someone requiring close supervision. However, institutionalization is not in itself a sufficient basis for assuming inability to function outside of a special supportive environment.
Residual Functional Capacity Assessment for Schizophrenia
What Is RFC?
When schizophrenia is not severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process, the Social Security Administration will need to determine residual functional capacity (RFC) to decide whether the claimant is disabled at Step 4 and Step 5 of the Sequential Evaluation Process. RFC is a claimant’s ability to perform work-related activities. In other words, it is what you can still do despite your limitations.
An RFC for mental impairments is expressed in terms of whether Social Security Administration believes the claimant can do skilled, semi-skilled, or unskilled work in spite of impairments, or whether the claimant cannot even do unskilled work.
Denial Is Likely for RFCs for Unskilled Work or Better
Claimants with a mental RFC for the ability to perform unskilled work who have no physical impairments will almost always be denied Social Security disability benefits. Rare exceptions are claimants with no more than a limited education, who are close to retirement age, and who have a lifelong history of unskilled work that they can no longer perform. Large numbers of claimants are denied with mental RFCs for unskilled work because the Social Security Administration can cite many jobs that require only unskilled work.
Mental and Physical Impairments Together May Qualify
Many claimants have both physical and mental impairments. The claimant may be found disabled when the effect of both impairments is considered, even though the physical impairment alone or the mental impairment alone would not be sufficient.
Inability to Perform Even Unskilled Work Should Result in Allowance
A marked impairment in any of the abilities required for unskilled work will result in allowance of a claim even in the absence of any physical impairment. These basic mental demands are:
- Remember work-like procedures (locations are not critical).
- Understand and remember very short and simple instructions.
- Carry out very short and simple instructions.
- Maintain attention for extended periods of 2-hour segments (concentration is not critical).
- Maintain regular attendance and be punctual within customary tolerances. (These tolerances are usually strict.) Maintaining a schedule is not critical.
- Sustain an ordinary routine without special supervision.
- Work in coordination with or proximity to others without being (unduly) distracted by them.
- Make simple work-related decisions.
- Complete a normal workday and workweek without interruptions from psychologically based symptoms and perform at a consistent pace without an unreasonable number and length of rest periods. (These requirements are usually strict.)
- Ask simple questions or request assistance.
- Accept instructions and respond appropriately to criticism from supervisors.
- Get along with coworkers or peers without (unduly) distracting them or exhibiting behavioral extremes.
- Respond appropriately to changes in a (routine) work setting.
- Be aware of normal hazards and take appropriate precautions.
The Social Security Administration requires a lot of information to assess whether a claimant has these abilities. This is an important area in which the Social Security Administration may not develop the case very well. Information from family members about how the claimant behaves at home and in social situations can help. This information can be extrapolated to a work setting. Specific work-setting information can sometimes be obtained from former supervisors or co-workers. Treating physicians may have made observations or have opinions regarding the claimant’s ability to perform these basic capacities.
Negative Symptoms of Schizophrenia
Individuals with schizophrenia always have significant residual functional limitations if not qualifying under the listing criteria. Delusions, hallucinations, catatonia, and disorganized speech are known as positive symptoms. Flattening of affect (loss of emotion), alogia (poverty of speech), anhedonia (inability to experience pleasure), and avolition (lack of motivation) are known as negative symptoms. Negative symptoms are more difficult to control and more disabling in the long term.
Most of the claimants suffering from schizophrenia that are seen by the Social Security Administration are under treatment and have control of their positive symptoms, but are limited by their negative symptoms as well mood and cognitive abnormalities. These abnormalities can affect their self-care, social relationships, and ability to work. A claimant who is not actively psychotic and who has memory problems should be tested (if not actively psychotic), as by the Wechsler Memory Scale. Some require IQ testing, but considerable skill must be used to assure valid results if the person has significant residual symptoms affecting motivation or attentional ability.
Getting Your Doctor’s Medical Opinion About What You Can Still Do
Your Doctor’s Medical Opinion Can Help You Qualify for Social Security Disability Benefits
The Social Security Administration’s job is to determine if you are disabled, a legal conclusion based on your age, education and work experience and medical evidence. Your doctor’s role is to provide the Social Security Administration with information concerning the degree of your medical impairment. Your doctor’s description of your capacity for work is called a medical source statement and the Social Security Administration’s conclusion about your work capacity is called a residual functional capacity assessment. Residual functional capacity is what you can still do despite your limitations. The Social Security Administration asks that medical source statements include a statement about what you can still do despite your impairments.
The Social Security Administration must consider your treating doctor’s opinion and, under appropriate circumstances, give it controlling weight.
The Social Security Administration evaluates the weight to be given your doctor’s opinion by considering:
- The nature and extent of the treatment relationship between you and your doctor.
- How well your doctor knows you.
- The number of times your doctor has seen you.
- Whether your doctor has obtained a detailed picture over time of your impairment.
- Your doctor’s specialization.
- The kinds and extent of examinations and testing performed by or ordered by your doctor.
- The quality of your doctor’s explanation of your impairment.
- The degree to which your doctor’s opinion is supported by relevant evidence, particularly medically acceptable clinical and laboratory diagnostic techniques.
- How consistent your doctor’s opinion is with other evidence.
When to Ask Your Doctor for an Opinion
If your application for Social Security disability benefits has been denied and you have appealed, you should get a medical source statement (your doctor’s opinion about what you can still do) from your doctor to use as evidence at the hearing.
When is the best time to request an opinion from your doctor? Many disability attorneys wait until they have reviewed the file and the hearing is scheduled before requesting an opinion from the treating doctor. This has two advantages.
- First, by waiting until your attorney has fully reviewed the file, he or she will be able to refine the theory of why you cannot work and will be better able to seek support for this theory from the treating doctor.
- Second, the report will be fresh at the time of the hearing.
But this approach also has some disadvantages.
- When there is a long time between the time your attorney first sees you and the time of the hearing, a lot of things can happen. You can improve and go back to work. Your lawyer can still seek evidence that you were disabled for a certain length of time. But then your lawyer will be asking the doctor to describe your ability to work at some time in the past, something that not all doctors are good at.
- You might change doctors, or worse yet, stop seeing doctors altogether because your medical insurance has run out. When your attorney writes to a doctor who has not seen you recently, your attorney runs the risk that the doctor will be reluctant to complete the form. Doctors seem much more willing to provide opinions about current patients than about patients whom they have not seen for a long time.
Here is an alternative. Suggest that your attorney request your doctor to complete a medical opinion form on the day you retain your attorney. This will provide a snapshot description of your residual functional capacity (RFC) early in the case. If you improve and return to work, the description of your RFC provides a basis for showing that you were disabled for a specific period. If you change doctors, your attorney can get an opinion from the new doctor, too. If you stop seeing doctors, at least your attorney has one treating doctor opinion and can present your testimony at the hearing to establish that you have not improved.
If you continue seeing the doctor but it has been a long time since the doctor’s opinion was obtained, just before the hearing your attorney can send the doctor a copy of the form completed earlier, along with a blank form and a cover letter asking the doctor to complete a new form if your condition has changed significantly. If not, your attorney can ask the doctor to send a one-line letter that says there have been no significant changes since the date the earlier form was completed.
There are times, though, that your attorney needs to consider not requesting a report early in the case.
- First, depending on the impairment, if you have not been disabled for twelve months, it is usually better that your attorney wait until the twelve-month duration requirement is met.
- Second, if you just began seeing a new doctor, it is usually best to wait until the doctor is more familiar with your condition before requesting an opinion.
- Third, if there are competing diagnoses or other diagnostic uncertainties, it is usually best that your attorney wait until the medical issues are resolved before requesting an opinion.
- Fourth, a really difficult judgment is involved if your medical history has many ups and downs, e.g., several acute phases, perhaps including hospitalizations, followed by significant improvement. Your attorney needs to request an opinion at a time when the treating doctor will have the best longitudinal perspective on your impairment.
Medical Opinion Forms
Medical opinion forms can be great time savers for both your attorney and your doctor, but they must be used with care. Forms may not be appropriate at all in complex cases; and they need to be supplemented in many cases so that all issues are addressed. The best forms are clear and complete but not too long.
When the time is right, here is a form for your disability attorney to use: