Evaluating the Severity of Mental Impairments in Social Security Disability Cases

John M. FitzGerald

When evaluating the severity of mental impairments, SSA must follow a specific technique at each level in the administrative review process.

The technique is meant to identify the need for additional evidence to determine impairment severity, consider and evaluate functional consequences of the mental disorder as relating to ability to work, and to present findings in a clear and consistent manner.

SSA first evaluates pertinent symptoms, signs, and laboratory findings to determine whether a medically determinable mental impairment is present. If determined that a medically determinable mental impairment exists, SSA must specify the symptoms, signs, and laboratory findings that substantiate the presence of the impairment and document findings.

The degree of functional limitation resulting from the impairment is then rated.

Assessment of functional limitations is a "highly individualized process" that requires consideration of all relevant evidence to obtain a picture of overall degree of functional limitation. All relevant clinical signs and laboratory findings are considered, along with the effects of symptoms, and how ability to function may be affected by factors such as chronic mental disorders, structured settings, medication, and other treatment.

The degree of functional limitation is based on the extent to which one's impairment interferes with ability to function independently, appropriately, effectively, and on a sustained basis. Thus, such factors as the quality and level of overall functional performance, recurrence of episodes, the amount of supervision or assistance one requires, and the settings in which one is able to function must all be considered.

SSA has identified four broad functional areas in which to rate the degree of functional limitation: Activities of daily living, social functioning concentration, persistence, or pace, and episodes of decompensation.

The first three functional areas are rated using a five-point scale:

None, mild, moderate, marked, and extreme.

The degree of limitation in the fourth functional area is rated using a four-point scale: None, one or two, three, four or more.

The last point on each scale represents a degree of limitation that is incompatible with the ability to do any gainful activity.

After rating the degree of functional limitation, the severity of one's mental impairment must be determined. If the degree of one's limitation in the first three functional areas is "none" or "mild" and "none" in the fourth area, the conclusion is one's impairment is "not severe," unless evidence indicates there is more than a minimal limitation in ability to do basic work activities.

If one's mental impairment is severe, it is then determine whether it meets or equals a listed mental disorder. This is done by comparing the medical findings and rating the degree of functional limitation to the criteria of the relevant listing. At the initial and reconsideration levels of the administrative review process, the presence or absence of the criteria and the rating of the degree of functional limitation is recorded on a standard document, known as the Psychiatric Review Technique.

At subsequent levels, the presence or absence of the criteria and the rating of the degree of functional limitation is recorded in the decision, and must show the significant history, including examination and laboratory findings, and the functional limitations that were considered in reaching a conclusion about the severity of the mental impairment. The decision must also include a specific finding as to the degree of limitation in each of the functional areas described above.

If determined that a severe mental impairment neither meets or equals a listing, one's residual functional capacity is then assessed at step four of the sequential evaluation process, as in any other case.