Columbia Center for Occupational and Forensic Psychiatry - Washington, D.C. - Dr. David J. Fischer, M.D. Medical Director

COLUMBIA CENTER FOR
OCCUPATIONAL & FORENSIC PSYCHIATRY

DAVID J. FISCHER, MD MEDICAL DIRECTOR

PHONE: 202-363-4333
PHONE: 202-686-0114
 

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PSYCHIATRIC DISABILITY THROUGH SOCIAL SECURITY

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SOCIAL SECURITY DISABILITY BENEFIT

A number of public programs and many private insurance plans provide compensation to persons who become disabled.

The Social Security Act (SSA) provides for two kinds of payments to disabled persons. The 1956 Social Security Act amendments: Social Security Disability Insurance (SSDI) is a benefit payable to disabled persons who qualify under the Act by reason of coverage earned by tax payments made to the Social Security system during their employment. An individual who has earned the proper number of quarters of coverage is considered "insured for disability insurance benefits." Eligibility for and the amount of this benefit payment is based on the claimant's work and earnings history. Causation is not an issue as in Workman’s Compensation.

The 1972 Supplemental Security Income (SSI) program (title XVI), in contrast, is a benefit available to "aged, blind and disabled individuals" whose income and resources fall below a certain level. Eligibility is not based on work history but on present level of financial need. The procedures and criteria for disability determination are the same as those used to determine eligibility for disability insurance. In addition, the claimant must be a resident of the United States, either as a citizen or as an alien admitted for permanent residence.

 

MENTAL DISORDERS AND DISABILITY

INTRODUCTION

The evaluation of disability on the basis of mental disorders requires the documentation of a medically determinable impairment(s) as well as consideration of the degree of limitation such impairment(s) may impose on the individual's ability to work and whether these limitations have lasted or are expected to last for a continuous period of at least 12 months.

Parameters used by the SSA to determine disability in cases that do not fit their listings are the following 4 areas to be assessed:

  • Understanding and Memory
  • Sustained Concentration and Persistence
  • Social Interaction
  • Adaptation NEED FOR MEDICAL EVIDENCE

The existence of a medically determinable impairment of the required duration must be established by medical evidence consisting of clinical signs, symptoms and/or laboratory or psychological test findings. These findings may be intermittent or persistent depending on the nature of the disorder. Clinical signs are medically demonstrable phenomena, which reflect specific abnormalities of behavior, affect, thought, memory, orientation, or contact with reality. These signs are typically assessed by a psychiatrist or psychologist and/or documented by psychological tests.

ASSESSMENT OF SEVERITY

For mental disorders severity is assessed in terms of the functional limitations imposed by the impairment.

  • ACTIVITIES OF DAILY LIVING
    Include adaptive activities such as cleaning, shopping, cooking, taking public transportation, paying bills, maintaining a residence, caring appropriately for one's grooming and hygiene, using telephones and directories, using a post office, etc. In the context of the individuals overall situation, the quality of these activities is judged by their independence, appropriateness and effectiveness.
  • SOCIAL FUNCTIONING
    Refers to an individual's capacity to interact appropriately and communicate effectively with other individuals. Social functioning includes the ability to get along with others. Impaired social functioning may be demonstrated by a history of altercations, evictions, firings, fear of strangers, avoidance of interpersonal relationships, social isolation, etc.
  • CONCENTRATION, PERSISTENCE, AND PACE
    Refer to the ability to sustain focused attention sufficiently long to permit the timely completion of tasks commonly found in work settings. In activities of daily living, concentration may be reflected in terms of ability to complete tasks in everyday household routines.
  • DETERIORATION OR DECOMPENSATION IN WORK OR WORK-LIKE SETTINGS
    Refers to repeated failure to adapt to stressful circumstances which cause the individual either to withdraw from that situation or to experience exacerbation of signs and symptoms (i.e., decompensation) with an accompanying difficulty in maintaining activities of daily living, social relationships and/or maintaining concentration, persistence or pace (i.e., deterioration which may include deterioration of adaptive behaviors).

DOCUMENTATION

The presence of a mental disorder should be documented primarily on the basis of reports from individual providers, such as psychiatrists and psychologists, and facilities such as hospitals and clinics.

CHRONIC MENTAL IMPAIRMENTS

Particular problems are often involved in evaluating mental impairments in individuals who have long histories of repeated hospitalizations or prolonged outpatient care with supportive therapy and medication.

EFFECTS OF STRUCTURED SETTINGS

Particularly in cases involving chronic mental disorders, overt symptomatology may be controlled or attenuated by psychosocial factors such as placement in a hospital, board and care facility, or other environment that provides similar structure. Highly structured and supportive settings may greatly reduce the mental demands placed on an individual. With lowered mental demands, overt signs and symptoms of the underlying mental disorder may be minimized. At the same time, however, the individual's ability to function outside of such a structured and/or supportive setting may not have changed. An evaluation of individuals whose symptomatology is controlled or attenuated by psychosocial factors must consider the ability of the individual to function outside of such highly structured settings.

EFFECTS OF MEDICATION

Attention must be given to the effect of medication on the individual's signs, symptoms and ability to function. While psychotropic medications may control certain primary manifestations of a mental disorder: e.g. hallucinations. Such treatment may or may not affect the functional limitations imposed by the mental disorder in cases where overt symptomatology is attenuated by the psychotropic medications.

EFFECTS OF TREATMENT

It must be remembered that with adequate treatment some individuals suffering with chronic mental disorders not only have their symptoms and signs ameliorated but also return to a level of function close to that of their premorbid status. Present day treatment of a mentally impaired individual may or may not assist in the achievement of an adequate level of adaptation required in the work place.

BASIC CONCEPTS TO DETERMINE DISABILITY

There must be a medically determinable impairment, physical or mental. The impairment must result in the inability to engage in any substantial gainful activity, being totally unable to work. The condition can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months. There is the permanent exclusions to the program of felony-related impairment and impairments arising to persons in prison.

 

DEFINITIONS

IMPAIRMENT

  • Any loss or abnormality of psychological, physiological, or anatomical structure or function.
    • Specifically in psychiatric evaluations the loss or abnormality of psychological function
  • Impairment is determined by a psychiatrist or psychologist.
  • Extent of the impairment, determined by psychiatric expert

FUNCTIONAL LIMITATIONS

A partial or total impairment of instrumental (usually vocational or homemaking) role performance. Any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being. The restriction or lack (resulting from an impairment) of ability to perform an activity.

  • Activities of Daily Living
  • Social Functioning
  • Concentration, persistence and pace in job-related activities
  • History of Deterioration or Decompensation at work or work-like settings

DISABILITY

  • Disabled means not able or unable to work or function
  • Disability is a judicial determination
    • Judge makes definitive determination of the percentage of disability

These reports may also contain other observations and opinions or conclusions on such matters as the individual's:

  • Ability to Cope With Stress
  • The Ability to Relate to Other People
  • The Ability to Function in a Group or Work Situation

THE PSYCHIATRIC EXPERT

The psychiatric expert determines the extent of impairment.

JUDGE

The judge makes definitive determination of the percentage of disability.

The psychiatrist who is evaluating claimants for disability has to be aware not only of the psychiatric data, but of the need to frame it in a way that the evaluators of claims can find useful in making their determination according to the laws that establish the requirements for awards of disability.



 
 
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