"Decompensating" in Mental Health Disability Claims

Psychiatrists and psychologists use the term “decompensating" to describe worsening symptoms of mental illness. An “episode of decompensation” is a period of significant, often rapid, deterioration in mental health, like a panic attack. In the past, the Social Security Administration (SSA) had used the terms “period of decompensation” and “decompensatory period” when evaluating disability claims based on psychological impairments such as schizophrenia.

While the terms aren’t used any longer to determine disability based on Social Security’s “Blue Book” of mental health disorders, the SSA recognizes the impact that episodes of decompensation can have on your ability to complete your daily activities and work full-time. If you keep experiencing episodes where your mental health just seems to fall apart, you should understand how to document these episodes in your claim for disability benefits.

What Causes Mental Decompensation or Deterioration?

People who struggle with mental health issues might already find it harder to handle life’s ups and downs, so a stressful or unexpected situation can be a tipping point for somebody who was previously able to maintain an adequate level of functioning. Or, previously effective medication may stop working properly as the body gets used to it. The exact reasons for mental deterioration aren’t usually important to your eligibility for benefits, as long as you have medical evidence documenting the episodes.

What Does “Episodes of Decompensation” Mean to Social Security?

Social Security used to look at the duration and frequency of any decompensatory episodes in a disability application in order to determine whether the applicant (“claimant”) could be found disabled under a listed impairment. Listed impairments are conditions—including many mental illnesses—that the SSA considers severe enough to be automatically disabling, provided that certain medical requirements are met.

Having documented evidence of periods of decompensation was previously one of the requirements to meet a mental health listing, but the agency removed this criteria in 2017. However, much of the language defining what constitutes an episode of decompensation is still used to help the SSA determine whether a claimant meets the updated listing criteria.

For example, in the old listings, Social Security defined episodes of decompensation as:

• temporary increases in symptoms or signs of mental illness
• accompanied by a loss of the ability to adapt and function
• resulting in difficulties performing activities of daily living, maintaining social relationships, or concentrating on completing tasks.

Several of the old mental listings also required that you show “repeated episodes of decompensation, each of extended duration,” defined as:

• three episodes within one year, or on average every four months (“repeated”), and
• each episode lasted for at least two weeks (“extended”).

If a claimant wasn’t able to show repeated episodes of decompensation, they could still qualify for benefits under the listings if the only reason they were able to function as well as they did is because they had an extensive support system, such as inpatient mental health treatment.

New Disability Listings and Mental Deterioration

Social Security updated its mental disability listings to reflect a better understanding of mental health disorders and symptoms. The new listings aren’t as strict in requiring a specific length and duration of decompensatory episodes, but the basic premise behind them is the same: people with mental illnesses so severe that they can’t take care of basic needs aren’t going to function well in a work environment.

Previous listings that used the “episodes of decompensation” language now state that claimants can document a mental condition that has been “serious and persistent” for at least two years. Additionally, your medical records must contain evidence of the following:

• intensive, ongoing mental health treatment that keeps your symptoms under control, and
• minimal capacity to adapt to changes in your environment or daily routine (“marginal adjustment”).

The SSA will find that claimants have only marginal adjustment when an increase in demands asked of them, or a change in their daily routine, sets off a deterioration in functioning—roughly the same state as an episode of decompensation. Somebody who can take care of themselves within a highly structured routine (like a group home) but can’t cope with small changes—such as the grocery store being unexpectedly closed—would likely be considered to have marginal adjustment.

Listings With Marginal Adjustment and Deterioration Language

Even though having an episode of decompensation is no longer enough to prove that you meet one of the Social Security listings for mental health, a period of mental deterioration is still important evidence showing that your mental symptoms severely limit your functioning.

Listings that formerly required a certain number and frequency of decompensatory episodes, but now use “marginal adjustment” and “deterioration in functioning” as standards, include:

• neurocognitive disorders, such as dementia or traumatic brain injury (formerly called “organic mental disorders”)
• schizophrenia spectrum and other psychotic disorders
• depression and bipolar disorders
• anxiety and obsessive-compulsive disorders, and
• trauma- and stressor-related disorders (such as PTSD or PTSI).

Similar language about episodes of decompensation was removed from the following listings:

• autism spectrum disorders
• intellectual disability (low IQ)
• personality or impulse-control disorders, and
• somatic symptom disorders.

Even though you can no longer get approved automatically for these four conditions based on periods of decompensation, if you can show that your limitations prevent you from working full-time, you can still qualify for benefits under a medical-vocational allowance.

Documenting Episodes of Decompensation or Deterioration

Your medical records are the foundation of your Social Security claim, so it's important to document each episode of deterioration. Ideally, this means that you’ll get treatment—such as going to a hospital—each time your mental health decompensates. Not every episode warrants such drastic (and expensive) measures, however, so you can also report to your doctor how long your decompensation episodes last and how frequently they occur.

You can help document your episodes of decompensation by filling out your function report in detail. Be sure to mention the differences in your activities of daily living when you’re decompensating and when you’re feeling more stable. This gives the SSA an idea of your mental health “baseline” and helps the agency determine how severe your mental disorder is.

Additionally, if you feel comfortable asking your doctors, friends, or family members to write statements in support of your disability claim, consider doing so. The SSA values the opinions of any mental health professionals that you’ve seen regularly, and having a letter from a close friend or relative who is familiar with your episodes of decompensation can help shed light on your limitations.

How to Submit Evidence of Decompensation

When you first file for disability benefits, the SSA will request medical records from the sources you’ve listed in your application (based on the contact information you provide, so make sure to double-check the names, dates, and locations of your treatment for accuracy). But because the disability determination process can take a long time, you may experience a period of decompensation after you’ve originally filed for benefits. It’s important that you submit evidence of any decompensation to the SSA so that the agency can add it to your file and use it to make a decision.

You can submit evidence to Social Security via fax machine, using a unique barcode provided to you after your initial application has been filed as a cover letter. You can also get access to the agency’s Electronic Records Express online filing system, where you can upload medical documents through a secure portal without having to provide a paper copy.

Applying for Disability Benefits

Filing for disability benefits is a fairly straightforward process, and you don’t have to do anything differently when filing for a mental health disorder (as opposed to a physical disorder). You have several options to choose from when starting your application:

• Apply online at ssa.gov. This method has many benefits, such as giving you the option to save your application and return to it later.
• Call Social Security’s national number at 800-772-1213 (TTY 800-325-0778) from 8:00 a.m. to 7:00 p.m., Monday through Friday, to speak with a representative.
• Visit your local Social Security field office in person.

If you’re not sure which method to use, check out our article on the best way to apply for Social Security disability for more detailed information about each process.

My Claim Was Denied, Now What Do I Do?

Not everybody who applies for disability benefits is awarded on their first try. If, after reading over the denial letter, you disagree with the SSA’s decision, you have 60 days to submit an appeal. Social Security’s appeals process typically involves getting another denial before you can request a hearing with an administrative law judge.

You aren’t required to have an attorney to appeal a denial, but it’s usually a good idea. An experienced disability lawyer or advocate can help you gather the proper medical paperwork, make sure you don’t miss important deadlines, and represent you at a disability hearing. And because disability lawyers aren’t allowed to charge you if you don't win—and they’re limited to a small percentage of your disability backpay if you do win—there’s little risk in finding a lawyer near you to help with your claim.