Episodes of Decompensation in Mental Illness: Social Security Disability

Social Security has updated its listings that used the term “episodes of decompensation” to describe periods of mental deterioration.

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The term "episodes of decompensation" is used by psychiatrists and psychologists to describe the deterioration of the mental health of an individual who, up till that point, was maintaining his or her mental illness. It used to be a term that Social Security used in evaluating some psychiatric and emotional claims for Social Security and SSI disability benefits. While the term is no longer used in Social Security's mental disability listings, the concept of periods of mental or psychiatric deterioration still plays a big role in the evaluation of some types of mental illness.

If you experience times when your symptoms are exacerbated, or you just seem to fall apart, this means that your mental illness is not being maintained. And Social Security knows that you can't function and work when your mental illness is not being maintained. Increases in mental or emotional symptoms lead to a lessened ability to engage in normal daily activities and work. For that reason, you may have an easier time getting disability benefits if you suffer from these episodes of deterioration, as they are a way for some mental illnesses to qualify as disabilities.

Causes of Episodes of Decompensation or Deterioration

There are different potential causes of mental deterioration:

Your medical treatment is no longer working. This may call for an increase in medications to decrease symptoms and allow you to function on a more normal level.

A stressful situation may be affecting you. You may have taken on more mental demands, such as an attempt to work, that you are not able to handle. Or you may need changes in your environment or more structure in your support system, such as hospitalization or placement in a halfway house.

The causes of mental deterioration are not usually important to your eligibility for benefits, except those due to work attempts. What is important is that the episodes are documented and provable (see below).

Use of "Episodes of Decompensation" Term in Old Listings

The Social Security Administration (SSA) previously defined episodes of decompensation to include:

  • a temporary worsening of symptoms
  • a loss of the ability to adapt to normal changes and stress, and
  • difficulty with normal activities of life, including concentrating, being persistent at tasks, pacing oneself, or maintaining social relationships.

In short, an episode of decompensation refers to a time when you experience an exacerbation of (increase in) symptoms and a loss of function.

Several of the old mental listings included having repeated episodes of decompensation as a way to prove that a mental illness was affecting an individual's ability to function. (Generally, you had to have had at least three episodes of decompensation per year, and each episode must have lasted for a minimum of two weeks.) Alternatively, if an individual had such a fragile mental status that a "minimal increase in mental demands or change in the environment would be predicted to cause the individual to decompensate" could help qualify someone for disability.

New Disability Listings and Mental Deterioration

Social Security updated its mental disability listings in 2017 and, in doing so, removed the term "episodes of decompensation" from all mental disability listings. However, Social Security left in similar language for some of the listings (see list below).

An individual can still qualify under the listings if an individual has had the disorder for two years, it has been serious and persistent, and the individual is receiving intensive treatment and has "minimal capacity to adapt to changes in their environment or to demands that are not already part of their daily life." In Social Security's words, this means the individual has achieved only "marginal adjustment."

According to the new listings, Social Security will find that an individual has made only marginal adjustment if the medical records show that changes or increased demands have led to an "exacerbation of symptoms and signs" and to a "deterioration in functioning" (roughly the same thing as episodes of decompensation). Evidence of marginal adjustment can be documentation of "episodes of deterioration that have required you to be hospitalized or absent from work, making it difficult for you to sustain work activity over time."

The listings no longer include any guidelines for how many episodes of deterioration an individual must have had or how long they must have lasted.

Listings Including Marginal Adjustment and Deterioration Language

Social Security included the above language on minimal capacity to adapt to changes and episodes of deterioration that can prove marginal adjustment for the following mental listings:

Similar language about episodes of decompensation was removed from the listings for autistic spectrum disorders, intellectual disability (low IQ), personality disorders, and somatic symptom disorders. In other words, having had periods of deterioration, or having a doctor who is worried a patient will have periods of deterioration, is no longer allowed a way to show limitations in functioning for these mental disorders.

Documenting Episodes of Decompensation or Deterioration

It's important to have the proper documentation for any episodes of deterioration. This means that you have to seek treatment during each period of deterioration, if possible. Just as seizure patients need to have their seizures documented, and asthma patients need to have their asthma attacks documented, you need to have a record of your episodes of decompensation. And your doctor's notes concerning your deterioration must be very detailed as to the character and duration of your decompensation episodes, and how your functioning is impaired during the episodes.

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