Revised Medical Criteria for Evaluating Mental Disorders (Final Rule)

The Policy

What it does

Updates the criteria used by the Social Security Administration to evaluate claims of mental disorders in application for supplemental security income.

Synopsis

Title XVI (42 U.S.C. 1381 et seq.) of the Social Security Act (“Act”; 42 U.S.C. 301 et seq.) guarantees Supplemental Security Income (SSI) to disabled persons. Section 221 (42 U.S.C. 421) of the Act extends this guarantee to persons suffering from mental impairments. A new regulation, noticed via 81 Federal Register 6617, provides the final rule for the structure of mental disorder claim evaluation by the Social Security Administration (SSA). The rule specifies which mental disorders and in what degree of severity qualify as a disability and could therefore make an affected individual eligible for SSI benefits.

The most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published in 2013 to update criteria for diagnosing mental disorders. This rule revises the standards and terminology used by the SSA in evaluating mental disorders claims to reflect the new information in the DSM-5. These revisions also reflect suggestions made by medical experts, the public, advocacy groups, disability policy experts, and adjudicators.

Specifically, the final rule:

  • Reorganizes the listing criteria for intellectual disorders to better reflect the three diagnostic criteria for intellectual disability (significant limitations in general intellectual functioning; significant deficits in adaptive functioning; and evidence that a disorder began during the developmental period);
  • Updates the titles of most of the listings of impairments;
  • Creates a new listing for trauma and stressor-related disorders;
  • Removes all references to using standardized test scores for rating degrees of functional limitations for adults (except for claims of intellectual disorders);
  • Includes substance-induced cognitive disorders under neurocognitive disorders;
  • Includes disruptive, impulse-control, conduct, and intermittent explosive disorders as personality disorders for adults and children;
  • Removes Asperger’s disorder as a separate diagnosis;
  • Includes community support, outreach workers, and case managers as non-medical sources for longitudinal evidence of mental disorder;
  • Includes chronic homelessness as an example situation wherein longitudinal medical evidence can be difficult to obtain;
  • Includes 24/7 “wrap-around” mental health services, social workers, crisis response teams, and community mental health workers as psychosocial support structures; and
  • Removes substance use disorders as a separate diagnosis of disability.

Context

<p>This rule is the most comprehensive revision to the SSA criteria for evaluating mental disorders since 1985. In addition to updating old regulations to reflect new scientific vocabulary and understandings, these regulations contain more detail. The characterization of mental disorders, the symptoms that accompany mental disorders, and the examples of names used to describe variations of similar mental disorders are all described with more precision than the previous regulation.</p>

<p>In addition to the regulations for evaluating mental disorder claims in adults, there are separate regulations for evaluating claims in children. Because many of the regulations for adults are based on an individual’s ability to perform a job, regulations regarding children require different criteria. Moreover, the children’s regulations are in some cases different than those for adults.</p>

The Science

Science Synopsis

The rule categorizes its listings of mental disorders in eleven groups as described by the DSM-5, plus one additional group applying only to children.

  1. Neurocognitive disorders
    • Characterized by: a clinically significant decline in cognitive functioning
    • Examples: substance-induced cognitive disorder; Alzheimer’s disease; vascular dementia; dementia due to a medical condition such as metabolic disease, human immunodeficiency virus infection, progressive brain tumor, or vascular malformation
    • Symptoms: memory loss, gait disturbance, personality and mood changes, depression, anxiety, hallucinations
    • Prevalence: 5-10% of those aged 65 and older
  2. Schizophrenia spectrum and other psychotic disorders
    • Characterized by: delusions, hallucinations, disorganized speech, or grossly disorganized behavior that causes a clinically signification decline in functioning
    • Examples: schizoaffective disorder, delusional disorder, psychotic disorder due to another medical condition
  3. Depressive, bipolar, and related disorders
    • Characterized by: irritable, depressed, elevated, or expansive mood, or by a loss of interest or pleasure in all or most activities
    • Examples: bipolar disorder, cyclothymic disorder, major depressive disorder, persistent depressive disorder
    • Prevalence: 2.6% of adults in US
  4. Intellectual disorder
    • Characterized by: significantly sub-average general intellectual functioning, significant deficits in current adaptive functioning, and manifestation of the disorder before age 22
    • Examples: intellectual disability, intellectual developmental disorder, mental retardation
    • Prevalence: 1% of adults in US
  5. Anxiety and obsessive-compulsive disorders
    • Characterized by: excessive anxiety, worry, apprehension, and fear, or by avoidance of feelings, thoughts, activities, objects, places, or people
    • Examples: social anxiety disorder, panic disorder, generalized anxiety disorder, agoraphobia, obsessive-compulsive disorder
    • Symptoms: restlessness, difficulty concentrating, hyper-vigilance, muscle tension, sleep disturbance, fatigue, panic attacks, obsessions and compulsions, constant thoughts and fears about safety, frequent physical complaints
    • Prevalence: 32% of adults in US have at least one diagnosis over a lifetime
  6. Somatic symptom and related disorders
    • Characterized by: physical symptoms or deficits that are not intentionally produced or feigned and that, following clinical investigation, cannot be fully explained by a general medical condition, another mental disorder, the direct effects of a substance, or a culturally sanctioned behavior or experience
    • Examples: somatic symptom disorder, illness anxiety disorder, and conversion disorder
    • Symptoms: pain and other abnormalities of sensation, gastrointestinal symptoms, fatigue, high level of anxiety about personal health status, abnormal motor movement, pseudoseizures, pseudoneurological symptoms such as blindness or deafness
    • Prevalence: 0.1% of adults in US
  7. Personality and impulse-control disorders
    • Characterized by: enduring, inflexible, maladaptive, and pervasive patterns of behavior, with onset typically occurring in adolescence
    • Examples: paranoid, schizoid, schizotypal, borderline, avoidant, dependent, obsessive-compulsive personality disorders and intermittent explosive disorder
    • Symptoms: patterns of distrust, suspiciousness, and odd beliefs; social detachment, discomfort, or avoidance; hypersensitivity to negative evaluation; an excessive need to be taken care of; difficulty making independent decisions, a preoccupation with orderliness, perfectionism, and control; inappropriate, intense, impulsive anger and behavioral expression grossly out of proportion to any external provocation or psychosocial stressors
  8. Autism spectrum disorder
    • Characterized by: qualitative deficits in the development of reciprocal social interaction, verbal and nonverbal communication skills, and symbolic or imaginative activity; restricted repetitive and stereotyped patterns of behavior, interests and activities; and stagnation of development or loss of acquired skills in early life
    • Examples: autism spectrum disorder with or without intellectual and/or language impairment
    • Symptoms: abnormalities or unevenness in the development of cognitive skills; unusual responses to sensory stimuli; behavioral difficulties including hyperactivity, short attention span, impulsivity, aggressiveness or self-injurious actions
    • Prevalence: roughly 2% of individuals in US
  9. Neurodevelopment disorders
    • Characterized by: onset during childhood or adolescence
    • Examples: specific learning disorder, borderline intellectual functioning, tic disorders
    • Symptoms: underlying abnormalities in cognitive processing, deficits in attention or impulse control, low frustration tolerance, excessive or poorly planned motor activity, difficulty with organizing, repeated accidental injury, deficits in social skills
    • Prevalence: 15% of children in US
  10. Eating disorders
    • Characterized by: disturbances in eating behavior and preoccupation with, and excessive self-evaluation of, body weight and shape
    • Examples: anorexia nervosa, bulimia nervosa, binge-eating disorder, avoidant/restrictive food disorder
    • Symptoms: restriction of energy consumption, reoccurring episodes of binge eating or behavior intended to prevent weight gain, self-induced vomiting, excessive exercise, misuse of laxatives, mood disturbances, social withdrawal, irritability, amenorrhea, dental problems, cardiac abnormalities
    • Prevalence: 10% of adults in US affected by eating disorders at some time in their life
  11. Trauma and stressor related disorders
    • Characterized by: experiencing or witnessing a traumatic or stressful event, or learning of a traumatic event occurring to a close family member or friend and the psychological aftermath of clinically significant effects on functioning
    • Examples: posttraumatic stress disorder, adjustment-like disorders with prolonged duration without prolonged duration of stressor
    • Symptoms: distressing memories, dreams, and flashbacks related to the trauma or stressor; avoidant behavior; diminished interest or participation in significant activities; persistent negative emotional states or persistent inability to experience positive emotions; anxiety; irritability; difficulty concentrating; and sleep disturbance
    • Prevalence: about 10% of adults in US
  12. Developmental disorders in infants and toddlers
    • Characterized by: delay of deficit in the development of age appropriate skills or loss of previously acquired skills including motor planning and control, learning, relating and communicating, and self-regulating
    • Examples: developmental coordination disorder, separation anxiety disorder, autism spectrum disorder, regulation disorders of sensory processing

Relevant Experts

Dr. Geraldine Dawson is a professor in the Departments of Psychiatry and Behavioral Sciences, Pediatrics, and Psychology and Neuroscience and Director of the Duke Center for Autism and Brain Development at Duke University, North Carolina.


The Debate

Endorsements & Opposition

There are currently no publicly reported endorsements or opposition to this regulation.