Christmas Carols For Psychiatric Patients

     I deal with a lot of clients with psychiatric illness. Most Social Security and Disability Determination employees deal with the same mix of claimants. The piece below has been around for years. It may be a bit insensitive but it's funny.

BORDERLINE PERSONALITY DISORDER:
Thoughts of Roasting on an Open Fire

DEMENTIA:
I Think I'll Be Home for Christmas

DEPRESSION:
Silent Anhedonia, Holy Anhedonia, All is Flat, All is Lonely.

MANIC:
Deck the Halls and Walls and House and Lawn and Streets and Stores and Office and Town and Cars and Busses and Trucks and Trees and Fire Hydrants and...

MULTIPLE PERSONALITY DISORDER:
We Three Queens Disoriented Are

NARCISSISTIC:
Hark the Herald Angels Sing About Me

OBSESSIVE-COMPULSIVE DISORDER:
Jingle Bell, Jingle Bell, Jingle Bell Rock, Jingle Bell, Jingle Bell, Jingle Bell Rock, Jingle Bell, Jingle Bell, Jingle Bell Rock, Jingle Bell, Jingle Bell, Jingle Bell Rock, Jingle Bell, Jingle Bell, Jingle Bell Rock, Jingle Bell, Jingle Bell, Jingle Bell Rock, Jingle Bell, Jingle Bell, Jingle Bell Rock, Jingle Bell, Jingle Bell, Jingle Bell Rock, Jingle Bell, Jingle Bell, Jingle Bell Rock,............(better start again)

PARANOID:
Santa Claus is Coming to Get Me.

PASSIVE-AGGRESSIVE PERSONALITY:
On the First Day of Christmas My True Love Gave to Me (and then took it all away).

PERSONALITY DISORDER:
You Better Watch Out, I'm Gonna Cry, I'm Gonna Pout, Maybe I'll tell you Why.

SCHIZOPHRENIA:
Do you Hear What I Hear?

And Another One Bites The Dust

     From David Weaver writing for The Hill:

The Social Security Administration (SSA) recently released the results of a major study on disability and work patterns. ...

The new study, called the Supported Employment Demonstration, sought to determine whether service interventions could promote success in the labor market for younger adults (that is, under the age of 50) who suffer from mental impairments.

Individuals in the treatment groups received employment support integrated with behavioral health services. These services and supports, known as the Individual Placement and Support (IPS) model, focuses on rapid job placement and eliminating barriers to work. The control group received no direct services or supports.

An important feature of the Supported Employment Demonstration is that it focused on individuals who were denied Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) disability benefits. Thus, the experiences of the control group illuminate the likely outcomes of proposals by Republican leaders and conservative economists that would shrink the reach of such programs. ...

In the third year of the study, the average monthly earnings of individuals in the control group were only $395 — not nearly enough to ward off extreme hardship. ...

Conservatives often emphasize the importance of financial disincentives of disability programs. But, gold-standard random-assignment demonstrations by SSA have not found any effect on earnings from financial incentives embedded in the benefit rules. Why? Because the fundamental problem facing disability applicants stems from the way in which severe health problems, directly and indirectly, interfere with every aspect of employment. ...

Average monthly earnings among those who received employment support and behavioral health services were 40-50 percent higher than for those who received no services — further evidence that individuals with severe health problems need services and support to have some success in the labor market. ...

To be sure, the monthly average earnings of those who received services in the Supported Employment Demonstration were still modest, ranging from $553 to $590. ...

In the idealized view, only full-time work at high levels of earnings is considered a successful outcome for disabled persons. A rethink of disability and work would allow for programs, policy and communications to support diverse work patterns among persons with disabilities, including part-time work, episodic work and less formal work, including volunteer. ...

    The problem with Mr. Weaver's position, which he acknowledges, is that policymakers are only interested in programs that knock people off benefits, not programs that help them earn a little more while staying on benefits. By this standard, this study was a near complete failure, just as every other study of work incentives and work assistance programs has been a near complete failure. Even those whose disability claims are denied are too sick to work on a regular basis. They really are sick. The standards to get benefits really are difficult to meet. You can't make rational decisions about Social Security disability benefits until you realize just how harsh these programs are. One of the signs that policymakers don't realize how harsh these programs are has been the endless adoption of new work incentives and the endless funding of demonstration programs designed to put disability claimants back to work. None of it can work. The claimants are just too damn sick to benefit from these efforts in any significant number.

Deaths Of Children And Social Security Disability

    If you're directly involved with Social Security's process of disability determination, have you noticed the number of claimants who have suffered the death of a child? I've got no numbers but I've been struck over the years by how frequently this comes up. I'm talking about adult children as well as young children. I'm talking about deaths from disease as well as death in accidents and assaults and death by drug overdose. We all know these deaths occur and that they're tragic but, thank goodness, it's uncommon. Yet, it seems that once a month I'm seeing a case. We all know that these deaths have terrible effects upon families when they do occur. Most of the time it's not psychiatric illness that gets the claimant but a very real physical ailment.

    I wish someone would do a study on this.

    I don't know how people survived in the bad old days when childhood deaths were so common. My own grandmother was a generally cheerful woman and certainly a wonderful person to me but there always seemed a tinge of sadness about her. I only found out later that she had lost two children to a typhoid epidemic before my father was born and was never quite the same again. (Yes, I'm that old but typhoid epidemics aren't as far back in this country's history as you might think.) I now possess a memorial quilt that she made after these deaths. I'm sure that making that quilt helped with her grief.

Post-Covid Anxiety And Depression

      From the New York Times:

Social isolation, economic stress, loss of loved ones and other struggles during the pandemic have contributed to rising mental health issues like anxiety and depression.

But can having Covid itself increase the risk of developing mental health problems? A large new study suggests it can.

The study, published Wednesday in the journal The BMJ, analyzed records of nearly 154,000 Covid patients in the Veterans Health Administration system and compared their experience in the year after they recovered from their initial infection with that of a similar group of people who did not contract the virus.

The study included only patients who had no mental health diagnoses or treatment for at least two years before becoming infected with the coronavirus, allowing researchers to focus on psychiatric diagnoses and treatment that occurred after coronavirus infection.

 People who had Covid were 39 percent more likely to be diagnosed with depression and 35 percent more likely to be diagnosed with anxiety over the months following infection than people without Covid during the same period, the study found. Covid patients were 38 percent more likely to be diagnosed with stress and adjustment disorders and 41 percent more likely to be diagnosed with sleep disorders than uninfected people. ...

     You might say this won't have much impact on Social Security since there aren't many people found disabled due to depression and anxiety much less stress and adjustment disorders but I think that would be naive. Depression, anxiety, stress and adjustment disorders are bad for a person's physical health. These conditions also make people less able to cope with their physical ailments. There are many people who are still tenuously holding on to employment despite serious physical health problems. Add in depression and anxiety and those health problems can become too much to bear while still working. There are many people on the borderline who are still working but who can be easily tipped in the other direction. There's also the question of Covid's effects on those who already suffered significant mental illness. What effects will Covid have on people with bipolar disorder, for instance? I'm sure somebody is studying that question but I haven't heard of any research reports yet.

     I'm getting almost no calls from people with post-Covid syndrome but we'll have to see whether Covid is a significant indirect factor in producing disability.

Vignette From Representing A Social Security Disability Claimant

• Client: I need to work but every time I try to go back to work I end up in a psychiatric hospital.
• Me: Maybe you shouldn't try to return to work until your psychiatric condition is better stabilized.
• Client: But I HAVE to work. I'll lose everything if I don't work.

     The standard for involuntary psychiatric hospitalization is that the patient is dangerous to themselves or to others but for the most part even voluntary psychiatric hospitalizations don't happen unless the patient is dangerous. Thus, almost all psychiatric hospitalizations are a sign that a person has been at significant risk before the hospitalization. 

     I wasn't trying to talk the client out of returning to work because it would hurt the case if the client returns to work. No, just the opposite. Futile attempts to return to work followed by psychiatric hospitalizations make a case stronger. I don't want clients committing suicide. I've had clients commit suicide. That's terrible even for the attorney. I can't imagine what it's like for the family.

     I don't think that most people get just how dangerous it is to one's health to suffer from chronic mental illness.

Probably Isn't Good Enough

     I happened to re-read this somewhat chilling note I made on a client a couple of months ago:

He's not in psych treatment now. Didn't like his treating doc asking if he had access to guns and didn't like the meds he was taking. [I] Told him he needs to get back in treatment. He was in special forces.

     Guns really are a problem in this country. This man probably won't harm himself or other people. Probably.

The Invisible Dog Named Timmy

     From The Spectator:

The Social Security office in Detroit is a dispiriting place done up in industrial grays. It is filled with the long, glum faces of those who molder in the bowels of the federal bureaucracy waiting for some faceless bureaucrat to help them. ...

Into this purgatory enters Gus Malone, a raggedy 52-year-old homeless man, along with his invisible dog Timmy. Gus parades Timmy up and down the gray carpet of the waiting room as if it were the competition floor of the Westminster Kennel Club. ...

Here, Gus casts a sideways glance up at the government clerk who is sitting behind the bulletproof glass, wanting to be sure she is taking all this in. But it appears that imaginary dogs are as common at the Social Security office as daffodils in spring. The bureaucrat bats not an eyelash at the dog who is not there.

Gus has come to the Detroit office to file a disability claim with the federal government, hoping to hit the jackpot of all jackpots — $771 a month, every month, for the rest of his natural-born days.

Gus then admits that there really is no Timmy. It is a ruse that he characterizes as ‘playing crazy’. The invisible-dog bit may be the dollop of perceived schizophrenia that will fast-track his application directly to the top of the ‘approved’ basket. ...

For all the electronic chatter about the comeback of Detroit, it is hard to see it here at the Social Security office, miles from the refurbished office towers of downtown where the artificial beach, deck chairs and outdoor cocktail stands have become something of a surrogate Puerto Vallarta for the skinny-jeaned millennials who work the cubicles there. ...

The Motor City is hardly alone. Nationwide, more than 8.5 million people of working age collect a federal disability check. The phenomenon has been dubbed the ‘disability-industrial complex’. Consider: more is paid for federal disability claims than for welfare and food stamps combined. It is into this army of have-nots that Gus hopes to enlist. ...

      A few thoughts:

• I guess Gus is real but I've seen a few contrived psychiatric disability claims but I don't think that I've ever seen one as ridiculously contrived as the one described here.
• It's actually quite difficult to get Social Security disability based upon psychiatric illness. It's almost impossible to get a claim approved if the claimant isn't receiving active treatment. 
• What are the odds that Gus will be willing to see a psychiatrist for treatment even once, much less on a regular basis?
• What are the odds that Gus could fool a psychiatric professional for a minute? I'll answer that one since I may have some readers who have less than no knowledge of psychiatry. The answer is NO!
• Assuming Gus is real, he really may have serious psychiatric illness; just not the sort of thing he's acting out. There are "gild the lily" claimants who are quite ill but who add a layer of contrivance on top that makes it harder to get them approved. Factitious disorder is itself a real psychiatric illness. 
• My experience is that the vast majority of homeless people have serious psychiatric problems. Sometimes, it's substance abuse that won't qualify for disability benefits but mostly it's other problems.

Proposed Regs On CDRs

     Social Security will publish proposed regulations on the frequency of continuing disability reviews in the Federal Register on Monday. You can read the proposal today.

     They propose to add a new category, Medical Improvement Likely (MIL), to be reviewed every two years. MIL is aimed at a group of impairments which they say fit between the categories of Medical Improvement Expected (MIE) and Medical Improvement Possible (MIP). They say they will include anxiety related disorders in this category. I don't understand that. Anxiety disorders don't respond well to treatment. Panic disorders, the most commonly disabling anxiety disorder, are quite unresponsive to treatment.

     They propose to increase the frequency of reviews for the category of Medical Improvement Not Expected (MINE) from seven years to six years.

     Overall, they expect to increase Continuing Disability Review (CDRs) by more than 1.1 million a year.

     I love how this is all couched in language about helping people get back to work. That's baloney.  Disability benefits recipients already have plenty of incentives to return to work. Some people who are cut off benefits return to work; many don't. This certainly doesn't help anyone return to work.

     This is just a proposal. The public can comment. Social Security must review the comments. Once the agency is finished reviewing the comments and making any changes they want to make, it has to go back to the Office of Management and Budget for review before publication as final regulations. This process may extend past the next inauguration day. Even if pushed out before that date, an incoming Administration may decide not to implement them.

Maybe He Really Is Disabled; Definitely, He Shouldn't Have Access To Weapons

     An Oregon man has been arrested after threatening to shoot up a Social Security office. This was not the first time he had made such threats. Here's what happened at the Administrative Law Judge hearing on his case:

At the July hearing, he yelled at his attorney and an administrative judge and threatened future physical violence, the complaint says. Salem police responded and Carlsen was allowed to leave without arrest after he was escorted out of the hearing room. Carlsen live-streamed his actions, according to prosecutors.

Two Social Security Rulings Rescinded

     From a notice published by Social Security in the Federal Register (footnote omitted):

   ... In accordance with 20 CFR 402.35(b)(1), we give notice that we are rescinding the following SSRs [Social Security Rulings]: 

• SSR 96-3p: Titles II and XVI: Considering Allegations of Pain and Other Symptoms in Determining Whether a Medically Determinable Impairment is Severe.
• SSR 96-4p: Titles II and XVI: Symptoms, Medically Determinable Physical and Mental Impairments, and Exertional and Nonexertional Limitations.

These SSRs are unnecessarily duplicative of SSR 16-3p Titles II and XVI: Evaluation of Symptoms in Disability Claims, which was applicable on March 28, 2016 , published in the Federal Register on March 16, 2016, 81 FR 14166. SSR 16-3p, a more comprehensive statement of our policy on symptoms, explains how we evaluate the extent to which alleged symptoms limit an adult’s ability to perform work-related activities and a child’s ability to function effectively in an age-appropriate manner. ...

Merry Christmas?

The Christmas season is the busiest time of the year for psychiatrists

I'll Take A Guess

     The Vermont Legislative Joint Fiscal Office is asking why there is a higher percentage of Vermonters drawing Social Security disability benefits due to mental illness than the national average. I'll give them an answer they haven't considered. Vermont is in Social Security's Region I. That Region has long had higher approval rates than other Regions. Regions matter since Regional Office Quality Assurance reviews most favorable determinations (but few unfavorable determinations) made within the Region. Mental illness disability determinations are particularly sensitive to differences in adjudicative climate.

The Struggle To Work As A Schizophrenic

     Erica Crompton has written a moving piece for the New York Times describing her struggle to work as a schizophrenic -- actually now her diagnosis is schizoaffective disorder but that doesn't affect the story.

     In reading this piece, you may want to say "See, that shows you can work even if you're a schizophrenic." However, her work history has been extremely fragmented. Fragmentation is an inevitable part of schizophrenia, affecting both work and private life. It's part of the disease. By the end of the story, Crompton isn't earning enough to support herself. Maybe most important, Crompton is a talented writer. She has had opportunities that are not open to the vast majority of schizophrenics and she still can't support herself.

     I've said it many times. Social Security ought to just go ahead and approve every last disability claim filed by a person suffering from schizophrenia or schizoaffective disorder. Very few people who suffer from either of these conditions are able to maintain regular employment for extended periods of time. Social Security approves a lot of these claims but not all.

Another Attack On People Suffering From Mental Illness

     From the Washington Post:

The food was nearly gone and the bills were going unpaid, but they still had their pills, and that was what they thought of as the sky brightened and they awoke, one by one. First came Kathy Strait, 55, who withdrew six pills from a miniature backpack and swallowed them. Then emerged her daughter, Franny Tidwell, 32, who rummaged through 29 bottles of medication atop the refrigerator and brought down her own: oxcarbazepine for bipolar disorder, fluoxetine for depression, an opiate for pain. She next reached for two green bottles of Tenex, a medication for hyperactivity, filled two glasses with water and said, “Come here, boys.”

The boys were identical twins William and Dale, 10. They were the fourth generation in this family to receive federal disability checks, and the first to be declared no longer disabled and have them taken away. In days that had grown increasingly tense, as debts mounted and desperation grew to prove that the twins should be on disability, this was always the worst time, before the medication kicked in, when the mobile home was filled with the sounds of children fighting, dogs barking, adults yelling, television volume turned up. ...

Talk of medications, of diagnoses, of monthly checks that never seem to cover every need — these are the constants in households like this one, composed of multiple generations of people living on disability. Little-studied and largely unreported, such families have become familiar in rural communities reshaped by a decades-long surge that swelled the nation’s disability rolls by millions before declining slightly in 2015 as older beneficiaries aged into retirement benefits, according to interviews with social workers, lawyers, school officials, academics and rural residents. ...

“I hesitate to use a term like ‘culture.’ It’s not a specific, measurable metric,” said Kathleen Romig, an analyst with the Center on Budget and Policy Priorities, who studies disability in the United States. “Certain things like toxic stress or nutrition or preterm births or parental depression or genetics” offer a more revealing context for understanding generational disability.

And yet others say it’s about money.

Ruth Horn, director of social services in Buchanan County, Va., which has one of the country’s highest rates of disability, has spent decades working with profoundly poor families. Some parents, she said, don’t encourage their children academically, and even actively discourage them from doing well, because they view disability as a “source of income,” and think failure will help the family receive a check. ...

     For the record, genetic influences account for 60-85% of the risk for bipolar disorder so it is hardly surprising to find several people with bipolar disorder in the same family. Many who are initially diagnosed with attention deficit disorder in childhood are eventually diagnosed with bipolar disorder.
     Bipolar disorder is a very serious mental disorder. Although many people with bipolar can be stabilized with medication to the point that they can work and live fairly normal lives, that is certainly not the case with all. The disability produced by bipolar disorder has nothing to do with where a person lives or what their source of income is. Cutting off the income of people with bipolar disorder doesn't effect any cure. It just causes stress which makes the condition worse.
     With one exception, I don't often see two members of the same family as clients either at the same time or at different times. The exception is families where there's a lot of bipolar disorder.
     By the way, I don't know if there have been any studies, but I think a fair number of people with bipolar disorder get involved in relationships with other people with bipolar disorder producing children who face a really high risk of bipolar disorder. Why would this happen? Well, I guess you could say "birds of a feather ..." or "misery loves company" or you could say there was a lack of alternatives. Sometimes people meet in a psychiatrist's waiting room or in a psychiatric hospital. For better or worse, love finds a way and that's not always a good thing.
     In presenting a family where there's a lot of bipolar disorder, the reporter presented a skewed picture. He would have found it very hard to find a family to illustrate the point he wanted to make, and he definitely had a point he wanted to make, where the genetics of bipolar disorder weren't a major part. Would the reporter have used a family where there was a lot of hemophilia present to make the same point? I think not since he would have known that genetics were the problem, not culture or poverty or living in a rural area. This reporter was almost certainly unaware of how big a role genetics play in bipolar disorder.

Early Intervention For Schizophrenia Not Preventing Disability

     Schizophrenia is a truly horrible disease. It's tragic to see once promising young people reduced to unstable, unproductive lives haunted by the madness of schizophrenia. Schizophrenia always starts before age 30 but continues for the rest of a person's life. There is no cure for schizophrenia. The treatments available generally make long term institutionalization unnecessary and can prevent frequent hospitalization but do little to restore normal functioning. In particular, the treatments available don't touch the negative symptoms of schizophrenia -- lethargy and inability to have appropriate emotional and social responses. The negative symptoms may not sound that bad but they are actually devastating. Everyone familiar with the disease prays for some treatment that would improve the lives of schizophrenics.

     One approach to schizophrenia that seemed to have promise was early intervention -- identifying schizophrenics as soon as possible and offering them intensive treatment. This led to various Recovery After an Initial Schizophrenia Episode (RAISE) studies funded by the National Institutes of Mental Health (NIMH).

     Some results from a RAISE study are available and they're not encouraging, at least insofar as Social Security might be concerned. Here's an excerpt from the abstract of a RAISE study:

Method: The Recovery After an Initial Schizophrenia Episode–Early Treatment Program (RAISE-ETP) study, a 34-site cluster-randomized trial, compared NAVIGATE, a coordinated specialty care program, to usual community care over 2 years. Receipt of SSA benefits and clinical outcomes were assessed at program entry and every 6 months for 2 years....

Results: Among 399 RAISE-ETP participants, 36 (9%) were receiving SSA disability benefits at baseline; of the remainder, 124 (34.1%) obtained benefits during the 2-year study period. The NAVIGATE intervention improved quality of life, symptoms, and employment but did not significantly reduce the likelihood of receiving SSA disability benefits. Obtaining benefits was predicted by more severe psychotic symptoms and greater dysfunction and was followed by increased total income but fewer days of employment, reduced motivation (e.g., sense of purpose, greater anhedonia), and fewer days of intoxication. [I'm not sure what sort of intoxication they're talking about. Substance abuse isn't a part of schizophrenia. Some schizophrenics have substance abuse problems like some schizophrenics have high blood pressure but as far as I know there's no connection.]

Conclusions: A 2-year coordinated specialty care intervention did not reduce receipt of SSA disability benefits. There were some advantages for those who obtained SSA disability benefits over the 2-year treatment period, but there were also some unintended adverse consequences. Providing income supports without impeding recovery remains an important policy challenge.

New Somatoform Listing

     From Social Security's new mental impairment Listings effective January 17, 2017:

12.07 Somatic symptom and related disorders (see 12.00B6), satisfied by A and B

     A. Medical documentation of one or more of the following:

          1. Symptoms of altered voluntary motor or sensory function that are not better explained by another medical or mental disorder;

        2. One or more somatic symptoms that are distressing, with excessive thoughts, feelings, or behaviors related to the symptoms; or

      3. Preoccupation with having or acquiring a serious illness without significant symptoms present.

AND

     B. Extreme limitation of one, or marked limitation of two, of the following areas of mental functioning (see 12.00F):

          1. Understand, remember, or apply information (see 12.00E1).

          2. Interact with others (see 12.00E2).

          3. Concentrate, persist, or maintain pace (see 12.00E3).

          4. Adapt or manage oneself (see 12.00E4).

New Personality Disorder Listing

     From Social Security's new mental impairment Listings effective January 17, 2017:

12.08 Personality and impulse-control disorders (see 12.00B7), satisfied by A and B:

     A. Medical documentation of a pervasive pattern of one or more of the following:

          1. Distrust and suspiciousness of others;

          2. Detachment from social relationships;

          3. Disregard for and violation of the rights of others;

          4. Instability of interpersonal relationships;

          5. Excessive emotionality and attention seeking;

          6. Feelings of inadequacy;

          7. Excessive need to be taken care of;

          8. Preoccupation with perfectionism and orderliness; or

          9. Recurrent, impulsive, aggressive behavioral outbursts.

AND

     B. Extreme limitation of one, or marked limitation of two, of the following areas of mental functioning (see 12.00F):

          1. Understand, remember, or apply information (see 12.00E1).

          2. Interact with others (see 12.00E2).

          3. Concentrate, persist, or maintain pace (see 12.00E3).

          4. Adapt or manage oneself (see 12.00E4).

New Neurodevelopmental Listing

     From Social Security's new mental impairment Listings effective January 17, 2017:

12.11 Neurodevelopmental disorders (see 12.00B9), satisfied by A and B:

     A. Medical documentation of the requirements of paragraph 1, 2, or 3:

          1. One or both of the following:

           a. Frequent distractibility, difficulty sustaining attention, and difficulty organizing tasks; or

            b. Hyperactive and impulsive behavior (for example, difficulty remaining seated, talking excessively, difficulty waiting, appearing restless, or behaving as if being “driven by a motor”).

        2. Significant difficulties learning and using academic skills; or

       3. Recurrent motor movement or vocalization. [So in the original; must be typo. They only had a few years to work on it.]

AND

     B. Extreme limitation of one, or marked limitation of two, of the following areas of mental functioning (see 12.00F):

          1. Understand, remember, or apply information (see 12.00E1).

          2. Interact with others (see 12.00E2).

          3. Concentrate, persist, or maintain pace (see 12.00E3).

         4. Adapt or manage oneself (see 12.00E4).

New Childhood Listings For Depression, Bipolar And Disruptive Mood Dysregulation Disorder

     From Social Security's new mental impairment Listings for children:

112.04 Depressive, bipolar and related disorders (see 112.00B3), for children age 3 to attainment of age 18, satisfied by A and B, or A and C: 

     A. Medical documentation of the requirements of paragraph 1, 2, or 3: 

          1. Depressive disorder, characterized by five or more of the following:

               a. Depressed or irritable mood; 

               b. Diminished interest in almost all activities; 

              c. Appetite disturbance with change in weight (or a failure to achieve an expected weight gain); 

               d. Sleep disturbance; 

               e. Observable psychomotor agitation or retardation; 

               f. Decreased energy; 

               g. Feelings of guilt or worthlessness; 

               h. Difficulty concentrating or thinking; or

              i. Thoughts of death or suicide. 

          2. Bipolar disorder, characterized by three or more of the following: 

               a. Pressured speech; 

               b. Flight of ideas; 

              c. Inflated self-esteem; 

              d. Decreased need for sleep; 

              e. Distractibility; 

            f. Involvement in activities that have a high probability of painful consequences that are not recognized; or

              g. Increase in goal-directed activity or psychomotor agitation. 

         3. Disruptive mood dysregulation disorder, beginning prior to age 10, and all of the following: 

               a. Persistent, significant irritability or anger; 

               b. Frequent, developmentally inconsistent temper outbursts; and 

               c. Frequent aggressive or destructive behavior. 

     AND 

     B. Extreme limitation of one, or marked limitation of two, of the following areas of mental functioning (see 112.00F): 

          1. Understand, remember, or apply information (see 112.00E1). 

          2. Interact with others (see 112.00E2). 

          3. Concentrate, persist, or maintain pace (see 112.00E3). 

          4. Adapt or manage oneself (see 112.00E4). 

     OR 

     C. Your mental disorder in this listing category is ‘‘serious and persistent;’’ that is, you have a medically documented history of the existence of the disorder over a period of at least 2 years, and there is evidence of both: 

          1. Medical treatment, mental health therapy, psychosocial support(s), or a highly structured setting(s) that is ongoing and that diminishes the symptoms and signs of your mental disorder (see 112.00G2b); and 

          2. Marginal adjustment, that is, you have minimal capacity to adapt to changes in your environment or to demands that are not already part of your daily life (see 112.00G2c).

New Autism Listing

     From Social Security's new mental impairment Listings effective January 17, 2017:

12.10 Autism spectrum disorder (see 12.00B8), satisfied by A and B:

     A. Medical documentation of both of the following:

      1. Qualitative deficits in verbal communication, nonverbal communication, and social interaction; and

       2. Significantly restricted, repetitive patterns of behavior, interests, or activities.

AND

     B. Extreme limitation of one, or marked limitation of two, of the following areas of mental functioning (see 12.00F):

          1. Understand, remember, or apply information (see 12.00E1).

          2. Interact with others (see 12.00E2).

          3. Concentrate, persist, or maintain pace (see 12.00E3).

          4. Adapt or manage oneself (see 12.00E4).