Listing 1203 Schizophrenic Paranoid and Other Psychotic Disorders Adults

Psychotic disorders involve a widespread disturbance in mental function with severe distortion of the ability to distinguish external reality from an abnormal mental reality.

The most serious and common psychotic disorder the SSA evaluates for disability is schizophrenia, an affliction affecting about 1% of the U.S. population, with a typical onset in the teenage years or early adulthood. However, some cases have an onset in childhood and rare cases can start in middle age or later. After many years of research, the cause of schizophrenia remains unknown, although there is no question it involves abnormalities in the structure and function of the brain. The newer drugs used to treat schizophrenia such as olanzapine (Zyprexa), resperidone (Risperdal)

and clozapine (Clozaril) decrease the activity of dopamine and serotonin neurotransmitter chemicals in the brain. They have fewer side effects than the older drugs and have greatly improved the treatment of people with schizophrenia.

Hallucinations, especially auditory hallucinations in the form of persecutory voices, are often present. Delusions are common, especially paranoid delusions that others are out to harm the person in some way. Thinking may be confused and extremely irrational. The types of abnormalities in schizophrenia and other psychotic disorders that are of interest to the SSA are given in part ® of the listing. Parts ® and © are used to determine the overall functional severity of the psychotic disorder.

The psychotic symptoms, such as hallucinations and delusions, of an acute schizophrenic episode can be controlled in the majority of cases. However, it should be remembered that a treating psychiatrist's medical note that a schizophrenic patient is "doing well," "stable" or something similar, does not imply normality and is not sufficient for the SSA to determine that a claimant does not qualify under the listing.

People with chronic schizophrenia should be evaluated with great care; they may not be capable of meaningful work. Symptoms that appear absent or mild while the claimant is in a protected environment, such as a family member's household, may become much more severe when the claimant is put under psychological stress. This possibility is addressed by part ©. It is in these cases of chronic schizophrenics living in highly structured environments that psychiatrists and psychologists working for the SSA are particularly apt to make mistakes in thinking that a claimant is more capable than is actually the case. That is why it is so important that the medical records of these claimants be clearly documented with any episodes of decompensation when subjected to stresses outside of a protected environment. In this way, the SSA has actual examples of the claimant's inability to function in real work situations, rather than having to make a judgment without that information.

The various subtypes of schizophrenia are paranoid, disorganized, catatonic, residual and undifferentiated. There is also a schizophreniform disorder that is not as severe as schizophrenia and has a better prognosis for recovery of ability to function in a work-related and social environment.

It is important to understand that the suspiciousness and delusions of persecution that characterize paranoid thinking may be a part of schizophrenia or other psychotic disorders. However, paranoia can also be a part of nonpsychotic mental disorders, such as occurs in a paranoid personality disorder.

Psychotic mental illness known as schizoaffective disorder is also seen by the SSA. In schizoaffective disorder, there are mental abnormalities characteristic of schizophrenia and also of mood (affective) disorders. There are other, atypical or more unusual types of psychotic disorders that could potentially qualify under this listing.

It cannot be too strongly emphasized that good medical records over the time of the claimant's psychotic disorder can be critical to the SSA's making an accurate determination. An appropriate determination is much more difficult if the only evidence the SSA can obtain is one mental status examination report since this represents only one small slice of time.

a. Listing Level Severity

For your condition to be severe enough to meet the listing, it must be characterized by the onset of psychotic features with deterioration from your previous level of functioning. The required level of severity is met when both ® and ® are satisfied or when © is satisfied.

® Medically documented persistence, either continuous or intermittent, of one or more of the following:

1. Delusions or hallucinations.

2. Catatonic or other grossly disorganized behavior.

3. Incoherence, loosening of associations, illogical thinking or poverty of content of speech if associated with one of the following:

a. Blunt affect.

b. Flat affect.

c. Inappropriate affect.

4. Emotional withdrawal and/or isolation.

® Medically documented persistence, either continuous or intermittent of the abnormalities described in part A, resulting in at least two of the following:

1. Marked restriction of activities of daily living.

2. Marked difficulties in maintaining social functioning.

3. Marked difficulties in maintaining concentration, persistence or pace; or

4. Repeated episodes of decompensation, each of extended duration.

© Medically documented history of a chronic schizophrenic, paranoid or other psychotic mental disorder of two years or more that has caused more than a minimal limitation of ability to do basic work activities, with symptoms or signs currently decreased by medication or psychosocial support and one of the following:

1. Repeated episodes of decompensation, each of extended duration; or

2. A residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause you to decompensate; or

3. A current history of one year or more of an inability to function outside a highly supportive living arrangement, with signs that you'll continue to need such an arrangement.

b. Residual Functional Capacity

The comments about RFC under Listing 12.02 also apply here. Some additional observations specifically about schizophrenia are also appropriate.

Although some people with schizophrenia can be improved greatly with drugs, it is difficult to find someone with schizophrenia who does not have some significant residual abnormality in mental function. While the positive psychotic symptoms like hallucinations and delusions may respond to drug therapy, some degree of negative psychotic symptoms like blunted emotions, poor motivation and poor social skills are more difficult to improve and usually remain present to some degree.

If you have no significant abnormalities after treatment for schizophrenia, the accuracy of your diagnosis should be questioned. It is very difficult, if not impossible, to restore schizophrenics to complete normality. If schizophrenia is the correct diagnosis, then the SSA would almost never be justified in determining that a claimant had a mild (not severe) impairment. To the contrary, significant limitations are most likely present and require a mental RFC if the listing is not satisfied.

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