Mental Impairment Claims - Personality Disorders-Are They Real, How Can You Prove your Case?
The mental disorder listing does contain a separate listing for personality disorder. That listing is set out at 12.08. The section A criteria is:
Examples of personality disorders include: antisocial, avoidant, borderline, dependent, histrionic, narcissistic, obsessive-compulsive, paranoid, schizoid and schizotypal.1 Two of these examples seem to be encountered in SSD cases more frequently than others. The first is borderline personality. A borderline personality is a condition in which people have long-term patterns of unstable or turbulent emotions, such as feelings about themselves and others. These inner experiences often cause them to take impulsive actions and have chaotic relationships. In the extreme, these people experience depression, drug abuse, problems at work, family and social relationships and suicide attempts. The second is obsessive-compulsive disorder personality(OCDP). OCD in which a person is preoccupied with rules, orderliness, and control. Signs of OCPD include excessive devotion to work, inability to throw things away, even when those things have no value, lack of flexibility, lack of generosity, not wanting to allow other people to do things, not willing to show affection, preoccupation with details, rules and lists. Comorbid with OCPD may be anxiety and depression.
The mental impairment of personality disorder has several problems. First, it is condition that does not lend itself to a quick diagnosis. As a result, often times I see that when a DSM –IV assessment has been performed by either a treating mental health provider or a consultative examiner, the Axis II portion of the assessment will say “deferred”. A second problem presents to the Social Security advocate is that personality disorder often presents itself with other mental impairments such as depression and anxiety. More problematically, the existence of alcohol or other substance abuse is often present. When depression or anxiety is present, it is difficult to distinguish between the comorbidities. As a consequence, a 12.08 claim may be missed. When drug or alcohol abuse is present, it is challenging to determine whether the abuse is the result of an under lying personality disorder and the need to “feel better” and relieve the psychological symptoms or whether the abuse actually is the cause of the aberrant behavior which is presented as a personality disorder. An argument may be made that mental illness can precipitate drug abuse (see Kangail v. Barnhart, 454 F.3d 627 (7th Cir. 2006) holding that bi-polar disease can precipitate drug abuse and the fact that substance abuse may have aggravated a mental illness does not mean that the underlying mental illness is not disabling in itself.) However, drug addition blurs not only the claimant but also the case. It is common in a case of a person suffering from mental illness who is also abusing drugs or alcohol to find that SSA has determined that the substance abuse is a material factor in the case and that if drugs and alcohol were not used, the ability to work would be restored.
David A. Morton, III, M.D., the former chief medical consultant for the Social Security Administration, who has personally made more than 50,000 disability determinations for SSA wrote in his book, Medical Issues in Social Security Disability Cases, James Publishing:
Personality disorders diagnoses are common in Social Security disability claimants who allege a mental disorder. The great majority of individuals with personality disorders are capable of working at some level of skill, so allowance under the listing is rare. Personality disorder diagnoses are popular with psychiatrists and psychologists, even in claimants with no history of any mental disorder. In many instances, their reports contain no compelling information supporting such diagnosis, because often little attention is actually paid to the diagnostic requirements of the DSM or the listing. Also, when diagnosis is based on a single one-hour mental status examination, one must wonder if that is really sufficient time for proper evaluation. 2
One of the tools used to assess mental disorders, particularly in the area of personality disorders is the Minnesota Multiphasic Personality Inventory (MMPI) [which is copyrighted by the university of Minnesota]. This test was initially developed in 1939. The test grouped items that were known to be endorsed by persons with certain mental disorders. This test has gone through several “improvements” with the latest version being named MMPI-2RF. The test contains several validity scales which are designed to determine whether the test taker is over reporting or underreporting his/her symptoms. One validity scale which has attracted notoriety was initially labeled the “fake bad scale”. Because of the pejorative label appended to such a name (since motivation or the reason for scoring high on the scale cannot be determined by the test) it was renamed the symptom validity scale. This scale was designed by Paul Lees-Haley, Ph.D. Dr. Lees-Haley worked primary for defendants in personal injury cases (insurance companies). A high score on such a scale suggest symptom exaggeration.
From a Social Security disability perspective, a high score on the fake bad scale presents challenges. Some ALJs are tempted to use that score as empirical evidence that the claimant is not credible and therefore can perform substantial gainful activities. The fact is that the MMPI in general and the fake bad scale in particular are very complex measurements and difficult to interpret.
For example, in a case that I recently completed, a claimant was diagnosed with depression and anxiety. During the course of his Social Security disability process, the claimant (I’ll call “Henry”) was administered an MMPI-II. On the MMPI-II he scored an extremely elevated F score and a relatively low VRIN3 scale score. That combination of results suggested to examining psychologist that “his endorsement of extreme items is a result of careful item responding rather than a random response pattern.” The psychologist concluded that Henry apparently understood the test, the item context and endorsed the symptoms as descriptive of his current functioning. His self-description was extremely disturbed and required further consideration because he claimed many more extreme psychological symptoms then most patients do.
The psychologist did not consider the MMPI-II test results as invalid due to the elevated F scale scores. Rather, the psychologist suggested several possibilities that required further evaluation including: exaggeration and or unusually severe psychological problems. The psychologist allowed for the possibility that the response could have been from poor reading ability; confusion; disorientation; stress or need to seek a great deal of attention for his problems. The psychologist acknowledged that a severe psychological disorder was reflected in this profile.
Just before the ODAR hearing, the ALJ referred Henry to DDB for a mental status examination and appropriate testing. As part of that testing, another DDB hired psychologist administered a second MMPI to Henry. On the MMPI-II, Henry’s F scales were elevated with a T-score of 120 which in the psychologist’s opinion would have an invalidated test scores if it was assumed that Henry had exaggerated his symptoms. However, if the tests were to be interpreted, the psychologist indicated that the profile would indicate Henry was truthful in his responses, that he had low self-esteem and did not exaggerate when he rated himself negatively. The psychologist’s opinion was that the clinical scales strongly indicated symptoms of schizophrenia, paranoid type. The doctor believed that these symptoms were consistent with Henry's clinical presentation.
At the ODAR hearing, a testifying psychologist commented that the F Scale score indicated that it made the test uninterruptable. The ALJ decided to hold that the “extremely elevated MMPI scores simply reflected an exaggeration of symptoms in order to gain the attention of services.” The ALJ denied benefits. On appeal to the U.S. District Court, the court held that, inter alia, that there was no evidence in the record to support the ALJ’s conclusion that the MMPI test results meant that Henry was attempting to gain the attention of services. The case was remanded.
Before the second ODAR hearing, Henry underwent yet another psychological examination (without an MMPI-II). This psychologist found that Henry’s mental state had marked limitations. At the hearing, the same ALJ concluded (with the support of another testifying psychologist) that “the results [of the MMPI-II tests] were technically ‘invalid’, it was not due to malingering or being uncooperative. Rather the results indicated that he had persisted difficulties managing his emotions, and as such, difficulties taking the test. Thus, this confirmed that the claimant had significant mental health problems.”
1 U. S. National Library of Medicine and National Institutes of Health. Medline Plus, Personality Disorder. http://www.nlm.nih.gov/medlineplus/ency/article/000939.htm [last accessed March 2, 2012.]
2 David A. Morton, III, M.D., Medical Issues in Social Security Disability Cases©, James Publishing, page 12-55. Reprinted with Permission.
3 VRIN is an acronym for “Variable Response Inconsistency”. VRIN is one of the validity scales built into the MMPI. It is designed to access answering similar/opposite question pairs inconsistently.