What Happens at a Social Security Psychological Exam?

When you file a mental disability claim (or appeal) with the Social Security Administration (SSA), the agency must gather medical evidence before deciding on your case. Specifically, your reviewer (claims examiner) will contact your treating doctor (or psychologist) and try to obtain the medical records related to your disability claim.

If you haven't been treated by a physician, psychiatrist, or psychologist lately, or you don't have medical records that provide a clear overview of your disability, Social Security can order that you go to a "consultative examination" (CE).

A Social Security exam, or CE, could include medical and/or mental examinations, depending on the kinds of impairments you're asking the SSA to consider in your disability claim. If Social Security requests that you have a CE done to assess your impairments, the agency must pay for the examination.

This article will cover what to expect from a psychological consultative exam and how Social Security uses the CE report in deciding your disability claim.

Who Performs the Social Security Examination?

Generally, Social Security prefers that your own psychologist or psychiatrist complete the mental examination. There are situations, however, in which an independent doctor might be used, including the following:

• The healthcare provider treating you doesn't want to perform the mental examination. (Learn more about applying for disability without your doctor's support.)
• Inconsistencies in your record can't be resolved by a mental examination performed by your treating doctor or psychologist (because the SSA considers your treating doctor the source of the inconsistencies).
• It's your preference to have an independent psychologist or psychiatrist perform the examination, and you have valid reasons for the request.
• Your treating doctor isn't considered a productive source of information based on prior experience with the SSA (or isn't regarded as qualified to conduct the exam).

Once the Social Security claims examiner decides that you should have a mental examination performed, the SSA will coordinate with a doctor or psychologist to set up an appointment time and place. The agency will try to get an appointment close to where you live.

Social Security can also help with your travel expenses (like if you need to pay someone to drive you because you can't drive yourself). Let the claims examiner know right away if you need help arranging or paying for transportation to your exam.

What the Psychological Examination Includes

Social Security will order the tests and evaluations that the claims examiner thinks are necessary to make a fair assessment of your disability. Which ones you'll face will depend on the following:

• the specific impairments you claim
• the medical records you've provided to the SSA, and
• the services and treatments you've received.

That said, at the mental examination, Social Security requires the doctor (or psychologist) to cover several specific elements. These elements are laid out below.

Your identity. The doctor must establish your identity through proof of identification, your claim number, and a physical description of you.

Your medical history related to your ability to work. The examiner will review all your available medical records. The doctor or psychologist will ask you to provide the following information:

• the symptoms that prevent you from working
• when they started and how they've progressed, and
• your treatment history.

Any past hospitalizations, operations, and procedures, including the dates and whether they were successful.

Your other medical history—all significant past medical events (even if they're unrelated to your disability) and when they happened, including:

• illnesses
• injuries
• operations, and
• other significant diagnoses.

Your current medication and its effects on you.

Your social and family history—including asking about your past and present relationships with:

• your parents
• other family members
• your friends and neighbors, and
• other people you interact with (like customers, co-workers, and supervisors).

Your educational background, including the highest grade you achieved and any recent training.

Your involvement in social activities or hobbies, including a description of your typical daily activities.

Any attempts to return to work and the results.

Any history of substance abuse and the effects your use of drugs or alcohol has on your ability to function.

Past and current participation in rehabilitation, supported living, or other treatment, and your success or failure in those programs.

Physical observations. The doctor or psychologist must report on:

• your general appearance and behavior
• observations as to how you got to the appointment (with whom and how), and
• any physical impairments, such as involuntary movements or problems with walking.

Mental status evaluation. The doctor or psychologist will make these determinations by observation throughout the mental examination. Areas that the doctor will assess include:

• your attitude and approach toward the evaluation
• your self-care (hygiene, dress, and so on)
• your mood
• your eye contact
• your ability to communicate
• how well you remember and recall information
• your ability to think through questions and answer them
• how well you can concentrate and pay attention
• any problems with perception
• suicidal or homicidal thoughts
• your judgment or insight, and
• your estimated level of intelligence.

Interpretation of testing. The doctor or psychologist will provide clinical assessments of your performance on any psychological tests or other examinations performed.

Diagnosis. The psychiatrist or psychologist must diagnose you based on the American Psychiatric Association standards.

Prognosis and recommended treatment—including whether you need further evaluations.

What's In the Social Security Psychological Exam Report?

After completing the examination, the doctor or psychologist must provide their clinical opinion on the following:

• the nature and extent of your mental disorder
• your abilities and limitations based on all available information, including your ability to:
  • carry out instructions (both simple and complex)
  • complete work at a reasonable rate
  • manage your money
  • interact with others appropriately (like co-workers and the general public), and
  • handle the normal pressures of work.
• whether you must avoid specific hazards (like machinery or dangerous materials) and why
• any apparent discrepancies in your records and how they were resolved, and
• whether the doctor or psychologist thinks you're exaggerating your symptoms.

For an individual with intellectual impairments, the doctor will also need to provide the following information:

• standardized IQ results and interpretation of those results
• consistency of the test results with educational records, and
• a description of any adaptive behaviors.

How Social Security Uses the Mental Exam Results

After receiving the report from your consultative examination, the Social Security claims examiner will generally do one of two things:

• decide your case, or
• order additional testing or evaluation.

The claims examiner will consider the mental examination report along with the rest of your record when deciding if you're disabled and unable to work. Although all your medical records will have an impact on your claim, Social Security tends to put a lot of weight on the results of a mental consultative examination. That's why it's good to have an opinion on file from your own psychiatrist or psychologist; Social Security should give that opinion some weight as well.

If Social Security denies your claim for disability benefits because of a consultative examination report (or other reason), you have the right to appeal. (Learn more about the Social Security disability appeals process.)