Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Adjustment Disorder with Anxiety


Related Terms

  • Adjustment Disorder with Anxious Mood
  • Adjustment Reaction
  • Adjustment Reaction with Anxious Mood

Differential Diagnosis

Specialists

  • Clinical Psychologist
  • Psychiatrist

Comorbid Conditions

  • Alcohol or substance abuse disorders
  • Mental or medical disorders
  • Personality disorder

Factors Influencing Duration

Continued exposure to the stressor will often lead to continuing maladaptive behavior and symptoms in adjustment disorders. The severity of the stressor is not always predictive of the severity of adjustment disorder. The severity of the condition depends on degree, quantity, duration, and reversibility of the stressor, the overall environment, and social support structure. Underlying personality traits and characteristics, and personal context in terms of what the stressor means to the individual also affect severity. The context of the individual's cultural setting should also be taken into account in determining whether the reaction to stress is in excess of what would be expected.

Medical Codes

ICD-9-CM:
309.24 - Adjustment Reaction with Predominant Disturbance of Other Emotions; Adjustment Disorder with Anxiety or Disturbance of Conduct
309.28 - Adjustment Reaction with Predominant Disturbance of Other Emotions; Adjustment Reaction with Mixed Anxiety and Depression

Overview

In an adjustment disorder, a psychological response occurs to an identifiable stressor or life event. This response includes significant emotional or behavioral symptoms that are usually manifested as decreased performance at work and temporary changes in social relationships. The life stressor may be a single event such as termination of a relationship, a recurrent situation such as seasonal business crises, a continuous stressor such as living in a crime-ridden neighborhood, or a prolonged circumstance such as a chronic, debilitating medical condition. A life stressor can also consist of multiple events such as business difficulties plus marital problems. The development of emotional or behavioral symptoms must occur within 3 months of the onset of the stressor(s).

Psychological distress following exposure to a traumatic or stressful event can often be understood within an anxiety- or fear-based context. However, some individuals exhibit symptoms that are anhedonic and dysphoric, externalizing angry and aggressive symptoms, or dissociative symptoms. Because of these variable responses to catastrophic or aversive events, adjustment disorders have been included in the section Trauma- and Stressor-Related Disorders in DSM-5, together with reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder (PTSD), and acute stress disorder. This differs from the stand- alone chapter for adjustment disorders in DSM-IV-TR.

In adjustment disorder with anxiety, the predominant symptoms include nervousness, worry, or jitteriness (DSM-IV-TR). DSM-5 adds separation anxiety to the list of symptoms. In order to make this diagnosis, it is important to be aware that the symptom complex does not meet the criteria for some other psychiatric disorder and that it is not merely an exacerbation of a preexisting mental disorder. The symptoms must exceed those evident for expected bereavement, considering cultural, religious, and age-appropriate norms (DSM-IV-TR and DSM-5).

Incidence and Prevalence: Adjustment disorders are fairly common, depending upon the population studied and the assessment methods used. A number of studies have reported rates around 12% across a variety of populations. In clinical patient populations, rates approaching 23% have been recorded. In outpatient mental health treatment, about 5% to 20% of individuals have a principal diagnosis of an adjustment disorder. In hospital psychiatric consultation settings, adjustment disorder is often the most common diagnosis, as high as 50% (Frank).

Source: Medical Disability Advisor



Causation and Known Risk Factors

As many as 50% of individuals who experience a specific stressor, such as cardiac surgery, will experience an adjustment disorder. Individuals from disadvantaged circumstances who experience a high rate of stressors may be at an increased risk (DSM-IV-TR).

Source: Medical Disability Advisor



Diagnosis

History: A diagnosis of adjustment disorder should only be made when the magnitude of distress exhibited in alterations in mood, anxiety, or conduct exceeds what would normally be expected given the context surrounding the stressor event(s). Adjustment disorders may be diagnosed, for example, following the death of a loved one when the intensity, quality, or persistence of grief reactions are greater than normally expected when cultural, religious, or age-appropriate norms are considered (DSM-5). Adjustment disorder may be diagnosed in the presence of another psychiatric disorder if the latter does not account for the pattern of symptoms that have occurred in response to the stressor.

It is expected for individuals with adjustment disorder to exhibit emotional or behavior symptoms to a recognizable stressor(s) within 3 months of the onset and for those symptoms to resolve no longer than 6 months after the stressor and its consequences have ceased. If the stressor is an acute event such as being fired from a job, the onset of the symptoms usually occurs within a few days and then resolve within a few months. However, if the stressor or its consequences linger, the adjustment disorder may become continuous and become the persistent form (DSM-5). Both DSM-5 and DSM-IV-TR acknowledge that if a stressor or its consequences persist, the disorder may become chronic, which DSM-IV-TR defines as lasting 6 months or longer.

Under the category of stressor-related disorders, it is necessary to specify the sub-category of adjustment disorder with anxiety by identifying a predominance of nervousness, worry, jitteriness and separation anxiety. Other sub-categories include depressed mood, or a mixed anxiety and depressed mood, disturbance of conduct, or mixed disturbance of emotions and conduct (DSM-5 and DSM-IV-TR).

Physical exam: The physical exam is important in ruling out anxiety caused by the physiological effects of a medical condition such as hyperthyroidism or chronic obstructive pulmonary disease (COPD). Observation of the individual's orientation, dress, mannerisms, behavior, and content of speech provide essential signs to help diagnose adjustment disorder with anxiety. For example, there may be poor attention to grooming, or verbalizations inconsistent with emotional state (affect), such as saying, "I feel fine" while clenching the jaw and frowning. Physical manifestations of anxiety may include sweaty palms, rapid pulse, pale or flushed skin, frequent sighing, and restless behavior such as pacing or fidgeting.

Tests: Psychological testing, such as the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) or the State-Trait Anxiety Inventory, can be a useful adjunct to diagnosing Adjustment Disorders. It is better to use objective psychological tests, such as the MMPI-2 or the Personality Assessment Inventory (PAI) or the Millon Clinical Multi-axial Inventory-III (MCMI-III), instead of subjective inventories, such as the State-Trait Anxiety Inventory. Inventories and other subjective tests may allow outcomes of the testing to be easily influenced by the test taker, resulting in exaggeration of psychological distress.

Note: It must be kept in mind that just because a physical diagnosis cannot be established as the cause of the presenting symptomatology, it does not necessarily mean that the cause is a mental one. That is to say that the presence of medically unexplained symptomatology does not necessarily establish the presence of a psychiatric condition. The first step in identifying the presence of a mental disorder is excluding the presence of malingering and/or of factitious disorder. Although factitious disorder is conscious and purposeful, it is classified as a psychiatric disorder. The strong need for this step is especially true whenever there is a medicolegal context associated with the presenting problem(s). Additionally, using DSM-5 and/or ICD-9-CM or ICD-10-CM, the clinician will find that many presentations fail to fit completely within the boundaries of a single mental disorder. There are systematic ways to go about making psychiatric diagnoses, however.

Source: Medical Disability Advisor



Treatment

Psychotherapy is the treatment of choice for adjustment disorders. Ending the stressful situation or removing the individual from the stressful situation is desirable. Group therapy has been effective, especially when individuals in the group have experienced similar stressors. Short-term, problem-focused, individual psychotherapy may be helpful to explore the meaning of the stressful situation to the individual so that the reactive anxiety may be resolved. Brief psychotherapy, when used in a crisis intervention, can help resolve the situation quickly through supportive techniques, suggestion, reassurance, environmental modification, and even hospitalization, if necessary. Cognitive behavioral therapy has a strong empirical base and helps correct disordered thinking and maladaptive behavior. Relaxation techniques such as transcendental meditation and/or meditative yoga are also useful interventions. Pharmacotherapy utilizes antidepressants, anti-anxiety agents, and anxiety-relieving antidepressants to reduce symptoms of anxiety. These should be used judiciously and for brief periods.

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Stress-related Conditions
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

The overall prognosis for adjustment disorder is favorable with appropriate treatment. Adjustment disorders generally occur within a short period of time following the stressor and, by definition, should last no longer than 6 months after the stressor or its consequences have ended. See the Diagnosis section for more about the exception to these expectations. Individuals generally return to normal functioning within a few months.

Source: Medical Disability Advisor



Complications

Adjustment disorders are associated with alcohol or substance abuse, physical (somatic) complaints, and suicidal attempts or suicide. If an individual with a pre-existing mental or medical illness is also diagnosed with an adjustment disorder, the course of that illness may be complicated or prolonged by decreased compliance with recommended treatment or increased hospital length of stay.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions or accommodations are necessary only infrequently, and only for the most serious cases. In these instances, time-limited restrictions and work accommodations should be individually determined based on the characteristics of the individual's response to the disorder, the functional requirements of the job and work environment, and the flexibility of the job and work site. The purpose of the restrictions/accommodations is to help maintain the worker's capacity to remain at the workplace without a work disruption, or to promote timely and safe transition back to full work productivity. Often, the sense of fulfillment and distraction from one's concerns that work can provide may improve symptoms and speed recovery.

Risk: Risk is affected by the severity of symptoms and whether the individual engages in suicidal thoughts or attempts. However, adjustment disorder with anxiety typically poses little risk to the working individual or to his or her coworkers. Recurrence is not normally a concern unless the identifiable stressor is related to the individual's working environment.

Capacity: Capacity is usually unaffected by this disorder. In rare circumstances, the individual may be temporarily less productive at work secondary to symptoms of nervousness, jitteriness, and anxiety until recovery is complete.

Tolerance: Tolerance factors include the source of the stressor (e.g., work, health, home) and the individual’s compliance with treatment. In most cases, participation in job duties may be beneficial to recovery.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is expected at 6 months of treatment or less.

Note: MMI is estimated under the assumption that the vagaries involved in psychiatric diagnoses have been taken into consideration.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was diagnosis confirmed?
  • Was an underlying medical disorder overlooked?
  • Did symptoms and behaviors match the criteria needed for diagnosis?
  • Was stressor identified?
  • What was individual's previous level of functioning?
  • Was there a significant reduction in functioning?
  • In what ways was individual's level of functioning impaired?
  • Did individual have symptoms of other psychiatric disorders, such as major depression, dysthymic disorder, bipolar disorder, personality disorders, post-traumatic stress disorder, acute stress disorder, psychological factors affecting medical condition, attention-deficit/hyperactivity disorder, or persistent complex bereavement disorder?
  • Does the adjustment disorder represent the early stages of a more severe psychiatric disorder that has not yet been diagnosed?
  • Was there a history of depression or other psychological problem that may be contributing to the current condition?
  • If there is concurrent drug or alcohol abuse, to what extent are these conditions causing additional problems?

Regarding treatment:

  • Has stressor been identified?
  • Has stressor been resolved?
  • Does individual need more frequent therapeutic encounters or the addition of another type of therapy or therapist?
  • If group psychotherapy is being used, have individuals in the group experienced similar stressors? If not, is a more appropriate group environment available?
  • Has pharmacotherapy been added to the psychotherapy regimen for the most effective results?
  • Have anti-anxiety agents and antidepressants been considered to reduce symptoms of anxiety or depression?
  • Are side effects preventing optimal treatment response?
  • Is individual motivated to participate in treatment, and does individual possess the capacity to engage in psychological exploration?

Regarding prognosis:

  • If symptoms persist despite treatment, is environmental modification or hospitalization being considered?
  • Does diagnosis need to be revisited?
  • How are current stresses being dealt with?
  • How were major stresses dealt with in the past?
  • If healthy and adaptive methods were used in the past, are they being used currently?
  • If maladaptive, such as drug or alcohol abuse, to what extent are these conditions causing additional problems?
  • Does individual have a functional support system? Family? Friends? Church or other community affiliations? Are these being utilized effectively?
  • Did individual enjoy previous work?
  • What is happening outside of work that may be contributing to or worsening the problems experienced at work?
  • Is individual motivated to recover, or do symptoms fulfill psychological, personal, or economic factors?

Source: Medical Disability Advisor



References

Cited

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. American Psychiatric Association, 2013.

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000.

Frank, Julie, et al. "Adjustment Disorders." Medscape. 11 Dec. 2014. WebMD, LLC. 15 Apr. 2015 <http://emedicine.medscape.com/article/2192631-overview#a0156>.

Source: Medical Disability Advisor






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