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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 Depressed Mood


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Medical Codes

ICD-9-CM:
309.0 - Adjustment Disorder with Depressed Mood
309.28 - Adjustment Reaction with Predominant Disturbance of Other Emotions; Adjustment Reaction with Mixed Anxiety and Depression

Related Terms

  • Adjustment Reaction
  • Adjustment Reaction with Depressed Mood
  • Depressive Reaction (Brief and Chronic)
  • Depressive Reaction (Brief)
  • Depressive Reaction (Chronic)
  • Grief Reaction

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 depressed mood, the predominant symptoms include low mood, tearfulness, or feelings of hopelessness. 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. Of those individuals diagnosed with adjustment disorders, the most common subtype is depressed mood followed by, in order of frequency, anxious mood, mixed anxiety and depressed mood, with disturbance of conduct being least frequent. 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 depressed mood by identifying a predominance of symptoms such as low mood, tearfulness, or feelings of hopelessness. Other sub-categories include anxiety, 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 exam is generally not helpful in diagnosing adjustment disorders. Observation of the individual's orientation, dress, mannerisms, behavior, and content of speech provide essential signs to help diagnose the illness. For example, the individual may show poor attention to grooming or give statements inconsistent with emotional state (affect) such as saying, "I feel fine" while clenching the jaw and frowning. Depressed mood may be associated with low volume and output of speech, blank or sad expression, and decreased or slowed spontaneous movement (psychomotor retardation). The mental status examination may reveal a decrease in attention and concentration.

Tests: Psychological testing can be helpful as an adjunct to diagnosing adjustment disorders. This may include the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), or other tests.

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 along with resolving the stressful situation or removing the individual from the situation. Group therapy can be effective especially when individuals in the group have experienced similar stressors. Individual psychotherapy helps explore the meaning of the stressor to the individual so that earlier traumas can be explored. Brief psychotherapy when used in a crisis intervention can help resolve the situation quickly using supportive techniques, suggestion, reassurance, environmental modification, and, if necessary, hospitalization. Cognitive behavioral therapy helps correct disordered thinking and maladaptive behavior. Pharmacotherapy utilizes antidepressants agents and may include anti-anxiety agents to reduce symptoms of depression and anxiety. Anti-anxiety agents should be used judiciously and for brief periods.

Source: Medical Disability Advisor



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 this expectation. Individuals generally return to normal functioning within a few months.

Source: Medical Disability Advisor



Differential Diagnosis

  • Acute stress disorder
  • Anxiety disorders
  • Mood disorders (dysthymic disorder, major depressive disorder, or bipolar disorder)
  • Normative stress reactions
  • Personality disorders
  • Post-traumatic stress disorder (PTSD)
  • Psychological factors affecting medical conditions

Source: Medical Disability Advisor



Specialists

  • Clinical Psychologist
  • Occupational Therapist
  • Psychiatrist

Source: Medical Disability Advisor



Comorbid Conditions

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

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



Factors Influencing Duration

In adjustment disorders, continued exposure to the stressor often leads to continuing maladaptive behavior and symptoms. The apparent severity of the stressor is not always predictive of the severity of symptoms, which depends on the degree, quantity, duration, and reversibility of the stressor. Severity is also influenced by the work and home environment and support structure and the personal context or the significance of the stressor to the individual.

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.

Risk: Risk is affected by the severity of symptoms and whether the individual engages in suicidal thoughts or attempts. Individuals with a persistently low mood and feelings of hopelessness may place their coworkers at risk, and may need temporary job reassignment to tasks that are not safety-sensitive.

Capacity: Capacity is dependent on the severity and expression of maladaptive symptoms. As long as risk is adequately addressed, individuals with adjustment disorder with depressed mood may work without limitations.

Tolerance: Tolerance is affected by the individual's compliance with treatment (e.g., attending psychotherapy and cognitive behavioral therapy sessions, taking prescribed medications). Engagement in structured, non safety-sensitive work tasks 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?
  • Were similar disorders considered and ruled out such as major depression, bipolar affective disorder, mood disorders due directly to medical disorders or substance abuse, dysthymic disorders, acute stress disorder, post-traumatic stress disorder, or persistent complex bereavement disorder?
  • Was there a history of depression or other psychological problem contributing to the current condition?
  • What was the previous level of functioning?
  • Was there significant reduction in functioning and if so, in what ways?
  • If there is concurrent drug or alcohol abuse, to what extent were these conditions causing additional problems?

Regarding treatment:

  • Was the stressful situation resolved?
  • Was individual removed from it?
  • If suicidal tendencies are present, is environmental modification being considered?
  • Is the frequency of psychotherapy visits adequate?
  • Is additional supportive group or individual therapy needed?
  • Has pharmacotherapy been added to the psychotherapy regimen for more effective results?
  • If utilized, were antidepressants or tranquilizers effective?
  • Would a longer trial be warranted?
  • Are social supports adequate?

Regarding prognosis:

  • 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 drug and/or alcohol abuse is present, to what extent are these conditions causing additional problems?
  • Are social supports available? Family? Friends? Church or other community affiliations? Are these being utilized?
  • Are events outside of work contributing to or worsening the problems experienced at work?
  • Are there incentives not to improve such as ongoing litigation, social security, or disability insurance?
  • Did individual enjoy working previously?

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, Julia. "Adjustment Disorders." eMedicine. Ed. . 11 Dec. 2014. Medscape. 20 Apr. 2015 <http://emedicine.medscape.com/article/2192631>.

Source: Medical Disability Advisor