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 Disturbance of Conduct


Related Terms

  • Adjustment Disorder with Predominant Disturbance of Conduct
  • Adjustment Reaction with Predominant Disturbance of Conduct
  • Predominant Disturbance of Conduct

Differential Diagnosis

Specialists

  • Clinical Psychologist
  • Psychiatrist

Comorbid Conditions

  • Chronic medical conditions
  • Mental or medical disorders
  • Personality disorder
  • Substance abuse disorders

Factors Influencing Duration

Continued exposure to the stressor can often lead to continuing maladaptive behavior and symptoms. The severity of the stressor is not always predictive of the severity of symptoms. This depends on degree, quantity, duration, and reversibility of the stressor, work and home environment and social supports, and personal context in terms of significance of the stressor to the individual. 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
309.3 - Adjustment Reaction with Predominant Disturbance of Conduct
309.4 - Adjustment Disorder with Mixed Disturbance of Emotions and Conduct

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 disturbance of conduct, the main feature is abnormal conduct violating the rights of others or going against societal norms. Examples include truancy, vandalism, reckless driving, fighting, or defaulting on legal responsibilities. 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.

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 least common is with disturbance of conduct. The most common subtype diagnosed is depressed mood. 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

Adjustment disorders are fairly common depending on the population studied; as many as 50% of those who experience a specific stressor, such as cardiac surgery, will experience an adjustment disorder (DSM-IV-TR). Typically, adjustment disorder with disturbance of conduct occurs when there are changes in the workplace (e.g., down-sizing, workplace performance issues, supervisor issues), marital problems, and other types of problems within the family or personal relationships.

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 disturbance of conduct by identifying a predominance of symptoms such as abnormal conduct violating the rights of others or going against societal norms, such as truancy, vandalism, reckless driving, fighting, or defaulting on legal responsibilities. Eliciting a description of the individual's atypical conduct in his or her customary environment is essential. Other sub-categories include depressed mood, anxiety, or a mixed anxiety and depressed mood, or mixed disturbance of emotions and conduct (DSM-5 and DSM-IV-TR).

Physical exam: The physical exam is important in ruling out aberrant changes in behavior caused by the physiological effects of a medical condition. Observation of the individual's orientation, dress, mannerisms, behavior, and content of speech provide important signs to help diagnose the adjustment disorder.

Tests: Psychological testing can be helpful as an adjunct to diagnosing adjustment disorders and may include the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) or other personality tests. However, subjective tests, such as inventories, are not appropriate to measure psychological distress in an objective manner.

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 it 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. Use of role-playing, directive therapy, and behavioral logs can help the individual to make meaningful behavioral changes. Pharmacotherapy utilizes anti-anxiety agents and antidepressants to reduce symptoms of disordered mood that may accompany disturbed conduct. These medications 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

Overall outcome for adjustment disorder is favorable with appropriate treatment. Adjustment disorders generally occur within a short period following the stressor and 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



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, 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 exhibits aggressive tendencies (e.g., vandalism, fighting, reckless driving) or has suicidal thoughts or attempts. Individuals whose abnormal conduct violates the rights of others may place their coworkers at risk, and the individual may need temporary job reassignment. Recurrence is not normally a concern unless the identifiable stressor is related to the individual's working environment.

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

Tolerance: Tolerance factors include the source of the stressor (e.g., work, personal relationships) and the individual’s compliance with treatment. In most cases, participation 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:

  • Does individual exhibit significant emotional or behavioral symptoms as a result of a stressor or life event?
  • Was diagnosis confirmed? Were other psychiatric and substance abuse disorders ruled out?
  • Were medical disorders with psychiatric presentations rule out?
  • If there is concurrent drug or alcohol abuse, to what extent are these conditions causing additional problems?

Regarding treatment:

  • Has stressor been identified?
  • Was stressful situation eliminated? Would environmental modification or hospitalization be beneficial?
  • Is additional or extended use of group or individual therapy warranted?
  • Is individual motivated to participate in treatment, and does individual possess the capacity to engage in psychological exploration?
  • Has pharmacotherapy been added to the psychotherapy regimen for the most effective results?
  • Were anti-anxiety agents or antidepressants prescribed?
  • Are social supports adequate?

Regarding prognosis:

  • How are current stresses being dealt with?
  • How were major stresses dealt with in the past? If methods of coping are maladaptive (i.e., drug or alcohol abuse), to what extent are these conditions causing additional problems?
  • Who are individual's social supports? Family? Friends? Church or other community affiliations? Are these being utilized?
  • What is happening outside of work that may be contributing to or worsening the problems experienced at work?
  • Are there incentives not to improve such as ongoing litigation, social security, or disability insurance?
  • Does individual have an underlying condition that may impact recovery?
  • Does individual have symptoms of other disorders that may be affecting recovery?
  • Does a stressor exist that has not been identified?
  • 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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