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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.

Avoidant Personality Disorder


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Medical Codes

ICD-9-CM:
301.82 - Avoidant Personality Disorder

Related Terms

  • Personality Disorder
  • Social Anxiety Disorder
  • Social Phobia

Overview

Avoidant personality disorder is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and being overly sensitive to negative evaluation. It represents a "detached" personality pattern. Detached individuals are typically introverted, aloof, and reclusive; tend to avoid social activities; and are usually quite uncomfortable when forced to participate in such activities. They are extremely sensitive to rejection, which may lead to social isolation and a withdrawn life. They tend to be shy, apprehensive, awkward, and uncomfortable with face-to-face contact, and may appear timid, withdrawn, evasive, and sometimes strange. Their speech may be slow and constrained, with frequent hesitations and fragmented thought sequences. Their avoidance of social situations and inhibition in interpersonal relationships is related to feelings of ineptitude and inadequacy, anxious preoccupation with negative evaluation and rejection, and fears of ridicule or embarrassment.

Individuals with this disorder fear placing their welfare and feelings in the hands of others and hesitate to trust or confide in others. They tend to be extremely introspective and self-conscious. They often perceive themselves as different from others and tend to be unsure of their identity and self-worth, lacking overall self-esteem. They often devalue their own achievements, seeing themselves as isolated, discontented, and empty.

Avoidant personality disorder is thought to begin in infancy and childhood but, unlike developmentally appropriate shyness, does not dissipate with maturity. Because it is difficult to distinguish long-term traits in the evolving personality of children, the disorder is usually not diagnosed until young adulthood.

Incidence and Prevalence: The estimated prevalence of avoidant personality disorder is about 2.4% (DSM-5).

Source: Medical Disability Advisor



Causation and Known Risk Factors

The disorder appears with equal frequency in males and females (DSM-IV-TR). Having a biological relative with severe social anxiety or social phobia is associated with a two- to threefold increase in risk for developing either social phobia or avoidant personality disorder.

Source: Medical Disability Advisor



Diagnosis

History: A psychiatric interview and mental status exam are the primary methods utilized by the practitioner. In a clinical interview, the most striking aspect is the individual's anxiety about talking with the interviewer. The physician looks for symptoms of a pervasive pattern of social inhibition, feelings of inadequacy, and extreme sensitivity to negative evaluation.

According to the Diagnostic and Statistical Manual of Mental Disorders, both 4th Edition, Text Revision (DSM-IV-TR), and 5th Edition (DSM-5), individuals with avoidant personality disorder display a pervasive pattern of social inhibition, feelings of inadequacy, and undue sensitivity to negative evaluation that begins by early adulthood. The disorder is present in a variety of contexts that include at least 4 of the following: avoiding work-related activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection; reluctance to get involved with others unless there is certainty of being liked; restraint within intimate relationships because of the fear of being shamed or ridiculed; preoccupation about being criticized or rejected in social situations; inhibition in new interpersonal situations due to feelings of inadequacy; self-concept as socially inept, personally unappealing, or inferior to others; and an unusual reluctance to take risks or to engage in any new activities because they may prove embarrassing (DSM-IV-TR, DSM-5).

The DSM-5 diagnostic criteria for personality disorders, which are thought by many to be a more effective way to delineate those disorders, suggest that there has to be a moderate or greater impairment in personality functioning in at least 2 of the following 4 areas: identity, self-direction, empathy, and/or intimacy. There must also be 3 or more of the following 4 pathological personality traits, one of which must be anxiousness. The other three, withdrawal, anhedonia and/or avoidance of intimacy, are each aspects of detachment.

Physical exam: A physical exam is not helpful in diagnosing this disorder.

Tests: When used in conjunction with the history, standardized psychological assessment strategies such as the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and the Structured Clinical Interview for Axis II Disorders (SCID-II) can be helpful in diagnosing personality disorders.

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. This 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

Treatment for avoidant personality disorder depends on establishing an alliance (based on trust) between the therapist and the individual. Psychotherapeutic modalities include individual and group counseling, especially long-term cognitive behavioral therapy focusing on the development of effective coping strategies and social skills. A primary goal of any psychotherapy for this disorder is to encourage the individual to move out into the world and take what are perceived as great risks of humiliation, rejection, and failure. The therapist should be cautious, however, when suggesting that the individual exercise new social skills outside therapy because failure may reinforce feelings of poor self-esteem. Group therapy may help the individual cope with the exaggerated threat of rejection.

Pharmacotherapy has been used to deal with depression and anxiety, the most common features associated with avoidant personality disorder. Antianxiety agents may be useful in treating high levels of anxiety associated with this disorder. However, antianxiety agents of the benzodiazepine group come with other significant risks, including habituation and dependency, and synergistic effects with other agents such as opioids.

Source: Medical Disability Advisor



Prognosis

Many individuals with avoidant personality disorder can function in society, provided they are in a protected environment. A stable support system and a positive network of family and friends usually ensures a good outcome.

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Clinical Psychologist
  • Psychiatrist

Source: Medical Disability Advisor



Comorbid Conditions

  • Alcohol or substance abuse disorders

Source: Medical Disability Advisor



Complications

Any type of rejection in the life of the avoidant personality may lead to increasing social withdrawal. Criticism in any form is usually devastating and intensifies the dysfunction. Other complicating factors are the presence of anxiety, depression, or other coexistent psychiatric disorders, including substance abuse. At work or home, any type of rejection or perceived rejection usually leads to withdrawal.

Source: Medical Disability Advisor



Factors Influencing Duration

The progress and effectiveness of the psychotherapy and the individual's level of functioning are all factors in the length of disability. Should their support system fail, these individuals are subject to symptoms of depression and anxiety that may lengthen disability.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

High-profile positions with frequent contact on a one-to-one basis may be uncomfortable and in some cases intolerable for the individual with avoidant personality disorder. A work environment involving a small group of people is recommended. Contact with a large or unfamiliar group should be avoided.

Risk: Recurrence depends on management of risk factors such as the degree of interpersonal contact, the frequency of unfamiliar work tasks, and the potential for unconstructive criticism from managers and coworkers.

Capacity: Capacity is typically unaffected, as most individuals with avoidant personality disorder are already working within their psychological comfort zones. Individuals taking medications to control concurrent symptoms of anxiety or depression may require periodic drug testing to ensure that substance abuse or addiction does not become an issue.

Tolerance: Tolerance is dependent on the severity of the individual's symptoms, the individual's motivation and compliance with treatment (e.g., cognitive behavioral therapy, individual and group therapies), and the individual's response to treatment. In many cases, involvement with activities in protected work environments is beneficial.

Source: Medical Disability Advisor



Maximum Medical Improvement

Because no disability is expected, adults with avoidant personality disorder can be thought of as typically being at MMI at presentation. Enhancement of functioning usually cannot be induced with medications.

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 of avoidant personality disorder confirmed? Does individual's behavior fit criteria?
  • Because individual may deem important life or medical history information about himself or herself too unimportant to mention, was physician able to get a comprehensive, realistic history? Do nonverbal clues give an indication of important information that may have been omitted?
  • Were conditions with similar symptoms ruled out?

Regarding treatment:

  • Is psychotherapy focused on finding solutions to specific life problems?
  • Has individual been able to establish and maintain a good working rapport with therapist? If not, what can be done to help facilitate rapport?
  • If individual is taking medication, is it short-term and for a specific coexisting psychiatric condition? Could medication actually be interfering with the effectiveness of the overall treatment?

Regarding prognosis:

  • Since avoidant personality disorder may require long-term therapy, would group therapy be a good adjunct after termination of current individual therapy?
  • Does individual have a stable, understanding support system?

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.

Rettew, David C. "Avoidant Personality Disorder." eMedicine. Eds. Caroly Pataki, et al. 28 Oct. 2013. Medscape. 13 Aug. 2014 <http://emedicine.medscape.com/article/913360-overview>.

Source: Medical Disability Advisor