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.

Borderline Personality Disorder


Related Terms

  • Borderline Disorder
  • Borderline Personality
  • Borderline Syndrome
  • BPD
  • Multiple Complex Developmental Disorder

Differential Diagnosis

  • Identity problems
  • Mood disorders
  • Other personality disorders
  • Personality change due to a general medical condition
  • Symptoms that may develop in association substance abuse

Specialists

  • Clinical Psychologist
  • Psychiatrist

Comorbid Conditions

  • Alcohol or substance abuse disorders
  • Eating disorders
  • Mood disorders
  • Post-traumatic stress disorder

Factors Influencing Duration

Complications, severity of the condition, response to treatment, support systems, and job duties may influence the length of disability.

Medical Codes

ICD-9-CM:
301.83 - Borderline Personality Disorder

Overview

The key feature of the borderline personality disorder is the individual's instability in several areas, including social behavior, mood, and self-image. Individuals with borderline personality disorder are characterized by an extraordinarily unstable affect, mood, behavior, and self-image. They often appear anxious or impulsive, with abrupt, unexpected, and apparently spontaneous outbursts (sometimes reaching psychotic proportions) that make their behavior seem unpredictable. Irregular sleep-wake cycles suggest some form of instability in regulated patterns of arousal. Borderline individuals tend to shift from experiencing a normal mood to inappropriately intense anger and rage, then to excitement or euphoria. In addition to their vacillating and unstable mood, they also seem to experience chronic anxiety.

Borderlines may engage in self-damaging behaviors related to poor impulse control, and as a mechanism to deal with extreme anxiety brought on by feelings of guilt and self-loathing. These behaviors may include recurrent accidents, fights, self-mutilation, suicidal gestures, overeating, gambling, spending sprees, shoplifting, or promiscuous sexual behavior. They have difficulty tolerating normal levels of frustration, anxiety, rejection, and loss, and almost always appear to be in a state of crisis.

Separation anxiety and fear of abandonment are prime motivators in the interpersonal behavior of borderline individuals, as they are exceedingly dependent on others. They usually form unstable and intense "love-hate" relationships, tending to view others simplistically as being all good or all bad. Identity disturbances are common, as they are uncertain about who they are and where they are headed in life.

Incidence and Prevalence: This disorder occurs in about 2% of the general population (Bienenfeld).

Source: Medical Disability Advisor



Causation and Known Risk Factors

The DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision) indicates that borderline personality disorder is five times as common among first-degree biological relatives of individuals diagnosed with the disorder than in the general population. Biological relatives also show an increased prevalence of major depressive disorder, alcohol use disorders, and substance abuse. Borderline personality disorder is diagnosed 3 times more frequently in women than in men (Bienenfeld).

Source: Medical Disability Advisor



Diagnosis

History: Psychiatric interview and mental status exam are the primary methods of diagnosis. According to the DSM-IV-TR, diagnosis of borderline personality disorder requires a pervasive pattern of instability of interpersonal relationships, self-image, and mood (affect), and marked impulsivity beginning by early adulthood and present in a variety of situations, with at least five of the following nine criteria: frantic efforts to avoid real or imagined abandonment (not including suicidal or self-mutilating behavior); a pattern of unstable and intense interpersonal relationships alternating between seeing others as all good (idealization) or all bad (devaluation); identity disturbance with a markedly and persistently unstable self-image; impulsivity in at least two areas that are potentially self-damaging other than suicidal or self-mutilating behavior (spending, sex, substance abuse, reckless driving, or binge eating); recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior; rapidly changing and extreme variation in mood (affective instability) such as intense episodic feelings of displeasure (dysphoria), irritability, or anxiety usually lasting a few hours and only rarely more than a few days; chronic feelings of emptiness; inappropriate, intense anger or difficulty controlling anger, such as frequent displays of temper, constant anger, or recurrent physical fights; or transient, stress-related paranoid ideas or severe feelings of being detached from reality (dissociative symptoms).

Physical exam: The exam is generally not helpful in the diagnosis of borderline personality disorder. Observation of the individual's orientation, dress, mannerisms, behavior, and content of speech may provide essential signs to help diagnose the illness.

Tests: Sleep studies may be helpful, as some individuals show shortened rapid eye movement (REM) latency and sleep continuity disturbances, abnormal dexamethasone-suppression test results, and abnormal thyrotropin-releasing hormone test results. These changes are also seen in some cases of depressive disorders. Functional MRI's (fMRI) are showing initial promise in identifying a neurobiological substrate of the disorder.

Psychological testing such as the Minnesota Multiphasic Personality Inventory - 2 (MMPI-2) can be helpful in diagnosing Personality Disorders. The Structured Clinical Interview for Axis II Disorders (SCID-II) is sometimes used for differential diagnosis (First).

Source: Medical Disability Advisor



Treatment

The primary treatment for borderline personality disorder is psychotherapy. As these individuals tend to form intense love-hate relationships, they may first cast their therapist as an idealized rescuer, then despise him as the villain when things go wrong. The therapist must avoid this struggle, and must be aware that the borderline personality tends to pit different caregivers against each other. At the same time, the therapist must tolerate the borderline's episodic angry outbursts to demonstrate that he need not fear abandonment.

Borderline patients are often hospitalized for their suicide attempts, but both admission and discharge are difficult because of power struggles with caregivers and family. In the hospital setting, intensive individual and group psychotherapy are both useful. A multidisciplinary approach is most successful, utilizing staff trained in recreational, occupational, and vocational therapy. Group therapy should be supportive rather than focused on analyzing motivations for the individual's behavior. Both in individual and group therapy, the therapist should help the individual set limits for their own behavior, respect limits set by other people, and solve problems using a reality-based approach. Ideally, individuals remain in the hospital until they show marked improvement, but long-term hospitalization can sometimes make the borderline worse due to increased acting-out and mimicking the behaviors of more disturbed individuals. After hospitalization, an outpatient therapist can stabilize the individual and help prevent future hospitalizations. Outpatient psychotherapy usually consists of 2 to 3 sessions weekly over a period of years. Family counseling may help families deal with the stress involved in relating to the borderline patient.

Behavior therapy and social skills training are utilized in an inpatient or outpatient setting. Research suggests that behavior therapy may be better than traditional psychotherapy in terms of decreasing suicidal behavior and anger, and improving social adjustment. Dialectical Behavioral Therapy is a relatively new psychotherapeutic approach with a growing evidence-base that has shown promise in treating borderline personality disorder. Outpatient settings utilized for these individuals include halfway houses, day treatment programs, night hospitals and other support groups.

Antipsychotics may help control anger, hostility, and brief psychotic episodes. Mood-stabilizing medications including lithium or anti-epileptic drugs may help with mood swings. Serotonergics and monoamine oxidase inhibitors (MAOIs) may help stabilize impulsive behavior and depressive symptoms. Benzodiazepines (anti-panic or anti-anxiety drugs) can help anxiety, but long-term use should be avoided due to addictive potential.

Source: Medical Disability Advisor



Prognosis

Without adequate treatment, borderline personality disorder may be life-long, and may even result in suicide. Outcome is better as long as treatment is initiated and maintained. In this scenario, psychotherapy and pharmacotherapy may allow the individual to maintain relationships.

Source: Medical Disability Advisor



Complications

The borderline personality tends to be in a constant state of turmoil. There appears to be a continual and intense quest for support, security, and love in relationships. Complications occur when there is separation from, perceived abandonment by, or disapproval from another person. The work setting may provide a forum for turmoil in relationships with supervisors and coworkers. Coexisting substance abuse, eating disorders, and promiscuity can all lead to complications in the course of the disorder. Other psychiatric disorders associated with the disorder will complicate the course, prognosis, and outcome. Suicidal gestures as well as completed suicide are the most serious complications. Injury to self or others can also occur.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

The borderline individual functions best in a disciplined environment with consistent support from coworkers and supervisors. These individuals become bored easily, and should avoid jobs requiring repetitious acts, such as working on an assembly line. Due to the irregularity in their sleep-wake cycle, frequent shift changes are to be avoided. Some flexibility in scheduling may be needed to accommodate ongoing therapy (which normally should occur during the employee's personal time).

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's behavior fit the criteria for borderline personality disorder?
  • Was diagnosis confirmed?
  • Were underlying medical conditions ruled out?
  • Was substance abuse ruled out?

Regarding treatment:

  • Can physician and therapist keep in mind that individual's behavior is caused by the disorder and not through a desire to be disruptive?
  • Has individual displayed any suicidal tendencies? Is physician/therapist aware of these?
  • Is this individual aware of what to do and who to contact when in crisis?
  • If individual has difficulty with daily functioning, would he or she benefit from a more structured in-house treatment program?
  • Because there is currently a controversy regarding appropriate use versus overuse of psychiatric medication, are antidepressant and anti-anxiety medications used appropriately and only during suitable times in treatment?
  • How long has individual been taking this medication? Is medication used in combination with psychotherapy?
  • Would individual benefit from a dialectical behavior therapy approach to better control life and emotions?
  • Is individual involved in a group therapy or support group that allows individual to share common experiences and feelings, expand coping skills, and develop new, healthier social relationships?

Regarding prognosis:

  • Was goal of therapy toward independent functioning, not complete restructuring of individual's personality?
  • Since treatment is likely to be lengthy, lasting at least a year, has therapist helped individual set realistic goals?

Source: Medical Disability Advisor



References

Cited

Bienenfeld, David. "Personality Disorders." eMedicine. Eds. Sarah C. Aronson, et al. 18 Aug. 2004. Medscape. 4 Oct. 2004 <http://emedicine.com/Med/topic3472.htm>.

First, Michael B., Lorna Smith Benjamin, and Janet B. William. Structured Clinical Interview for DSM-IV AXIS II Personality Disorders (SCID-II). 1st ed. 1 vols. Washington, DC: American Psychiatric Association, 1997.

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

Source: Medical Disability Advisor






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