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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.

Borderline Personality Disorder


Text Only Home | Graphic-Rich Site | Overview | Risk and Causation | Diagnosis | Treatment | Prognosis | Differential Diagnosis | Specialists | Comorbid Conditions | Complications | Factors Influencing Duration | Length of Disability | Ability to Work | Maximum Medical Improvement | Failure to Recover | Medical Codes | References

Medical Codes

ICD-9-CM:
301.83 - Borderline Personality Disorder

Related Terms

  • Borderline Disorder
  • Borderline Personality
  • Borderline Syndrome
  • BPD
  • Multiple Complex Developmental 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. The shifts in mood may be severe enough to suggest the presence of cyclothymic disorder (which, in some cases, may also be present). 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, and then to excitement or euphoria. In addition to their vacillating and unstable mood, they also seem to experience chronic anxiety.

Individuals with borderline personality disorder 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 individuals with borderline personality disorder, 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 ("splitting"). Identity disturbances are common, as they are uncertain about who they are and where they are headed in life.

Incidence and Prevalence: The estimated median population prevalence is 1.6%but may be as high as 5.9%. The prevalence is approximately 6% among those in primary care settings, 10% in individuals treated in outpatient mental health clinics, and 20% among psychiatric inpatients. The prevalence may decrease with age (DSM-5).

Source: Medical Disability Advisor



Causation and Known Risk Factors

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) indicates that borderline personality disorder is 5 times more 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, antisocial personality disorder, bipolar disorder, alcohol use disorders, and substance abuse. Borderline personality disorder is diagnosed more frequently in women, who comprise about 75% of those with the disorder, than in men (DSM-5).

Source: Medical Disability Advisor



Diagnosis

History: Psychiatric interview and mental status exam are the primary methods of diagnosis. According to both the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) and the DSM-5, 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 5 of the following 9 criteria: frantic efforts to avoid abandonment (either real or imagined), 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 ideation or severe feelings of being detached from reality (dissociative symptoms) (DSM-IV-TR, DSM-5).

In the DSM-5 diagnostic criteria, a moderate or greater impairment of personality functioning in two or more of the following four areas is required: identity, self-direction, empathy, and/or intimacy. In addition, 4 or more of the 7 pathological personality traits must be present and at least one of those must either be impulsivity, risk taking, or hostility. The other 4 of the 7 pathological personality traits are manifestations of negative affectivity and include emotional lability, anxiousness, separation insecurity, and depressivity.

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.

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.

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

The primary treatment for borderline personality disorder is psychotherapy. Because these individuals tend to form intense love-hate relationships, they may first cast therapists as idealized rescuers, and then despise them as villains when things go wrong (“splitting”). Therapists must avoid this struggle, and must be aware that individuals with borderline personality disorder tend to pit different caregivers (and all other important people in their lives) against each other. At the same time, therapists must tolerate episodic angry outbursts to demonstrate that these individuals 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 individuals 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 individual 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, but longer intervals between sessions may also be useful. 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 behavior 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; some authorities think that these drugs are contraindicated because they reduce inhibitions and hence are likely to increase impulsivity.

Source: Medical Disability Advisor



Prognosis

Even with adequate treatment, borderline personality disorder may be lifelong, and may even result in suicide. The 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



Differential Diagnosis

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

Source: Medical Disability Advisor



Specialists

  • Clinical Psychologist
  • Psychiatrist

Source: Medical Disability Advisor



Comorbid Conditions

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



Factors Influencing Duration

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

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals with borderline personality disorder function 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).

Risk: Individuals with borderline personality disorder may be more prone to making mistakes at work that can compromise the safety of coworkers and themselves, especially if impulsive, angry, and/or suicidal behavior is present. Job duties that involve driving or the operation of heavy machinery should be avoided.

Capacity: Capacity is typically unaffected by borderline personality disorder as long as risk factors concerning safety are adequately addressed. Individuals taking medications to control their symptoms may require periodic drug testing to ensure that substance abuse or addiction is not a concern.

Tolerance: Tolerance is not an issue with this diagnosis.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is expected at 12 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'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 them?
  • 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 medications, 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 him or her to share common experiences and feelings, expand coping skills, and develop new, healthier social relationships?

Regarding prognosis:

  • Was goal of therapy to move 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

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.

Source: Medical Disability Advisor