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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.

Conversion 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 | Failure to Recover | Medical Codes | References

Medical Codes

ICD-9-CM:
300.11 - Conversion Disorder; Astasia-abasia, Hysterical; Conversion Hysteria or Reaction; Hysterical: Blindness, Deafness, Paralysis

Related Terms

  • Briquet's Syndrome
  • Hysteria
  • Hysterical Blindness
  • Hysterical Deafness
  • Hysterical Paralysis

Overview

Conversion disorder is a condition that presents as an impairment or loss of a physical function suggestive of a physical disorder but is actually the expression of an underlying psychological conflict or need. The symptom(s) are not under voluntary control. Unexplainable physical symptoms seen in conversion disorder may include a disturbance of sensation, muscle strength, seizures, involuntary movement, or some combination of these. Psychodynamic theory proposes that these symptoms develop in the presence of unconscious psychological conflict and stress, which in turn is expressed ("converted") in the form of a physical ailment. The physical symptom is thought to reduce anxiety by preventing conscious recognition of the frightening underlying psychological conflict. This is the primary gain from the symptoms.

The individual may also benefit from the symptoms in other ways (secondary gain) such as gaining attention or support from family and friends, a reward of some kind, or avoidance of unwanted responsibilities. Although most individuals appear unconcerned emotionally about their illness and are unaware of any psychological conflicts, some experience anguish over their new symptoms. The symptoms are not intentionally or consciously faked but there is no known medical condition to account for the findings. Instead of corresponding to any known anatomic or neurological patterns typical of illness having a physical basis, the symptoms may instead correspond to the individual's concept of a disease.

Conversion disorder is diagnosed only after a thorough medical examination fails to find a physical explanation for the symptoms. Some diseases take years for diagnosis so conversion disorder should be considered a tentative, working diagnosis. Even when a known disease is present, conversion disorder can still exist if the symptoms cannot be explained by the medical illness. Up to two-thirds of those with conversion disorder also have a neurological condition.

The symptoms of a conversion disorder are not drug-related or part of a culturally approved ritual or behavior. Conversion disorder is not diagnosed if symptoms are limited to pain or sexual dysfunction. These have separate diagnoses.

Incidence and Prevalence: The prevalence of conversion disorder varies widely ranging from 1 to 30 per 10,000 individuals.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Predisposing causes include prior physical disorders, exposure to people with real physical symptoms, and severe psychosocial stressors. Onset is usually between ages 10 and 35. It is more frequent in women (anywhere from 2 to 10 times more prevalent than in men), and in rural settings, lower socioeconomic groups, and military personnel exposed to combat. Studies indicate that conversion disorder may be found in between 1% to 14% of general medical and surgical inpatients (DSM-IV-TR).

Source: Medical Disability Advisor



Diagnosis

History: Individual has history of a sensory disturbance (i.e., numbness, double vision, blindness, deafness, or hallucinations), muscle disturbance (localized weakness or paralysis, incoordination, difficulty swallowing, or a "lump in the throat"), convulsions (seizures), or some combination of these. The disturbance closely follows a major psychological stress or conflict but the symptoms are not faked or intentionally produced. Symptoms cannot be fully explained by a general medical condition, the direct effects of a drug or other substance such as alcohol, or as a culturally typical behavior or experience. Significant distress, alteration in interpersonal relationships, or decrease in occupational functioning must be present. The symptoms are not limited to pain or sexual dysfunction and are not better explained by another mental disorder.

Physical exam: The exam shows findings inconsistent with medical knowledge. Numbness is often in a pattern resembling a glove or stocking, not the pattern of the known nerve supply. A paralyzed body part may not perform according to known nerve and muscle anatomy. Muscle strength may be normal in muscles opposite the "paralyzed" ones and reflexes are normal. Various specialized examination maneuvers can help the doctor differentiate complaints related to physical causes from those that are conversion symptoms; e.g., in hysterical blindness, nystagmus is observed when the individual is confronted with a moving painted cylinder (optokinetic nystagmus), confirming that from a physiologic standpoint, the visual pathways are intact.

Tests: Neurological tests are normal. Electromyogram (EMG) and nerve conduction velocity testing are normal in "paralyzed" muscles. Somatosensory evoked potential testing is normal in limbs with no sensation. Electroencephalogram (EEG) is normal in conversion seizures. Psychological tests such as the Minnesota Multiphasic Personality Inventory - 2 (MMPI-2) may show a profile characteristic of conversion disorder.

Source: Medical Disability Advisor



Treatment

Psychotherapy, based on a psychodynamic theory, is thought to be helpful by resolving the intrapsychic conflict manifested in the conversion symptom. As an alternative, non-challenging application of cognitive-behavioral therapy may be more effective - the goals being to unlearn maladaptive responses and to learn more appropriate responses to stressors. Because individuals may be resistant to the idea that symptoms are the result of a psychological problem, therapy of any type is usually couched in terms of stress reduction and coping skills for a chronic illness. Therapy should avoid reinforcing the sick role as a solution to the problem. Hypnotherapy can be useful. Drug therapy is used only if there is a coexisting anxiety or depressive disorder. Treatment of a comorbid anxiety or depressive disorder with psychotherapy and / or pharmacotherapy may lead to substantial improvement in the conversion disorder. The drugs amobarbital or midazolam may be used as part of a hypnosedative interview in treatment resistant cases. As physically based (organic) illness and conversion disorder may coexist, all individuals with conversion symptoms should be treated as if they have an organic illness.

Source: Medical Disability Advisor



Prognosis

Recovery rates range from 15% to 74%. Conversion symptoms are generally self-limited and may resolve within 2 weeks if hospitalization is part of the treatment. While psychotherapy may lead to dramatic recovery in some individuals, recurrence of symptoms is seen in one-fourth of individuals within 1 year of the first episode. Factors associated with good outcome include being male, sudden onset of symptoms, occurrence of symptoms following a stressful event, good health before appearance of conversion symptoms, and lack of accompanying physical or psychiatric disorder. Symptoms of paralysis and blindness have a good prognosis while seizures and tremor have a worse outlook. The longer the individual has been in the sick role and regressed, the more difficult treatment can be. If the individual has other psychopathology or a chaotic social situation, disability can be prolonged. A documented neurological disease may also determine disability.

Source: Medical Disability Advisor



Differential Diagnosis

  • Amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease)
  • Brain stem tumor
  • Dissociative disorder
  • Dystonias
  • Early stages of AIDS
  • Hypochondriasis
  • Major depression
  • Malingering
  • Multiple sclerosis
  • Myasthenia gravis
  • Optic neuritis
  • Other schizophrenia subtypes
  • Pain disorders
  • Periodic paralysis
  • Post-traumatic stress disorder (PTSD)
  • Schizophrenia, catatonic type
  • Somatization disorder
  • Vocal cord paralysis

Source: Medical Disability Advisor



Specialists

  • Clinical Psychologist
  • Internal Medicine Physician
  • Neurologist
  • Psychiatrist

Source: Medical Disability Advisor



Comorbid Conditions

  • Alcohol or substance abuse disorders
  • Bipolar disorder
  • Personality disorder
  • Somatization disorder

Source: Medical Disability Advisor



Complications

Loss of muscle tone or bulk related to not using the affected limb is a rare complication. Individuals may hurt themselves when falling, convulsing, or as a result of "blindness." Conversion disorder may lead to a vicious cycle in which "sick" behavior is reinforced through increased attention, avoidance of responsibility, or other secondary gain. This in turn may lead to worsening of conversion symptoms or development of new ones.

Source: Medical Disability Advisor



Factors Influencing Duration

Factors that may influence the length of disability include acute onset of symptoms and prompt treatment.

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.

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:

  • Has an extensive medical examination ruled out any underlying medical explanation or other cause of the symptoms?
  • Was clinically significant distress or impairment in social, occupational, or other important areas of functioning evident or reported by the individual?
  • Was diagnosis of conversion disorder confirmed?

Regarding treatment:

  • Because a trusting relationship with the physician is essential to treatment, has individual established a good doctor-patient relationship? If not, what can be done to build or restore this relationship?
  • If anxiety or depressive disorders are present, are these disorders being effectively addressed with drug therapy?
  • If individual is resistant to the idea that symptoms are a result of a psychological problem, would individual be more accepting if behavioral therapy was presented as stress reduction or coping skills for a chronic illness?
  • Would individual benefit from a group therapy environment where social support and interaction are used to reduce anxiety?

Regarding prognosis:

  • Since a strong positive correlation exists between duration of conversion symptoms and the time required to resolve them, what was the interval between onset of symptoms and start of treatment?
  • Has the individual experienced any recurrences that may predict future episodes?

Source: Medical Disability Advisor



References

Cited

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