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.

Delusional Disorder


Related Terms

  • Capgras' Syndrome
  • Delusions of Misidentification or Impersonation
  • Folie a Deux
  • Late-onset Paraphrenia
  • Paranoid States
  • Paraphrenia

Differential Diagnosis

Specialists

  • Clinical Psychologist
  • Psychiatrist

Comorbid Conditions

  • Alcohol or substance abuse disorders
  • Body dysmorphic disorder
  • Mood disorders
  • Post-traumatic stress disorder, chronic
  • Psychotic disorders

Factors Influencing Duration

Disability depends on the degree and nature of reality distortion and whether it interferes with work. The intensity of emotional disturbance (fear and hostility) also influences disability. Disability is variable for this general category of mental disturbances.

Medical Codes

ICD-9-CM:
297.1 - Delusional Disorder; Chronic Paranoid Psychosis; Sanders Disease; Systematized Delusions

Overview

In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), delusional disorder is included in the section schizophrenia and other psychotic disorders, together with schizophrenia, schizophreniform disorder, schizoaffective disorder, brief psychotic disorder, shared psychotic disorder, psychotic disorder due to a general medical condition, substance-induced psychotic disorder, and psychotic disorder not otherwise specified (DSM-IV-TR).

In the DSM-5, delusional disorder is included in the section schizophrenia spectrum and other psychotic disorders, together with schizophrenia, schizotypal (personality) disorder, schizophreniform disorder, brief psychotic disorder, psychotic disorder due to another medical condition, substance/medication-induced psychotic disorder, catatonia associated with another mental disorder, catatonic disorder due to another medical condition, unspecified catatonia, other specified schizophrenia spectrum and other psychotic disorder, unspecified schizophrenia spectrum and other psychotic disorder (DSM-5).

Delusional disorder is an uncommon psychiatric condition characterized by the presence of one or more persistent delusions or false beliefs that usually involve a misinterpretation of perceptions or experiences. At face value, these delusions often seem entirely believable (nonbizarre) as they focus on experiences that could conceivably occur in real life. One (or more) delusions must have been present for a duration of 1 month or longer.

Delusional disorders are divided into different types depending on the predominant delusion such as being followed (persecutory type), having a disease (somatic type), being loved at a distance (erotomanic type), having an unfaithful sexual partner (jealous type), or having inflated worth, power, identity, or knowledge (grandiose type) or mixed and/or unspecified type. Individuals are usually unaware of the psychiatric nature of the condition and may seek out internists, lawyers, or the police rather than psychiatrists or psychologists. Delusional episodes have no known cause. Delusions of persecution (paranoid states) may be acute and short-lived or persistent as they develop into an elaborate system of fixed beliefs.

Incidence and Prevalence: Estimates of the lifetime prevalence of delusional disorder place it at about 0.2%; the most common subtype is persecutory (DSM-5). The condition may be more common since the delusions can remain undetected for years and are manifested only in nonmedical situations.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Research evidence is conflicting, but some studies suggest that delusional disorder is more common among individuals who have a first-degree relative diagnosed with schizophrenia (DSM-IV-TR). Age at onset of symptoms is usually middle or late adulthood. Delusional disorder is more likely to be found among the married, employed, recent immigrants, and those with low socioeconomic status (Bourgeois).

Source: Medical Disability Advisor



Diagnosis

History: According to the DSM-IV-TR, individuals with delusional disorder have nonbizarre delusions (being followed, poisoned, infected, loved at a distance, deceived by spouse or lover, or having a disease) during at least 1 month; never have had 2 (or more) of the following for a significant portion of time during a month (or less if successfully treated): delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (affective flattening, alogia, or avolition—the main criterion for schizophrenia); apart from the impact of the delusion(s) or its ramifications, there is no marked impairment of functioning and there is no obviously odd or bizarre behavior; if mood episodes have coexisted with delusions, they have been brief compared with the duration of the delusional periods; and the disorder is not due to the physiological effects of a substance (a drug of abuse or a medication) or a medical disease. It is necessary to specify the type: erotomanic, grandiose, jealous, persecutory, somatic, mixed or unspecified (DSM-IV-TR).

According to the DSM-5, individuals with delusional disorder have 1 or more delusions present for at least 1 month; never have had 2 (or more) of the following for a significant portion of time during a month (or less if successfully treated): hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (affective flattening, alogia, or avolition—the main criterion for schizophrenia); apart from the impact of the delusion(s) or its ramifications, there is no marked impairment of functioning and there is no obviously odd or bizarre behavior; if manic or major depressive episodes have occurred, they have been brief compared with the duration of the delusional periods; and the disorder is not due to the physiological effects of a substance or another medical disease and is not better accounted for by another mental disorder. It is necessary to specify the type: erotomanic, grandiose, jealous, persecutory, somatic, mixed or unspecified. Also, it is necessary to specify if the delusions have bizarre content; if this is the first episode or if there have been multiple episodes (currently in acute phase, in partial remission, or in full remission); if the disorder is continuous; and if the disorder is unspecified. Finally, it is recommended to specify the current severity (DSM-5).
History of the disorder centers around fixed beliefs that the individual holds to be true. Persecutory or paranoid delusions involve the belief that others are conspiring against and persecuting the individual. Delusions of grandeur (grandiose delusions) involve the belief that the individual possesses extraordinary powers or talents. Associated symptoms may be more readily disclosed by the family rather than the individual and include anger, irritability, suspiciousness, grandiose behavior or gestures, lack of humor, and extreme level of alertness and always being on guard (hypervigilance).

Individuals may have extreme sensitivity to criticism or setbacks (hypersensitivity), obstinate behavior, and resentfulness. The individual may act defensively, seem guarded or hostile, pay extreme attention to details, file frequent legal complaints, or be reclusive, secretive, excessively critical, self-righteous, aggressive, or violent. If hallucinations occur, are related to the delusional theme and are not prominent. The individual may hear voices that comment on his or her behavior, converse with one another, or make critical and abusive comments (auditory hallucinations). Hallucinations of sight, smell, taste, or touch may also occur, although auditory hallucinations are by far the most common.

Physical exam: The exam does not contribute significantly to this diagnosis, although observation of the individual's orientation, dress, mannerisms, behavior, and content of speech may help diagnose the condition.

Tests: Screening for drugs of abuse is crucial. Other routine laboratory tests as well as electroencephalogram (EEG) and brain imaging (computed tomography [CT] scan or MRI) often help to reveal the presence of organic pathology contributing to paranoid delusions. Assessment of intelligence through IQ testing may show discrepancies between verbal and performance scores as well as scatter in overall performance, suggesting the need for further assessment of medical disorders.

Psychological testing does not establish the diagnosis but may be recommended by the attending psychiatrist or psychologist to obtain more information about the delusions or associated symptoms. For example, the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) or other personality testing may reveal paranoid or grandiose beliefs or somatic concerns related to physical health. Neuropsychological assessment may help make known evidence of impaired cognitive functioning and suggest brain irregularities.

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

Individual psychotherapy may be helpful but is extremely difficult since the individual's distrust and lack of acceptance that they are mentally ill usually prevents contact with a therapist. Even if they do seek help, their fixed beliefs are resistant to therapy. Initially, it is more helpful to focus on associated depression or anxiety. With time, the therapist may gently challenge the beliefs by pointing out how they interfere with the individual's life. Therapy should be supportive and problem-oriented rather than insight-oriented because the individual's suspiciousness and hypersensitivity may lead to misinterpretation. Psychotherapy creates a therapeutic alliance that may permit patients with delusional disorder to manage whatever stressors and concerns play a part in the delusional experience. Group therapy is not recommended due to the individual's mistrust.

Medications are used, but the data concerning their effectiveness is limited. Antipsychotic medication is recommended if individual has active psychosis, anxiety, agitation, or severe impairment. The antipsychotic medication pimozide has been linked to partial or full recovery in some people with the disorder. As individuals are usually suspicious of medication and neglect to take it, long-lasting injections may be preferable to taking medications by mouth. Regular medication management sessions are often necessary in case the individual has side effects or no improvement in symptoms. Electroconvulsive therapy has been tried but is not recommended. Hospitalization may be recommended in circumstances in which the patient has become unsafe to others or self-destructive.

However, the data supporting the success of any type of treatment, psychological, pharmacological, or other somatic treatments is scant.

Source: Medical Disability Advisor



Prognosis

Outcome is variable. Individuals with this disorder are frequently loyal, hard-working employees who require flexible and tolerant managers. Fixed beliefs may interfere with good judgment and lead to problems at work, in financial affairs, or within personal relationships. However, the success of treatment of the disorder has been very limited.

Source: Medical Disability Advisor



Complications

Violence to self or others could occur if the individual's delusions are of a persecutory or homicidal nature. Delusions seen in this disorder may overlap with mood disorders or schizophrenia.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work accommodations might include the use of a job coach to establish consistent, predictable work behaviors; the development of a structured, consistent set of work activities; limiting contact with coworkers and the public; and flexibility in schedule to accommodate medical or psychiatric appointments.

Risk: Recurrence is dependent on management of risk factors such as the degree of interpersonal contact and the potential for non-constructive criticism from managers and coworkers. Individuals with aggressive, violent, or hostile behavior may present a safety risk to coworkers and themselves.

Capacity: Because individuals with delusional disorder usually have no marked impairment of functioning, capacity is typically unaffected. Individuals taking prescribed antipsychotic medications to control associated symptoms of anxiety or depression may require periodic drug testing.

Tolerance: Tolerance factors include whether the individual is compliant with medications for severe impairment, and with progressive psychological treatment. In many cases, involvement with activities in protected work environments is beneficial.

Accommodations: Accommodations should be made on a case-by-case basis.

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 have one or more persistent delusions or false beliefs that usually involve a misinterpretation of perceptions or experiences?
  • Does individual fit criteria set forth by the DSM-IV-TR or the DSM-5?
  • What specific type of delusion disorder does individual have? Persecutory, somatic, erotomanic, jealous, or grandiose?
  • Since other disorders may present with symptoms and features typical of delusional disorder, is there an overlap with another psychological condition such as paranoid personality disorder, schizophrenia, mood disorder with psychotic features, substance-induced psychotic disorder, body dysmorphic disorder, and obsessive-compulsive disorder?
  • Was diagnosis of delusional disorder confirmed?

Regarding treatment:

  • What treatment modalities or types of therapy have been used so far? If not effective, what else is being considered?
  • Would a treatment combination be more beneficial?
  • If individual has active psychosis, anxiety, agitation, or severe impairment, were antipsychotic drugs used?
  • If individual is suspicious of medication and neglects to take it, are long-lasting injections an option?
  • Is individual compliant with regular medication management sessions? What can be done to enhance compliance?
  • If individual's delusions are of a persecutory or homicidal nature, is the physician aware of this progression?
  • Has physician assessed the extent to which individual is willing to act on delusions?
  • Was individual hospitalized or is hospitalization being considered until individual is no longer a threat to self or others?

Regarding prognosis:

  • Although delusional disorders do not generally lead to severe impairment or changes in personality, where on this continuum does individual appear to be? Is individual remaining static or progressing to an unhealthy level?
  • Does individual have an underlying condition such as mood disorders, chronic post-traumatic stress disorder, alcohol or other substance abuse, body dysmorphic disorder, suicidal tendencies, or schizophrenia that may be complicating treatment or impacting recovery?

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.

Bourgeois, James A. "Delusional Disorder." eMedicine. 3 Jun. 2013. Medscape. 20 Apr. 2015 <http://emedicine.medscape.com/article/292991-overview#showall>.

Source: Medical Disability Advisor






Feedback
Send us comments, suggestions, corrections, or anything you would like us to hear. If you are not logged in, you must include your email address, in order for us to respond. We cannot, unfortunately, respond to every comment. If you are seeking medical advice, please contact your physician. Thank you!
Send this comment to:
Sales Customer Support Content Development
 
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is published with the understanding that the author, editors, and publisher are not engaged in rendering medical, legal, accounting or other professional service. If medical, legal, or other expert assistance is required, the service of a competent professional should be sought. We are unable to respond to requests for advice. Any Sales inquiries should include an email address or other means of communication.