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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.

Depersonalization / Derealization Disorder


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Medical Codes

ICD-9-CM:
300.6 - Depersonalization Disorder; Derealization (Neurotic); Neurotic State with Depersonalization Episode

Related Terms

  • Dissociation
  • Psychiatric Disorder
  • Psychological Trauma
  • Repressed Memory

Overview

Depersonalization / derealization disorder (DSM-5) (depersonalization disorder (DSM-IV-TR)) is included in the dissociative disorders (a sudden or gradual, transient or chronic disruption in the usually integrated functions of consciousness, memory, identity, or perception (DSM-IV-TR); a disruption of the normal integration of consciousness, identity, memory, perception, emotion, body representation, motor control, or behavior, and/or discontinuity in such integration (DSM-5)). Dissociative symptoms may disrupt all areas of psychological functioning (DSM-5).

Depersonalization disorder is characterized by persistent or recurrent episodes of feeling detached or removed from one's thoughts, feelings (mental processes), or body, with intact reality testing (the ability to differentiate between one's feelings and external reality) (DSM-IV-TR). The features of depersonalization/derealization disorder are clinically significant persistent or recurrent depersonalization (experiences of unreality or detachment from one's mind, self, or body) and/or derealization (experiences of unreality or detachment from one's surroundings); such alterations of experience coexist with intact reality testing. Evidence of a distinction between individuals with predominantly depersonalization versus derealization symptoms has not been found; hence, there may be depersonalization, derealization, or both (DSM-5). Individuals may feel as if they are watching themselves as outside observers, may experience themselves as being in a dream or a movie, or may feel like a robot not in charge of their own actions.

It is not a psychosis, in that the person only feels like a robot and does not believe that he or she actually is a robot. These individuals are aware that their experience is abnormal, unlike those with psychotic disorders. Depersonalization disorder causes marked distress to the individual and/or impaired social or occupational functioning.

Depersonalization/derealization disorder episodes vary in duration: brief (hours or days) or prolonged (weeks, months, or years) (DSM-5). Onset can be sudden if the person is in a life-threatening situation (DSM-IV-TR).

Experiences of depersonalization are quite common, usually provoked by severe stress, trauma, or traveling to a new place, but they are normally limited to a single episode. Depersonalization may coexist with major depression, hypochondriasis, substance-related disorders, or other mental disorders. Depersonalization disorder is diagnosed only when it is the individual's primary or only symptom.

Incidence and Prevalence: An episode of depersonalization is found in 50% of normal individuals at some time in their lives. An estimated 2.4% of the general population meets the diagnostic criteria for this depersonalization disorder, although this number is considered too high by many clinicians (Sharon). The symptom of depersonalization is found in up to 80% of psychiatric populations. Lifetime prevalence of depersonalization/derealization disorder both in US and internationally is about 2% (range, 0.8-2.8%). The disorder affects both sexes equally (DSM-5).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Depersonalization/derealization disorder begins at a mean age of 16 years; however, it may start in early or middle childhood. Onset occurs after age 20 in fewer than 20% of individuals and after age 25 in only 5%; onset in the fourth decade of life or later is exceptional (DSM-5).

This disorder is seen equally in men and women. Women with depersonalization tend to have feelings of displeasure (dysphoria), whereas men with depersonalization tend to be intellectually obsessive. As in obsessive-compulsive disorder, neurobiological studies have shown dysfunction in the left half (hemisphere) of the brain (DSM-IV-TR).

Source: Medical Disability Advisor



Diagnosis

History: Individuals with depersonalization disorder have persistent or recurrent experiences of feeling detached from their mental processes or bodies, as if they were outside observers of their mental processes or bodies (feeling as if they are in a dream); reality testing remains intact during the depersonalization experience.

Individuals with depersonalization/derealization disorder have persistent or recurrent experiences of depersonalization, derealization, or both; regarding depersonalization, individuals experience unreality, detachment, or being an outside observer of their thoughts, feelings, sensations, bodies, or actions (perceptual alterations, distortion of the sense of time, unreal or absent self, emotional and/or physical numbing); regarding derealization, individuals experience unreality or detachment from surroundings (individuals or objects are experienced as unreal, lifeless, foggy, dreamlike, or visually distorted). Reality testing remains intact during the depersonalization or derealization experiences. The symptoms produce clinically significant distress or impairment in social, occupational, or other areas of functioning. The disturbance can’t be accounted for the physiological effects of a substance (a drug of abuse or a medication) or another medical condition (DSM-IV-TR). Finally, the disturbance is not better explained by another mental (or dissociative) disorder (DSM-5).

The person with this disorder usually seeks treatment for some other symptom; however, anxiety and depression may be associated with this disorder, along with obsessive thinking or worries about bodily concerns. The person may find it difficult to describe the symptoms, either because it is hard to put into words or for fear of being considered crazy.

Physical exam: The exam does not contribute to this diagnosis, except for the appearance of a bland or flat emotional state (flat affect). Observation of the individual's orientation, dress, mannerisms, behavior, and content of speech provide essential signs to diagnose the illness.

Tests: This diagnosis is not established with specific tests, but an electroencephalogram (EEG) should be done to rule out temporal lobe seizures.

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

Specific, effective treatments have yet to be developed for depersonalization disorder. There is controversy regarding the efficacy of psychotherapy and/or medication. Some therapists believe that if depersonalization has clearly resulted from psychological trauma, then recovery of the unconscious traumatic memories and releasing the emotions surrounding them can be helpful. This might be done with hypnotherapy, since these individuals are good subjects for hypnosis. Some people benefit from knowing that depersonalization or derealization has happened to others, that they are not going crazy, and that they can survive it.

Selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines are thought by some to be helpful, but benzodiazepine use should be restricted to times of maximum distress. Stress management techniques may help reduce anxiety, and hence the need for escape from reality. However, meditation or other relaxation techniques are often contraindicated as they may contribute to further depersonalization. Anti-anxiety drugs and alcohol should usually be avoided. Self-instruction training, in which individuals attempt to change negative self-statements and replace them with coping self-statements, may help individuals deal with stressful situations to avoid an episode of depersonalization. Most authorities believe that, due to the current lack of empirically supported treatments, the most feasible intervention is to assist the patient in attaining some level of ease and constancy, away from distressing interactions.

Source: Medical Disability Advisor



Prognosis

Approximately half of individuals with depersonalization disorder have a chronic course, either continuous or with relapses in response to actual or perceived threats.

Source: Medical Disability Advisor



Differential Diagnosis

  • Anxiety disorders (DSM-5)
  • Direct physiological effects of a general medical condition
  • Illness anxiety disorder (DSM-5)
  • Major depressive disorder (DSM-5)
  • Mental disorders secondary to another medical condition (DSM-5)
  • Obsessive-compulsive disorder (DSM-5)
  • Psychotic disorders (DSM-5)
  • Substance- or medication-induced disorders (DSM-5)

Source: Medical Disability Advisor



Specialists

  • Clinical Psychologist
  • Psychiatrist

Source: Medical Disability Advisor



Comorbid Conditions

Source: Medical Disability Advisor



Complications

Drug or alcohol abuse could result from an attempt to self-medicate and relieve the underlying anxiety. The disorder may interfere with work and other activities, and cause problems in relationships with family and friends. Individuals may become forgetful and have difficulty staying focused on tasks.

Source: Medical Disability Advisor



Factors Influencing Duration

The frequency and severity of symptoms, exacerbating factors, and associated disorders influence length of disability.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

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

Risk: Individuals with recurrent brief episodes of depersonalization disorder may compromise the safety of coworkers and therefore should not be assigned job tasks that involve the use of power tools, heavy equipment, or vehicles. These individuals may be best suited to positions in which they are not responsible for the health, safety, or well-being of others.

Capacity: The presence of this condition in an adult who is already performing a job does not have an additional effect on capacity.

Tolerance: Tolerance varies from individual to individual but is typically not an issue with this diagnosis. Some individuals may benefit from the use of stress management techniques or self-instruction training to help them cope with distressing symptoms and enhance work productivity. For those who have these conditions continuously, the only issue is that stress can make the condition worsen temporarily. For those who have these conditions sporadically, stressors likely to cause an exacerbation should be identified and then avoided or mitigated. The provoking situation may be eliminated partially or fully, and/or the individual may learn techniques to cope with it.

Accommodations: Individuals with symptoms of detachment, distorted time sense, or apathy may require more supervision than individuals without the disorder. If medications are prescribed to control symptoms, the individual may require periodic drug testing to ensure that substance abuse or addiction does not become a concern.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is expected at 6 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 fit the criteria for depersonalization disorder or depersonalization/derealization disorder? Was diagnosis confirmed?
  • Are individual's depersonalization or depersonalization/derealization experiences a part of another mental disorder or a separate condition?
  • Were other mental disorders with similar symptoms ruled out?
  • Were physiological effects of a substance (abuse or medication) and general medical condition such as temporal lobe epilepsy ruled out as the cause of the symptoms?

Regarding treatment:

  • What type of treatment (psychodynamic psychotherapy, behavior therapy, SSRIs, benzodiazepines) did individual receive?
  • What additional therapy options might now be warranted?
  • Would hypnosis be beneficial in recovering unconscious traumatic memories and releasing the emotions surrounding them?
  • Since stressors associated with the onset of the depersonalization episodes must be addressed, were these stressors identified? How are they being managed?

Regarding prognosis:

  • Is individual making any appreciable, even if gradual, progress?
  • Have exacerbations occurred with actual or perceived stressful events?
  • What progress was made to identify and relieve these stressors?

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.

Sharon, Idan, et al. "Depersonalization Disorders." eMedicine. 27 Mar. 2014. Medscape. 20 Apr. 2015 <http://emedicine.medscape.com/article/294508-overview#aw2aab6b5>.

Source: Medical Disability Advisor