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.

Dissociative Identity Disorder


Medical Codes

ICD-9-CM:
300.14 - Multiple Personality Disorder; Dissociative Identity Disorder
300.15 - Dissociative Disorder or Reaction, Unspecified

Related Terms

  • Dissociative Personality Disorder
  • MPD
  • Multiple Personality Disorder

Overview

Dissociative identity disorder was formerly known as multiple personality disorder (DSM-IV-TR). An individual with this disorder exhibits two or more distinct personality states or identities (sometimes called alters, or alter identities), each appearing at different times and governing the individual's behavior at that time. It is a serious, chronic, and potentially disabling or fatal condition, due to the risk of self-injury or suicide.

Each alternate personality state or identity has its own characteristic way of thinking, feeling, and perceiving. Each may have a different name, mannerisms, speech, mood, social preferences, age, race, habits, and memories. Each personality state determines the individual's behavior and attitudes while it is dominant. One personality state may appear normal, another hostile and aggressive, and yet another shy and withdrawn. Each identity is usually unaware of events that occurred when another identity was in charge. One personality state, however, may have full knowledge of all the others. The other personality states may only have a sense of another individual, with a directing voice, coming from inside and taking control of them. The average number of personality states is between five and ten, but there may be as few as two or as many as a hundred. About 50% of cases report 10 or fewer identities (DSM-IV-TR).

Frequent memory gaps in personal history (dissociation) are prominent features of dissociative personality disorder. Dissociation is a psychological defense mechanism in which the individual's identity, memories, ideas, feelings, or perceptions are separated from conscious awareness and can't be remembered or experienced voluntarily. The fragmentation or splitting into multiple identities may be to protect the individual from memories of unbearably painful events such as incest or physical abuse.

Substance abuse, significant stress, or pain (headache) can trigger a shift among identities. This shift may occur in a matter of seconds or more gradually over hours or days. Sudden frightening memories (flashbacks) can intrude on any of the identities.

Some authorities believe that dissociative identity disorder is over-diagnosed, and a number of experts even question its existence. Part of the skepticism is based upon semantics, as by definition, an individual can have only one personality, however many facets or personae may be demonstrated.

Incidence and Prevalence: The 12-month prevalence of dissociative identity disorder among adults has been reported as 1.5% and the prevalence across genders as 1.6% for males and 1.4% for females (DSM-5).

Source: Medical Disability Advisor



Diagnosis

History: According to DSM-IV-TR criteria for this disorder, there must be two or more distinct identities or personality states (each with a relatively consistent pattern of perceiving, relating to, and thinking about the environment and self) that periodically take control of the individual's behavior. Memory gaps (amnesia) regarding important life events are too extensive to result from ordinary forgetfulness. In order to be diagnosed as dissociative personality disorder, the disturbance cannot be due to the direct physiological effects of a substance such as alcohol or a general medical condition such as a seizure disorder (DSM-IV-TR).

According to DSM-5 criteria for this disorder, there must be a disruption of identity characterized by two or more distinct personality states (in some cultures this may be described as an instance of possession). The disruption in identity entails marked discontinuity in sense of self (sense of self means that the individual knows who he or she is and that he or she is comfortable with himself/herself; sense of self provides the answer to the question "Who am I?") and sense of agency (the sense of personal ownership or control), with related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. The signs and symptoms may be observed by others or reported by the individual. There are recurrent memory gaps (amnesia) regarding everyday events, important personal information, and/or traumatic events that are too extensive to result from ordinary forgetfulness. The symptoms create clinically significant distress or impairment in social, occupational, or other areas of functioning. The disturbance is not an ordinary part of a commonly accepted cultural or religious practice. In order to be diagnosed as dissociative personality disorder, the disturbance cannot be due to the direct physiological effects of a substance such as alcohol or a general medical condition such as a seizure disorder (DSM-5).

The individual may refer to himself or herself as "him," "her," "we," or "us." The history may also reveal three or more previous psychiatric diagnoses with poor response to treatment. Various symptoms that may appear at different times include severe headaches, various types of physical pain, time distortions, and time lapses. Ability to function fluctuates from independence at work and home to disability. The individual may report feeling detached from self (depersonalization) or experience the surroundings as being unreal (derealization).

Physical exam: A dramatic change in appearance, mood, and behavior may occur when a particular personality is inquired about during a therapy session. Frequently, eye blinking and staring announce the transition from one personality to another. Physical signs of self-injury or physical abuse may also be present.

Tests: Although tests are not generally useful in making this diagnosis, an electroencephalogram (EEG) may be done to check for complex partial seizures that can mimic the loss of memory seen with dissociation. Relevant laboratory and/or imaging studies may be performed to confirm suspected abuse. Standardized tests can provide additional information critical to both diagnosis and adequate treatment planning. Such screening tools include the Dissociative Experience Scale, Dissociation Questionnaire, Questionnaire of Experiences of Dissociation, and informal office interviews.

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 and group psychotherapy are used to treat this complex and chronic disorder. Therapy may be frequent and intense, sometimes including two or more weekly psychotherapy sessions over several years, followed by periodic relapse prevention visits thereafter. Hypnosis has been used to access the different personalities and retrieve memories. However, in many ways, hypnosis itself is a dissociative condition. Some sources are concerned that hypnosis and searching for this disorder can actually produce it. Group therapy and group-format 12-step work may be helpful. Identifying triggers and developing a crisis management plan are common treatment goals. Drug therapy can treat symptoms of anxiety or depression when present in a specific personality state, but do not relieve dissociation as such. Treatment is often emotionally painful as previous crises are remembered and reprehensible actions committed on and/or carried out by one or more of the personality states come to light. Psychiatric hospitalization may be needed to help the individual deal with this emotional trauma.

Source: Medical Disability Advisor



Prognosis

Dissociative identity disorder is a severe, chronic disorder that rarely resolves spontaneously. Individuals that receive early treatment have the greatest possibility of full recovery. Psychotherapy is usually needed long-term, with occasional hospitalizations for disruptive behavior or severe symptoms. Although a return to steady employment is possible, it is more difficult in those whose symptoms remain significant. Suicide is a risk in the disorder.

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Clinical Psychologist
  • Psychiatrist

Source: Medical Disability Advisor



Comorbid Conditions

  • Alcohol or substance abuse disorders
  • Anxiety disorders
  • Conversion disorder (functional neurological symptom disorder) (DSM-5)
  • Depressive disorders
  • Eating disorders
  • Headaches
  • Illness anxiety disorder (DSM-5)
  • Obsessive-compulsive disorder
  • Personality disorders (especially avoidant and borderline personality disorders) (DSM-5)
  • Posttraumatic stress disorder (PTSD) (DSM-5)
  • Sexual dysfunction
  • Sleep disorders (DSM-5)
  • Trauma- and stressor-related disorders (DSM-5)

Source: Medical Disability Advisor



Complications

A depressive disorder or substance abuse can complicate this condition. One of the personalities may commit a crime or an act of violence either against another individual or as self-mutilation. Complications such as prostitution and antisocial outbursts and actions have also been reported. Impulsive behavior can lead to loss of important relationships and employment. Individuals with dissociative personality disorder may frequently attempt suicide and are thought to be more likely to commit suicide than individuals with any other psychiatric disorder.

Improper treatment can increase symptoms and impairment by reinforcing the disorder. The ability to remain neutral and maintain proper boundaries is crucial in the therapeutic relationship.

Source: Medical Disability Advisor



Factors Influencing Duration

Length of disability may be influenced by the degree of personality fragmentation; the presence of disruptive, aggressive, or self-destructive behavior; the individual's response to treatment; and whether the individual remains involved with perpetrators of earlier abuse. Comorbid conditions may contribute to disability, which may be significant in some cases.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

The work schedule may need to incorporate flex time, part-time, or job-sharing positions, as well as a break time according to individual's needs rather than according to a fixed schedule. 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 enable the worker to remain at the workplace without a work disruption or to promote timely and safe transition back to full work productivity.

Risk: Individuals with dissociative identity disorder who exhibit hostile and/or aggressive personality traits, recurrent amnesia, time distortions, and severe depersonalization or derealization may compromise their own safety and/or that of coworkers and should not be placed in positions of responsibility. Those with suicidal tendencies may require more supervision than is usual for the job tasks at hand.

Capacity: The presence of dissociative identity disorder may have an effect on the individual’s job performance, depending on which personalities are being expressed throughout the work day. Capacity may be influenced by the frequency and severity of aggressive outbursts on the job site, and productivity may be affected by the individual’s need to engage in intensive psychotherapy sessions and/or periods of psychiatric hospitalization.

Tolerance: Tolerance varies with this diagnosis according to the number of personalities being expressed, the frequency of personality changes, and the degree of emotional distress experienced.

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 meet the criteria for dissociative personality disorder?
  • Was there a history of childhood trauma, particularly with continued and repeated sexual and/or physical abuse beginning in early childhood?
  • Are there distinct personality states that have the capacity to take control of the body, each with its own unique behavior patterns and social relationships?
  • Does disruption in identity entail marked discontinuity in sense of self and sense of agency, with related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning?
  • Is individual's inability to recall personal information too great to be explained by ordinary forgetfulness?
  • Has the diagnosis been confirmed? On what basis?
  • What procedures were used to diagnose the individual?
  • Is there a history of earlier psychiatric diagnoses? Was individual previously misdiagnosed?
  • Has substance abuse and/or the presence of underlying medical conditions been ruled out?

Regarding treatment:

  • Does therapist have sufficient skills and knowledge to address the challenges faced by those with this diagnosis?
  • Has psychotherapy been effective in integrating the fragmented personality states into one personality?
  • Would individual benefit from in-patient therapy during the difficult time it takes to come to grips with particularly painful memories?
  • If anxiety or depression is present in a specific personality, would individual benefit from drug therapy?
  • If individual has been involved in therapy for several months, and the therapy has not been effective or individual has worsened, should a consultation with an independent colleague or referral to another therapist be considered?

Regarding prognosis:

  • What progress has been made toward integration of the separate identities?
  • If individual is still involved with an alleged abuser, is treatment aimed at reducing symptoms rather than achieving integration?
  • If individual is still deeply involved with an alleged abuser, what is being done to dissolve alliance or promote a more healthful relationship?
  • Is individual aware of the risk of renewed dissociation if he or she does not practice or is not capable of following through with newfound defenses and coping mechanisms?

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