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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.

Dissociative Identity 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:
300.14 - 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. 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.

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 527). Females with this disorder average 15 separate identities, while males report 8 on average.

Frequent memory gaps in personal history (dissociation) are prominent features of dissociative personality disorder. Dissociation is a psychological defense mechanism where 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 suddenly 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, while 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: Dissociative identity disorder can be found in 3% to 4% of individuals hospitalized for other psychiatric problems. It is found in 1% to 3% of the general population (Sharon).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Dissociative identity disorder is usually diagnosed around age 30 with symptoms often present for 6 or 7 years before diagnosis. It is 3 to 10 times more frequent in women than men. Some research suggests that the disorder is more prevalent among first-degree biological relatives (DSM-IV-TR 528).

Source: Medical Disability Advisor



Diagnosis

History: According to DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision) criteria for this disorder, there must be two or more distinct identities or personalities 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 physical effects of a substance such as alcohol intoxication or a general medical condition such as a seizure disorder.

There is nearly always a childhood history of severe physical, emotional, or sexual abuse. The individual may refer to himself or herself as "him," "her," "we," or "us." 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 that 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-mutilation may also be present.

Tests: Although tests are not usually useful in making this diagnosis, an electroencephalogram (EEG) may be done to check for partial-complex seizures that can mimic the loss of memory seen with dissociation. Hypnosis or use of a sedative drug-facilitated interview may help reach alter personalities. 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.

Source: Medical Disability Advisor



Treatment

Individual as well as group psychotherapy is used to treat this complex and chronic disorder. Therapy may be frequent and intense, sometimes including two or more weekly psychotherapy sessions over a several year period and followed by periodic relapse prevention visits thereafter. Hypnosis has been used to access the different personalities and retrieve memories. Group therapy and group-format 12-Step work may be helpful. Identifying triggers and developing a crisis management plan are frequent treatment goals. Drug therapy can treat symptoms of anxiety or depression when present in a specific personality state. Eye movement desensitization reprocessing (EMDR) is still a controversial treatment, but is supported by an accumulating evidence base that is, with some modification, being applied to this disorder. Treatment is often emotionally painful as previous crises are remembered and reprehensible actions committed by the one or more of the personality states come to light. Several periods of 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. 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

  • Anxiety disorders
  • Bipolar disorder with rapid cycling
  • Direct physiological effects of a substance
  • Dissociative symptoms due to complex partial seizures
  • Factitious disorder
  • Malingering
  • Other dissociative disorders
  • Other psychotic disorders
  • Personality disorders
  • Schizophrenia
  • Somatization disorder
  • Symptoms that are caused by direct physiological effects of a general medical condition

Source: Medical Disability Advisor



Specialists

  • Clinical Psychologist
  • Psychiatrist

Source: Medical Disability Advisor



Comorbid Conditions

  • Alcohol or substance abuse disorders
  • Anxiety disorders
  • Depressive disorders
  • Eating disorders
  • Headaches
  • Obsessive-compulsive disorder
  • Personality disorder
  • Sexual dysfunction
  • Somatization disorder

Source: Medical Disability Advisor



Complications

Complications may include psychosomatic conditions such as migraine headaches or irritable bowel syndrome. A depressive disorder or substance abuse can also complicate this condition. One of the personalities may commit a crime or an act of violence either against another individual or as self-mutilation. 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; 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)

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 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:

  • 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?
  • 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 diagnostic or screening procedures were utilized in individual's diagnosis?
  • 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 of 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 is currently 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 capable of following through with new-found defenses and coping mechanisms?

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.

Sharon, Idan, and Roni Sharon. "Dissociative Disorders." eMedicine. Eds. Sarah C. Aronson, et al. 4 Jun. 2004. Medscape. 5 Oct. 2004 <http://emedicine.com/med/topic3484.htm>.

Source: Medical Disability Advisor