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.

Persistent Depressive Disorder (Dysthymia)


Related Terms

  • Dysthymia
  • Neurotic Depression
  • Reactive Depression

Differential Diagnosis

  • Major depression
  • Mood disorder due to general medical condition
  • Personality disorders
  • Substance-induced mood disorder

Specialists

  • Clinical Psychologist
  • Internal Medicine Physician
  • Psychiatrist

Comorbid Conditions

Factors Influencing Duration

Length of disability may be influenced by severity of symptoms (i.e., sleep disturbance) or the degree of psychomotor retardation (slowing of physical and mental processes) and job requirements. A suicide attempt may lengthen disability due to necessary medical treatment and the need for further psychological assessment. Emotionally stressful job duties may increase the length of disability. Symptoms may interfere with optimal work performance.

Medical Codes

ICD-9-CM:
300.4 - Dysthymic Disorder; Anxiety Depression, Depression with Anxiety, Depressive Reaction, Neurotic Depressive State, Reactive Depression

Overview

In DSM-5, persistent depressive disorder (dysthymia) consolidates chronic major depressive disorder and dysthymic disorder from DSM-IV-TR.

Persistent depressive disorder (dysthymia) (as well as dysthymic disorder) is a chronically depressed mood that occurs almost all day, almost every day, for 2 years at a minimum in adults (DSM-5).

Persistent depressive disorder may be preceded by major depression, and may coexist with major depressive episodes. When symptoms meet the criteria for major depressive disorder for 2 years in adults, a diagnosis of persistent depressive disorder as well as major depressive disorder should be made.

Incidence and Prevalence: In the course of their lifetime, about 5% of adults have dysthymic disorder (“Mood Disorders). Point prevalence of the disorder is about 3% (DSM-IV-TR). The 12-month prevalence of persistent depressive disorder in the US is approximately 0.5%, and 1.5% for chronic major depressive disorder (DSM-5).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Adult women are 2 to 3 times more likely to develop dysthymia than men ("Persistent Depressive Disorder (Dysthymia)"). Individuals originally diagnosed with dysthymic disorder before the age of 21 are more likely to experience major depressive episodes later, and the disorder is more common in individuals with close biological relatives diagnosed with major depression (DSM-IV-TR).

Individuals with persistent depressive disorder may have a higher proportion of first-degree relatives with persistent depressive disorder than do individuals with major depressive disorder, and may have more first-degree relatives with depressive disorders in general (DSM-5).

Source: Medical Disability Advisor



Diagnosis

History: According to standard criteria set forth in the DSM-5, the individual with persistent depressive disorder (dysthymia) has a depressed mood for most of the day, almost daily (by subjective account or observation by others), for at least 2 years. While depressed, the individual exhibits 2 (or more) of the following: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness. During those 2 years the individual has never been free of the aforementioned symptoms for more than 2 months in a row; criteria for a major depressive disorder may be continuously present for 2 years (note the change with respect to DSM-IV-TR). The individual has never had a manic (note the deletion of "mixed") or hypomanic episode, and has never met the criteria for cyclothymic disorder. Persistent depressive disorder (dysthymia) is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum or other psychotic disorder (note the change with respect to DSM-IV-TR). The symptoms are not due to the physiological effects of a drug of abuse or a medication, or another medical condition. The symptoms produce clinically significant distress or impairment in social, occupational, or other important areas of functioning (DSM-5).

DSM-5 also states that since the criteria for a major depressive episode include four symptoms not listed in the symptoms of persistent depressive disorder (dysthymia), very few individuals will have depressive symptoms for more than 2 years but will not meet criteria for persistent depressive disorder. When full criteria for a major depressive episode have been met at some time during the current episode, a diagnosis of major depressive disorder should be assigned; otherwise, a diagnosis of other specified depressive disorder or unspecified depressive disorder may be given (DSM-5).

It is necessary to specify whether the disorder occurs with anxious distress; with mixed features, melancholic features, atypical features, mood-congruent or mood-incongruent psychotic features, or peripartum onset; if the disorder is in partial or full remission; if onset is early (before age 21 years) or late (age 21 years or older); if (for the most recent 2 years of persistent depressive disorder) the disorder is concurrent with pure dysthymic syndrome, a persistent major depressive episode, or intermittent major depressive episodes (with or without current episode); finally, it is necessary to specify whether disorder is currently mild, moderate, or severe (DSM-5).

Physical exam: There are no typical abnormalities on physical examination. Facial expressions may reveal a depressed mood. Some individuals show uncharacteristic disregard for their appearance. Recent weight gain or loss or slowing of physical and mental processes (psychomotor retardation) may also be present. Observation of the individual's orientation, dress, mannerisms, behavior, and speech content may help diagnose the illness.

Tests: Persistent depressive disorder (dysthymia) cannot be diagnosed by laboratory tests. Psychological testing such as the Beck Depression Inventory (BDI), the PHQ9, the Minnesota Multiphasic Personality Inventory 2 (MMPI-2), or other tests may reveal evidence of depressed mood. The Prime MD Structured Clinical Interview for DSM-IV can be helpful.

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

Treatment usually consists of psychotherapy and/or antidepressant medications. Supportive counseling can address feelings of hopelessness. Cognitive therapy may help change the pessimistic ideas, unrealistic expectations, and overly critical self-evaluations that sustain the depressed mood, and can also help the individual distinguish between critical and minor life problems. Both cognitive behavioral therapy and interpersonal therapy are empirically based treatment strategies with demonstrated effectiveness. A number of studies have found both strategies to be as effective as antidepressant medications in the treatment of persistent depressive disorder (dysthymia). They can be delivered individually or in a group setting, and typically require 8 to 16 weekly sessions. Problem-solving therapy can help change stressful situations contributing to depression. Family and friends may benefit from counseling or a support group to help them cope with the demands of the loved one's illness.

Antidepressant medications, primarily selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), or tricyclic antidepressants (TCAs), are often seen as the treatment of choice in the treatment of persistent depressive disorder (dysthymia). Treatment begins with a low dose and continues for up to 3 months. If there is significant improvement in symptoms, therapy should continue for as long as needed, which may be up to 2 to 3 years or for life. Approximately 55% of individuals with persistent depressive disorder (dysthymia) benefit from antidepressant medication (Halverson). Guidelines for assessing the potential of drug therapy include a positive family history and a past history of poor response to other forms of treatment. Hospitalization is generally not necessary unless there is a suicide plan or attempt.

Source: Medical Disability Advisor



Prognosis

Outcome is good with improvement in symptoms, well-being, and functioning after several months of drug treatment and/or psychotherapy. Since the disorder is chronic, long-term or recurrent treatment may be necessary depending on the severity of symptoms. Up to 80% of individuals have severe, long-term symptoms that cause problems with social and occupational functioning. Individuals often have trouble forming or sustaining relationships. Emotional distress can be serious, with dysthymia increasing the risk of suicide (Halverson). Accompanying symptoms such as sleep disorder and chronic fatigue can be debilitating and lead dysthymic individuals to use health care services five times more often than unaffected individuals.

Source: Medical Disability Advisor



Complications

The most common complication is major depression (sometimes known as double depression when it occurs with dysthymia) or an underlying personality disorder. Suicidal thoughts, plans, or gestures may also complicate persistent depressive disorder. If a suicide attempt is made, the individual must be reassessed by a mental health professional and treated for ongoing psychological needs. Medical needs such as wound care or other physical complaints must be addressed and a new psychiatric diagnosis formulated. If the individual has adopted ineffective coping techniques, this can also impede or complicate treatment.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions or accommodations are necessary 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.

For more information, refer to "Work Ability and Return to Work," pages 411–426.

Risk: There is no risk to individuals working with persistent depressive disorder or risk to the individual's coworkers unless substance abuse or suicidal ideation is present. Participation in work activities is usually beneficial for improved socialization and physical health.

Capacity: Capacity depends on the individual’s level of mental alertness and ability to concentrate, and the presence of any comorbid sleep disorders. Work tasks that are familiar, simple, and do not require intense concentration or multitasking may be appropriate.

Tolerance: Tolerance depends on the individual’s motivation, as well as compliance with treatment (cognitive behavioral therapy, interpersonal therapy). In most cases, involvement with work activities is beneficial to recovery.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is expected at 6 months of treatment or less. Chronicity is implicit in this diagnostic entity.

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:

  • Has diagnosis been confirmed?
  • Is functional impairment evident or reported by individual?
  • Does individual meet the specific criteria for this diagnosis?

Regarding treatment:

  • Has substance abuse and/or the presence of underlying medical conditions been ruled out?
  • Has individual's treatment plan included inappropriate long-term use of amphetamines, barbiturates, and/or benzodiazepines?
  • What is the focus of the therapy individual has received or is currently receiving?
  • Is individual currently receiving drug therapy? If not, would the addition of drug therapy be beneficial to the current treatment plan?
  • Is individual involved in a therapy group?
  • Is individual's family involved in therapy?
  • What education or support has the family received?

Regarding prognosis:

  • Is individual aware that depression of this kind is often chronic with recurring episodes?
  • Is individual able to ask for help if symptoms return?
  • Have relapse prevention strategies been planned?

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.

Goldberg, Joseph. "Persistent Depressive Disorder (Dysthymia)." Internet Mental Health. Phillip W. Long. 21 Apr. 2015 <http://mentalhealth.com/home/dx/dysthymic.html>.

Halverson, Jerry L. "Dysthymic Disorder." Medscape. 15 Jun. 2012. WebMD, LLC. 21 Apr. 2015 <http://www.medscape.com>.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

Source: Medical Disability Advisor






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