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.

Eating Disorders


Related Terms

  • Anorexia Nervosa
  • Binge Eating Disorder
  • Bulimia Nervosa

Differential Diagnosis

Specialists

  • Clinical Psychologist
  • Internal Medicine Physician
  • Psychiatrist

Comorbid Conditions

Factors Influencing Duration

Factors that might influence length of disability include severity, age at which the disorder started, time span of the disorder, mental health of the individual, response or resistance to treatment, and the presence of complications. Eating disorder complications range from relatively minor to life threatening.

Medical Codes

ICD-9-CM:
307.1 - Special Symptoms or Syndromes, Not Elsewhere Classified; Anorexia Nervosa
307.50 - Special Symptoms or Syndromes, Not Elsewhere Classified; Eating Disorder, Unspecified
307.51 - Special Symptoms or Syndromes, Not Elsewhere Classified; Bulimia Nervosa; Overeating of Nonorganic Origin
307.54 - Special Symptoms or Syndromes, Not Elsewhere Classified; Psychogenic Vomiting

Overview

Eating disorders are psychological disturbances related to body image and eating habits. Both anorexia nervosa and bulimia nervosa are serious, life-threatening conditions that are difficult to treat. A third condition, binge eating disorder, was first described in 1959, but was only added as a separate condition in the 2013 DSM-5.

Anorexia nervosa, a potentially life-threatening condition, is characterized by obsessive concern over one's body weight, specifically the fear of appearing fat or gaining weight. As a result, individuals with this disorder rigidly restrict their dietary intake, are markedly underweight, and often suffer from malnutrition. Frequently the individual will abuse laxatives or deliberately cause vomiting in an effort to avoid what he or she regards as excess calories. The individual may exercise excessively. Because their self-image is greatly distorted, individuals may see themselves or parts of their bodies as grossly overweight even though they may appear emaciated to others. A major feature of this eating disorder is denial, or lack of insight. While the problem is painfully evident to those around them, the afflicted individual is blind to it. Even when the condition is brought to the individual's attention, there is little or no change in eating habits until failing health finally forces medical attention.

Bulimia nervosa, a closely related condition, is characterized by episodes of "binge" eating followed by desperate measures to avoid weight gain. Usual measures include dieting, self-induced vomiting, laxative and/or diuretic abuse, and, in some cases, excessive exercise. Like anorexia, body image is distorted, and there is a preoccupation with physical appearance. Unlike anorexia nervosa, most individuals with bulimia are less conspicuous, being of normal or near normal weight, or even being somewhat overweight. Individuals with bulimia are at risk for a number of potentially serious health hazards including malnutrition, electrolyte imbalances, esophageal ulcers or rupture, and rampant dental decay.

While the cause of anorexia nervosa is unknown, social factors, especially the desire to be thin, appear to be important. Bulimia, on the other hand, stems from a combination of factors. Personality traits include impulsiveness, vulnerability, feelings of low self-esteem and helplessness, and the fear of becoming fat and unattractive. Although bulimia and other eating disorders are considered learned behavior, a suspected genetic link may also explain why they tend to run in families. Biochemical, metabolic, and endocrine abnormalities may help to explain why some bulimic women cease to have their monthly menstrual period and why there appears to be a relationship between eating disorders and depression, as evidenced by the unusually high suicide rate among bulimics.

Binge eating disorder, the third condition, stands in contrast to bulimia nervosa by the absence of purging. Occurring most commonly in individuals who are already obese, the additional caloric intake leads to increasing body weight. These individuals struggle with eating behavior. The binges occur at least once a week for a 3-month period, but the pattern does not meet the full criteria for bulimia nervosa.

Incidence and Prevalence: The data for males are insufficient to provide an accurate estimate of occurrence (DSM-IV-TR). In women, the estimated lifetime prevalence of anorexia nervosa is 0.5% to 3.7% and of bulimia nervosa is 1.1% to 4.2% (ANAD).

The prevalence of binge eating disorder in diet clinic samples is about 30%; in general population samples, it is less than 5%. However, it is estimated that over a 6-month period, 2% to 5% of individuals in the US experience binge eating disorder (ANAD).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Anorexia nervosa and bulimia nervosa predominantly afflict adolescent and younger-adult females, and are about 10 times more common in women than in men. Individuals with binge eating disorder tend to be older than those who have anorexia nervosa or bulimia nervosa, and nearly half of them are male. There is an increased risk of anorexia nervosa for individuals with first-degree relatives diagnosed with the disorder (DSM-IV-TR).

Source: Medical Disability Advisor



Diagnosis

History: For all three types of eating disorder, it is important to note whether the disorder is in partial or in full remission.

According to the DSM-5 and DSM-IV-TR, diagnostic criteria for anorexia nervosa include reluctance to maintain a minimally normal body weight for age and height, with the result that body weight is maintained at less than 85% of the expected weight. The individual has severe fear of gaining weight or becoming obese, even though underweight. There is disruption in the way in which the individual experiences body weight or shape, excessive influence of body weight or shape on self-evaluation, or denial of the severity of the low body weight. With anorexia, abnormal behaviors that include excessive exercise, restricted eating patterns (e.g., dieting, fasting), and/or purging with vomiting or laxatives occurs on a recurrent basis over a 12-week period. Amenorrhea (i.e., the absence of at least three consecutive menstrual cycles in females after menarche) may be present. Current severity should be also specified; for adults, the minimum level of severity is based on body mass index (BMI) as follows: mild (>17kg/m2), moderate (16 to 16.99 kg/m2), severe (15 to 15.99 kg/m2), or extreme (<15 kg/m2). The level of severity may be increased based on clinical symptoms, functional disability, and need for supervision (DSM-5).

The DSM-5 and DSM-IV-TR diagnostic criteria for bulimia nervosa include recurrent episodes of binge eating followed by recurrent inappropriate compensatory behavior in order to avoid weight gain (e.g., self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise). Binge eating is defined as eating in a given period of time an amount of food that is definitely larger than most individuals would eat during a similar period of time and under similar circumstances. It is accompanied by a sense of lack of control over food intake during the episode. With bulimia, binge eating is followed by inappropriate compensatory behaviors, on average, at least once a week (DSM-IV, twice a week) for 12 weeks. As with anorexia, body shape and weight have an excessive influence on self-evaluation. The type of behavior should be specified: purging (during the current episode of bulimia nervosa, the individual has regularly incurred in self-induced vomiting or the misuse of laxatives, diuretics, or enemas), or nonpurging (during the current episode of bulimia nervosa, the individual has incurred in other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly incurred in self-induced vomiting or the misuse of laxatives, diuretics, or enemas) (DSM-IV-TR). Current severity should be also specified, with a minimum level of severity based on the frequency of inappropriate compensatory behaviors, as follows: mild (an average of 1 to 3 episodes of inappropriate compensatory behaviors per week), moderate (4 to 7 episodes per week), severe (8 to 13 episodes per week), or extreme (14 or more episodes per week). The level of severity may be increased based on other symptoms and functional disability (DSM-5).

For binge eating disorder, the DSM-5 diagnostic criteria include episodes that are associated with three or more of the following criteria: eating much more quickly than normal; eating too much and feeling uncomfortably full afterward; eating too much food without feeling hungry; eating alone because of embarrassment about how much one is eating; feeling upset with oneself, depressed, or very guilty after eating; and severe distress regarding the binge eating. Binge eating occurs at least once a week for 12 weeks, and the binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa. Current severity should be also specified, with the minimum level of severity based on the frequency of episodes of binge eating as follows: mild (1 to 3 binge eating episodes per week), moderate (4 to 7 episodes per week), severe (8 to 13 episodes per week), and extreme (14 or more episodes per week). The level of severity may be increased based on other symptoms and functional disability.

Because the individual may consciously or unconsciously hide the eating disorder from others, laboratory and physical examination data may be used to support the diagnosis.

Physical exam: Because individuals with eating disorders rarely admit to their behavior, the physician may be alerted to the condition by unexplained symptoms. Signs of anorexia include emaciation, low blood pressure, low body temperature, skin dryness, fine downy hair covering the skin surface (lanugo), a severely slow heart rate (bradycardia), brittle nails, and thinning hair. Signs of bulimia include loss of dental enamel on teeth and tooth decay, enlarged salivary glands, irritation of the esophagus, sores or calluses on the index finger or knuckle, and scars on the back of the dominant hand as a result of the hand rubbing against the teeth during forced vomiting episodes. Bulimia may not be evident until persistent vomiting causes a serious metabolic disturbance or internal bleeding. In some cases, attempted suicide is the first obvious indication. Symptoms associated with the excess body weight of binge eating disorder include shortness of breath (dyspnea); fatigue; joint pain (arthralgia) in the hips, knees, and ankles; and a general dissatisfaction with their state of health.

Tests: Laboratory testing is useful in making the diagnosis and monitoring for complications, such as blood acid-base and electrolyte imbalances, hormonal disturbances, heart problems, and dehydration. Another useful aspect of testing is to monitor compliance with treatment recommendations and to watch for relapse.

Two psychological screening instruments useful in eliciting the symptoms of anorexia nervosa and bulimia nervosa are the Eating Disorder Inventory-2 (EDI-2) and the Bulimia Test–Revised (BULIT–Revised).

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 and family therapy are designed to address the physical, emotional, and behavioral elements involved in anorexia nervosa and bulimia nervosa. A variety of treatment approaches have been tried with moderate success. The more successful treatments involve multiple disciplines and include behavioral modification, psychotherapy, and careful medical attention. Individual therapy may be supplemented with an eating disorders group therapy.

When weight loss from anorexia has been rapid or severe (more than 25% below ideal body weight), restoring body weight is crucial. Because such weight loss can be life threatening, the individual is usually hospitalized so that experienced staff members can firmly but gently encourage the individual to eat. If unsuccessful, the individual may have to be fed intravenously (parenteral nutrition [PN]) or through a tube inserted in the nose and passed into the stomach (nasogastric tube nutrition).

Antidepressant medication has been found to be helpful for some individuals with bulimia nervosa, whether or not there is accompanying depression. In contrast, antidepressant medication is typically not helpful for individuals with anorexia nervosa, unless it is used to treat accompanying depression.

Specific treatment for binge eating disorder has been based on the treatment of bulimia nervosa. Although antidepressants and appetite suppressants are proving to be reasonably effective in controlling binge eating, psychotherapy appears to have longer-lasting effects. For binge eating disorder, research suggests that cognitive behavioral therapy focused on modifying the binge, coupled with antidepressants (particularly the selective serotonin re-uptake inhibitors [SSRIs]) and the anticonvulsant topiramate may result in better outcomes.

Typically, treatment for eating disorders is carried out over months to years. In severe cases, inpatient treatment may be necessary. Medical complications may require hospitalization. Because eating disorders are potentially life threatening, good medical care, including frequent physical exams, is important.

The professional discipline of psychotherapists treating individuals with eating disorders is said not to be as important as their competence. Desirable characteristics include specialized knowledge; personality traits like non-possessive warmth and perseverance; training in scientific, manual-based psychotherapy; and supervised experience.

Source: Medical Disability Advisor



Prognosis

Because eating disorders are usually quite complicated, it is difficult to predict the outcome. Generally, the younger the age at which the symptoms appear, the poorer the prognosis. Over a 5-year span, approximately one-third of individuals will have a complete or near complete remission of their symptoms, one-third will show significant improvement, while the remaining one-third either fail to improve or deteriorate. The mortality rate is significant, with one study estimating that up to 4% of all individuals with anorexia nervosa and bulimia nervosa will die from the disease (Crow), and another study suggesting that individuals with anorexia nervosa are at higher risk of death (often by suicide) than individuals with other eating disorders (Yager).

When an individual becomes malnourished, either from not eating or from constant purging, every major body system can be affected. The most dangerous are problems with the heart and fluid or electrolyte imbalances. As the heart gets weaker, less blood is pumped throughout the body. As the blood becomes more acidic (metabolic acidosis), potassium levels may decrease. Vomiting, laxatives, and diuretics worsen the situation. Resulting abnormal heart rhythms can lead to sudden death.

Source: Medical Disability Advisor



Complications

Eating disorders can lead to serious medical problems, depression, and suicide. Complications associated with anorexia include absence of menstrual cycling, other hormonal problems, and malnutrition. Severe imbalances in blood chemistry can cause irregular heartbeat, seizures, coma, and death. Muscle wasting, kidney failure, problems due to poor liver function, and superior mesenteric artery syndrome are other possible complications. Weight can drop to less than 75% of normal, a very dangerous condition requiring hospitalization.

Individuals with bulimia also risk severe blood chemistry imbalances with associated complications, including rupture of the stomach or esophagus, and advanced dental decay. Depression, irritability, insomnia, and generally poor mental functioning are some of the more common psychological complications. Suicide is unusually high among bulimics.

Excessive accumulation of body fat (obesity) from binge eating disorder can lead to degenerative joint disease, arthritis, diabetes, and high blood pressure.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions or accommodations are necessary only infrequently for the most serious cases. When they are necessary, time-limited accommodations are based on individual need because of the variety of serious complications possible with eating disorders.

Risk: Any job duty that heightens awareness of the individual's physical appearance such as modeling or dancing is apt to make these conditions worse. Highly stressful situations may worsen these illnesses or trigger a relapse.

Capacity: Capacity may be affected if the individual has a severe eating disorder that results in physical symptoms from electrolyte imbalances, kidney failure, diabetes, malnutrition, or obesity. Muscle weakness is often an issue in more severe cases.

Tolerance: Tolerance is dependent on the mental health and motivation of the individual and the success of multidisciplinary treatments to address denial and foster healthy behaviors.

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's condition meet the criteria for an eating disorder? Has the diagnosis of anorexia nervosa, bulimia nervosa, or binge eating disorder been confirmed?
  • Have psychiatric disorders and underlying medical conditions with similar symptoms been ruled out?
  • Does individual have an underlying condition that may impact recovery?
  • If there is evidence of drug or alcohol abuse, how are these issues being addressed?

Regarding treatment:

  • Is individual being seen by a physician with training or experience in treating eating disorders? Does individual feel comfortable with the physician?
  • Does the therapist have special training and expertise in the treatment of eating disorders?
  • Does the physician routinely monitor the individual for medical complications?
  • What type of therapy is individual involved in? Is therapy individual or family oriented? Does individual feel comfortable with the therapist? Does current therapy mode appear to be effective?
  • Would individual benefit from being involved in a group therapy with other eating disorder individuals?
  • Have medications such as antidepressants, anticonvulsants, or appetite suppressants been effective in controlling binge eating?

Regarding prognosis:

  • How motivated is individual to cooperate with his or her own health care?
  • Do treatment goals need to be revisited? Are expectations realistic?
  • Does individual need assistance finding referrals, making appointments, and getting to appointments?
  • Does individual have support from family, friends, and coworkers?

Source: Medical Disability Advisor



References

Cited

"Eating Disorders Statistics." National Association of Anorexia Nervosa and Associated Disorders. 21 Apr. 2015 <http://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics/>.

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.

Crow, S. J. "Increased Mortality in Bulimia Nervosa and Other Eating Disorders." American Journal of Psychiatry 166 (2009): 1342-1346.

Yager, Joel. "Bulimia Nervosa." eMedicine. 15 Sep. 2014. Medscape. 21 Apr. 2015 <http://emedicine.medscape.com/article/286485-overview#aw2aab6b2b3>.

Source: Medical Disability Advisor






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