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.

Somatic Symptom Disorder and Illness Anxiety Disorder


Medical Codes

ICD-9-CM:
300.7 - Hypochondriasis; Body Dysmorphic Disorder

Related Terms

  • Atypical Somatoform Disorder
  • Hypochondria
  • Hypochondriacal Neurosis

Overview

According to the DSM-IV-TR, hypochondriasis is a type of mental health disorder called a somatoform disorder in which the individual believes that real or imagined physical symptoms are signs of a serious illness despite medical reassurance that they are not. The individual's concerns about having a serious illness are generally based on a preoccupation with bodily functions and the interpretation of normal sensations (such as heartbeats, sweating, peristaltic action, and bowel movements) or minor abnormalities (e.g., a runny nose, minor aches and pains, or slightly swollen nodes) as indications of highly disturbing problems needing medical attention. An individual with hypochondriasis might think, "I have a headache; therefore, I must have a brain tumor." Hypochondriasis is sometimes episodic, suggesting that it may be related to stressful life events (DSM-IV-TR).

Negative results of diagnostic evaluations and reassurance by physicians only increase the individual's anxious concern about his or her health. The individual feels distressed because of the negative findings and seeks further medical attention. The ability of many hypochondriacs to function in social, occupational, and interpersonal roles may be impaired (DSM-IV-TR).

Frequent appointments with health care providers are typical, and time off from work is often taken for doctors' appointments, treatments, laboratory tests, and so on. In one general medical outpatient clinic, 88% of patients with this condition also had a concurrent disorder such as general anxiety disorder, depression, or panic disorder (Xiong).

In the DSM-5, hypochondriasis is included in somatic symptom disorder and illness anxiety disorder; it is thought that about 75% of individuals previously diagnosed with hypochondriasis will fall into the diagnosis of somatic symptom disorder, and that about 25% of individuals with hypochondriasis who have high health anxiety without somatic symptoms and without qualifying for an anxiety disorder diagnosis will fall into the diagnosis of illness anxiety disorder (DSM-5).

Incidence and Prevalence: Hypochondriasis can occur at any age but peaks in adolescence and during middle age. Men and women appear to be affected equally. The prevalence of hypochondriasis in the general population is 1% to 5%, and 2% to 7% among primary care outpatients (DSM-IV-TR). It has been reported that 10% to 20% of healthy people and 45% of people without a major psychiatric disorder have intermittent unfounded worries about their health; international rates are similar to US rates (Xiong).

Source: Medical Disability Advisor



Diagnosis

History: According to the DSM-IV-TR, individuals with hypochondriasis are preoccupied with fears of having, or the idea that they have, a severe disease based on the individual's misinterpretation of symptoms. The preoccupation continues despite medical evaluation and reassurance; the belief is not of delusional magnitude (as in delusional disorder, somatic type) and is not restricted to a concern about appearance (as in body dysmorphic disorder); the preoccupation causes significant distress or impairment in occupational, social, or other areas of functioning; the disturbance persists at least 6 months; and the preoccupation is not better explained by another mental disorder. It is necessary to specify if there is poor insight, that is, if the individual does not recognize that the preoccupation is excessive or unreasonable (DSM-IV-TR).

The DSM-5 changed the nomenclature for this disorder, giving the following reasons: "The DSM-IV term somatoform disorders was confusing and is replaced by somatic symptom and related disorders. In DSM-IV there was a great deal of overlap across the somatoform disorders and a lack of clarity about the boundaries of diagnoses. Although individuals with these disorders primarily present in medical rather than mental health settings, nonpsychiatric physicians found the DSM-IV somatoform diagnoses difficult to understand and use." Individuals with somatic symptom disorder have one or more somatic symptoms that are distressing or produce great disruption of daily life. There are excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns, as manifested by at least one of the following: disproportionate and continuous thoughts about the severity of symptoms, persistent high anxiety levels regarding health or symptoms, and/or excessive time and energy devoted to these symptoms or concerns. It is necessary to specify if the disorder is mild (only one symptom), moderate (two or more symptoms), or severe (two or more symptoms and multiple somatic complaints or one very severe somatic symptom). Although the presence of any one somatic symptom may not be continuous, the symptoms persist for more than 6 months. It is also necessary to specify if there is predominant pain (previously pain disorder), and if the disorder is persistent, involving severe symptoms and impairment, and long duration (more than 6 months) (DSM-5).

Also according to the DSM-5, individuals with illness anxiety disorder have a preoccupation with having or acquiring a severe illness; there are no somatic symptoms or they are mild; in the presence of another medical condition or if there is a high risk for a medical condition (strong family history), the preoccupation is excessive or disproportionate; there are high anxiety levels about health, and the individual is easily worried about his or her health status; the individual exhibits excessive health-related behaviors or maladaptive avoidance; illness preoccupation has persisted at least 6 months, but the illness that is feared may change over that time; and the preoccupation is not better explained by another mental disorder. It is necessary to specify whether the disorder is the care-seeking type or care-avoidant type (DSM-5).

Physical exam: The physical exam is usually normal.

Tests: Invasive diagnostic tests should be minimized, but appropriate psychological and psychiatric evaluations should be performed to rule out related disorders.

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 may be difficult. It is important to establish a trusting physician-patient relationship. Sometimes consistent reassurance helps after a reasonable non-endangering workup to exclude a medical condition; instead of trying to eliminate the symptoms, it is necessary to optimize the individual's ability to cope with the symptoms; the individual should also receive information about the manifestations of hypochondriasis. Group therapy rather than individual therapy is most helpful. Coexisting mental health conditions should be treated.

Techniques used to treat obsessive-compulsive disorder (OCD) may also be effective for hypochondriasis. Two such techniques, cognitive therapy and exposure and response prevention (ERP), show favorable results. Illness anxiety disorder may be treated with a selective serotonin reuptake inhibitor (SSRI). Use of antidepressant and anti-anxiety medications may be effective when hypochondriasis coexists with a depressive or anxiety disorder.

Source: Medical Disability Advisor



Prognosis

Hypochondriasis has been shown to fluctuate in intensity, with periods of relative remission and exacerbation that may wreak havoc in the individual's life. About 30% to 50% of patients achieve recovery. Predictors of a good prognosis appear to be higher socioeconomic status, treatment-responsive anxiety or depression, and the absence of a personality disorder and of a related medical condition. Predictors of a bad prognosis (persistence of the diagnosis of hypochondriasis) include the use of a psychoanalytic treatment approach, coexistence of depression, longer duration of hypochondriasis prior to treatment, history of childhood physical punishment, and lower use of SSRI during therapy. The diagnosis of hypochondriasis persists in 40% of Individuals with hypochondriasis treated with SSRI for 4-16 years (Xiong).

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Clinical Psychologist
  • Internal Medicine Physician
  • Neurologist
  • Psychiatrist

Source: Medical Disability Advisor



Comorbid Conditions

Source: Medical Disability Advisor



Complications

Possible complications include health risks associated with unnecessary medical procedures, depression, anxiety disorders, excessive anger and frustration, and substance abuse. A coexisting anxiety or mood disorder, especially major depression, complicates the course and prognosis of hypochondriasis. The individual's refusal of psychological treatment and any life stresses (e.g., financial, marital) may exacerbate the disorder. A bona fide disease may be overlooked and go untreated because of the individual's previously unfounded complaints.

Source: Medical Disability Advisor



Factors Influencing Duration

Factors that may influence the intensity of the disorder and the tendency to relapse are the presence and severity of associated mental health disorders, the intensity of the individual's belief system, and the individual's willingness to undergo psychotherapy. Psychosocial stressors may influence the time between exacerbations of hypochondriasis. The social support and social interaction of group therapy may help ease these exacerbations.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions or accommodations are generally only necessary 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 restrictions/accommodations should help the worker remain at the workplace without a work disruption and promote timely and safe transition back to full work productivity.

Risk: Individuals with somatic symptom disorder or illness anxiety disorder may be poorly suited to working in health-related fields secondary to illness preoccupation. If excessive anger and frustration are present, individuals may need additional intervention to help cope with symptoms.

Capacity: Capacity is typically unaffected with this disorder. Individuals may require time off to attend group therapy, cognitive behavioral therapy, or ERP sessions, but this can usually be accomplished outside working hours. Individuals unwilling to participate in psychological treatment may be less productive than their coworkers due to distraction over perceived health issues.

Tolerance: Tolerance is not a concern with this diagnosis. In most cases, involvement with work activities is beneficial to recovery.

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:

  • Have existing medical conditions been ruled out through medical history and physical exam by a physician?
  • Has a psychological evaluation been performed?
  • What is individual's health care history?
  • Has individual previously been under medical supervision for this same problem?
  • Was medical condition previously established or ruled out?

Regarding treatment:

  • Were physical exam and diagnostic testing performed to identify or rule out an organic basis for complaints?
  • Were existing complaints treated symptomatically as appropriate?
  • Is individual scheduled for or receiving regular follow-up visits?
  • Because it is very difficult for individual to accept that the health problem is not a serious organic illness, is individual and/or family receiving psychotherapy to help deal with this situation?
  • Is individual involved in group therapy that provides needed support and social interaction? Is therapy sufficient to reduce fear and anxiety?
  • Is antidepressant or anti-anxiety medication warranted?

Regarding prognosis:

  • Is individual making an effort to avoid going to different doctors and getting repeat medical tests?
  • Is individual involved in an effective group therapy?
  • Is individual able to focus on other aspects of life and move on?
  • Would additional psychotherapy help?

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.

Xiong, G. L. , et al. "Hypochondriasis." eMedicine. 10 Jun. 2013. Medscape. 22 Apr. 2015 <http://emedicine.medscape.com/article/290955-overview#showall>.

Source: Medical Disability Advisor