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.

Intermittent Explosive Disorder


Related Terms

  • Aggressive Personality Disorder
  • Anger Attacks
  • Episodic Dyscontrol
  • Impulse Control Disorder
  • Rage Attacks

Differential Diagnosis

  • Alzheimer's disease
  • Antisocial personality disorder (DSM-5)
  • Attention-deficit/hyperactivity disorder (DSM-5)
  • Autism spectrum disorder (DSM-5)
  • Borderline personality disorder (DSM-5)
  • Brain injury
  • Brain tumor (neoplasm)
  • Conduct disorder (DSM-5)
  • Delirium, major neurocognitive disorder, and personality change due to another medical condition, aggressive type (DSM-5)
  • Disruptive mood dysregulation disorder (DSM-5)
  • Head trauma
  • Oppositional defiant disorder (DSM-5)
  • Paranoid schizophrenia
  • Psychosis
  • Substance intoxication or substance withdrawal (DSM-5)
  • Temporal lobe epilepsy

Specialists

  • Clinical Psychologist
  • Neurologist
  • Psychiatrist

Comorbid Conditions

  • Antisocial personality disorder {DSM-5}
  • Anxiety disorders {DSM-5}
  • Attention-deficit/hyperactivity disorder {DSM-5}
  • Borderline personality disorder {DSM-5}
  • Conduct disorder {DSM-5}
  • Depression
  • Impulse control disorders (e.g., pathological gambling, kleptomania, pyromania, trichotillomania)
  • Oppositional defiant disorder {DSM-5}
  • Substance abuse (alcohol or drugs)

Factors Influencing Duration

The presence of underlying conditions, the type and quality of treatment, compliance with recommended treatment, and the extent of the condition may influence the length of disability.

Medical Codes

ICD-9-CM:
301.3 - Explosive Personality Disorder
312.34 - Disorders of Impulse Control, Not Elsewhere Classified; Intermittent Explosive Disorder

Overview

Intermittent explosive disorder was first recognized as a mental disorder by the American Psychiatric Association in 1980.

In the DSM-IV-TR, the condition is categorized as an impulse-control disorder not elsewhere classified, that is, disorders of impulse control that are not classified as a feature of disorders in other sections of the manual (substance-related disorders, paraphilias, antisocial personality disorder, conduct disorder, schizophrenia, and mood disorders). Impulse-control disorders include intermittent explosive disorder, addressed in the present topic, kleptomania, pyromania, pathological gambling, and trichotillomania.

In the DSM-5, intermittent explosive disorder is included in the chapter about disruptive, impulse-control, and conduct disorders, together with oppositional defiant disorder; conduct disorder; antisocial personality disorder; pyromania; kleptomania; other specified disruptive, impulse-control, and conduct disorders; and unspecified disruptive, impulse-control, and conduct disorders.

Intermittent explosive disorder may begin abruptly with usual age of onset from childhood to the early twenties (DSM-IV-TR). The disorder rarely begins after age 40 (DSM-5).

Incidence and Prevalence: One-year prevalence data for intermittent explosive disorder (narrow definition) in the US is about 2.7%. Intermittent explosive disorder is more prevalent among individuals younger than 35-40 years, and in individuals with less education (DSM-5).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals with a history of trauma (physical and emotional) during the first two decades of life, and first-degree relatives of individuals with intermittent explosive disorder are at higher risk for intermittent explosive disorder; twin studies have revealed a considerable genetic influence for impulsive aggression.

Source: Medical Disability Advisor



Diagnosis

History: On several occasions, the individual has been unable to resist aggressive impulses that result in severe assaultive acts or destruction of property, and the degree of aggressiveness during the episodes is out of proportion to any precipitating psychosocial stressors. The aggressive episodes are not better explained by another mental disorder, and are not caused by the physiological effects of a substance (a drug of abuse or a medication) or a general medical condition. The individual may provide a history of severe temper tantrums, impaired attention, hyperactivity, and other behavioral difficulties such as stealing or setting fires during childhood. Aggressive episodes frequently result in physical or verbal assaults or property destruction (for example, road rage). The individual may report feeling tension prior to the episode, as well as irritability, increased energy, or racing thoughts during the aggressive impulses and acts and afterward. The aggressive episodes may be preceded by tingling, tremors, a very fast heart rate (palpitations), tightness in the chest, head pressure, or the sound of an echo. The episode is followed by relief of the tension, rapid onset of fatigue and depression, and then feelings of remorse, regret, shame, or embarrassment. This disorder may lead to occupational and relationship difficulties, accidents, hospitalizations, financial problems, or legal problems (DSM-IV-TR). Individuals may also report having aggressive impulses that they resisted or acted out in a less assaultive way, such as hitting a wall.

According to the DSM-5, either the individual has recurrent behavioral outbursts reflecting a failure to control aggressive impulses as manifested by verbal or physical aggression about twice weekly during 3 months, which do not result in damage or destruction of property and or in physical injury to animals or other individuals, or the individual has 3 behavioral outbursts with damage or destruction of property and/or physical assault within 1 year. The aggressiveness manifested during the recurrent outbursts is out of proportion to the stimulus. The recurrent aggressive outbursts are not planned (are impulsive and/or anger-based) and have no tangible objective. These outbursts distress the individual, cause problems in relationships, or result in financial or legal consequences. The individual is at least 6 years old. Outbursts are not better accounted for by another mental disorder, another medical condition, or the effects of a drug of abuse or a medication (DSM-5).

Physical exam: History is more important than physical examination in diagnosing intermittent explosive disorder. The physical examination may reveal signs of tension or anxiety such as pacing or clenched jaws or fists. Bruises or abrasions may occur if the individual has recently had a fight as a result of aggressive impulses. Otherwise, physical examination is used to eliminate other possible causes of the rage episodes.

Tests: There are no specific diagnostic tests, but nonspecific changes may be noted in brain wave patterns (electroencephalogram, EEG), neurological measurements of the visual system (visual evoked potentials), or altered serotonin metabolism. Magnetic resonance imaging (MRI) or computed tomography (CT) scan of the brain may help eliminate neurologic disorders as a cause of aggression.

Psychological evaluation tools such as the Minnesota Impulsive Disorders Interview, the Minnesota Multiphasic Personality Inventory, and facial-emotion recognition tasks may reveal difficulty with impulse control.

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

The treatment goal is to decrease or end the destructive episodes. Group and individual psychotherapy and pharmacotherapy are treatments of choice in various combinations. Self-help and anger-management groups may also be useful. Pharmacotherapy involves anti-anxiety agents such as lorazepam or clonazepam, and antidepressants of the selective serotonin reuptake inhibitor (SSRI) class such as fluoxetine, to reduce symptoms of anxiety and depression. Tricyclic antidepressants, and mood stabilizers such as lithium, are often effective in controlling the explosive episodes.

Behavioral interventions play an important role in treatment. Group therapy may be effective, especially when individuals in the group have experienced similar disorders. Group therapy may help the individual identify, understand, and deal with underlying problems that result in aggressive behavior. Group situations can also help the individual learn how to improve interpersonal relationships and find more appropriate ways of expressing feelings.

Source: Medical Disability Advisor



Prognosis

There are few data on the course of this disorder. Some individuals have a chronic course and others a more episodic course. Many individuals experience some decrease in symptoms or a change in fixed patterns of thoughts, feelings, or behaviors that are causing difficulty over a period of time or after receiving treatment. Studies suggest that serotonin reuptake inhibitors and mood stabilizers help reduce aggressive impulses and explosive acts. Some individuals respond to treatment and are able to learn to control their aggressive impulses. Individuals who are able to develop supportive relationships and make use of self-help groups are more likely to experience continued improvement in social and occupational functioning.

Source: Medical Disability Advisor



Complications

This disorder often results in repeated loss of employment, damage to personal relationships, divorce, social isolation, accidental injury, legal entanglements, or prison confinement. Assaultive behavior poses an increased risk of premature death from suicide, accident, or homicide.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Job accommodations, when possible, should include a quiet, predictable, low-stress environment. Work should be completed independent of reliance on coworkers. Provisions may be needed for flexible breaks to control stress and anger levels. Flexibility may also be needed in the work schedule so that the individual may contact his or her support system and attend treatment programs and meetings with the employer, supervisor, and job coach to explore sources of tension on the job, and to discuss any solutions or other accommodations.

Risk: Tolerance for explosive rage is minimal in the workplace, particularly in light of concern for the safety of coworkers; individuals with this disorder may also present a safety risk to themselves. Frequency of episodes has a direct bearing on employability, as verbal and/or physical abuse initiated by the affected individual is typically not tolerated.

Capacity: Capacity depends on tolerance, which is affected by the individual's ongoing motivation and compliance with treatment. Individuals taking prescribed medications to control their symptoms may require periodic drug testing to ensure that substance abuse or addiction does not become an added concern.

Tolerance: Tolerance factors include whether or not the individual is committed to treatment, and whether he or she is willing to consistently attend group and individual behavioral intervention therapies to help develop supportive relationships and learn self-control of aggressive impulses and actions.

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 fit the criteria for intermittent explosive disorder?
  • Has diagnosis been confirmed? Are symptoms better accounted for by a different diagnosis?
  • Have psychological and medical disorders with similar symptoms been ruled out?

Regarding treatment:

  • If individual is not responding effectively to current medication, what other drug options are available?
  • Is individual currently involved in appropriate individual or group therapy?
  • Does therapy help individual identify, understand, and deal with underlying problems that result in aggressive behavior?
  • Is individual learning how to improve interpersonal relationships and find more appropriate ways of expressing feelings?
  • Would individual benefit from enrollment in a self-help or anger-management group?
  • Are comorbid conditions being treated?

Regarding prognosis:

  • Does individual have an underlying condition that may affect recovery?
  • Has individual been involved in the current form of treatment for more than 6 weeks without a noticeable effect?
  • Should treatment plan be reassessed?

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






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