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.

Narcissistic Personality Disorder


Related Terms

  • Ego Personality Disorder

Differential Diagnosis

Specialists

  • Clinical Psychologist
  • Psychiatrist

Comorbid Conditions

  • Any other psychiatric illness
  • Substance abuse

Factors Influencing Duration

Influences from their interpersonal relationships and job, if unstable, affect length of disability. Loss or rejection, even if resulting from their own behavior, creates further stress and more dysfunctional behavior that lengthens disability.

Medical Codes

ICD-9-CM:
301.81 - Narcissistic Personality Disorder

Overview

The term narcissistic comes from the Greek myth of Narcissus, who saw his reflection in a clear pond and fell in love with himself. Individuals with narcissistic personality disorder possess a heightened sense of self-importance and grandiose feelings that they are unique in some way. The essential features of narcissistic personality disorder are a pervasive pattern of grandiosity, need for admiration, and lack of empathy that begins by early adulthood and is present in a variety of contexts. These individuals overvalue their personal worth, direct their affections toward themselves rather than others, and expect others to recognize their unique value. Narcissistic personalities are often viewed by others as arrogant, pompous, snobbish, and highly conceited. They believe and behave as if they are above the conventions and ethics of their culture.

While interacting with others, narcissists range from being interpersonally exploitative (in milder variants) to shameless in their disregard for others (in more severe variations). They may exploit others to enhance themselves or indulge their own desires. They often feel entitled to express themselves in ways denied to others. Individuals who live or work with narcissists often feel taken advantage of or used.

Narcissists' relationships are fragile, since they refuse to obey conventional rules of relating to others and have little or no ability to show and/or experience empathy. They may use shaming in a relationship as a means of control. They may resort to lies or fabrications to maintain or redeem their illusions of self-worth. Narcissistic individuals may see themselves as admirable, extra-special, wonderful, and superior.

Individuals with narcissistic personality disorder are at higher risk for other psychiatric disorders. Several common psychiatric disorders may be associated with the narcissistic personality. Persistent depressive disorder (dysthymia; formerly chronic major depressive disorder and dysthymic disorder) (DSM-5) is less severe than a major depressive disorder and may develop when narcissistic individuals cannot live up to their inflated self-image. Acute anxiety reactions can occur when individuals are confronted or challenged with their own incompetence. Somatoform disorders, such as symptoms of somatic symptom disorder and illness anxiety disorder (formerly hypochondriasis) (DSM-5), can occur as a way of excusing or explaining defeats or failures. Paranoid disorders, an unwillingness to accept facts about inadequacy or incompetence, and delusions of persecution may evolve. Individuals are also at especially high risk for anorexia nervosa and substance abuse.

Incidence and Prevalence: Prevalence estimates (based on DSM-IV definitions) range from zero up to 6.2% in community samples (DSM-5).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Narcissistic personality disorder is found in all races. In the US, one-half to three-quarters of individuals with narcissistic personality disorder are men (DSM-5).

Source: Medical Disability Advisor



Diagnosis

History: Narcissistic personality disorder often presents in combination with another personality disorder such as borderline, histrionic, antisocial, or passive-aggressive. This can complicate making the diagnosis.

According to the Diagnostic and Statistical Manual of Mental Disorders, both 4th Edition, Text Revision (DSM-IV-TR) and 5th Edition (DSM-5), individuals with narcissistic personality disorder show a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy beginning by early adulthood and present in a variety of contexts. Five or more of the DSM-IV-TR/DSM-5 criteria need to be met for this diagnosis. These include a grandiose sense of self-importance and expectation of being recognized as superior without commensurate achievements; a preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love; a belief that he or she is "special" and unique and can only be understood by or should associate with other special or high-status people (or institutions); a need for excessive admiration; a sense of entitlement (unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations); interpersonal exploitation (takes advantage of others to achieve his or her own ends); a lack of empathy and an unwillingness or inability to recognize or identify with the feelings and needs of others; envy of others, or a belief that others are envious of him or her; and arrogant, haughty behaviors or attitudes (DSM-IV-TR, DSM-5).

Individuals with narcissistic personality disorder may handle the aging process poorly as they value beauty, strength, and youthful attributes. They have a tendency to frequently seek cosmetic surgery, especially when it is not necessary. Family history may reveal an emotionally distant parent who tried to mold the individual according to the parent's needs. Individuals with narcissistic personality disorder often have trouble forming intimate relationships and are overly sensitive to criticism and disapproval and may be emotionally labile.

Physical exam: The physical exam is not particularly useful in diagnosing this disorder. Observation of the individual's orientation, dress, mannerisms, behavior, and content of speech provide essential clues in diagnosing this illness.

Tests: In conjunction with the individual's history, the psychiatric interview and mental status examination are the main tools leading to diagnosis of this disorder. A variety of psychological tests can be done, including the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and the Eysenck Personality Inventory (EPI), which may help identify and classify personality disorders; however, none of these tests provide a foolproof diagnosis.

A urine toxicology screen should be done, because many individuals with personality disorders are also substance abusers. A screening for sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection, should also be done, because lack of impulse control may put the individual at a higher risk of contracting STDs.

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

Psychotherapy is usually not helpful in treating narcissistic personality disorder because of the individual's inability to renounce his or her narcissism. Dialectical behavioral therapy may be effective in changing the individual's behavior. Pharmacotherapy does not cure the disorder, but can help alleviate symptoms of depression that frequently accompanies it. Mood-stabilizing agents may be helpful for mood swings.

Hospitalization may be needed for individuals who are impulsive or self-destructive or have poor reality testing. These stays should be brief, with treatment specific to the particular symptom involved. Long-term residential treatment may be needed for individuals with poor motivation for outpatient treatment, unstable relationships, chronic destructive behavior, or a chaotic lifestyle. In this situation, individual therapy, family involvement, and a specialized residential environment can provide needed support while psychotherapy tries to solve conflicts. The individual is often contemptuous of the physician, which can make treatment more difficult. Goals for group therapy include helping the individual acknowledge others as separate individuals with their own needs.

Source: Medical Disability Advisor



Prognosis

The outcome depends on the individual's willingness to renounce narcissism and seek treatment. The course of this disorder is chronic and difficult to treat.

Source: Medical Disability Advisor



Complications

Any experience narcissistic individuals may have that results in an attack on their self-esteem can have significant behavioral consequences. The term "narcissistic injury" describes a blow to their godlike perception of themselves. These injuries may include being a victim of infidelity, losing a job, or being turned down for a job, and may result in substance and/or alcohol abuse, and depression. When the individual reacts outwardly to criticism or defeat with disdain, rage, or defiant counterattack, relationship difficulties, accidental injury, suicide, or homicide may occur.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions or accommodations are necessary only for the most serious cases. In these instances, time-limited restrictions and work accommodations should be 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 and/or accommodations is to help maintain the worker's capacity to remain at the workplace without a work disruption or to a promote timely and safe transition back to full work productivity.

Risk: Individuals with narcissistic personality disorder are at risk for exploiting coworkers in their quest to enhance their own standing in the workplace; they are also prone to lying and cheating in an effort to elevate themselves above others. Those who experience narcissistic injury may lash out and cause injury to coworkers or themselves.

Capacity: Capacity is typically unaffected by this disorder, and no disability is expected unless another comorbid personality disorder is present to complicate the diagnosis with potentially disabling symptoms. Because many individuals with personality disorders are also substance abusers, drug testing may be necessary.

Tolerance: Tolerance is usually not a concern. Recovery depends on the individual's willingness to seek treatment and renounce narcissistic tendencies.

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 behavior fit the criteria for narcissistic personality disorder? Has diagnosis been confirmed?
  • Have other personality disorders with similar symptoms been ruled out?

Regarding treatment:

  • If individual is impulsive, self-destructive, or exhibits poor reality testing, would he or she benefit from hospitalization? If hospitalized, was inpatient treatment brief and targeted toward the specific symptom involved?
  • If individual is poorly motivated for outpatient treatment, has fragile object relationships, chronically acts out in a destructive manner or has a chaotic lifestyle, is a residential treatment program indicated?
  • Has health care team been able to establish a trust rapport with individual? If not, what can be done to foster a trusting relationship?
  • Instead of focusing on the crisis symptoms, is the therapist helping individual rebuild a functional self-image?
  • If the individual is not already involved in group therapy, would this be a beneficial adjunct to the current treatment plan?

Regarding prognosis:

  • Are expectations and treatment goals realistic?
  • Does individual appear to be building a healthy self-image?
  • Is the individual learning effective coping skills, or does he or she still rely on self-defeating behavior?

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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