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.

Obsessive-Compulsive Disorder


Related Terms

  • Obsession-compulsion Personality Disorder
  • Obsessive-compulsive Anxiety Disorder

Differential Diagnosis

Specialists

  • Clinical Psychologist
  • Psychiatrist

Comorbid Conditions

  • Depression

Factors Influencing Duration

Duration depends upon response to medications and psychotherapy and the presence of other psychiatric disorders. Although the condition is chronic, there may be exacerbations that require hospitalization or intensive outpatient treatment. Response to treatment, type of job responsibilities, and the individual's insight into OCD could influence the length of disability.

Medical Codes

ICD-9-CM:
300.3 - Obsessive-compulsive Disorders; Anancastic Neurosis; Compulsive Neurosis; Obsessional Phobia, Any

Overview

In the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, (DSM-IV), obsessive-compulsive disorder (OCD) is classified as an anxiety disorder characterized by persistent, intrusive, and inappropriate thoughts, images, or urges that are not pleasurable or experienced as voluntary (obsessions). These intrusions are unwanted and produce marked distress or anxiety in the individual. Obsessions are accompanied by ritualistic, repetitive behaviors (compulsions). These disturbing thoughts and behaviors occupy more than 1 hour each day and can significantly interfere with an individual's normal routine, occupational or academic functioning, social activities, or relationships.

In DSM-5, obsessive-compulsive disorder falls in the category of Obsessive-Compulsive and Related Disorders. Also included in this section in DSM-5 are body dysmorphic disorder, wording disorder, trichotillomania (compulsive pulling out of hair), excoriation (skin picking) disorder, substance/medication induced obsessive-compulsive and related disorder, obsessive-compulsive related disorder due to another medical condition, other specified obsessive-compulsive and related disorder and unspecified obsessive-compulsive and related disorder.

Obsessions are persistent and recurrent thoughts, urges, or images experienced as intrusive and unwanted. Compulsions are repetitive behaviors or mental acts that the person experiencing them feels driven to perform with increasing anxiety/tension related to delay in carrying out the activity.

Common obsessions are fear of contamination by germs or dirt, imagining having harmed self or others, imagining losing control of aggressive urges, intrusive sexual thoughts or urges, excessive religious or moral doubt, forbidden thoughts, a need to have things "just so," or a need to tell, ask, or confess. Common compulsions are washing, repeating, checking, touching, counting, ordering/arranging, hoarding, or praying. Some behaviors, such as gambling, drinking, or sexual activity, are termed "compulsive." Nevertheless, in these cases, the behavior is experienced as pleasurable and is not done to defend against an obsession, so these behaviors would not be considered OCD.

Although OCD and obsessive-compulsive personality disorder are similar names, the manifestations of these disorders are quite different. Individuals with obsessive-compulsive personality disorder do not have intrusive thoughts, images, or urges, nor do they have repetitive behaviors as a response to these intrusions. Instead, obsessive-compulsive personality disorder involves a pervasive and enduring maladaptive pattern of perfectionism and rigid control. Individuals who have symptoms of both OCD and obsessive-compulsive personality disorder may receive both diagnoses (DSM-5).

Incidence and Prevalence: The 12-month prevalence of OCD in the US is 1.2%. The international with prevalence is similar to that in the US. Males are more commonly affected in childhood, and females are affected at a slightly higher rate than males in adulthood (DSM-5).

Source: Medical Disability Advisor



Causation and Known Risk Factors

The cause of OCD is not known but may be related to an insufficient level of a chemical in the brain called serotonin. An individual's risk of developing OCD is slightly higher if a parent or other family member has the disorder. A biological predisposition to react strongly to stress may also trigger the thoughts and rituals associated with OCD, which generally begins during early childhood or adolescence.

Source: Medical Disability Advisor



Diagnosis

History: According the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), individuals with OCD have either obsessions or compulsions. The definition of obsessions includes recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disorder as intrusive and inappropriate and that cause severe anxiety or distress. The thoughts, impulses, or images are not simply excessive worries about real-life problems. The individual tries to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action and recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion). The definition of compulsion includes a repetitive behavior or mental act that the individual feels driven to perform in response to an obsession, or according to rules that must be applied strictly. The goal of the behavior or mental act is the prevention or reduction of distress or the prevention of some dreaded event or situation. However, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are obviously excessive. At some point during the course of the disorder, the individual has recognized that the obsessions or compulsions are excessive or unreasonable.

The obsessions or compulsions produce severe distress, are time consuming (more than 1 hour a day), or significantly interfere with the individual's normal routine, occupational (or academic) performance, or social activities or relationships. In the presence of another axis I disorder, the content of the obsessions or compulsions is not restricted to it. The disorder is not due to the effects of a substance (a drug of abuse, a medication) or a general medical condition. It is necessary to specify if the disorder courses with poor insight (DSM-IV-TR).

According the DSM-5, individuals with OCD have obsessions, compulsions, or both. DSM-5 refers to "obsession and/or compulsion,” but also states, "The characteristic symptoms of OCD are the presence of obsessions and compulsions (Criteria A).”

The definition of obsessions includes recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disorder, as intrusive and unwanted, and that in the majority of the individuals cause severe anxiety or distress particularly if the individual tries to avoid carrying them out. The individual tries to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (a compulsion). The definition of compulsions includes repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. The goal of the behaviors or mental acts is the prevention or reduction of anxiety or distress, or the prevention of some dreaded event or situation. However, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent or are obviously excessive.

The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or produce clinically significant distress or impairment in social, occupational, or other important areas of functioning. The obsessive-compulsive symptoms are not attributable to effects of a substance (a drug of abuse, a medication) or another medical condition. The disorder is not better accounted for by the symptoms of another mental disorder. It is necessary to specify if the disorder courses with good or fair insight, with poor insight, or with absent insight/delusional beliefs. Also, it is necessary to specify if the disorder is tic-related (DSM-5).

About 33% of people with OCD are depressed at the time of diagnosis, and 40% become depressed at some point (Phillips).

Physical exam: A physical exam might show things such as raw, chapped hands from repeated hand washing, or the individual might be observed performing ritualistic actions such as checking and rechecking the position of his or her chair.

Tests: There are no specific diagnostic tests for this disorder. However, positron emission tomography (PET) scans used in the research of OCD may show abnormal metabolism in certain sections of the brain.

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

Medication therapy combined with cognitive-behavioral therapy is the most successful treatment. The most effective group of drugs for treating OCD is the selective serotonin reuptake inhibitor (SSRI) antidepressant group. These medications increase the level of serotonin, a neurochemical messenger, in the brain. Tricyclic antidepressants such as clomipramine may also be used. The most effective, nondrug type of therapy is cognitive-behavioral therapy, which helps the individual learn to change his or her thoughts and feelings by first changing behavior through the techniques of exposure and response prevention (ERP).

The exposure technique is based on the fact that anxiety tends to decrease after repeated exposure to a feared thought or situation. Thus, an individual with obsessions about germs is told to stay in contact with "germy" objects (e.g., handling money) until anxiety disappears. In response prevention, the individual with excessive worries about germs must not only stay in contact with "germy things," but must also refrain from ritualized washing.

Family therapy might be useful, since this disorder is quite stressful to family members. It may be helpful for family members to understand the characteristics of the disorder and the way in which it is most effectively treated. The individual may meet with a psychiatrist or psychologist one or more times a week at the beginning of treatment and then gradually spread out the appointments until a maintenance level of once every 3 to 6 months is reached. Group therapy might also be a useful and cost-effective way to provide cognitive behavioral treatment.

Source: Medical Disability Advisor



Prognosis

Outcome is worse when individuals do not realize their obsessions and/or compulsions are not reality-based. Although up to 25% of patients may refuse cognitive-behavioral therapy. Those who do complete it show a 60% to 80% reduction in OCD symptoms ("How is OCD Treated?").

Source: Medical Disability Advisor



Complications

Suicide could be a risk for those who develop major depression with OCD. Tics or secondary complications, such as skin problems from continuous hand washing, may occur.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work accommodations may include modifying identifiable work situations that provoke symptoms of anxiety including decreasing workplace stimulants such as noise, cigarette smoke, or noxious chemicals, introducing the individual to stressful situations gradually under close supervision and support, providing a flexible work schedule to accommodate medical or psychiatric appointments (which normally should occur during the employee's personal time), allowing break time according to individual needs rather than a fixed schedule, and temporarily adjusting highly stressful activities.

Risk: Individuals with severe OCD may be more prone to making errors at work that can compromise the safety of others by their need to perform time-consuming repetitive behaviors. Consequently, those working in safety- or time-sensitive jobs may require reassignment. However, as it is unlikely that individuals with severe OCD will have met the criteria for this type of employment to begin with, risk is minimal.

Capacity: Capacity is typically unaffected by OCD, as most individuals with the disorder are already successful in working within their psychological comfort zones. However, the persistent performance of time-consuming rituals may affect job productivity.

Tolerance: Tolerance is usually not a concern with this diagnosis unless the individual fails to recognize the existence of a problem and refuses treatment.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is expected at 15 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 meet the criteria for OCD?
  • Has diagnosis been confirmed?
  • Have physiological effects of substance abuse or medication been ruled out?
  • Have underlying neurological and general medical conditions been ruled out?

Regarding treatment:

  • Has individual's treatment included behavioral therapy and drug therapy?
  • What type of medication is individual currently taking?
  • If one SSRI was not effective, would another SSRI give a better response?
  • Would individual benefit from taking an SSRI as the primary medication and another kind of medication to augment it?
  • Does individual's behavioral therapy include exposure and response prevention (ERP)? Would this type of approach be beneficial?
  • Do repeated exposures to the situations or people that trigger the obsessions help individual forego the usual ritual while diminishing the anxiety and discomfort?
  • Does individual currently attend a therapy group?
  • Are coexisting or resultant psychological conditions, such as depression, being appropriately treated?

Regarding prognosis:

  • Is a coexisting depression interfering with treatment?
  • Is therapist trained and experienced in this form of therapy?
  • Is individual highly motivated and faithful in completing homework assignments?
  • Is family cooperative?

Source: Medical Disability Advisor



References

Cited

"How is OCD Treated?" International OCD Foundation. 4 May 2015 <http://iocdf.org/about-ocd/treatment/>.

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.

Phillips, Katharine A., and Dan J. Stein. "Obsessive-Compulsive Disorder (OCD)." Merck Manual: Consumer Version. Jun. 2014. Merck & Co., Inc. 4 May 2015 <http://www.merckmanuals.com/home/mental-health-disorders/obsessive-compulsive-and-related-disorders/obsessive-compulsive-disorder-ocd>.

Source: Medical Disability Advisor






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