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.

Panic Disorder with Agoraphobia


Related Terms

  • Fear of Open Spaces

Differential Diagnosis

Specialists

  • Clinical Psychologist
  • Internal Medicine Physician
  • Occupational Therapist
  • Physical Therapist
  • Psychiatrist

Comorbid Conditions

Factors Influencing Duration

Length of disability is influenced by the duration and severity of the panic attacks and agoraphobia, any underlying mental illness, substance abuse, the individual's social support system, appropriateness of treatment choice, response to medications, compliance with treatment, and adequacy of ongoing care.

Medical Codes

ICD-9-CM:
300.21 - Agoraphobia with Panic Disorder; Panic Disorder with Agoraphobia

Overview

Agoraphobia is the fear of being alone in any place or situation from which escape might be difficult or embarrassing or where help may be unavailable should the need arise. Most individuals with agoraphobia develop the disorder after first suffering from one or more spontaneous panic attacks. Panic disorder with agoraphobia is characterized by recurrent, unexpected panic attacks brought on by being in an open place usually one that is unfamiliar. This is followed by persistent concern about having another attack, worries about the consequences of the attacks, or a behavioral change related to the attacks. A panic attack is the sudden onset of feelings in the absence of real danger of intense apprehension, fearfulness, terror, or a sense of impending doom.

Panic attacks occur suddenly, build quickly in intensity, and frequently dissipate within 15 to 60 minutes. Panic attacks with agoraphobia include feelings of anxiety about being in places or situations where escape is thought to be difficult. Individuals with panic attacks and agoraphobia are fearful of leaving home, as the attacks are often triggered by being alone in public. Typically, panic attacks occur when standing in line or traveling in a bus or airplane, where help may be unavailable or escape is thought to be impossible. Examples of feared situations are being in a sports stadium during an event, shopping mall, or other crowded situations.

Incidence and Prevalence: The incidence of panic attack is approximately 1% to 2% of the population but can be up to 10% in those hospitalized for mental disorders or 60% of those in cardiology clinics. About one-third of individuals diagnosed with panic disorder also have agoraphobia.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Age at onset is usually between the late teens and mid-30s.

Source: Medical Disability Advisor



Diagnosis

History: Individual reports a history of recurrent panic attacks that includes at least four of the following: a pounding heart, sweating, trembling, shortness of breath or suffocating, choking, chest pain, nausea, dizziness, feelings of unreality, fear of going crazy, fear of dying, numbness, or chills. Onset of the attack is sudden with symptoms peaking in 10 minutes or less. There is chronic worry about having another attack or that the attacks indicate a serious medical or mental disease. Agoraphobia is the additional fear about being in a public place and experiencing a panic attack with the belief that help would be unavailable and escape from this situation difficult or embarrassing. The fear leads to consistently avoiding those situations.

If accompanied by someone they trust, individuals may be able to expose themselves to the situation, but not without difficulty. The panic attacks are judged not directly due to drug abuse, a medical condition (i.e., an overactive thyroid gland), or side effects of medication. The panic is not explained by other anxiety disorders such as a specific phobia or social phobia, obsessive-compulsive disorder, post traumatic stress disorder (PTSD), or separation anxiety disorder.

Physical exam: The exam if performed during a panic attack can demonstrate a rapid heart rate and elevated blood pressure. Observation of the individual's orientation, dress, mannerisms, behavior, and content of speech may provide signs helpful in diagnosis.

Tests: Tests do not help establish this diagnosis although personality tests such as the Minnesota Multiphasic Personality Inventory may indicate anxiety and specific fears. Anxiety scales may be useful in determining response to treatment.

Source: Medical Disability Advisor



Treatment

Panic disorder with agoraphobia is treated with both drug therapy and cognitive-behavioral therapy. Medications can control the panic experienced during phobic situations as well as the anxiety aroused by anticipation of the situation and usually include the administration of a selective serotonin reuptake inhibitor (SSRI) along with some use of a benzodiazepine. Tricyclic antidepressants or MAO inhibitors are occasionally prescribed. A benzodiazepine can be used in the first weeks of treatment to help the individual calm down until the antidepressant becomes effective; however, it should only be used for short periods of time because of the risk of abuse and dependence. Safety and effectiveness plus the personal needs and preferences of the individual determine what drug is used.

Medication produces not only a pharmacologic effect, but also alleviates anxiety by breaking the cycle of attacks. This gives the individual confidence that the condition is controllable, which further decreases the frequency of attacks. Consequently, medication may only be needed on a short-term basis.

The goal of cognitive therapy is to suggest that panic is a misinterpretation of body sensations and that the danger is not as extreme as perceived. Cognitive-behavioral therapy teaches the individual effective ways to reduce anxiety and view fearful situations differently. It is estimated that appropriate treatment by an experienced professional can reduce or prevent panic attacks in 70% to 90% of cases. Individuals with panic disorder are often unaware of the distortions in their thinking that can cause the fear cycles.

Cognitive-behavioral therapy can help individuals recognize their earliest thoughts and feelings in the panic cycle, eliminate thought patterns contributing to symptoms, and change their behavior. Cognitive-behavioral therapy may also involve "interoceptive exposure" where the individual is encouraged to artificially bring on the symptoms experienced during a panic attack. The individual is then taught to cope effectively with these sensations.

Exposure therapy is a useful treatment where the individual is exposed little by little to the dreaded situation. Relaxation training and progressive muscle relaxation can also be performed along with respiratory control training. For example, diaphragmatic breathing helps counteract hyperventilation.

Many therapists include homework and specific readings (bibliotherapy) for the individual to do between sessions. Since the individual may only spend a few sessions in one-on-one contact with a therapist, this method allows the individual to continue to work on his or her own with the aid of a printed manual.

Psychodynamic treatment refers to another "talk therapy" where the therapist and individual work together to uncover underlying emotional conflicts. Although this type of therapy may help relieve the stress that contributes to panic attacks, there is no scientific evidence this form of therapy by itself is effective in overcoming panic disorder or agoraphobia. However, if a panic disorder occurs along with another emotional disturbance, psychodynamic therapy may be a helpful addition to the overall treatment plan.

Therapy groups can also be beneficial. In weekly meetings, the group discusses progress, exchanges encouragement, and receives guidance from the therapist.

Source: Medical Disability Advisor



Prognosis

Outcome is variable. The panic attacks may come and go over the years. Early treatment of panic disorder can help prevent the development of agoraphobia. Prognosis worsens as the individual gradually constrains their mobility and develops a support system around the maintenance of symptoms.

The agoraphobia may subside if the panic attacks subside but not necessarily. Although many individuals show significant progress after a few weeks of therapy, cognitive-behavioral therapy generally requires at least 8 to 12 weeks. However, some individuals may need longer to learn and implement skills. Some studies show that after 6 to 10 years in tertiary care settings, 30% of individuals have no symptoms. About 40% to 50% are better but have some symptoms, and around 20% to 30% have the same or slightly worsened symptoms.

Source: Medical Disability Advisor



Complications

Staying at home can often result in a loss of most relationships and employment. Some individuals may become convinced they are "going crazy" and so limit their activities even further. Approximately 20% of individuals with panic disorder attempt suicide.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Temporary work accommodations may include reducing or eliminating activities where the safety of self or others is contingent upon a constant and / or high level of alertness, such as driving a motor vehicle, operating complex machinery, or handling dangerous chemicals; introducing the individual to new or stressful situations gradually under individually appropriate supervision; allowing some flexibility in scheduling to attend therapy appointments (which normally should occur during the employee's personal time); promoting planned, proactive management of identified problem areas; and offering timely feedback on job performance issues.

It will be helpful if accommodations are documented in a written plan designed to promote timely and safe transition back to full work productivity. Situations and settings bringing on feelings of agoraphobia should be avoided if possible.

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 the individual fit the criteria for panic disorder with agoraphobia?
  • Has diagnosis been confirmed?
  • Have coexisting psychological disorders been ruled out?
  • Have medical conditions with similar symptoms been ruled out?

Regarding treatment:

  • If the individual is not responding effectively to current medication, what other drug options are available?
  • Is therapist trained and experienced in cognitive-behavioral therapy?
  • Has individual learned to recognize early thoughts and feelings in the panic cycle?
  • Has individual learned to eliminate thought patterns that contribute to panic behavior?
  • Does therapy incorporate interoceptive exposure? Through repeated, controlled exposure experiences, has individual learned to cope effectively with sensations that bring on a panic attack?
  • Does the individual's current therapy program include in vivo or real-life exposure therapy?
  • Is the therapist willing and able to go to the individual's home to conduct sessions?
  • Has individual learned relaxation techniques to reduce anxiety and stress leading to a panic attack?
  • Would individual benefit from psychodynamic therapy in order to uncover underlying emotional conflicts?

Regarding prognosis:

  • Has the individual been involved in the current form of treatment for over 6 weeks without a noticeable effect? Has the treatment plan been reassessed?
  • Would the individual benefit from extended therapy?
  • Are coexisting conditions such as substance abuse (both intoxication and withdrawal states) or depression interfering with treatment? Are these conditions being appropriately addressed?
  • Does individual have a functional support system?
  • Besides family and one-on-one therapy support, is individual currently involved in a therapy group?

Source: Medical Disability Advisor



References

General

Crone, Catherine, and Geoffrey Gabriel. "Herbal and Nonherbal Supplements in Medical-Psychiatric Patient Populations." Psychiatric Clinics of North America 25 1 (2002): 211-230. MD Consult. Elsevier, Inc. 23 May 2005 <http://home.mdconsult.com/das/journal/view/47425872-4/N/12227698?sid=268529641&source=MI>.

Frances, Allen, ed. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000.

Larzelere, Michele M., and Pamela Wiseman. "Anxiety, Depression, and Insomnia." Clinics in Office Practice 29 2 (2002): 339-360. MD Consult. Elsevier, Inc. 23 May 2005 <http://home.mdconsult.com>.

Zamorski, Mark A. "What to Do When SSRIs Fail: Eight Strategies for Optimizing Treatment of Panic Disorder." American Family Physician 66 8 (2002): 1477-1484. MD Consult. Elsevier, Inc. 23 May 2005 <http://home.mdconsult.com>.

Source: Medical Disability Advisor






Feedback
Send us comments, suggestions, corrections, or anything you would like us to hear. If you are not logged in, you must include your email address, in order for us to respond. We cannot, unfortunately, respond to every comment. If you are seeking medical advice, please contact your physician. Thank you!
Send this comment to:
Sales Customer Support Content Development
 
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is published with the understanding that the author, editors, and publisher are not engaged in rendering medical, legal, accounting or other professional service. If medical, legal, or other expert assistance is required, the service of a competent professional should be sought. We are unable to respond to requests for advice. Any Sales inquiries should include an email address or other means of communication.