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.

Phencyclidine Use Disorder


Related Terms

  • Angel Dust Abuse
  • PCP Abuse
  • Phencyclidine Addiction
  • Phencyclidine Dependence

Differential Diagnosis

Specialists

  • Cardiovascular Internist
  • Clinical Psychologist
  • Neurologist
  • Occupational Therapist
  • Physical Therapist
  • Psychiatrist

Comorbid Conditions

Factors Influencing Duration

Length of disability is influenced by the duration and severity of phencyclidine use, the presence or absence of organ damage, any underlying mental illness, other substance use, the individual's social support system, the appropriateness of treatment, the individual's compliance with treatment and motivation to change, and the adequacy of ongoing care.

Medical Codes

ICD-9-CM:
304.60 - Drug Dependence, Other Specified; Unspecified
304.61 - Drug Dependence, Other Specified; Continuous
304.62 - Drug Dependence, Other Specified; Episodic
305.30 - Hallucinogen Abuse; Unspecified
305.31 - Hallucinogen Abuse; Continuous
305.32 - Hallucinogen Abuse; Episodic
305.33 - Hallucinogen Abuse; in Remission

Overview

The phencyclidines—a group of drugs with pain-killing (analgesic), numbing (anesthetic), and dissociative hallucinogenic properties—include phencyclidine (PCP, Sernylan), ketamine, and others. PCP is mainly used in veterinary medicine but has become popular as an illegally obtained recreational drug. These drugs can be taken orally, smoked, or injected intravenously to produce a sensory deprivation syndrome by affecting the central nervous system. Small doses create a feeling of euphoria, whereas larger doses may cause irrational rage and violent actions (suicide, mutilation, assault, or homicide), convulsions (seizures), psychosis, coma, or death. Common street names of phencyclidine are Angel Dust, Ashy Larry, Embalming Fluid, Hog, Illy, Love Boat, Lovely, PeaCe Pil, Rocket Fuel, Sherm, Tranq, Wack, Water, and Wet, reflecting the wide range of effects of the drug.

Phencyclidine intoxication includes behavioral symptoms, such as belligerence, assaultiveness, impulsiveness, psychomotor agitation, unpredictability, or impaired judgment; and clinical symptoms, such as increased blood pressure (hypertension) or heart rate (tachycardia), uncoordinated muscle movements, or hypersensitive hearing (hyperacusis). There are currently no strongly established symptoms of withdrawal for phencyclidines. These behavioral symptoms may be related to disturbances in two brain chemicals, dopamine and serotonin.

Note: For the substance/medication-induced disorders approach established by the DSM-IV-TR, and the DSM-5, please see the following topics: Substance/Medication-Induced Anxiety Disorder, Substance/Medication-Induced Bipolar and Related Disorder, Substance/Medication-Induced Depressive Disorder, Substance/Medication-Induced Major or Mild Neurocognitive Disorder, Substance/Medication-Induced Obsessive-Compulsive and Related Disorder, Substance/Medication-Induced Psychotic Disorder, Substance/Medication-Induced Sexual Dysfunction, and Substance/Medication-Induced Sleep Disorder.

Incidence and Prevalence: Seventy-five percent of emergency department cases involving the use of PCP involve men (DSM-IV-TR). In Canada, PCP is just as popular as in the US; in Mexico, there is not a great demand for artificial hallucinogens due to the large number of available indigenous hallucinogens, such as peyote, psilocybin mushrooms, and psychedelic morning glory seeds (Schmetzer).

The prevalence of phencyclidine use disorder is unknown. About 2.5% of the population reports having ever used phencyclidine. The proportion of users increases with age (DSM-5).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Seventy-two percent of people who use phencyclidine are males, and men from 20 to 40 years old are twice as likely as females of the same age to use phencyclidines (Schmetzer; DSM-IV-TR). About 3% of adolescents of either sex over age 12 have used these drugs at least once, with the highest recent use (0.7%) being in the 12- to 17-year-old age range (DSM-IV-TR). PCP users are more often members of inner-city minority groups than of the middle class (Schmetzer).

Source: Medical Disability Advisor



Diagnosis

History: The guidelines for diagnosis are the same as many stimulant use disorders. Individuals have a problematic pattern of phencyclidine (or a pharmacologically similar substance) use leading to clinically significant impairment or distress, as manifested by 2 or more (as specified in DSM-5) or at least 3 (as specified in the DSM-IV-TR) of the following, occurring within a one-year period:
• Phencyclidine is often taken in larger amounts or over a longer period than was intended.
• There is a persistent desire or failed efforts to reduce or control phencyclidine use.
• Much time is spent in activities necessary to obtain phencyclidine, use phencyclidine, or recover from its effects.
• There is a craving (a strong desire or urge) to use phencyclidine.
• There is recurrent phencyclidine use that results in a failure to fulfill major role obligations at work, school, or home.
• There is continued phencyclidine use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of phencyclidine.
• The individual gives up or reduces important social, occupational, or recreational activities because of phencyclidine use.
• There is recurrent phencyclidine use when it is physically hazardous.
• The individual continues phencyclidine use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by phencyclidine.
• There is tolerance (a need for markedly increased amounts of phencyclidine to achieve intoxication or desired effect, or a markedly diminished effect with continued use of the same amount of phencyclidine).
• Withdrawal symptoms and signs are not established for phencyclidines.
It is also necessary to specify the current severity: mild (presence of 2-3 symptoms), moderate (4-5 symptoms), or severe (6 or more symptoms) (DSM-5).

In individuals who use phencyclidine less often than those with dependence, a maladaptive pattern of phencyclidine use may lead to clinically significant impairment or distress, as manifested by at least 1 of the following occurring within a 1-year period: recurrent use resulting in repeated failure to fulfill major role obligations at school, work, or home because of phencyclidine intoxication; recurrent use when it is physically hazardous; recurrent legal problems related to phencyclidine use (possession, or behaviors resulting from intoxication); and continued use despite persistent or recurrent social or interpersonal problems related to the effects of the substance (behavior while intoxicated, chaotic lifestyle, multiple legal problems, or arguments with significant others). These symptoms should have never met the criteria for phencyclidine dependence.

Because there may be no dramatic physical effects when the drug is withdrawn, the history is of great importance in establishing this diagnosis. Violence, agitation, and bizarre behaviors, such as confused wandering, may lead to multiple emergency room visits or legal and relationship problems. The individual may complain of visual or hearing disturbances or hallucinations.

When determining remission, it is necessary to specify if the phencyclidine use disorder is in early remission or sustained remission, as well as if the individual is in a controlled environment where access to phencyclidine is restricted.

Physical exam: If intoxicated when examined, the individual may exhibit fast, jerky, sideways movements of the eyeballs (nystagmus), hypertension or tachycardia, significantly increased or decreased body temperature, decreased sensitivity to pain, hypersensitive hearing, uncoordinated muscle movements, muscle rigidity, seizures, or coma. Other physical signs of chronic use might be evidence of injuries from accidents, fights, or falls. Needle tracks, hepatitis, HIV, or bacterial endocarditis might be present in individuals who inject phencyclidines intravenously.

Tests: Phencyclidines can be detected in the urine of acutely intoxicated individuals and may be detected for a week or more after use, since these drugs are fat-soluble. Muscle damage from falls and fights might show increased enzyme levels of creatine phosphokinase (CPK) or aspartate aminotransferase (AST). Hair analysis during active use detects PCP and its breakdown products (metabolites). If seizures occur, an electroencephalogram (EEG) may be indicated. Imaging studies are not useful in detecting PCP intoxication.

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

In general, phencyclidine recovery can be described as occurring in 4 phases. Although there are no formally recognized withdrawal symptoms, there is usually a detoxification phase of a few days. During the second phase of abstinence, lasting about a month, the individual focuses on changing his or her behaviors. The early remission phase can last up to 12 months, and the sustained remission phase lasts as long as the individual abstains from phencyclidine use.

Abstinence is the treatment goal. Fatigue, restlessness, and depression may occur several days after quitting the drug. Although antidepressant medications can be helpful in combating the depressive symptoms, severely depressed individuals may become suicidal. For this reason, chronic users may need to be hospitalized during drug withdrawal.

Individuals generally benefit from being sedated with benzodiazepines because it not only helps to calm them down but it also prevents seizures. For individuals who experience delusions or hallucinations (lasting beyond 1 to 3 days), antipsychotic medications may be given to calm and relieve distress. Although haloperidol has been used in the past, atypical antipsychotic medication (e.g., short-acting injectable ziprasidone and olanzapine, quick-dissolving olanzapine and risperidone) is now preferred before traditional antipsychotic medication because of reduced extra-pyramidal signs (Schmetzer). Individuals in this condition often benefit from psychiatric hospitalization.

The most effective treatments for phencyclidine dependence appear to be addiction care and support groups. These interventions are designed to help modify the individual's thinking, expectancies, and behaviors, and to increase coping skills for various life stressors. Early treatment following detoxification, which usually occurs in an outpatient setting, may include education on physical, emotional, and mental aspects of addiction and recovery; identification of stressors and stress management skills; improved coping skills; assertiveness training; relaxation training; or individual or family psychotherapy. Ongoing, structured self-help programs (e.g., Narcotics Anonymous, Rational Recovery) are recommended as an adjunct to treatment services. Regular but random drug screens may be part of the treatment process.

Source: Medical Disability Advisor



Prognosis

Many individuals respond to treatment and stay in remission from phencyclidine use disorder for many years. However, some individuals experience periods of relapse, in which they begin using phencyclidine after a period of remission, and again meet the criteria for phencyclidine use disorder. There are other individuals who are never able to abstain from substance use and who do not experience any periods of remission. Individuals who are able to develop new relationships, and who consistently make use of self-help groups, are more likely to experience continued abstinence and achieve improvement in social and occupational functioning.

Factors usually associated with a more favorable outcome include a good occupational history, a group of supportive family and friends, older age at first use, motivation to change, lack of a criminal or antisocial lifestyle, and good psychosocial adjustment. Most phencyclidine users quit using the drug once they reach adulthood (62% of individuals abusing phencyclidine are aged 20-29 years) (Schmetzer).

Overdose can cause coma and death.

Source: Medical Disability Advisor



Rehabilitation

In addition to phencyclidine use disorder treatment and support groups, physical therapy might be helpful if the individual has chronic problems with gait and balance and if the individual has become deconditioned due to inactivity during the period of addiction and early recovery. Occupational therapy could assist the individual in developing communication skills, identify and match personal skills and work habits to the workplace, and learn how participation in leisure activities unrelated to drug use contributes to overall health and well-being.

Source: Medical Disability Advisor



Complications

Other psychiatric illnesses may complicate treatment of phencyclidine use, and the substance use disorder complicates treatment of the other illness (dual diagnosis). About one-half of those with bipolar mood (affective) disorder or schizophrenia are thought to have drug or alcohol problems. Those with post-traumatic stress disorder (PTSD) also are likely to have substance use disorders. The individual may experience psychological problems, including disinhibition, anxiety, rage, aggression, panic, or flashbacks. Medical problems may include fever (hyperthermia), tachycardia, hypertension, or seizures. Intravenous use may lead to skin infections, bacterial endocarditis, HIV, or hepatitis. Respiratory problems might include bronchospasm, periods of not breathing (apnea), or aspiration during coma. Kidney (renal) impairment may be seen in a small number of those seeking emergency care. Patients with PCP use problems may have continued psychosis and flashbacks.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Many employers have systems in place for individuals recovering from substance use disorders to return to work under special contracts or conditions. These conditions may provide guidelines for random testing of blood and urine levels of identified substances and provide work performance and substance use disorder treatment guidelines for the recovering individual.

Temporary work accommodations may include reducing or eliminating activities in which the safety of self or others is contingent upon a constant and/or high level of alertness, such as driving motor vehicles, 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 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 a timely and safe transition back to full work productivity.

If the individual has medical complications from phencyclidine use disorder, he or she may need to be restricted to sedentary activities.

Risk: An individual with phencyclidine use disorder may display a general lack of judgment that presents a safety risk for both the individual and his or her coworkers, even when not using the drug; therefore, such individuals must be closely monitored and should be prevented from performing safety-sensitive work tasks. Risk of recurrence may be reduced by scheduling regular yet random blood and/or urine tests to ensure compliance with the work contract, and by encouraging attendance in substance use treatment and support groups during the individual’s personal time.

Capacity: Capacity may be temporarily reduced if the individual has injuries from accidents, fights, or falls sustained while using the drug, but capacity is usually unaffected unless the individual comes to work while intoxicated, in which case he or she should be prevented from working.

Tolerance: Tolerance is typically not a concern with this diagnosis.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is expected at 3 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:

  • Did individual's evaluation include detailed history of past and present substance use, including its effects on cognitive, psychological, behavioral, and physiologic functioning? General medical and psychiatric history and examination? History of prior psychiatric treatments with outcomes? Family and social history? Screening of blood, breath, or urine for abused substances? Other laboratory tests to help confirm the presence or absence of comorbid conditions frequently associated with substance use disorders? If not, what areas were omitted?
  • Would this information affect the current treatment plan? What changes should be made?
  • Have all underlying medical and psychiatric disorders been identified or ruled out?

Regarding treatment:

  • Since phencyclidine use disorder may lead to irrational or violent behavior and multiple emergency room visits before individual is ready to seek treatment for substance use disorder, what brought individual to treatment this time?
  • Does treatment include detoxification, psychiatric and addiction care, and regular attendance at support groups such as Narcotics Anonymous or Rational Recovery?
  • Has individual experienced any psychotic symptoms?
  • Was drug therapy effective?
  • Would individual benefit from psychiatric hospitalization?
  • Is individual involved in an addiction program?
  • Does this therapy appear to be helping to modify the individual's thinking, expectancies, and behaviors, and increase coping skills for various life stressors?
  • Does individual's treatment plan consider all underlying psychiatric or general medical conditions, sex-related factors (including the possibility of pregnancy), social and living environment, cultural factors, and family characteristics? If current treatment plan does not take these factors into consideration, what changes could be made to better meet this individual's needs?
  • Is individual currently in a period of high relapse risk, such as the early stages of treatment, periods of transition to less intensive levels of care, or the first year after completion of active treatment? Is an intensive monitoring system for substance use in place during these periods of high relapse risk?
  • Are individual's needs being effectively met?

Regarding prognosis:

  • Does individual participate in a formal support group that provides the external support and motivation to continue in treatment beyond the initial stage of detoxification?
  • Is individual currently involved in a support group, such as Narcotics Anonymous or Rational Recovery?
  • What other support systems does individual have in place? Family? Friends?
  • Is individual improving in social and occupational functioning?
  • Does individual have the necessary tools, skills, and encouragement to move ahead with his or her life?

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.

Schmetzer, Alan D., et al. "Phencyclidine (PCP)-Related Psychiatric Disorders." eMedicine. 3 Oct. 2013. Medscape. 4 May 2015 <http://emedicine.medscape.com/article/290476-overview>.

Source: Medical Disability Advisor






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