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.

Post-traumatic Stress Disorder


Related Terms

  • Chronic Post-traumatic Stress
  • Extreme Stress Response
  • Posttraumatic Stress Disorder
  • PTSD

Specialists

  • Clinical Psychologist
  • Occupational Therapist
  • Psychiatrist

Factors Influencing Duration

Factors that influence outcome and lengthen disability include previous trauma, poor or marginal levels of functioning before the diagnosis of PTSD, the presence of any other psychiatric disorders, previous or current substance abuse, lack of a support system, reluctance to get appropriate treatment, the individual’s response to medications and psychotherapy, and the persistence of denial regarding the event or its consequences. Recurrence of symptoms can also be triggered by new stressors.

Medical Codes

ICD-9-CM:
309.81 - Posttraumatic Stress Disorder

Overview

Post-traumatic stress disorder (PTSD) is a complex group of symptoms that includes pathological anxiety. PTSD occurs when an individual is exposed to an extremely traumatic, usually life-threatening stressor such as military combat or a violent personal assault. This traumatic event is outside the individual's normal realm of experience and overwhelms the individual's usual psychological defenses. In PTSD, the memory of the trauma is repeatedly experienced in ways that are nearly as distressing as the original trauma. PTSD can be acute, chronic, or occur with delayed onset. PTSD symptoms are believed to develop in some individuals when traumatic stimuli activate structures in the brain (primarily the amygdala, and also the hypothalamus and locus ceruleus), leading to fear conditioning and increased autonomic neurotransmitter and endocrine activity.

It is not known why some individuals develop PTSD and others sharing the same experience do not. For example, of all Vietnam War veterans, only a fraction of the combatants developed PTSD. The same is true across a wide spectrum of survivors of violence or violent situations (accident victims, battered spouses, hostages, or prisoners of war). Among civilians, a higher proportion of rape victims develop PTSD than those who suffer any other traumatic event (Paige). Personality factors can either promote emotional resilience after a trauma or predispose the individual to significant impairment. The prevailing belief is that every individual, however well-adjusted, has a point of tolerance that, if exceeded, will result in PTSD. For example, wounded veterans have 5 times the likelihood of later developing PTSD than their uninjured comrades. Of all identified risk factors for PTSD, the most important is believed to be the lack of a supportive network of friends and family. Cultural aspects, such as the belief that it is dishonorable to reveal instances of torture, may affect an individual's willingness to seek help for PTSD symptoms.

The traumatic events most often associated with PTSD in men are rape, combat exposure, childhood neglect, and childhood physical abuse. In women, the traumatic events most likely to precede PTSD are rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse.

A diagnosis of PTSD is based on criteria listed in the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision). The history, psychiatric interview, and mental status exam of an individual who has experienced or witnessed a traumatic event will help establish whether the individual's response or behavior meets the diagnostic criteria from the DSM-IV-TR. The event must have involved another person’s death or must have threatened the individual or another person with serious injury or loss of physical integrity. The individual's response is one of intense fear, helplessness, and / or horror. It is very common to see this diagnosis offered in the absence of this stressor criteria being met. It is important to evaluate the context under which a claim of PTSD is being made. In the medicolegal arena, for example, it is important to consider the possibility that symptoms are merely being represented as present, rather than truly an issue. For example, a minor physical injury or accident or interpersonal altercation does not meet the diagnostic criteria.

Persistent avoidance of stimuli associated with the trauma should include three or more of the following in order to comply with diagnostic criteria: efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid activities, places, or people that arouse recollections of the trauma; the inability to recall an important aspect of the trauma; markedly diminished interest or participation in significant activities; a feeling of detachment or estrangement from others; an inability to relate emotionally to others (restricted range of affect or warmth toward others); and a sense of a foreshortened future in which the individual does not expect to have a career, marriage, children, or normal lifespan.

At least two or more of the following symptoms occur with PTSD: difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, or exaggerated startle response. These symptoms were not present before the trauma and result in a significant decline in social or occupational functioning. The symptoms must persist for 1 month to support the diagnosis of PTSD. In the first 28 days after a trauma, if such symptoms are present, they are termed acute stress reaction, not PTSD. If the symptoms do not appear until 6 months after the original event, it is considered PTSD with delayed onset. In this case, a second, lesser traumatic event may have added to and reinforced the original trauma.

Individuals with PTSD must show evidence of preoccupation with the original trauma. This may take any of several forms such as recurrent nightmares or frequently feeling as if the event is happening again or is just about to happen. In the most dramatic case, the event is vividly re-experienced as a flashback that completely replaces normal awareness (a form of dissociation). More typically, this preoccupation takes the form of intrusive memories and thoughts that constantly compete with normal attention and are triggered by cues that remind the individual of the trauma. Bodily signs of anxiety may accompany these cues. As a result, performance of even simple tasks such as freeway driving may become impossible. In an effort to ward off painful memories and feelings, victims of PTSD begin to avoid situations that remind them of the trauma. They may pretend the trauma never happened (denial). In attempting to forget the trauma, they may forget important pieces (repression). As the severity of PTSD increases, this process becomes more generalized.

Just as a serious stressor is required to warrant the diagnosis, the other criteria are required. For example, there are many examples of individuals who have undergone life-threatening events who do not have PTSD. While certain symptoms such as avoidance or apprehension when reminding circumstances are encountered might be present, the individual may not experience other required symptoms. All criteria must be met and may not be overlooked.

Incidence and Prevalence: According to the DSM-IV-TR, the prevalence in groups at risk is about 33% to 50% (466). Approximately 30% of war combatants, male and female, experience PTSD (Gore). A national study of comorbidity reveals an overall lifetime prevalence of 5% in males and 10.4% in females (Brand).

Source: Medical Disability Advisor



Causation and Known Risk Factors

PTSD can occur in individuals of all ages, with females at higher risk than males. The risk of PTSD is highest among war combatants; victims of criminal or domestic violence; victims of rape, incest, or molestation; victims of childhood physical or mental abuse; and victims of natural disasters (Gore). Research has shown a direct relationship between trauma severity and risk for developing PTSD (de Quervain). Research has also shown a cumulative effect, in which repeated traumatic events seem to make it more likely an individual will develop PTSD.

Source: Medical Disability Advisor



Diagnosis

History: Symptoms reported by individuals with PTSD include being constantly anxious and alert because danger is imagined everywhere (hypervigilance), irritability, sleep disturbance, an inability to concentrate, an impaired ability to express emotion, self-destructive and impulsive behavior, and the sensation of losing awareness of self and not remembering what one has done or said for extended periods of time (dissociative symptoms). Individuals may report physical complaints such as indigestion, headaches, and fatigue. They may have feelings of ineffectiveness, shame, despair, or hopelessness and feel permanently damaged. Individuals can experience a loss of previously sustained beliefs and become socially withdrawn or have impaired relationships with others. A complete health history may be obtained to assess the influence of previous illness, abuse, or injury.

Physical exam: The exam may reveal evidence of previous trauma or injury; signs of a physical trauma such as burn scars, abrasions, or contusions; or an increased rate of somatic complaints. A complete physical may be performed to evaluate health status and rule out underlying illness.

Tests: No specific tests are indicated to diagnose PTSD, but there are some psychological tests available that can help support the conclusion that PTSD is present. Autonomic functioning may be evaluated by monitoring heart rate or sweat gland activity. Cortisol levels may be decreased if measured, and norepinephrine and epinephrine levels may be increased. Evidence of impaired attention and concentration may be present, or the range of expressed emotion or affect may be considerably reduced. Individuals may be unreceptive to humor. Psychological testing can help in substantiating the diagnosis but cannot be used as the sole diagnostic tool. A few tests are designed specifically to detect PTSD, but they have mostly been used with combat veterans. Increased arousal may be measured through studies of autonomic functioning such as heart rate, electromyography, or sweat gland activity.

Source: Medical Disability Advisor



Treatment

Treatment for PTSD includes a mix of pharmacologic and nonpharmacologic therapy. Drug therapy consists primarily of antidepressants and beta-blockers, although research has indicated promising results with glucocorticoid treatment (de Quervain). In general, non-pharmacologic treatment consists of individual, family, and group psychotherapy, as well as cognitive behavioral therapy. Retelling of the event is encouraged, especially in groups composed of fellow trauma victims. PTSD and other anxiety disorders are frequently treated by desensitization and related techniques. Desensitization includes repeated exposure to a feared thought or situation based on the fact that anxiety tends to decrease after such exposure. The most successful treatment interventions are those implemented immediately after a civilian disaster or war zone trauma. This type of treatment is referred to as critical incident stress debriefing. Every effort should be made to develop the individual's social support network. Unfortunately, many individuals in the early phases of PTSD assume their symptoms will resolve with time and do not seek attention until much later, when the symptoms are more entrenched.

Source: Medical Disability Advisor



Prognosis

Outcomes vary greatly. Most individuals subjected to events outside the normal realm of human experience never become symptomatic. Complete recovery occurs within 3 months in about 50% of the cases of PTSD, but others have symptoms lasting longer than 12 months after the trauma. Some individuals improve, but new stress may cause PTSD symptoms to recur. Patients who receive treatment generally need only 36 months to recover, whereas those without treatment take 64 months to recover; more than one-third of individuals diagnosed with PTSD never get better (Gore). The prognosis improves for individuals who were functioning at a high level prior to the onset of symptoms, have no other mental illness and seek treatment early, have a good social network of family and friends, and are not exposed to trauma again.

Prognosis may also be affected by the nature and duration of the trauma. A direct result between the level of trauma and the development of symptoms has been demonstrated.

Source: Medical Disability Advisor



Complications

Significant disruption of relationships is a common complication, along with high rates of unemployment, divorce, and substance abuse. Those complications may result from irritability, isolation, anger, and compromised coping skills in general. A number of psychiatric disorders may appear, including generalized anxiety, major depression, and panic attacks. Individuals with any of these disorders are at particularly high risk for suicide.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work accommodations may include modifying specific environments that trigger memories or reactions of the original stressor, introducing the individual to new or stressful situations gradually under close supervision and support, providing some flexibility in scheduling for medical therapy appointments, allowing work-at-home or job-sharing opportunities, providing conflict resolution mechanisms, providing guidelines for feedback on problem areas and proactive management of problem areas, and reducing or eliminating activities in which the safety of the self and / or others is contingent upon constant and / or high levels of alertness (e.g., driving or operating machinery).

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 meet all the criteria for PTSD?
  • Has diagnosis been confirmed?
  • Have other psychiatric disorders or underlying medical conditions been ruled out?

Regarding treatment:

  • Based on the fact that anxiety tends to decrease after repeated exposure to a feared thought or situation (desensitization), has individual been encouraged to retell the experience, especially in groups composed of fellow trauma victims?
  • Would individual benefit from more frequent therapeutic encounters or additional types of therapy?
  • Has individual taken antidepressants and / or sedatives as prescribed? Have side effects prevented individual from using or benefiting from that particular medication?
  • Has glucocorticoid treatment been tried?

Regarding prognosis:

  • Although individual showed initial improvement, has a new stress triggered a period of recurring PTSD symptoms?
  • Has a subsequent trauma intensified the effects of the initial event?
  • How are current stresses being dealt with?
  • How were major stresses dealt with in the past? If healthy and adaptive methods were used in the past, are they being used currently?
  • If coping methods are maladaptive, such as drug or alcohol abuse, to what extent are these conditions causing additional problems?
  • Who are individual's social supports? Family? Friends? Church or other community affiliations? Are they being utilized?
  • What is happening at work or outside work that may contribute to the problem?
  • Are there incentives not to improve, such as ongoing litigation, Social Security, or disability insurance?

Source: Medical Disability Advisor



References

Cited

Brand, Bethany. "Trauma and Women." Psychiatric Clinics of North America 26 3 (2003): 759-779.

de Quervain, D. J., and J. Margraf. "Glucocorticoids for the Treatment of Post-traumatic Stress Disorder and Phobias: A Novel Therapuetic Approach." European Journal of Pharmacology 365-371.

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

Gore, Allen T., and Georgianna Richards. "Posttraumatic Stress Disorder." eMedicine. Eds. Denis F. Darko, et al. 18 Dec. 2008. Medscape. 18 Mar. 2009 <http://emedicine.medscape.com/article/288154-overview>.

Paige, Stephen. "Post-traumatic Stress Disorder." eMedicine Health. Eds. Ronald C. Albucher, et al. 29 Nov. 2005. WebMD, LLC. 18 Mar. 2009 <http://www.emedicinehealth.com/post-traumatic_stress_disorder_ptsd/page13_em.htm>.

Source: Medical Disability Advisor






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