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.

Posttraumatic Stress Disorder


Medical Codes

ICD-9-CM:
309.4 - Adjustment Disorder with Mixed Disturbance of Emotions and Conduct
309.81 - Posttraumatic Stress Disorder

Related Terms

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

Overview

In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), posttraumatic stress disorder (PTSD) is included in the section Anxiety Disorders, together with panic disorder without agoraphobia, panic disorder with agoraphobia, agoraphobia without history of panic disorder, specific phobia, social phobia, obsessive-compulsive disorder, acute stress disorder, generalized anxiety disorder, anxiety disorder due to a general medical condition, substance-induced anxiety disorder, and anxiety disorder not otherwise specified.

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), PTSD is included in the section Trauma- and Stressor-Related Disorders, together with reactive attachment disorder, disinhibited social engagement disorder, acute stress disorder, adjustment disorders, other specified trauma- and stressor-related disorder, and unspecified trauma- and stressor-related disorder.

Posttraumatic stress disorder is a complex group of symptoms that includes pathological anxiety. PTSD occurs when an individual is exposed to an extremely traumatic, usually life-threatening situation 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 or 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 coeruleus), 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. 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.

A diagnosis of PTSD is based on criteria listed in the DSM-IV-TR or DSM-5. 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. The event must have been directly experienced, witnessed, and/or involve learning that the traumatic event occurred to a close family member or close friend; and must have involved another person's death or threatened death or threatened the individual or another person with serious injury, sexual violence, or loss of physical integrity. Repeated exposure to details of the traumatic event can also lead to PTSD, but this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related. The individual's response has to be one of intense fear, helplessness, and/or horror. It is very common to see this diagnosis offered in the absence of these 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. For example, a minor physical injury or accident or interpersonal altercation does not meet the diagnostic criteria.

The symptoms must persist for more than 1 month to support the diagnosis of PTSD. In the first 28 days after a trauma, if such symptoms are present, the symptom complex is 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, which 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 may completely replace 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 driving down the freeway 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 elements (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. Although certain symptoms, such as avoidance or apprehension when similar circumstances are encountered, might be present, the individual may not experience other required symptoms. All criteria must be met and may not be overlooked.

In the DSM-5, there are four broad categories of symptomatology: (1) intrusive symptoms, (2) avoidance of stimuli reminiscent of the inciting event, (3) negative alterations in cognitions and mood, and (4) marked alterations in arousal and reactivity, each and all associated with the traumatic event. In DSM IV, the negative alterations category was included in the avoidance category. In DSM-5, 1 symptom from categories 1, 2, and 3 is required, and 2 symptoms from category 4 are required. The symptom complex must be present longer than 1 month, and as with all of the conditions in DSM-5, the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning and cannot be attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Incidence and Prevalence: According to the DSM-IV-TR, the prevalence in groups at risk is about 33% to 50%. Approximately 30% of war combatants, male and female, experience PTSD (Gore). Lifetime prevalence is 8% to 10% (Gore).

Source: Medical Disability Advisor



Diagnosis

History: 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.

According to the DSM-IV-TR, an individual with PTSD has been exposed to a traumatic event in which the individual experienced, witnessed, or was confronted with an event or events that involved death or threatened death or severe injury, or a threat to the physical integrity of the individual or others; the individual's response involved intense fear, helplessness, or horror. The individual re-experiences the event over and over again in at least one of the following ways: having recurrent and intrusive distressing recollections (images, thoughts, or perceptions) of the event; having recurrent nightmares; acting or feeling as if the event were happening again (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, such as those that occur on awakening or when intoxicated); feeling intense psychological distress at exposure to internal or external cues that remind the individual of the event; and having physiological reactions on exposure to internal or external cues that remind the individual of the event.

There is persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following: efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid activities, places, or individuals that arouse traumatic recollections; an inability to recall an important aspect of the event; notoriously diminished interest or participation in significant activities; feelings of detachment or estrangement from others; an inability to relate emotionally to others (restricted range of affect); and a sense of a foreshortened future (the individual does not expect to have a career, marriage, children, or a normal lifespan). There are also persistent symptoms of increased arousal (not present before the trauma), as indicated by at least two of the following: difficulty falling asleep or staying asleep; irritability or outbursts of anger; difficulty concentrating; being constantly anxious and alert because danger is imagined everywhere (hypervigilance); and exaggerated startle response. The symptoms of PTSD last more than 1 month. The disorder causes clinically significant distress or impairment in social, occupational, or other areas of functioning. Symptoms may last less than 3 months (acute PTSD) or 3 months or more (chronic PTSD)may appear at least 6 months after the stressor (delayed onset) (DSM-IV-TR).

According to the DSM-5, an individual with PTSD was exposed to death or threatened death, severe injury, or sexual violence in at least one of the following ways: directly experiencing the traumatic event (or events, as the case may be); witnessing the event as it occurred to others; learning that the event occurred to a family member or friend (in cases of death or threatened death of a family member or friend, the event must have been violent or accidental); or experiencing repeated or extreme exposure to aversive details of the event (this last criterion does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related).

At least one of the following symptoms associated with the event, but beginning after the event occurred, must be present: recurrent, involuntary, and intrusive distressing memories of the event; nightmares in which the content and/or affect of the dream are related to the event; dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the event were recurring (such reactions may occur on a continuum—the most extreme expression is a complete loss of awareness of present surroundings); intense or prolonged psychological distress at exposure to internal or external cues that remind the individual of an aspect of the event; and/or marked physiological reactions to internal or external cues that remind the individual of the event. Beginning after the event occurred, the individual persists in avoiding stimuli associated with the event, as evidenced by one or both of the following: avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the event; and avoidance of or efforts to avoid external reminders (individuals, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the event. There are negative changes in the individual’s cognitions and mood associated with the event, beginning or worsening after the event occurred, as shown by at least two of the following: an inability to remember an important aspect of the event (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs); persistent and exaggerated negative beliefs or expectations about oneself, others, or the world; persistent, distorted cognitions about the cause or consequences of the event that lead the individual to blame himself or herself or others; a persistent negative emotional state (fear, horror, anger, guilt, or shame); notoriously diminished interest or participation in significant activities; feelings of detachment or estrangement from others; and/or a persistent inability to experience positive emotions. The individual shows marked changes in arousal and reactivity, beginning or worsening after the event occurred, as indicated by at least two of the following: irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward individuals or objects; reckless or self-destructive behavior; hypervigilance; exaggerated startle response; problems with concentration; and sleep disturbance (difficulty falling or staying asleep or restless sleep) (DSM-5).

The disorder lasts more than 1 month; produces clinically significant distress or impairment in social, occupational, or other areas of functioning; and is not attributable to the effects of a substance (medication, alcohol) or another medical condition. If the disorder involves dissociative symptoms, in addition to having symptoms meeting the criteria for PTSD given above, the individual experiences either of the following: depersonalization (persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body) and derealization (persistent or recurrent experiences that one’s surroundings are unreal). To use this subtype, the dissociative symptoms must not be attributable to the effects of a substance or another medical condition. Finally, there may be delayed expression of the disorder, if the full diagnostic criteria are not met until 6 months or more after the event, although the onset and expression of some symptoms may be immediate (DSM-5).

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. 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.

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

Treatment for PTSD includes a mix of pharmacologic and nonpharmacologic therapy. Drug therapy consists primarily of antidepressants and beta-blockers and sometimes alpha-blockers (for nightmares). 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, which 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 relationship between the level of trauma and the development of symptoms has been demonstrated.

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Clinical Psychologist
  • Occupational Therapist
  • Psychiatrist

Source: Medical Disability Advisor



Comorbid Conditions

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



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.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work accommodations may include modifying specific environments that trigger memories of or reactions to 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).

Risk: Individuals with PTSD who exhibit symptoms of impaired attention, excessive fatigue, angry outbursts, physical aggression, or reckless behavior may present a risk to themselves and their coworkers. Recurrence is not usually a concern unless the life-threatening traumatic event is related to the individual’s working environment.

Capacity: Capacity is typically unaffected by this disorder, but some individuals may be less productive at work because of reduced coping skills. Individuals with PTSD who normally work in safety-sensitive positions may require temporary job reassignment. Job duties that are predictable, simple, and structured may be the most appropriate.

Tolerance: Tolerance factors include the nature and duration of the traumatic event and the individual’s compliance with treatment. In many cases, participation in job duties may be beneficial to recovery.

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 beta-blockers as prescribed? Have side effects prevented individual from using or benefiting from that particular medication?

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

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.

Gore, Allen T., and Joel Z. Lukas. "Posttraumatic Stress Disorder." eMedicine. 17 Apr. 2014. Medscape. 9 Jun. 2015 <http://emedicine.medscape.com/article/288154-overview#showall>.

Source: Medical Disability Advisor