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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.

Somatic Symptom Disorder


Text Only Home | Graphic-Rich Site | Overview | Risk and Causation | Diagnosis | Treatment | Prognosis | Differential Diagnosis | Specialists | Comorbid Conditions | Complications | Factors Influencing Duration | Length of Disability | Duration Trends | Ability to Work | Maximum Medical Improvement | Failure to Recover | Medical Codes | References

Medical Codes

ICD-9-CM:
300.81 - Somatization Disorder; Briquets Disorder; Severe Somatoform Disorder
306.1 - Physiological Malfunction Arising from Mental Factors, Respiratory; Psychogenic: Air Hunger, Cough, Hiccough, Hyperventilation, Yawning
306.2 - Physiological Malfunction Arising from Mental Factors, Cardiovascular; Cardiac Neurosis; Cardiovascular Neurosis; Neurocirculatory Asthenia; Psychogenic Cardiovascular Disorder

Related Terms

  • Briquet's Disorder
  • Briquet's Syndrome
  • Hysteria

Overview

In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), somatization disorder falls under the classification of Somatoform Disorders, together with undifferentiated somatoform disorder, conversion disorder, pain disorder, hypochondriasis, body dysmorphic disorder, and somatoform disorder not otherwise specified (DSM-IV-TR).

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) no longer recognizes somatization disorder, and instead proposes the diagnosis of somatic symptom disorder for individuals that in the past would have received the diagnosis of somatization disorder. The change in DSM-5 reduces ambiguity, clarifying the boundaries of diagnoses by recognizing the overlap across the somatoform disorders in DSM-IV. In the DSM-5, somatic symptom disorder is included in the new category called Somatic Symptom and Related Disorders, together with illness anxiety disorder, conversion disorder (now called functional neurological symptom disorder), psychological factors affecting other medical conditions, factitious disorder (includes factitious disorder imposed on self, and factitious disorder imposed on another), other specified somatic symptom and related disorder, and unspecified somatic symptom and related disorder (DSM-5).

According DSM-IV-TR, somatoform disorders in general are characterized by physical complaints lacking a known physical (organic) basis, and somatization disorder in particular is characterized by many somatic symptoms that cannot be explained adequately on the basis of physical and laboratory examinations. It begins early in life, affecting mostly women, and is characterized by recurrent multiple complaints involving most organ systems. The physical complaints, often dramatically described, are unexplained and typically include pain, anxiety and mood-related symptoms; gastrointestinal disturbance; and genitourinary symptoms. For a symptom to be significant, the individual may report that it caused him or her to take a medicine, alter his or her life pattern, or see a physician (DSM-IV-TR).

This centrality of medically unexplained symptoms is essential to somatic symptom disorder but, according to DSM-5, must be attended by high levels of worry about illness, and thoughts, feelings, and behaviors that are disproportionally excessive. Followed long-term, individuals are shown to have an excessive number of surgeries. They develop both anxiety and depression and have a history of suicidal threats, occupational difficulties, and marital discord. This disorder is considered chronic and is associated with impairment in the individual's social and occupational functioning. Although the cause is unknown, it is thought that development of symptoms may be a way to make social contact, to avoid obligations, to express emotions, or to symbolize a feeling or belief.

Incidence and Prevalence: Somatization disorder is not uncommon. Reported lifetime prevalence rates range from 0.2% to 2% in women and less than 0.2% in men (DSM-IV-TR).

Although the prevalence of somatic symptom disorder is not known, it is expected to be higher than that of the more restrictive DSM-IV-TR somatization disorder (<1%) but lower than that of undifferentiated somatoform disorder (about 19%). The prevalence in the general adult population may be 5% to 7%. Females tend to report more somatic symptoms than do males, and the prevalence of the disorder is consequently likely to be higher in women (DSM-5).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Somatization disorder often begins in the teenage years. Social, ethnic, and cultural factors may be involved in the development of symptoms. The disorder is observed in 10% to 20% of first-degree female relatives (mother, sisters, or daughters) of women with somatization disorder (DSM-IV-TR). Females are 10 times more likely than males to be afflicted with somatization disorder. First-degree male relatives of individuals with somatization disorder show an increased prevalence of both antisocial personality disorder and alcoholism. About 50% of individuals with somatization disorder have a coexisting mental disorder. Somatization disorder has been reported to be more prevalent in rural areas and among the less educated.

Specifically concerning somatic symptom disorder, the personality trait of negative affectivity (neuroticism) has been an independent correlate/risk factor of a high number of somatic symptoms. Comorbid anxiety or depression is common and may exacerbate symptoms and impairment. Somatic symptom disorder is more frequent in individuals of low socioeconomic status and low education, as well as among individuals who have recently experienced stressful life events (DSM-5).

Source: Medical Disability Advisor



Diagnosis

History: According to the DSM-IV-TR, individuals with somatization disorder have a past medical history of many physical complaints starting before age 30 that happen over the course of several years and cause treatment seeking or severe problems in social, occupational, or other areas of functioning. Each of the following criteria must have been met, and individual symptoms can occur at any time during the course of the disorder: The individual must have complained of four pain symptoms related to at least four different areas of the body or functions, such as pain in the head, abdomen, back, joints, extremities, chest, or rectum, or pain during menstruation, sexual intercourse, or urination. At least two gastrointestinal symptoms other than pain must be present (e.g., nausea, bloating, emesis other than during pregnancy, diarrhea, or intolerance of many types of food). At least one sexual or reproductive symptom other than pain (e.g., sexual indifference, impotence or premature ejaculation [erectile or ejaculatory dysfunction]), irregular periods (menses), excessive menstrual bleeding (menometrorrhagia), or vomiting throughout pregnancy (hyperemesis gravidum) must have occurred, as must at least one unexplained neurological (pseudoneurological) symptom or deficit suggesting a neurological condition not limited to pain (e.g., conversion symptoms such as lack of coordination or balance, paralysis or localized weakness, difficulty swallowing [dysphagia] or lump in throat, inability to speak [aphonia], inability to urinate [urinary retention], seeing visions or hearing voices that are not there [hallucinations], loss of touch or pain sensation, double vision [diplopia], blindness, deafness, seizures, suddenly forgetting one's identity or whereabouts or feeling unreal [dissociative symptoms], or loss of consciousness other than fainting).

The aforementioned symptoms cannot be accounted for by a known medical condition or the effects of a substance (drug of abuse, medication), cannot occur in the presence of a related medical condition, or the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings. Finally, it is determined that the symptoms are not deliberately produced or feigned (as in factitious disorder or malingering) (DSM-IV-TR).

These individuals have demonstrated long-term, excessive medical help-seeking behavior, probably beginning in adolescence or in the late teens. Their history may reveal repeated surgical operations, drug dependence, marital separation or divorce, and suicide attempts. Their medical history can be long and complicated and involve many somatic complaints.

DSM-5 distills and deemphasizes the physical criteria, specifying that those with somatic symptom disorder have one or more somatic symptoms that are distressing or produce significant disruption of daily life. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months). If there is predominant pain (previously pain disorder) it is necessary to specify if the pain is characterized by severe symptoms, marked impairment, and having persisted more than 6 months. DSM-5 emphasizes the mental and emotional aspect of the disorder by stating that excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns are manifested by at least one of the following: disproportionate and continuous thoughts about the severity of symptoms, persistent high anxiety levels regarding health or symptoms, excessive time and energy devoted to these symptoms or concerns. Taking into account the somatic symptoms, the disproportionate concerns about these symptoms, and the longevity of both, the diagnostician must specify if the disorder is mild (only one mental/emotional/behavioral symptom), moderate (two or more mental/emotional/behavioral symptoms), or severe (two or more mental/emotional/behavioral symptoms and multiple somatic complaints or one very severe somatic symptom) (DSM-5).

Physical exam: Physical examination is an important part of the diagnosis of somatic symptom disorder. The individual's symptoms, which involve multiple organ systems, must not be accountable by nonpsychiatric (organic) conditions. Close attention should be focused on particular areas of complaints. For example, if one of the complaints is perceived menstrual irregularities (dysmenorrhea), then a pelvic exam would be indicated.

Tests: Tests should include psychological testing and psychiatric evaluation. The Whiteley 7-Scale and Illness Convection Subscale is a psychological test helpful in detecting somatoform disorders. The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is another psychological test that helps to confirm the diagnosis of somatoform disorder. Exhaustive medical workups are often done to rule out organic causes of the individual's symptoms. Patients may also need thyroid function tests, pheochromocytoma screen, urine drug screen, and blood alcohol level to rule out other medical problems. Imaging studies may be needed to rule out medical problems.

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

Individuals benefit from regular psychotherapy (individual and/or group therapy by a mental health worker or psychiatrist). The goal is to have individuals learn to cope with their symptoms. This may be done by having them identify ways to express their emotions other than by somatic complaints. Supportive primary care physicians may help these individuals by reassuring them that their complaints are being understood. However, individuals with somatic symptom disorder tend to be resistant to psychological explanations of their problems, and thus may be resistant to psychological interventions.

The effectiveness of drug treatment alone in somatic symptom disorder is unknown. However, coexisting mental disorders should be treated with drugs, if indicated. Monitoring medication(s) is essential with these individuals, as they are often erratic and unreliable with treatment.

Source: Medical Disability Advisor



Prognosis

This disorder is chronic and oftentimes debilitating. These individuals continue to seek medical attention for their symptoms, usually at least every year, and tend to have frequent hospitalizations. If they become involved in psychotherapy, their medical help-seeking behaviors and number of hospitalizations can decrease by as much as 50%. However, they tend to resist the idea that their symptoms are rooted in psychological conflicts rather than physical disorders.

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Clinical Psychologist
  • Gastroenterologist
  • Gynecologist
  • Internal Medicine Physician
  • Neurologist
  • Pain Medicine Physician/Pain Specialist
  • Psychiatrist
  • Urologist

Source: Medical Disability Advisor



Comorbid Conditions

Source: Medical Disability Advisor



Complications

Some of the most frequent and important complications of this disorder are repeated surgical operations, drug dependence, marital separation or divorce, and suicide attempts.

Source: Medical Disability Advisor



Factors Influencing Duration

Length of disability depends on severity of the illness, presence or lack of bona fide medical conditions, the individual's willingness to seek help from mental health professionals, the presence of an associated psychiatric condition, substance abuse, or other personality disorder and type of treatment.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Time-limited restrictions and work accommodations are necessary only infrequently and for the most serious cases. In these instances, time-limited restrictions and work accommodations should be individually determined, based on the characteristics of the individual's response to the disorder, the functional requirements of the job and work environment, and the flexibility of the job and work site. The purpose of the restrictions/accommodations is to help maintain the worker's capacity to remain at the workplace without a work disruption or to promote a timely and safe transition back to full work productivity.

Risk: Individuals with somatic symptom disorder may be unsuited to working in health-related fields secondary to illness preoccupation. If excessive anxiety is present, individuals may need additional intervention to help cope with symptoms.

Capacity: Capacity is typically unaffected with this disorder. Individuals may require time off to attend regular psychotherapy sessions but this may usually be accomplished outside of working hours. Individuals unwilling to participate in psychological treatment may be less productive than their coworkers due to distraction over perceived health issues.

Tolerance: Tolerance is not a concern with this diagnosis unless comorbid depression or anxiety is present, or if the individual resists psychological treatment. In most cases, involvement with work activities is beneficial to recovery.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is expected at 6 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 somatic symptom disorder?
  • Has diagnosis been confirmed?
  • Has an appropriate investigation been made for each physical complaint to rule out an underlying medical condition or to justify the symptoms?

Regarding treatment:

  • What medication is individual currently taking and for what condition(s)?
  • Is there any overlap of medications?
  • Is there any indication of medication overuse or abuse?
  • Is the physician aware of all medications that the individual is currently receiving from all participating healthcare providers?
  • Does individual have a therapeutic rapport with the physician? What can be done to facilitate this relationship?
  • Is individual participating in psychotherapy?
  • Does current therapy help the individual cope with symptoms and learn to express emotions in ways other than somatic complaints?

Regarding prognosis:

  • Because somatization is chronic and often debilitating, is the physician supportive and reassuring?
  • Does individual trust primary physician, or is individual constantly seeking assistance from other health care providers?
  • Is individual involved in a solo or group therapy program?
  • Has therapy helped individual decrease medical help-seeking behaviors?

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.

Source: Medical Disability Advisor