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.

Stress Disorder, Acute


Medical Codes

ICD-9-CM:
308.0 - Acute Reaction to Stress; Predominant Disturbance of Emotions
308.9 - Acute Reaction to Stress, Unspecified

Related Terms

  • Stress Anxiety
  • Stress-related Anxiety Disorder

Overview

In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), acute stress disorder 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, posttraumatic stress disorder, generalized anxiety disorder, anxiety disorder due to a general medical condition, and anxiety disorder (DSM-IV-TR).

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

Acute stress disorder is characterized by marked anxiety, feelings of unreality or of being in a dream (dissociative symptoms), and other symptoms that occur within 1 month after exposure to trauma (stressor) that could be considered life-threatening to the individual or to someone else. The individual may feel hopeless, as well as guilty at having survived the event if others did not. These feelings have a negative impact on relationships or work performance. Decreased emotional responsiveness may be reflected in difficulty enjoying any of life's previous pleasures. Individuals may neglect their basic personal health and even their safety.

Acute stress disorder is distinguished from other stress disorders by duration. The diagnosis is not applicable if symptoms are from a drug effect or medical condition, nor is acute stress disorder diagnosed if symptoms could be better explained by a brief psychotic disorder or deterioration of a preexisting mental disorder. Symptoms usually last at least 2 days but not more than 4 weeks. If symptoms last longer, a diagnosis of post-traumatic stress disorder (PTSD) is usually made. Therefore, diagnosing acute stress disorder can help to identify those who will develop a more chronic condition. Identifying acute stress disorder is also useful because disorganized behavior can leave the individuals unable to care for themselves, thus requiring treatment.

Incidence and Prevalence: Acute stress disorder tends to be identified in less than 20% of individuals who have experienced traumatic events that do not involve interpersonal assault; in 13% to 21% of those who have been in motor vehicle accidents, in 14% of individuals with mild traumatic brain injury, in 19% of assault victims, in 10% of individuals with severe burns, and in 6% to 12% of individuals in industrial accidents; higher rates (20% to 50%) are reported after interpersonal traumatic events, including assault, rape, or witnessing a mass shooting (DSM-5).

Source: Medical Disability Advisor



Diagnosis

History: The history, psychiatric interview, and mental status exam of an individual who has experienced or witnessed a traumatic event are used to establish whether the individual's response or behavior meets the diagnostic criteria.

According to the DSM-IV-TR, an individual with acute stress disorder experienced, witnessed, or was confronted with another individual's death, threatened death, severe injury, or a threat to the physical integrity of self or others; the individual's response involved intense fear, helplessness, or horror. Either while experiencing the distressing event or afterward, the individual had at least three of the following dissociative symptoms: a subjective sense of numbing, detachment, or lack of emotional responsiveness; a reduction in awareness of his or her surroundings; feelings of strangeness about the world (derealization); feeling distant from his or her own thoughts, feelings, or body (depersonalization); and the inability to recall an important aspect of the trauma (dissociative amnesia).

The individual re-experiences the traumatic event in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashbacks, or a sense of reliving the experience; or distress when there is exposure to reminders of the traumatic event. The individual avoids stimuli reminiscent of the traumatic event. The individual exhibits marked symptoms of anxiety or increased arousal, including difficulty sleeping, irritability, poor concentration, exaggerated alertness (hypervigilance), a tendency to jump or flinch at loud noises or sudden movements (exaggerated startle response), and hyperactivity (motor restlessness). The disorder produces significant distress or impairment in social, occupational, or other areas of life. It impairs the individual's ability to pursue some necessary task, such as obtaining assistance or mobilizing resources by telling family members about the traumatic experience. The disorder lasts for a minimum of 2 days and a maximum of 1 month, and it occurs within 1 month of the traumatic event. The disorder is not due to the effects of a substance (drugs or medication) or a general medical condition, is not better explained by brief psychotic disorder, and is not an exacerbation of a preexisting psychiatric disorder (DSM IV-TR).

According to the DSM-5, an individual with acute stress disorder has been confronted with death or threatened death, serious injury, or sexual violation in at least one of the following ways: directly experiencing the traumatic event (or events, as the case may be); witnessing the event; 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 has been violent or accidental); experiencing repeated or extreme exposure to unpleasant details of the traumatic event (this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related). At least 9 of the following symptoms from any of the 5 categories of intrusion, negative mood, dissociation, avoidance, and arousal must begin or worsen after the event.

1. Intrusion symptoms include recurrent, involuntary, and intrusive distressing memories of the traumatic event; recurrent distressing dreams in which the content and/or affect of the dream are related to the event; dissociative reactions (flashbacks) in which the individual feels or acts as if the traumatic event is recurring (such reactions may occur on a continuum—the most extreme expression is a total loss of awareness of present surroundings); and intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event.

2. Negative mood consists of a persistent inability to experience positive emotions.

3. Dissociative symptoms include an altered sense of the reality of one's surroundings or oneself and/or an inability to remember an important aspect of the traumatic event.

4. Avoidance symptoms involve efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event and/or efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings about the event.

5. Arousal symptoms comprise sleep disturbance; irritable behavior and angry outbursts, typically expressed as verbal or physical aggression toward people or objects; exaggerated alertness (hypervigilance); problems with concentration; and a tendency to jump or flinch at loud noises or sudden movements (exaggerated startle response).

The disorder lasts from 3 days to 1 month after trauma exposure. Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is required to meet disorder criteria. The disorder produces significant distress or impairment in social, occupational, or other areas of life, cannot be attributed to the effects of a substance (medication or alcohol) or another medical condition (mild traumatic brain injury), and is not better accounted for by brief psychotic disorder (DSM-5).

Physical exam: The exam may show signs of a physical trauma if one occurred, and could show evidence of restlessness or increased startle response.

Tests: Tests do not establish this diagnosis. However, the post-traumatic scales on tests such as the Minnesota Multiphasic Personality Inventory-2 revised may be elevated, and psychological tests may also reveal symptoms related to anxiety. Laboratory studies such as a complete blood count (CBC) and metabolic panel may be helpful to rule out a medical cause for their symptoms.

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

Psychotherapy is usually designed to allow full expression of the emotions and images connected with the trauma. The individual's story may be told and retold, to minimize the chance that he or she will disconnect from the reality of that experience. It may be done as individual or group therapy, or as hypnotherapy. Although psychotherapy is designed to enable individuals to somehow process and integrate this overwhelming experience into their lives, behavioral and cognitive therapies address coping with anxiety symptoms rather than exploring unconscious conflicts. Behavioral therapy aims to gradually increase exposure to the anxiety-provoking situation. Sedating medication, beta blockers, and antidepressants may also be helpful.

Source: Medical Disability Advisor



Prognosis

The majority of individuals experiencing acute stress disorder recover completely. If the disorder lasts more than 4 weeks, a significant percentage will develop posttraumatic stress disorder (PTSD). Of individuals who have cognitive-behavioral therapy (CBT) shortly after frightening events, only about 10% to 20% develop PTSD (Lubit). Decreased functioning following previous stresses, lack of a support system, substance abuse, and the coexistence of other psychiatric disturbances can negatively affect the outcome of the disorder.

Source: Medical Disability Advisor



Differential Diagnosis

  • Adjustment disorder
  • Anxiety disorders
  • Borderline personality disorder (BPD)
  • Brief psychotic disorder
  • Dissociative disorder
  • Exacerbation of preexisting mental condition
  • Head trauma
  • Major depressive episode
  • Malingering
  • Obsessive-compulsive disorder
  • Panic disorder
  • Posttraumatic stress disorder (PTSD)
  • Substance abuse

Source: Medical Disability Advisor



Specialists

  • Clinical Psychologist
  • Occupational Therapist
  • Psychiatrist

Source: Medical Disability Advisor



Comorbid Conditions

  • Alcohol abuse
  • Major depression
  • Substance abuse

Source: Medical Disability Advisor



Complications

Individuals may be indifferent to maintaining their health and safety. There is a possibility of progression to posttraumatic stress disorder. Feelings of despair can be severe enough to qualify as a major depressive episode.

Source: Medical Disability Advisor



Factors Influencing Duration

The intensity and duration of exposure to the traumatic event may influence disability. Factors that negatively influence outcome include previous trauma, poor or marginal levels of functioning prior to the traumatic event, previous or current substance abuse, lack of a support system, reluctance to get appropriate treatment, the presence of other psychiatric disorders, and the persistence of denial regarding the event or consequences stemming from it. These factors tend to result in longer periods of disability. A failure to promptly and decisively settle litigation issues can also be associated with a delayed recovery.

Duration also depends upon response to medications and psychotherapy.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work accommodations may include modifying the work space to decrease noise and visual distractions; introducing the individual to new or stressful situations gradually under appropriate supervision and support; providing some flexibility in work schedule to attend therapy appointments (which normally should occur during the employee's personal time); allowing work-at-home or job-sharing opportunities; allowing break time according to individual needs rather than a fixed schedule; providing praise and positive reinforcement; and allowing workers to phone supportive friends, family members, or professionals during the workday.

If the traumatic event leading to the acute stress disorder occurred at work, accommodations may include placing the individual in a different job environment. Similarly, duties that remind the individual of the event (such as driving in the event of a motor vehicle accident) may be avoided for a limited period.

Risk: Individuals with acute stress disorder typically pose little risk to themselves or their coworkers unless symptoms include indifference to maintaining health and safety. Recurrence is not normally a concern unless the traumatic event is related to the individual’s working environment.

Capacity: Capacity is usually unaffected by this disorder. In rare circumstances, the individual may be temporarily less productive at work secondary to symptoms of anxiety and low mood, but job duties can provide the individual with a beneficial distraction.

Tolerance: Tolerance factors include the source of the traumatic event and the individual’s compliance with treatment. In most 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:

  • Has a diagnosis of acute stress disorder been confirmed?
  • Has the stressful event been identified?
  • Have underlying medical conditions and other psychiatric disorders been identified or ruled out?
  • Does individual have an underlying condition or experience that may affect recovery?

Regarding treatment:

  • Does individual need more frequent therapeutic encounters?
  • Would individual benefit from the addition of another type of therapy or a change in therapist?
  • Has individual taken medication as prescribed?
  • Does individual experience medication side effects that may interfere with use or benefit from that particular medication?

Regarding prognosis:

  • Have symptoms persisted beyond 4 weeks?
  • Should diagnosis be changed to posttraumatic stress disorder?
  • Are coexisting psychiatric conditions being appropriately addressed?
  • Would individual benefit from substance abuse rehabilitation?
  • If a functional support system is not available, would the individual benefit from involvement in group therapy or a community support group?

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.

Lubit, Roy. "Acute Treatment of Disaster Survivors." eMedicine. 11 Dec. 2014. Medscape. 24 Jun. 2015 <http://emedicine.com/med/topic3540.htm>.

Source: Medical Disability Advisor