the psychiatry of physical injury dr tim web 24 march 2015

The Psychiatry of Physical InjuryDr Tim Web

24 March 2015

The Psychiatry

of Physical Injury

Dr Tim WebbConsultant in Adult Psychiatry

& Medico-legal Expert

Cambridge Medico-Legal ForumDowning College, Cambridge: 24 March 2015

Quick CV

1987 to date: Consultant in Adult PsychiatryPlymouth (3 years), West Suffolk (24 years, Care UK (1 year)

1989 to date: Medico-legal expert2400+ reports to date

What I aim to do

1. Give you an outline of mental disorder2. Explain those commonly found in Claimants3. Comment on how DSM-5 has affected things4. Give some candid insights into treatment5. Perhaps mention some common pitfalls

1. An outline of mental disorder• Brain diseases – (e.g. dementia, delirium)• Substance misuse – (intoxication, dependency, harmful

use, induced states)• Gross neurodevelopmental – (learning disabilities, autism)• Subtle neurodevelopmental – (ADHD, personality

disorder)• Psychosis – (schizophrenia et al)• Mood – (depression, bipolar et al)• Anxiety, psychosomatic & stress (formerly “neurosis”)

Dealing with mental disorder

• Psychiatrists and psychologists

• Children, working age adults and the old

• Other sub-specialities

• NHS priorities and real life

What NHS planners think of psychiatry

2. Common conditions in Claimants

• Trauma syndromes

• Depression and anxiety

• Psychosomatic pain and disability

• Brain injury – not for this talk

Post-Traumatic Stress Disorder

• PTSD definition in ICD-10: 600 words• PTSD definition in DSM-5: 9000 words• Definition creep: simple vs complex• 80% overlap with other conditions– Alcohol & substance abuse– Depression– (Brain injury, chronic pain & others)

• Still not based on any defined pathology

Depression and anxiety

• The first a disease• The second a pan-psychological symptom

• Causation grossly misunderstood• Impact grossly underestimated• Treatment rates scandalously low

Types of psycho-somatic disorder

• Somatic Symptom Disorder (psychological distress presenting with physical symptoms)

• Illness Anxiety Disorder (hypochondria)• Conversion Disorder (now 100% neurological)• Psychological Factors Affecting Other Medical

Conditions• Factitious Disorder (Munchausens)

Somatisation case study: chronic pain

• Defining its presence (active tissue damage)• Chronic pain syndromes (CNS facilitation)• CFSME / fibromyalgia (somatoform conditions)

• Pre-index vulnerability (with / without history)• Depressive amplification (?? CNS facilitation)• Pain behaviours (fears, beliefs & routines)

… and it doesn’t stop there

• 69% of severe pain have depression / anxiety• High rates of psycho-toxic medication• Antidepressants have multiple actions• Many mood stabilisers treat chronic pain

• … and that is the non-litigants

Treatability in theory

• Antidepressants – Useful in most conditions– Available via GP on the NHS

• CBT-based psychological interventions– Broad application– Available via IAPT teams on the NHS

• Mood stabilisers / pain modulators– Useful in some conditions

• Specific psychological interventions– Highly effective in some conditions

Treatability in practice• Antidepressants – GP skills and willingness highly variable– NHS mental health not geared to this

• CBT-based psychological interventions– NHS interventions cash-strapped and service-driven– Tailored programmes in private sector only

• Mood stabilisers / pain modulators– Beyond the scope of most GPs

• Specific psychological interventions– Only available in the private sector

Information in letter of instruction

• DO NOT SEND info on how to write a report

• DO NOT SEND hard copy hospital records

• ALWAYS SEND other reports and GP records

• Tell me why you want them to be seen

• Tell me what aspects concern you

Common pitfalls

• Culture-bound theories of distress– Underestimating the importance of physical illness– Overestimating the impact of upset

• Forgetting to mention the head injury

• Not bothering to make the Claimant better

Thank you!!

Dr Tim WebbMB ChB FRCPsych

www.mss-medicolegal.com