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