The Psychiatry of Physical Injury Dr Tim Web 24 March 2015

The Psychiatry of Physical Injury

Dr Tim Webb

Consultant in Adult Psychiatry & Medico-legal Expert Cambridge Medico-Legal Forum Downing College, Cambridge: 24 March 2015

Quick CV 1987 to date: Consultant in Adult Psychiatry

Plymouth (3 years), West Suffolk (24 years, Care UK (1 year)

1989 to date: Medico-legal expert

2400+ reports to date

What I aim to do

1. Give you an outline of mental disorder 2. Explain those commonly found in Claimants 3. Comment on how DSM-5 has affected things 4. Give some candid insights into treatment 5. 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 Webb MB ChB FRCPsych www.mss-medicolegal.com