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 1989 to date: Medico-legal expert 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 (Despite the slide I think you also say …) I spent 12 years in the NHS including 9 with the Pain Management Centre at Frenchay Hospital (cancer – “oh!, pain “why”). I also spent time as the only psychologist in the Breast Care Centre and also worked as the psychologist on COPD rehab programmes and at Southmead’s Neonatal Intensive Care Unit. I think the most valuable thing I learned in NHS practice was how essential it is to collaborate with medics – and how difficult some psychologists, and medics, find this. This is a big thing for me. It will become clearer later why I think the dualistic view – of us and them – can only serve Chronic Pain patients poorly. My move into private practice was prompted initially by the fact that it works better around school hours. I have stayed in it because more often it allows me to spend the amount of time on patients that they actually need, rather than that the system allows. In practice most of my self-funding patients are anxiety cases, the Chronic Pain patients being funded by private medical insurers or through Personal Injury solicitors.

What I aim to do Give you an outline of mental disorder Explain those commonly found in Claimants Comment on how DSM-5 has affected things Give some candid insights into treatment 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 I have a horrible feeling our friend here is demonstrating military style “no pain, no gain” as opposed to “Stop if it hurts”

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

Dr Tim Webb MB ChB FRCPsych www.mss-medicolegal.com Thank you!! Dr Tim Webb MB ChB FRCPsych www.mss-medicolegal.com