1. The Psychiatry of Physical Injury
Dr Tim Web
24 March 2015

2. 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

3. 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.

4. 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

5. 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”)

6. Dealing with mental disorder
Psychiatrists and psychologists
Children, working age adults and the old
Other sub-specialities
NHS priorities and real life

7. 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”

8. 2. Common conditions in Claimants
Trauma syndromes
Depression and anxiety
Psychosomatic pain and disability
Brain injury – not for this talk

9. 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

10. Depression and anxiety
The first a disease
The second a pan-psychological symptom
Causation grossly misunderstood
Impact grossly underestimated
Treatment rates scandalously low

11. 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)

12. 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)

13. … 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

14. 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

15. 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

16. 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

17. 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

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