Abstract
Psychiatrists involved in forensic practice within the civil jurisdiction have not been well served by British academic forensic psychiatry. The two standard UKpublished forensic psychiatry texts [1], [2] concentrate on criminal and prison psychiatry, with relatively little attention paid to civil forensic issues. Similarly, articles in the UK-published forensic psychiatry journals [3], [4] deal predominantly with non-civil issues.
Although there are a number of US-published books dealing with civil aspects of forensic psychiatry, to the best of my knowledge there is no volume specifically on the contentious subject of somatoform disorders in the medicolegal setting.
Professor Michael Trimble, Professor of Behavioural Neurology at the Institute of Neurology in London (where his distinguished predecessors included Eliot Slater and Harold Merskey), has written a book that will be immensely useful to both clinicians and lawyers working in the area of personal injury litigation.
Professor Trimble's previous contribution to this field [5], which provided both a historical and a clinical introduction to what used to be known in the nineteenth century as ‘railway spine’, and in the twentieth century was variously labelled ‘posttraumatic neurosis’ and ‘whiplash’ (as well as ‘accident neurosis’, ‘compensation neurosis’ and by numerous other terms), was written in a particularly lucid and readable style, and the volume under review follows that pattern.
Physical symptoms that are disproportionate to the extent of objectively demonstrable organic abnormalities are ubiquitous in civil forensic psychiatry, yet it is very uncommon for the formal diagnosis of, say, conversion disorder, to bemade. The physical symptoms complained of by personal injury litigants or claimants for workers' compensation often include headaches, low back pain or neck pain, abdominal discomfort or pain, numbness of the extremities and joint pains or stiffness. Frequently, such somatic complaints are associated with symptoms of anxiety and depression, as well as sleep disturbance, and yet the nature and severity of the emotional symptoms – and findings on mental state examination – do not meet the formal diagnostic criteria for any specific mental disorder.
It is this concatenation of physical and emotional symptoms that is the subject of Trimble's book. In the contemporary practice of civil forensic practice in Australia, more so than in New Zealand, clinicians are routinely requested to assess claimants with such complaints, and labels such as ‘functional somatic syndrome’, ‘multiple chemical sensitivity’, ‘repetitive strain injury’, ‘chronic fatigue syndrome’ and ‘fibromyalgia’ have been used to describe what are essentially somatoform disorders not otherwise specified.
The early chapters of the book under review provide a historical overview of the field, a discussion of the range of somatoform disorders and clinical presentations.
The syndromes of somatoform disorders discussed by Trimble include somatization disorder, hypochondriasis, pain, chronic fatigue syndrome, fibromyalgia, reflex sympathetic dystrophy (which has been renamed complex regional pain syndrome), dystonia, ‘whiplash injury’ and occupational disorders of the upper limb. Many would argue that dystonia and complex regional pain syndrome are organically based disorders, and hence do not fall within the ‘somatoform’ rubric. Some would argue the same for whiplash and fibromyalgia.
A chapter is devoted to malingering. As noted by Trimble, ‘malingering is not a psychiatric diagnosis at all… To categorise a patient as a malingerer, which implies fraud, is rightly the province of a judge, and for a medical expert to offer such an opinion could be seen as usurping judicial authority’ (p.88). Trimble also writes:
This chapter has expressed the view that classifying somebody as a malingerer is essentially a legal rather than a medical matter An allegation of malingering is essentially that of fraud, and in a legal setting such an allegation must be supported by admissible evidence. (p.103)
The chapter on memory, including a discussion of frontal lobe syndrome, while of interest is not, strictly speaking, within the scope of somatoform disorders. Similar comments apply to the section dealing with ‘pure’ psychiatric injury.
A discussion of the differences between civil and criminal lawwill be of interest to psychiatristswho lack experience in the forensic field, but the section on Lord Woolf's reforms and the Civil Procedure Rules (in England and Wales) will not be of direct relevance to Australasian psychiatrists.
In discussing the system of personal injury litigation in England and Wales the author introduces the concept of ‘lexigenic morbidity’, by analogy with iatrogenic morbidity, stating: ‘In the same way that doctors and medical treatments can be directly responsible for patients’ symptoms, so can lawyers and the legal process' (p.171). This concept has been discussed by other authors who have used the term ‘nomogenic disorders’ [6]. (The word nomogenic is to be preferred to ‘lexigenic’, both because it is already in use and because it does not combine Latin and Greek roots.)
The final chapter, titled ‘Causation and the question of consciousness’, provides a useful discussion of the differences in the concept of causation in medicine and psychiatry (where we use the term ‘aetiology’) when compared with the legal concept of causation (which seeks the assignation of blameworthiness and consequent liability for the payment of monetary compensation).
This book is a valuable addition to the libraries of forensic psychiatrists as well as those of lawyers who practice in the personal injury or workers' compensation jurisdictions.