The British Journal of Psychiatry (2005) 186: 81-82
© 2005 The Royal College of Psychiatrists
Somatoform Disorders: A Medicolegal Guide
Christopher Bass
Consultant in Liaison Psychiatry, Department of Psychological Medicine,
John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, UK
By Michael Trimble. Cambridge: Cambridge University Press. 2004. 254 pp.
£50 (pb). ISBN 0 521 81108 2
There have been many books published recently on somatoform disorders, but
this one deals specifically with the medicolegal perspective. The book is
timely because over the past decade a considerable amount of research has
suggested that psychosocial factors are the key maintaining factors in
disorders such as whiplash neck injury, upper limb pain (repetitive strain
injury), chronic widespread pain and functional paralyses. Trimble starts well
by taking a swipe at commentators such as Micale, Showalter and Shorter, who
suggest that ‘Victorian faints, swoons and convulsions’ are now
rare and have largely disappeared from clinical practice. Any clinician
currently working in the borderland between neurology and psychiatry would
dispute this observation. Indeed, in October 2003 the first international
conference on psychogenic movement disorders was held in the USA (Trimble and
I attended), and it is clear that these disorders are becoming so common (1 in
30 of consecutive referrals to a movement disorder clinic) that even
neurologists are taking note and wanting help. Trimble’s elegant riposte
to the social historians is that ‘hysteria has never risen from the
ashes: the fires have been burning brightly all along’. He goes on to
criticise the diagnostic categories of both the ICD and DSM as being arbitrary
(we all agree with that) and argues that, in a medicolegal setting, their use
can be not only misleading but also mischievous.
Chapters on the clinical presentations and assessment are sound and well
written, but I found most useful the chapters dealing with the legal context
and issues of causation and compensation. Trimble outlines the shortcomings of
Lord Woolf’s reforms and the role of the single joint expert (SJE), who
is unlikely to satisfy the needs of both parties in complex psychiatric cases.
There are up-to-date accounts of compensation as well as the problems of
legally aided claims. Issues of forseeability and rules for secondary
claimants/victims are described, with helpful case vignettes, and Trimble
introduces the term ‘lexigenic’ to emphasise the legal equivalent
of iatrogenic illness. Chapters about mechanisms and causation include
descriptions of recent imaging studies on hysteria and malingering.
This is a valuable text for psychiatrists involved in medicolegal work,
especially those asked to provide reports on patients with unexplained gait
disturbances, whiplash neck injuries and symptoms that are not matched by
organic findings. The Department for Work and Pensions informs us that 70% of
patients on long-term disability benefits have symptoms that are essentially
medically unexplained: Trimble’s book explains how to assess these
patients when they are involved in a legal claim and how to prepare a coherent
report for the court.
