Somatoform disorders in litigation: causation and prognosis

Abstract

Orthopaedic experts will be familiar with litigated accidents in which there is a relatively minor soft-tissue injury that does not explain the persistent severity of pain and the ensuing marked disability. They will also usually be aware that 90% of patients with chronic low back pain do not have any reliable evidence of a significant structural causative defect or injury.1 The International Association for the Study of Pain (IASP) definition of pain emphasises the importance of psychological factors in its perception: pain is regarded as an unpleasant sensory and emotional experience. Many people report pain in the absence of tissue damage or any likely pathophysiological cause and this usually happens for psychological reasons. Pain is always a psychological state.2 This article examines how claimants with medically unexplained pain may be diagnosed by psychiatrists, and the implications for their treatment and prognosis are discussed. The diagnosis of psychiatric disorders is generally made with reference to the current edition of the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association3 or the International Classification of Diseases published by the World Health Organization.4 Both of these classification systems are recognised by the British courts and neither is regarded as more valid. However, the relatively new diagnosis of a Somatic Symptom Disorder3 is of little utility in personal injury litigation. The accompanying text in the DSM states that “the reliability of determining a somatic symptom is medically unexplained is limited” and on this basis the presence or absence of a medical explanation is irrelevant to the diagnosis. However, in court, the psychiatrist that continued to entertain a probable persisting medical cause would be acting outside their area of expertise if, for example, an orthopaedic expert had already excluded a physical cause. The Somatic Symptom Disorder diagnosis is …