Medico-legal Context Research Articles

Somatoform Disorders: A Medicolegal Guide

Back to table of contents Previous article Next article Book ReviewsFull AccessSomatoform Disorders: A Medicolegal GuideJagannathan Srinivasaraghavan M.D.Jagannathan Srinivasaraghavan M.D.Search for more papers by this authorPublished Online:1 Jun 2006https://doi.org/10.1176/ps.2006.57.6.892aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Michael Trimble's Somatoform Disorders is packed with a lot of useful information for both clinicians and lawyers dealing with personal injury claims. The book contains current knowledge from scientific data. It is easily readable and simple enough for a person with a medical background. Although the book is intellectually stimulating, there is an inherent danger in how the clinicians and legal professionals who read this book would perceive and interpret the data, given that clinicians see various shades of grey and lawyers are often trained to see only black or white and weave the evidence to suit their bias. The first chapter deals with a historical review of hysteria, the historical name for somatoform disorder. This chapter describes the changes in psychiatric nosology from the wandering womb noted by Greeks and Egyptians over 2,000 years ago to witchcraft in the 16th century and further moving on to concepts of Freud, Charcot, war neurosis, and railway spine. The next chapter, which deals with classification, describes the view from DSM-IV-TR and ICD-10 . Because courts in the United Kingdom prefer DSM diagnoses in cases involving somatoform disorders for unclear reasons, there is ample information on the interaction of axis I and axis II diagnoses. Based on the social variability of behaviors related to illness, "abnormal illness behaviour" is a term introduced by Pilowsky. A nice paradigm combines the personality types in the classification. The next two chapters deal with clinical presentations and malingering. Trimble includes a thorough analysis of research findings from conversion disorders and symptoms and classification of Briquet's syndrome. In the clinical picture, pain syndromes, chronic fatigue syndrome, fibromyalgia, dystonia, whiplash injury, and occupational disorders of the upper limb are all described concisely. Although clinicians suspect malingering, most often they are reluctant to label this condition. The chapter on malingering not only provides examples of malingering from historical writings but also differentiates them in a superb manner from factitious illness, Munchausen's syndrome, pseudologica fantastica, and lying. This is one of the best written chapters in the book.We are all aware of the pivotal role played by memory in medicolegal settings. The classification of memory, false memories, assessment of memory, and malingering and memory are dealt with in outstanding depth, with emphasis of the unreliability of repeated recall of a story that gets more distorted with retelling. However, memories recovered by hypnosis that become important in legal matters are not mentioned. Several rating scales for assessment of somatoform disorders and various treatment options are included, but the author impresses on readers in no uncertain terms the paramount importance of clinical skills with intimate knowledge of psychiatry, neurology, and general medicine in evaluation of patients with complex disorders.In the last two chapters, the author articulates current knowledge of the theories of mechanisms involved: from biologic studies, psychological underpinnings, and sociocultural influences in one chapter and the causation of symptoms in law, medicine, and psychiatry and the question of consciousness in the other.Chapter 7, which deals with somatoform disorders in a medicolegal context, primarily addresses application of law in the United Kingdom. The author emphasizes the unique qualifications of psychiatrists in medicolegal matters compared with psychologists. However, the focus on British laws may prevent widespread use of this book as a guide on this side of the Atlantic.Overall the scientific merits of this book make it a worthwhile guide for clinicians.Dr. Srinivasaraghavan is professor and chief of the Division of Community and Public Psychiatry at the Southern Illinois University School of Medicine and medical director of Choate Mental Health Center, Anna, Illinois. FiguresReferencesCited byDetailsCited ByNone Volume 57Issue 6 June, 2006Pages 892-893PSYCHIATRIC SERVICES June 2006 Volume 57 Number 6 Metrics PDF download History Published online 1 June 2006 Published in print 1 June 2006

Fatal Respiratory Depression after??Multiple Intravenous Morphine Injections

A 26-year-old female was treated with morphine within the first 2 hours after knee surgery, in an attempt to titrate analgesia. The patient received a total of four intravenous injections of morphine 35 mg in total. Soon after the last injection the patient had adequate pain relief, was in a good clinical state and had adequate blood oxygenation. However, 40 minutes later, the patient had a deep respiratory depression followed by a fatal cardiac arrest. Solving the case in a medico-legal context was possible by applying results of clinical pharmacokinetic research on opioid analgesics, most importantly morphine, to this particular clinical case. This knowledge made it possible to estimate the probable concentrations of morphine at the site of its effect, the brain, during the time of the fatal event, and to show that these concentrations could have produced respiratory depression. We mainly attribute the fatal intoxication of morphine to the lag period needed for the transfer of morphine across the blood-brain barrier. Because of its slow transfer between plasma and the effect site, the CNS effects of morphine are delayed from its plasma concentrations to a clinically relevant degree. Successive injections at short intervals of relatively high amounts of morphine increase the clinical relevance of this delay. The present report demonstrates an important application of clinical pharmacokinetics for explaining clinical observations at a scientific level and transferring theoretical knowledge from clinical pharmacokinetics into daily clinical practice as a basis for rational opioid selection.

New life after prostate brachytherapy? Considering the fertile female partner of the brachytherapy patient

To examine several cases of unusual and unexpected pregnancy in the female partners of men treated with brachytherapy for cancer of the prostate. Self-reported pregnancy of partners of patients who had had prostate brachytherapy was assessed. The dosimetry to the testicles and sperm counts were used to examine the feasibility of pregnancy in the partners. Three reported cases of pregnancy showed the men to have viable counts of within several or all of the parameters of the World Health Organisation criteria for normal semen analysis. These cases provide a cautionary tale and suggest that all men being treated with prostate brachytherapy should be counselled about the possibility of continued fertility. Documentation of this 'risk' on the consent form will allow for proper discussion of this issue in a clinical and medicolegal context. The key to addressing this problem is to propagate much better patient information. The topic should be addressed clearly in information booklets for the patients. Prostate brachytherapy may allow for pregnancy to be achieved in the fertile partners of patients, even after full radiation treatment of the patient.

On Being Insane in Medico-Legal Places: The Importance of Taking a Complete History in Forensic Mental Health Assessment

Rosenhan's experiment (1973) showed that it is not difficult to simulate symptoms of psychiatric illness. A Parliamentary Committee in New South Wales and research from overseas have shown that, in the medicolegal context, such practices continue to exist. To illustrate the argument, there will be a discussion of Post Traumatic Stress Disorder. It is argued that such practices not only bring the area of mental health into disrepute, they also have the effect of distorting negatively the outcomes of litigation and raise ethical questions about the misuse of mental illness for personal benefit. It remains the case that expert mental health practitioners have an ethical duty to educate both the practitioners who employ them and the courts in general as to the reality of what constitutes mental illness. They can begin this action by taking thorough histories from plaintiffs. The term 'mental injury' or variations thereon, used in most criminal injuries compensation legislation, provides an opportunity to appreciate that being a victim of crime is often likely to result in distress that is more than transient and hence compensable, but not necessarily something that has to become pathological. That does not mean that some people will not develop psychopathology or have pre-existing psychopathology exacerbated. To adopt such an approach for personal injury matters in general may resolve some of the tensions experienced by mental health practitioners when they enter the forensic arena.

Methodenbewertung in der Orthopädie am Beispiel Robodoc®

The aim of this study was to assess the clinical benefit and rate of complications of robot-assisted primary total hip replacement. Electronic bibliographic databases, the reference lists of relevant articles and various health services research-related resources were analysed and selected studies were assessed using defined quality criteria. 57 publications and three HTA-reports were assessed. Only two prospective randomised controlled studies could be identified. There was no proof of clinical benefit but rather an increased incidence of complications. Patients must be informed on the risks, complications, benefits and especially alternatives to a robot-assisted operation. The importance of HTA reports to evaluate new or established procedures will even increase in Germany especially in the recent medico-legal context.

Proximal myotonic dystrophy mimicking progressive muscular atrophy

Sir, I read the article, A controlled prospective inception cohort study on the postconcussion syndrome outside the medicolegal context, by Mickeviciene et al. in the June 2004 issue with interest. Although the results are intriguing, they may not be generalizable to other patients with sequelae from mild head injuries. As the authors note, they arbitrarily defined mild head injury as loss of consciousness of up to 15 min. In other studies, a duration of up to 30 min has been used. In addition, 66% of the cases were the result of assaults and 16% as a result of car accidents. This contrasts with the relative causes of head trauma in industrialized countries such as the USA or Western Europe: motor vehicle accidents, 45%; falls, 30%; occupational accidents, 10%; recreational accidents, 10%; and assaults, 5% (Jennett and Frankowski, 1990). Different external causes of head trauma may have different sequelae. The authors conclude that the most important observation in the study was that the prevalence, frequency, and VAS scores of headache of head injured and controls did not differ at 3 months and 1 year. However, the prevalence of headaches more than 14 days in controls (6% at 3 months and 8% at 1 year) was higher than reported in other countries. Although I am not aware of any prevalence studies in Lithuania, compare this to population-based studies revealing the prevalence of chronic daily headache in 2.98% (4.18% in females and 1.62% in males) in France (Lanteri-Minet et al., 2003) and 4.1% in the USA (5% in females and 2.8% in males; Scher et al., 1998). The prevalence of headaches in controls in this study is especially high when you consider that 66% of both head injured and controls were males. In summary, the results may not be generalizable because of the following: the definition of concussion used; the predominant male population; assault was the most common cause of injury; and the inordinately high prevalence of headache in the control population.

Risk of disability due to car crashes: a review of the literature and methodological issues

With improving rates of survival following road traffic injuries in many countries, healthy years of life lost due to crashes increasingly reflect the prevalence of disabling sequelae. This review examines the epidemiological evidence regarding the risk of disability due to car crashes, published between 1980 and 2002. Studies of sequelae limited to specific domains (e.g. head injury, whiplash, psychiatric morbidity) were excluded. Of the 19 studies meeting the criteria for review, most focused on the prevalence of disability following crashes but not the association between them. Prevalence estimates of post-crash disability varied from 2 to 87%. The potential sources of heterogeneity included differences in study settings and period, duration of follow-up, and definitions of exposure and outcome. Methodological problems that compounded the difficulties in interpretation and generalisability of study findings included selection biases and use of non-representative samples, idiosyncratic outcome measures, inadequate adjustment for confounding, and the prevailing medico-legal or compensation context. The findings highlight the need for well-designed population-based epidemiological studies using validated outcome measures and appropriate comparison groups to determine the independent risk of disability due to car crashes. The review also revealed a critical need for data from low- and middle-income countries, the setting for over 90% of the estimated global burden of road traffic injury.

Traumatic Pasts: History, Psychiatry and Trauma in the Modern Age, 1870-1930 (review)

Reviewed by: Traumatic Pasts: History, Psychiatry and Trauma in the Modern Age, 1870–1930 Jenny Bourne Taylor (bio) Traumatic Pasts: History, Psychiatry and Trauma in the Modern Age, 1870–1930, edited by Mark S. Micale and Paul Lerner; pp. xix + 316. Cambridge and New York: Cambridge University Press, 2001, £45.00, $65.00. Shifting between the literal and the metaphorical and bringing together individual and collective history, "trauma" has become part of everyday language, easily debased by over- exposure, while remaining a contentious term whose meaning is bound up with the medical and legal contests it has generated. The essays in Traumatic Pasts trace the concept's complex social and political histories in a range of comparative Western settings, from the impact of mass forms of transport and factory production to the First World War. They do not attempt to establish a continuous genealogy of an identifiable condition so much as to specify the multiple points of connection and slippage between different descriptive terms—spinal concussion, railway spine, nostalgia, neurasthenia, traumatic hysteria, traumatic neurosis—through a series of case studies which explore how these conditions were discussed by scientific establishments, how they became the focus of government policy and social legislation, how they were interpreted and contested by specific social groups and overdetermined by precise ideological interests. The collection opens with the railway accident—that potent emblem of modernity and mobility that affects all classes, that is beyond the victims' control and strikes apparently by chance. Ralph Harrington and Eric Caplan describe how "railway spine" [End Page 342] contributed to a fundamental shift in the understanding of the relationship between soma and psyche in Britain and America in the late nineteenth century, within the precise medico-legal context of controversies about accountability and compensation. Harrington explores how the discussion about railway spine from the early 1860s took place within a hermeneutics of suspicion, as company doctors sought to establish that injuries existing "in the mind" could not be laid at employers' doors. In response, John Erichsen, whose experience of railway accidents sprang from his own role as an expert witness in compensation claims, stressed the delayed and nonspecific aspects of trauma in On Railway and Other Injuries of the Nervous System in 1866. Erichsen's concept of railway spine remained a somatic one; but in arguing that the extreme violence of the railway accident blurred the boundary between the physical event and the delayed psychological response, he paved the way for an analysis of how psychic shock produces physical symptoms—an analysis that would be developed in England by Fredreric Clark, John Furneaux Jordan, and above all Herbert Page, a railway company surgeon who claimed that fear, rather than direct injury to the spine, produced the symptoms of trauma. Both Harrington and Caplan discuss the implications of Page's arguments, first developed in response to Erichsen's somaticism. Caplan gives an overview of the main international figures—Page, Jean-Martin Charcot, Hermann Oppenheim—who contributed to the idea of psychological trauma in America. This development culminated in the formation of the National Association of Railway Surgeons in 1888, which returned the issue of railway spine back to the legal stage. Compensation and insurance, contained in the "private" arena of capitalist enterprise in England and America, reenters the public sphere in the two essays on work accidents and trauma in the early welfare state in late nineteenth-century Germany. Wolfgang Schaffner and Greg Eghigian both argue that legislation making insurance the centre of social policy, together with new medico-legal definitions of accidents in the 1880s, shaped the state within a "discourse of trauma" that embedded the legacy of debates on railway spine in the national economy and consciousness. Oppenheim—who makes numerous appearances throughout the collection—developed the concept of "traumatic neurosis" as a precise clinical condition, in which "the major part is played by the psychic" (qtd. in Micale 83). This diagnosis gave rise to charges of simulation when applied in the legal domain and set at the heart of social policy the vexed question, one that Sigmund Freud would return to, of how to draw a boundary between conscious and unconscious mimicry. Both Schaffner and Eghigian, often covering...

1. Pain concepts, assessment, and medicolegal issues

Lacerte M, Shah RV. Interventions in chronic pain management. 1. Pain concepts, assessment, and medicolegal issues. Arch Phys Med Rehabil 2003;84 Suppl 1:S35-8. This self-directed learning module highlights the concepts of pain and suffering, and chronic pain management from basic science and medicolegal perspectives. It is part of the study guide on chronic pain management in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on explaining the concepts of pain and suffering as an expert witness, the causes and mechanisms of pain, and qualifying as an expert witness. The article also discusses chronic pain management. Overall Article Objective: To summarize the concepts of pain and suffering in a medicolegal context.

A Survey of Report Writing by Neuropsychologists, II: Test Data, Report Format, and Document Length

Data are presented regarding current practices in the organization of neuropsychological reports, based on a representative sample of 414 US members of Division 40 of the American Psychological Association. The vast majority of the sample included some numeric test data in their reports, either within the text or as an addendum. The nature of the most predominant age groups and diagnostic categories served by neuropsychologists was of prominent influence on variables such as the frequency of utilization of age- and grade-equivalent scores, the inclusion of specific diagnostic codes, the provision of narrative recommendations, and the practice of deferring report distribution until after review with the patient or family. In addition, greater involvement with forensic evaluations in a medicolegal context through private practice tended to increase length of reports. It is concluded that, although there are many areas of consensus in the field with regard to the organization of neuropsychological reports, the final product needs to be shaped on the basis of consideration of the clinical presentation of the patient as well as the needs and knowledge base of the target audience.

Symptom Validity Testing: A Critical Review

This paper provides a comprehensive review of the published literature on symptom validity tests (SVT) and, with the accompanying tables, serves as a reference to assist in their selection, interpretation, and defense. Because malingering is inherently an applied problem that frequently arises in a medico-legal context, the use of SVTs must meet certain standards. Thus, a number of methodological and theoretical weaknesses of SVT research which limit the use of SVTs as clinical tools and sources of evidence are highlighted. These criticisms incorporate recommendations which must be addressed if conclusions based on SVT data are to meet the increasingly rigorous standards for the admissibility of scientific evidence.

Assessing stressful life events in relation to liability and compensation.

The aim of this paper is to outline limitations in the assessment of the relationship between stressful experiences and psychological disorder in the medico-legal setting. A research-derived approach to more objectively assessing stressful life events and disorder is discussed in the light of limitations or biases which may arise in the evaluation of the clinical significance of stressors in psychological disorder particularly in a medico-legal context. There may be considerable bias in the assessment of stressful experiences in a medico-legal setting. In addition to the purely subjective approach used in the appraisal of stressful life events it may be useful to (i) apply common sense and population-based appraisal as an initial basis for assessing the significance of a stressor; (ii) use evidence-based findings to support the link between stressors and disorder; and (iii) apply recognized criteria of causality where applicable. Conflicting psychiatric opinions in the medico-legal setting may arise both from psychiatrists' positional biases, from the often complex relationships that may exist between stressors and depression, and from a failure to use evidence-based findings to support psychological explanations.

The first cut is the deepest? Medicolegal aspects of male circumcision.

The first cut is the deepest? Medicolegal aspects of male circumcision.

Parens Patriae Jurisdiction in the Medico-Legal Context: The Vagaries of Judicial Activism

<i>Parens Patriae</i> Jurisdiction in the Medico-Legal Context: The Vagaries of Judicial Activism

Headache after whiplash: a historical cohort study outside the medico-legal context.

Headache is frequently reported as a chronic complaint after whiplash traumas. Criteria have been presented, but it has not been validated whether any specific headache type emerges after a trauma with whiplash mechanism. In a questionnaire-based historical cohort design, 202 adult Lithuanian individuals were interviewed 1-3 years after experiencing a rear-end car collision. The questionnaire was designed so that a diagnosis of migraine and tension-type headache in accordance with the International Headache Society criteria could be made. "Possible cervicogenic headache" was diagnosed according to Sjaastad et al.'s minimal criteria. The diagnostic panorama in those with traumas was compared with that of an age- and sex-matched control group. The introductory questions did not reveal differences in headache frequencies between the traumatized and control groups (p = 0.60). The prevalence of migraine and tension-type headache (both episodic and chronic) was also similar. A higher frequency of possible cervicogenic headache was observed in the traumatized group (10 vs 5), but the difference was not statistically significant (p = 0.28). Sixteen patients in the accident group had headache > 15 days per month, 11 of the 16 had similar complaints before the trauma, while 5 had worsened headache as compared to (the recollected headache) before the trauma. None of the patients with possible cervicogenic headache reported increased headache after the accident. Accordingly, the present results obtained outside the medico-legal context do not confirm that a specific headache pattern emerges 1-3 years after a rear-end car collision.

From delivery suite to laboratory: optimizing returns from placental examination in medico-legal defence.

While examinations of the placenta may reveal significant lesions that are helpful in a medico-legal context, its value maybe diminished by a lack of attention to detail in the period between delivery of the baby and receipt of the placenta in the pathology department. These fall generally into 2 groups: initial description and handling of the placenta and lack of relevant clinical information. This communication describes some of these pitfalls. By observing these details, the onus then falls on the pathologist to provide a meaningful assessment of the placenta.

Natural evolution of late whiplash syndrome outside the medicolegal context

Summary Background In Lithuania, few car drivers and passengers are covered by insurance and there is little awareness among the general public about the potentially disabling consequences of a whiplash injury. We took this opportunity to study the natural course of head and neck symptoms after rear-end car collisions. Methods In a retrospective questionnaire-based cohort study, 202 individuals (157 men; 45 women) were identified from the records of the traffic police department in Kaunas, Lithuania. These individuals were interviewed 1-3 years after experiencing a rear-end car collision. Neck pain, headache, subjective cognitive dysfunction, psychological disorders, and low back pain in this group were compared with the same complaints in a sex-matched and age-matched control group of uninjured individuals selected randomly from the population register of the same geographic area. Findings Neck pain was reported by 71 (35% [95% Cl 29-42]) accident victims and 67 (33% [27-40]) controls. Headache was reported by 107 (53% [46-60]) accident victims and 100 (50% [42-57]) controls. Chronic neck pain and chronic headache (more than 7 days per month) were also reported in similar proportions (17 [8·4%; 5-13] vs 14 [6·9%; 4-12] and 19 [9·4%; 6-15] vs 12 [5·9%; 3-10]) by the two groups. Of those who reported chronic neck pain or daily headache after the accident, substantial proportions had had similar symptoms before the accident (7/17 for chronic neck pain; 10/12 for daily headache). There was no significant difference found. No one in the study group had disabling or persistent symptoms as a result of the car accident. There was no relation between the impact severity and degree of pain. A family history of neck pain was the most important risk factor for current neck symptoms in logistic regression analyses. Interpretation Our results suggest that chronic symptoms were not usually caused by the car accident. Expectation of disability, a family history, and attribution of pre-existing symptoms to the trauma may be more important determinants for the evolution of the late whiplash syndrome.

Forensic anthropology in the 1990s.

Forensic anthropology has undergone considerable change over the past 10 years. Today it is utilized by most law enforcement, coroner, and medical examiner systems. The techniques for determination of age at death, sex, race, and stature from skeletal remains have been modified and greatly expanded. The role of the forensic anthropologist within a medicolegal context is much broader than in previous years. In addition to establishing individual identity, forensic anthropologists are now consulted for trauma analysis, facial reconstruction, photographic superimposition, determination of time interval since death, and crime-scene recovery. Not all physical anthropologists are forensic anthropologists. Qualified individuals are certified, through rigorous examination, by the American Board of Forensic Anthropology. A list of board-certified forensic anthropologists may be obtained through the American Academy of Forensic Sciences.

Apportionment of noise-induced hearing disability and its prognosis in a medicolegal context: a modelling study.

Apportionment of liability for noise-induced hearing loss is required in medicolegal work when two or more separate instances of noise exposure have occurred. In general there are insufficient audiometric records to determine how much hearing loss was caused by each noise exposure, and hence there is insufficient information on which to base apportionment of liability. Apportionment must then be based on a theoretical understanding of the way in which hearing loss is related to patterns of noise exposure and how the increased hearing threshold levels lead to greater disability. A model is developed which combines existing models of the relationship of hearing impairment to noise exposure and age, and the relationship of hearing disability to impairment. The model is evaluated for a wide range of notional patterns of noise exposure, leading to a simple equation which predicts the relative attribution of disability to previous noise exposures sufficiently accurately for the purposes of apportionment. The model also shows that disability due to noise exposure generally increases slightly with increasing age even after noise exposure has ceased. Thus the difference in disability between a person exposed to noise and a noise-free control of the same age and sex can be expected to increase somewhat as the subject and control grow older. However, the magnitude of this effect, often termed prognosis, is shown to be small and can be assumed to be zero in practice.

The right to refuse treatment: Paradox, pendulum and the quality of care

AbstractThis clinical and theoretical overview of the right to refuse treatment will address some of the themes that have dominated this area of interface between psychiatry and the law, and have, perhaps, obscured the real concern of the right to refuse treatment question; i.e., the issue of quality of care. Central themes include factors present in the medicolegal context and recent events, origin of the concept of the right to treatment, the separation of confinement from treatment, and the changing models of vicarious decision making. This review also addresses judicial conceptualizations of treatment, including the concept of quarantine, judicial risk‐aversiveness, and judicial fantasies of drug action. Some possible directions for the future are also examined.