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.
By Michael Trimble. Cambridge: Cambridge University Press. 2004. 254 pp. £ 50 (pb). ISBN 0 521 81108 2