We now hear from Dr Steven Hirsch, who reveals the complex, yet fascinating problems he faces in the world of psychiatry.
Are there developments in diagnosis and treatment, which has a bearing on legal practice?
Two issues of common concern for lawyers and doctors are medical symptoms for which there is no well understood physical cause, and injuries that inexplicably give rise to loss of function and disablement, or severe pain. There may be a number of psychiatric explanations – diagnoses which can often be effectively treated. These conditions have been subsumed under the rubric, Somatic Symptom Disorder; a diagnosis which has been widened in the American Diagnostic Manuel, DSM-5, to include conditions in which the medical practitioner considers that the severity of the symptoms is excessive and cannot be explained physiologically by the nature of the lesion or the original insult. For example, a man stepped on a nail that caused only a minor injury, but lead to such severe pain that he lost the function of his foot and could not walk. He subsequently developed changes in the appearance of his foot and ankle, which became cold, hairless, slightly swollen, and very weak. The diagnosis was Complex Regional Pain Syndrome (CPRS), something which pain specialists and rheumatologists often see; psychiatrists become involved because the pain is so out of proportion to the injury.
In another case, a man twisted his ankle, and only months later went for medical help, because pain and weakness seriously interfered with his ability to walk, but he did not have the tell-tale symptoms of CRPS.
How can we understand such apparently unexplainable complaints? Did either of these cases represent a Factitious disorder in which the symptoms are consciously fabricated in order to gain medical attention—e.g. so called Munchhausen’s syndrome? Or was it Hypochondriasis, in which the patient has become hyper-vigilant and over-reactive to the merest suggestion of illness? Or was it a Dissociative Disorder, also called Conversion disorder or Charcot’s Hysteria, in which there is a loss of memory or loss of a neurological or brain based function without a physical cause?
What about trauma, and threatening life experiences? Do they make up much of your practice?
Beside Pain and other Somatic Symptom disorders, Post Traumatic Symptom Disorder (PTSD) has become an important area of focus in psychiatric practice because it is very common, often latent, with a delayed and often misleading onset. I would suggest that lawyers, should ask clients who complain of psychiatric symptoms if they have ever experienced an emotional shock or trauma, because PTSD is an eminently treatable condition which can lie behind a range of symptoms and psychological dysfunction. The signs are hyper vigilance, such as jumping to a loud bang; flash-backs, or re-experiencing an event with nightmares or a recurrent disturbing thought or image; and characteristically, a change of behaviour involving avoidance of people and events which were enjoyed in the past. This was under-diagnosed in the past, but the symptoms are now too well known to the legal profession, if not the public in general.
How do these and other psychiatric issues come into play in employment cases, which is one of your areas of expertise?
Individuals may tend to perceive themselves as locked into their place of employment, and not find it easy to walk away when they feel threatened, are experiencing the exertion of power, or undermining of their self-esteem, be it from their superiors or their colleagues. The trauma can be compounded by the difficulty of escape, the sense of helplessness, and the implied threat to their future, and indirectly by its potential affect on their loved ones, and become too much to bear. Helplessness is one of the underlying dynamics leading to a Depressive Disorder, as well as Anxiety and Posttraumatic Stress Disorder. I have done follow-ups on some of my cases, and it is not at all uncommon to find that they never really recover, even when they have had a very ample financial settlement in their favour.
How do you think the workplace can be better organised to minimise the conditions which give rise to employment cases and prevent litigation?
Employers need to be sensitive to individuals showing signs of stress or depression in the workplace, and be aware of employees who develop a poor sickness record. They should be vigilant to rumours of abusive leadership within the workplace. HR needs to see itself as a sensitive listening post to pick up the signs of trouble, because in the long run that will better protect the employer than ignoring it or acting in a defensive manner. Creative and effective intervention requires sensitivity, open mindedness, and a desire to resolve conflict for the benefit of the common good, and should be part of the work policy. HR departments should have read and become familiar with the ACAS advise on dealing with mental health issues in the workplace.
What can be done to encourage this?
These principles should be written into a strong work policy, and HR departments should see their role in protecting the employee as being just as vital as their obligation to the employer, and not be reluctant to intervene when it is needed.
Steven Hirsch BA MD FRCP FRCPsych
Professor of Psychiatry Emeritus
Imperial College London
www.professorstevenhirsch.co.uk
I am Professor Steven Hirsch, Professor of Psychiatry Emeritus at Imperial College London, but since leaving the academic world, I have focused my interest on medico-legal issues; it is a second career. Psychiatric injury has become an important aspect of personal injury, employment, negligence, and testamentary capacity cases, with an increasing appreciation of the variety of psychiatric injurie, and the way psychiatric issues can affect the nature of the symptoms people present.
