Complex regional pain syndrome: the role of the psychiatrist as an expert witness.

Complex regional pain syndrome (CRPS) is a regional pain syndrome of unclear pathophysiology, typically affecting the hand or foot. CRPS can be subject to personal injury litigation and may be the cause of substantial future loss of earnings claims. In clinical practice, a variety of medical experts can be involved in the diagnosis and management of CRPS and this can lead to confusion about the most appropriate expert for lawyers to instruct. This paper defines the role of psychiatrists as experts to the court in CRPS and reviews the associated psychiatric literature. Psychiatrists do not have expertise in the clinical diagnosis of CRPS, but they are able to assess the presence of co-morbid psychiatric conditions. They can assist the court as experts in the underlying neuro-physiological and psychological processes which may explain some of the important features of CRPS and an individual's psychological vulnerability to CRPS. Their expertise in psychological and psycho-pharmacological interventions should be considered for any multidisciplinary treatment programme for CRPS along with the likely contribution of these interventions to the overall prognosis.

Psychosis in the British Army: a 2-year follow-up study.

BACKGROUND: Recent research into mental illness in military populations has tended to focus on minor mental illness and the consequences of trauma. The literature contains very little on serious mental illness, including its occupational implications. AIMS: To identify the incidence and factors associated with nonaffective psychosis in British Army personnel, to evaluate service quality in terms of duration of untreated psychosis, and to identify predictors of occupational outcome after 2 years, to inform future management of similar cases. METHODS: A retrospective study of the case notes of all Army personnel admitted to the U.K. military psychiatric inpatient facility in Catterick Garrison with a nonaffective psychosis over a 4-year period between 1999 and 2002 was performed. RESULTS: There were 48 cases of nonaffective psychosis and 14 cases of schizophrenia, corresponding to mean annual incidences of 0.11 cases per 1,000 and 0.03 cases per 1,000, respectively. The mean duration of untreated psychosis was 11 months, and 29 cases (60%) were diagnosed and treated in < 4 months. Officer status and longer duration of service predicted retention. Only eight patients (16.7%) were still in service at 2 years. CONCLUSIONS: These findings indicate (1) there is a low incidence of nonaffective psychosis, (2) the military performs well in early detection and intervention in psychosis, and (3) a well-established military career and the premorbid psychological stability this implies predict a good occupational outcome.

Acute military psychiatric casualties from the war in Iraq.

BACKGROUND: The view that most military personnel evacuated from war zones are suffering from combat stress reactions, or are otherwise traumatised by the horrors of war, has an impact on all aspects of military psychiatry. AIMS: To delineate the reasons for psychiatric aeromedical evacuation from Iraq from the start of build-up of UK forces in January 2003 until the end of October that year, 6 months after the end of formal hostilities. METHOD: A retrospective study was conducted of field and in-patient psychiatric assessments of 116 military personnel evacuated to the UK military psychiatric in-patient facility in Catterick Garrison. RESULTS: Evacuees were mainly non-combatants (69%). A significant proportion were in reserve service (21%) and had a history of contact with mental health services (37%). Only 3% had a combat stress reaction. In over 85% of cases evacuation was for low mood attributed to separation from friends or family, or difficulties adjusting to the environment. CONCLUSIONS: These findings have implications especially for screening for suitability for deployment, and for understanding any longer-term mental health problems arising in veterans from Iraq.

British military forensic psychiatry.

Military psychiatry has recently generated a lot of interest. In contrast there is virtually no literature on military forensic psychiatry. The first section of the paper is a brief review of British military psychiatric services and recent data on the prevalence of mental illness in British armed forces personnel. The second section summarizes the relevant aspects of the British military judicial and penal systems including the practice of summary justice, the court martial system, and sentencing and corrective training. The third section of the paper addresses issues which are particular to forensic psychiatry, including mental defences in relation to the military, the military offences of malingering and impersonation, risk assessment in military contexts and the notion of 'temperamental unsuitability' to military service.

Post-traumatic stress and disability.

BACKGROUND: Post-traumatic stress is thought to account for significant disability. It is also known to be highly comorbid with other psychiatric conditions such as depression and alcohol dependence. AIMS: To determine the relationship between post-traumatic stress, depression, alcohol dependence and disability. METHOD: Seventy armed services personnel were assessed for DSM-IV diagnoses of post-traumatic stress disorder, major depressive disorder and alcohol dependence, and with continuous measures of symptoms of post-traumatic stress, depression and alcohol dependence following a traumatic event. These variables, as predictors of disability (using the Sheehan Disability Scale), were analysed using multivariate analysis of variance, analysis of covariance and multiple regression backward elimination models. RESULTS: No significant interaction was found for the diagnostic variables even after controlling for the continuous symptom measures. In the regression models, symptoms of depression were a significant predictor of total disability (R(2)=0.39). Symptoms of alcohol dependence and post-traumatic stress did not significantly predict disability. CONCLUSIONS: Since post-traumatic stress was not found to be associated with disability, its clinical importance may be questionable.

Physical and psychiatric predictors of late whiplash syndrome.

Approximately 40% of people who sustain whiplash injuries, complain of chronic physical and psychiatric symptoms. Associations have been found between pre-accident physical symptoms and physical outcome and between pre-accident psychiatric variables and both physical and psychiatric outcome. There are no reported investigations of the association between pre-accident physical symptoms and psychiatric outcome. In this study, 33 consecutive cases of whiplash injury met inclusion criteria from a series of psychiatric reports used in civil litigation. Outcome was measured for each patient and correlated with a range of pre-accident physical and psychiatric variables using multivariate regression. There was no association between pre-accident psychiatric factors and overall outcome. Older age and a pre-accident history of musculoskeletal complaints correlated with the physical and psychiatric outcome. In whiplash injury, pre-accident psychiatric factors may have little bearing on long-term prognosis. Physical and psychiatric outcome of late whiplash syndrome is probably worse in older individuals and in patients with a pre-accident history of musculoskeletal complaints.

Management of mental illness by the British Army.

BACKGROUND: The Ministry of Defence has its own hospital for soldiers requiring admission for mental health problems. AIMS: To assess the efficiency of the army psychiatric hospital at restoring patients to full active duty. To assess whether a new military training and rehabilitation unit (MTRU) that emphasises military-skills training, improves outcome. METHOD: A 2-year, inception-cohort outcome study of hospital in-patients. A 12-month, case-matched, 'before and after' outcome study compared MTRU patients with hospital in-patients. RESULTS: I (hospital in-patients, n=309): at 2-year follow-up 67 (22%) were fully fit for active duty. Military psychiatrists' success rate at predicting recovery to active duty was 27%. 2: the odds of a soldier in the MTRU cohort (n=35) returning to active duty were 14 times greater than for the hospital cohort (n=35). The odds of remaining in the army while unfit for active duty were 20 times less for the MTRU than for the hospital cohort. CONCLUSIONS: The army hospital is inefficient at rehabilitation to active duty. The MTRU significantly increased the odds of returning to active duty and reduced the odds of remaining in the army while still unfit. These findings may be applicable to the emergency services.