Characteristics of patients with persistent severe disability and medically unexplained neurological symptoms: A pilot study. (Short Report).

This study audited 25 patients (21 female) from Oxfordshire who had been referred to either the liaison psychiatry or the neurological disability service between 1992 and 1998, reported a Barthel activities of daily living index score < 20 or a global assessment of functioning score of [less than or equal to] 30, and had no pathology to explain their neurological disability. Levels of motor impairment, disability, mood, and cognitive status were assessed using standardised scales, and all patients were assigned a psychiatric diagnosis according to the International classification of diseases, 10th revision. Of the 25 patients, 13 had a motor conversion disorder, 8 had diverse somatoform disorders, and 3 had chronic fatigue syndrome. Nine had extensive previous contact with psychiatric services and 11 had experienced physical or sexual abuse. In 6 patients cessation of repeated self harm was closely associated with the onset of wheelchair use. Seven were receiving treatment for depression. The commonest putative diagnoses were multiple sclerosis (6) and epilepsy (5). Twelve were unable to walk and 20 owned a wheelchair but only 3 had formal care packages. The mean (SD) Barthel score was 14.1 (3.3) and the mean (SD) Frenchay activity index score was 12.9 (7.5). All were unemployed and receiving a disability living allowance, and some had benefits of up to [pounds sterling]1815 a month. This small but significant group of disabled patients had a variety of psychiatric and neurological diagnoses and used considerable health care resources.

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Many patients are referred to hospital specialists with complaints that cannot be explained by underlying disease. (1-3) Most patients are referred back to the primary care doctor after investigation but a proportion remain symptomatic and become significantly disabled physically. When these disabilities involve loss of or alteration in limb function patients may be referred to neurological disability services. (4) The problem is of some economic importance to primary (5) and secondary (6) health care services. We audited patients attending services with significant "physical disability" to characterise them and to estimate a minimum prevalence of this phenomenon.

METHODS

Patients were identified from records in the liaison psychiatry department and neurological disability services in Oxford. All patients attending the liaison psychiatry outpatient clinic are given a rating of functional impairment using the global assessment of functioning (GAF) scale. (7)

Patients were initially contacted if they had a GAF score [less than or equal to] 30 ("unable to function in many areas") or a Barthel activities of daily living (ADL) index score (8) of < 20/20. …