Book Review
Somatoform Disorders
Somatoform Disorders:
A Medicolegal Guide Michael Trimble. Cambridge (UK): Cambridge University Press; 2004.
254 p. CAN$95.00.
Reviewer
rating*: Excellent
Review by: Allan Abbass MD, FRCPC
Halifax, Nova Scotia
This book is a balanced and clearly written resource for clinicians, employers, lawyers, and adjudicators working with people with somatoform disorders. Trimble examines the history, classification, assessment, mechanisms, and medicolegal issues of somatoform disorders. As well, he addresses consciousness in regard to these disorders. Each chapter begins at a general level suitable for a layperson and becomes more in-depth, providing a book suitable for a broad range of readers.
Trimble explores the history of somatoform disorders and discusses the evolution of medicolegal issues related to this area. Starting with the “wandering uterus,” Trimble notes that symptom complexes seen today are similar to those described over 2000 years ago. The emergence of this problem as a medicolegal issue began with cases of “railway spine,” in which legal and physician experts became involved in cases of disability and injury. Later, war neuroses, shell shock, and other conditions emerged and eventually were found to have indeterminate causes.
Along with clinical descriptions and theory, Trimble addresses diagnostic criteria and the limitations of existing diagnostic systems. He discusses the overlap of diagnoses such as personality disorders with somatoform disorders. He describes how some patients explain things somatically, whereas others explain things psychologically. Trimble also critiques the major limitations of rating scales as measures of somatization and other psychological functions.
Throughout, Trimble maintains balance and due respect for the sufferer. This balance is extended to his treatment of malingering, false memory syndrome, and patients with borderline personality disorder. The focus is on understanding experience and behaviour in such complex cases. A partial review of the literature on long-term outcomes in patients with somatoform disorders highlights the morbidity and increased mortality seen in these patients, underscoring the fact that these disorders can be severe and debilitating.
Trimble covers the areas of memory, will, and consciousness. Beginning with the biology of memory, he reviews false memory syndrome, suggestibility, fugue, dissociation, personality disorder, and malingering. These concise chapters may serve as course materials for administrators, lawyers, psychiatrists, and judges.
The chapter on medicolegal context covers the nature of the legal system and the experts’ role in regard to these cases. He reviews landmark cases regarding claims for psychiatric injury in several countries. The issue of “proximity” to a trauma and resulting psychological damage is discussed. Further, the “eggshell skull” case, the use of video evidence, and the issue of compensation in general are reviewed. This section is a great introduction to the physician thinking of serving the court as an expert in this type of case.
If there is any area the author appears to feel strongly about, it is the impact of “lexigenic” factors (that is, factors related to the legal process) in worsening the outcome in somatoform disorders. He states that, even though legal involvement generates increased morbidity and prolonged illness courses, the financial and other reinforcements to the litigator seem to override this deleterious effect in favour of winning a settlement. Lawyers are described as having different roles in the life of their client; thus, the rules of “doing no harm” and “best practices” do not apply in law as they do in medicine. In part, this book appears to aim to educate the legal profession about this issue.
In addition to lexigenic factors, Trimble addresses the multiple mechanisms that can generate nonorganic somatic symptom complaints. These include dissociation, repression, suggestion, information-processing problems, and sociocultural reinforcement. He notes that, although the pendulum of causation for these conditions has swung back to psychological theories, brain-based research may yet again bring organic causative factors back into favour. In summary, he states that “while many suffer from accidents . . . overdiagnosis, oversolicitous behaviour, excessive dependence and inappropriate prognostication contaminate the waters of the healing well” (p 216). This opinion is expressed in several ways throughout the text.
Trimble reserves the final chapter for a review of causation and consciousness from medicolegal and psychiatric perspectives. Was the insult “the straw that broke the camel’s back?” Would this have happened “but for” the injury? He reviews the challenges posed when a psychiatrist is asked by a lawyer “But was it conscious, Doctor?” Following a masterful discourse on this matter, he concludes that “calamity, conflict, constitution” and “compensation” all “impinge on human consciousness and have a bearing on causality” (p 240).
In conclusion, this is a very well-written book, obviously crafted by an observant man who is concerned about the care of these patients in our system. It is a succinct guide for those involved in similar legal cases. It is an excellent summary for any psychiatrist or physician interested in becoming an expert witness. Finally, it should become required reading for those prosecuting or defending somatoform disorder patients and those writing ethical and legal guidelines regarding these cases.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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