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Trends in Health and Disability 2002

Trends in Health and Disability 2002Chief Medical Officers Report

Chief Medical Officers Report 2002 Dr P Dewis 1

Recent Developments in Psychiatry Dr M Lipsedge 7

Functional Symptoms and Syndromes Dr M Sharpe 15

Doctor, I have a pain Dr A K Clarke 23

Recent Advances in General Medicine Dr G H Robb 31

Recent Developments in Cardiology Dr C W Pumphrey 37

Health and Welfare Prof M Aylward 43

Peter Dewis

Peter joined UnumProvident inJuly 2000 having spent 16years with the Department ofSocial Security. He qualified inmedicine in 1977 and becamea member of the RoyalCollege of Physicians, workingin general internal medicinebefore joining the DSS. Withinthe DSS he has held anumber of claims assessment,managerial and policy roles.He is a recognised expert inthe developing discipline ofDisability AssessmentMedicine. He has beeninstrumental in the setting upof the diploma of DisabilityAssessment Medicine of theFaculty of OccupationalMedicine of the Royal Collegeof Physicians. He continues towork as an examiner for thatdiploma.


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Chief Medical Officers Report 2002

Peter Dewis BSc MB ChB DDAM MRCP

The need for a thorough understanding of medical issues is essential ifUnumProvident is to maintain its position as the UKs leading provider ofincome protection insurance. Whilst we frequently emphasise the fact thata medical diagnosis does not equate to a certain level of disability, it isnevertheless true that a knowledge of the range of effects which can arisefrom a particular medical condition is an essential starting point for us inthe way we deal with individuals, whether as applicants for insurance coverin the Underwriting arena, or as claimants for income protection benefits.

Medical research is advancing rapidly on a number of fronts and thusthe expectations we may form on how a person might be affected by aparticular disease and condition today, in a number of areas might beconsiderably different to what they were a few years ago. This howeverhas to be set against the fact that the media will frequently highlightparticular areas of medical research and raise public expectations ofcures and advances which are way in excess of what can be permittedfrom a detailed knowledge of what the research actually shows.

It is against this background that we need to be in a position tounderstand where medical advances are taking us and to be able to forma balanced view on what the implications are for us as an insurer overthe years to come. To this end, I have commissioned a number of papersfrom leaders within the medical profession whose disciplines areparticularly relevant to those people we see most frequently makingclaims for benefit, or whose claims most frequently pose us difficultiesin their management.

Each contributor was asked to highlight the most recent developmentsin their particular discipline and to speculate on how things are likely todevelop over the next few years. Some of the contributors have workedclosely with us in either underwriting, claims or appeals over the lastyear or so and have been able to concentrate on issues, which are likelyto be of greatest importance to us.

Mental health issues have been of particular importance to us recentlyand thus Maurice Lipsedge who until very recently was consultantpsychiatrist at Guys Hospital, has reviewed the range of developmentswithin psychiatry in general. Complementing this, is a paper fromMichael Sharpe, consultant in liaison psychiatry from Edinburgh whohas reviewed the developments, not only in chronic fatigue syndrome,but also the range of disorders where the symptoms experienced by

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we need to be in aposition to

understand where medical advances

are taking us


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individual patients appear to be out of proportion with the physicalfindings or objective evidence of disease in its traditional sense.Ourother large area of work involves musculo-skeletal disorders. TonyClarke who is Medical Director of the National Rheumatic DiseasesHospital in Bath, has chosen to concentrate on the issue of chronic backpain, upper limb disorders and inappropriate pain. His paper thereforehas many points of similarity with those from the psychiatric field.

Charles Pumphrey, Consultant Cardiologist from St Georges Hospitalin London, has highlighted many of the exciting recent developmentswithin cardiology. Many of these have also been picked up by GeoffreyRobb who has been associated with UnumProvident for a number ofyears and fully understands how medical issues and insurance interact.He has also described a number of other relevant developments fromthe field of general medicine.

Finally, Mansel Aylward who is Chief Medical Advisor to theDepartment of Work and Pensions has set out the current trends ingovernment strategy relating to both health and social security. Clearlyany organisation working in this area needs to set its activities in acontext of government policy both in the short and long term.

Hopefully, each of these papers speaks for itself. I would however like todraw out a few specific points both in terms highlighting the technicaladvances, but also describing those areas which are likely to present uswith the greatest challenges as we move forward. My intention would befor this report to be repeated on an annual basis and so become anauthoritative and informative document on the current state of medicalthinking on those issues which are of greatest importance to us.

Medical Genetics

Before moving on to discuss the detail of the individual papers, I needto make some reference to the field of medical genetics. I have notcommissioned a paper on this particular subject which may appear to bean omission in light of the publicity which has surrounded the subjectover the past year and which has culminated in the ABI announcementof the moratorium on the use of genetics testing for insurance purposes.

The field of medical genetics is one in which I believe the media isportraying a future which is currently way beyond the current ability ofmedical technology to meet the expectations being put forward. Clearlysome fundamental advances have been made in medical research in thisarea, but it will still be some time before the benefits will be seen for themajority of people.

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Genetics testingcurrently is only of

real relevance to those suffering fromwhat are known assingle gene disorders.


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The insurance industry developments in this field have centred aroundthe ability of DNA testing to detect those who are at risk of developinginherited diseases. For most diseases seen commonly, genetics usuallyplays only a part in determining who will develop the disease. Geneticstesting currently is only of real relevance to those suffering from what areknown as single gene disorders. These are usually relatively uncommondisorders whose incidence can be predicted accurately from their patternof inheritance. Many also have their manifestations in childhood so thatby the time these people are making applications for insurance, wealready know whether or not they are going to develop the disease. All ofthis means that even before the recently announced moratorium, theonly genetic test which had been approved for use by the governmentsGenetics and Insurance Advisory Committee, was that for Huntingtonsdisease for life insurance purposes.

From a practical day to day point of view, the issue of genetics testingdoes not pose the sorts of significant problems as have been highlightedin the papers commissioned. We are more often in a position to use theresults of a genetics test favourably to an applicant that to exclude themfrom cover and will continue to do this. This does not mean that I amdismissing this issue, since it will undoubtedly assume greater practicalimportance as medical research continues to develop. We need to playour full part in helping the industry establish its position during thecourse of the five year moratorium. Almost certainly there will be scopefor an expert paper specifically on this subject in subsequent editions ofthe CMO report.

Technical Advances

Both Dr Robb and Dr Pumphrey have referred to the changes whichhave taken place in the diagnosis of heart attack (myocardial infarction)through the discovery of a new very sensitive biochemical marker ofheart muscle damage known as Tropinin T. This has changed the criteriafor the diagnosis of heart attacks in the clinical setting, to the extentthat a diagnosis of a heart attack may well be made now in peoplewhose episodes of chest pain might have remained undiagnosed.Moreover, this has important implications since the life expectancy ofsuch people may well not be impaired in the way that is traditionallythe case for people who have had heart attacks and indeed for somemight in fact be enhanced. Dr Robb, however urges caution in thewholesale adoption of these new diagnostic criteria within the criticalillness arena and this has been reflected in the definitions for heartattack (both major and minor) adopted for the new individual criticalillness product. This is an area which will need to be kept under activereview in discussion with our re-insurers. The overall prognosis ofpeople with coronary artery disease has also been referred to, especially

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the issue of geneticstesting does not pose

the sorts ofsignificant problems

as have beenhighlighted in the

papers commissioned.


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in relation to the more widespread use of the lipid lowering drugsknown as the statins. Dr Robb has also identified the fact that withgreater attention to detail in control of blood sugar, the prognosis forpeople with diabetes mellitus can be much better than has previouslybeen the case. I will, in discussion with the Chief Medical Underwriter,be looking critically at our underwriting policies in these particular areasover the coming year.

Dr Pumphrey has identified the improvements which have taken placein the surgical treatment of established coronary artery disease, whichshould lead us to expect an increasing trend in people being able toreturn to and remain in work. This is important information forbenefits claims managers in forming their expectations on individualcases. The increasing use of Percutaneous Coronary Intervention(coronary angioplasty) should also cause them to expect that this will beused more and more routinely so that uncontrolled ischaemic chest painwill become less and less common.

Within the musculo-skeletal field, the advances Dr Clarke describesrelate more to those of understanding of the nature of chronic painfulconditions rather than to any particular technical breakthrough. Mostsuch conditions do not have a serious underlying pathological basis.Stemming from this is the increasing realisation of the need for peopleto remain active and for clinicians to intervene early in the process toensure that optimum recovery and rehabilitation is achieved. Much ofwhat Dr Clarke has described has been mirrored by Dr Sharpe in hisdescription of the apparent rise in the prevalence of conditions forwhich no underlying disease process can be identified.

Dr Lipsedge has referred to a number of developments in the way inwhich imaging techniques are starting to delineate the neurological basisfor a number of psychiatric disorders. However, many of these currentlyare at a purely academic level and he points out that the treatment ofdepression has not improved significantly since the first discovery ofantidepressant drugs.

Ongoing Challenges

The fact that there have been few advances in the treatment ofdepression represents a challenge. This is particularly so since all theauthors have identified this as being of significance in their ownparticular field. Dr Lipsedge for example, has highlighted theimportance of symptoms which fall short of producing a definitedepressive illness, but which may well have an influence on overalldisability. Its impact in the field of cardiology and general medicine hasbeen particularly identified by Dr Robb. This presents us with a

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with greaterattention to detail in control of blood

sugar, the prognosisfor people with

diabetes mellitus canbe much better thanhas previously been

the case

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the treatment ofdepression has not improved

significantly sincethe first discovery of antidepressant drugs


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particular challenge in being able to identify those claimants wheredepression may be having a significant impact at an early stage of theirincapacity and where possible being able to influence their treatmentsince it is clear that these issues are not always being adequatelyaddressed within the constraints of primary care.

Dr Lipsedge, Dr Sharpe and Dr Clarke have identified the importanceof cognitive behaviour therapy of influencing the outcome indepression, chronic fatigue syndrome and chronic pain. This againrepresents a challenge in ensuring that people are directed towards thisapproach. This can be particularly difficult in relation to the availabilityof such services under the NHS. All of this needs to be considered inrelation to the other common theme, which has been emphasisedparticularly by Dr Sharpe and which relates to the need to interveneearly in the course of a disability to achieve a positive outcome.

Message for UnumProvident

Although contributions were sought from specialists across a widevariety of disciplines, when looking at those areas which are likely topose particular challenges, the importance of psychological factors indetermining long term disability emerges. In addition, in such peoplethere will frequently be a predominance of subjective complaints withlittle in the way objective findings to support these. All the findingspresented by Dr Aylward on the trends in social security statistics showthat these are also major issues for the public sector. Dr Aylwards dataalso supports strongly the view that early intervention appears to be theonly way of influencing this situation. He has also identified a numberof government initiatives, such as the New Deal for Disabled People andNHS Plus, which signify the governments intention of addressing theseissues. Clearly however, there is a tremendous amount of work thatneeds to be done to make these a reality.

Within UnumProvident, I believe that we need specifically to continueto develop in two particular areas and that the information presented bythe experts contributing to this report, support this view.

We need to continue to develop our capability within MedicalServices and Rehabilitation Services to be able to intervene earlier inthe course of any disability. This means increasing our ability to havean integrated approach within UnumProvident and to be able toengage with employers as well as individual disabled people.

We need to continue to develop the disciplined thinking required toassess fairly those claims from people, which are based entirely onsubjective factors.

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the importance ofpsychological factorsin determining long

term disabilityemerges

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We need to continueto develop our

capability withinMedical Services and

RehabilitationServices to be able to

intervene earlier

Maurice Lipsedge

Maurice Lipsedge is EmeritusConsultant Psychiatrist to theSouth London and MaudslayNHS Trust. He is also HonarySenior Lecturer in theDepartment of PsychologicalMedicine within Guys, Kingsand St Thomass school ofmedicine. His specialinterests include the fitnessfor work in patients withmental health problems. Hehas made a significantcontribution as an author, toa number of standardreference works in the fieldsof occupational andinsurance medicine, includingFitness for Work, Life andDisability Underwriting andMedical Selection of LifeRisks. He is a formermember of the Home OfficeParole Board and of theNolan Committee: Review onChild Protection in theCatholic Church in Englandand Wales.

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Recent Developments in Psychiatry

Maurice Lipsedge M.Phil FRCP FRCPsych FFOM(Hon)

IntroductionIn this brief review of recent developments in psychiatry, I have drawnon both the American and the British psychiatric journals published overthe past couple of years. The basis of selection has been developments inresearch which have potential implications for long term or recurrentoccupational disability arising from psychiatric disorders.

Given the current emphasis on neurological research, the bulk of theliterature deals with those disorders, which have a basis in cerebraldysfunction, especially schizophrenia, the affective disorders anddementia. Although the clinical onset of Alzheimers disease can be priorto the age of sixty it is, of course, typically a disorder of old age. Thefirst phase of Alzheimers disease, which can last for two to three years, ischaracterised by failing memory, muddled inefficiency over everydaytasks and spatial disorientation. Moreover, because disturbance of moodcan be prominent and since a degree of depressive pseudodementia isnot uncommon, presenile dementia has to be considered as a differential

diagnosis in the occupational setting in all people whoare referred for a psychiatric assessment after the onsetof middle age.

For this reason consideration of recent developments inthe cause and potential treatment of Alzheimersdisease merit inclusion in a review such as this. In viewof the increasing prevalence of schizophrenia and theestablished high level of affective disorders in thecommunity, these non-organic disorders require nosuch justification.

The 1990s were designated the Decade of the Brain by TimeMagazine and significant advances were made during that period in thebasic sciences of neurobiology and genetics. So far, however, thesedevelopments have had virtually no impact on psychiatric clinicalactivity. Thus, in the field of depressive illnesses, which have a wideprevalence, the efficacy and speed to onset of response to antidepressantshas changed little since the serendipitous discovery of the MAOIs(monoamise oxidase inhibitors) over forty years ago.

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the 1990s weredesignated the

Decade of the Brainby Time Magazine


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Neuroimaging

The neurochemical pathology of the major psychiatric disorders has beenelucidated recently by the use of functional brain imaging techniquesnamely Positron Emission Tomography (PET), Magnetic ResonanceSpectroscopy (MRS), Functional Magnetic Resonance Imaging (MRI)and Single Photon Emission Computed Tomography (SPECT).

Recent studies on the functional neuroanatomy of depression usingSPECT and PET imaging techniques have compared the effects ofpharmacotherapy with a form of psychotherapy. Surprisingly, both theadministration of antidepressant drugs and the psychosocialintervention were associated with increased blood flow to the lefttemporal or right basal ganglia regions. Furthermore, both theinterpersonal psychotherapy and the antidepressant treatmentnormalised metabolism in the prefrontal cortex and left anteriorcingular gyrus.

Although these results have emerged only frompreliminary studies and some methodologicalreservations have been expressed, the tangible cerebraleffects apparently brought about by psychotherapy arean interesting sequel to the earlier work on the changesinduced in the brain by the cognitive-behaviour therapyof obsessional compulsive disorder.

Working forwards conceptually from psychologicaltrauma to neurobiological changes, recent MRI studieshave demonstrated hippocampal atrophy in posttraumatic stress disorder. In functional terms, thisreduction in hippocampal volume is associated with

explicit memory deficits. The same picture has alreadybeen demonstrated in depression. It is still not clearly establishedwhether the hippocampal atrophy arises from the clinical disorder orprecedes it and whether a disturbance of glucocorticoids is theunderlying cause.

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it is possible toidentify changes in

cognitive performancewhen people are still

regarded as free of dementia

Early Detection of Alzheimers Disease

Recent studies of longitudinal changes in cognitive performance duringthe preclinical phase of Alzheimers disease show that in the near futureit may be possible to identify people at risk of developing this type ofdementia and to administer prophylactic treatments in order to delay orstop the progression of this disease. The possibility of identifying peopleat risk of developing Alzheimers disease carries implications forpotential therapeutic interventions. A number of recent studies haveattempted to identify the cognitive markers of preclinical Alzheimersdisease and it has been found that people who later developedAlzheimers disease experienced greater changes across multiple cognitivedomains compared with those who did not develop dementia. The mostprominent changes were an accelerated decline in episodic memory andin executive functioning.

By carrying out multiple measures longitudinally, it is possible toidentify changes in cognitive performance when people are still regardedas free of dementia and recent research shows that cross sectional deficitsin cognitive performance can appear years before the actual diagnosis of

Alzheimers disease. It is likely that individuals at risk ofAlzheimers disease will be more precisely identifiedbefore the clinical onset of the disorder by combininglongitudinal studies of cognitive performance withgenetic and neuroimaging techniques, since moreindividuals who go on to develop Alzheimers diseaseshow prediagnostic changes in neuroanatomy. Thesechanges have been demonstrated both in neuro-pathological studies as well as magnetic resonanceimaging which has demonstrated changes in thehippocampus and entorhinal cortex.


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it has been foundthat people who laterdeveloped Alzheimersdisease experiencedgreater changesacross multiple

cognitive domains

Prevention of Relapse in Residual Depression byCognitive Therapy

It is known that marked morbidity and disability occurs as a result of thesignificant rates of relapse and recurrence in major depression and thatdepression is a risk factor for the onset of both physical and psychosocial

disability while the effective treatment of depressionimproves functional outcomes. The rate of relapseand recurrence can be reduced by patients continuingto take antidepressants. It is recognised that manypatients still achieve only a partial remission and havepersistent residual symptoms. Residual depressioncan occur in about a third of patients suffering frommajor depression who have been treated withappropriate doses of antidepressants for an adequatetrial period. A recent meta-analysis of the drugtreatment of depression found response rates to be nobetter than 50 per cent for active treatment bycomparison to 32 per cent for placebo (Agency for

Healthcare Policy Research, 1999). Furthermore,patients with residual depression are particularly prone to relapse. It hasnow been shown that cognitive therapy is highly effective in reducingrelapse rates in cases of severe residual depressive symptoms, despiteantidepressant treatment. Cognitive therapy is a cost effective form oftreatment for depression requiring less than 20 weekly sessions. In thisstudy, cognitive therapy was added to antidepressants and thispsychological intervention was shown to prevent relapse into a furtherepisode of major depression.

Long-Term Disability Associated with Depression

A prospective study of psychosocial disability in relation to theseverity of depressive symptoms was conducted over a ten yearperiod. The results show a progressive gradient of psychosocialimpairment, which parallels the severity of depressivesymptoms. It was found that there is a significant stepwiseincrement in psychosocial disability as one progresses fromsubthreshold depressive symptoms through dysthymia tounipolar major depressive disorder. This common-senserelationship between the severity of depression andoccupational impairment (ie, the synchrony of change indepression and disability) shows that effective treatment ofdepression will improve functional outcome.


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depression is a riskfactor for the onset

of both physical and psychosocial

disability

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Cognitive therapy is a cost effective form

of treatment fordepression requiringless than 20 weekly

sessions.

This synchrony may be predictable, but an unexpected recent findingwas the link between depression and the course of coronary arterydisease. Recent studies have shown that there is an increased risk ofischaemic heart disease among depressed patients. Furthermore, patientswith depression following a myocardial infarction are over three timesmore likely to die than non-depressed patients. It has been suggested thatassociation between depression and coronary artery disease might bebased on changes in the autonomic nervous system or in a disturbance ofplatelet function. It has also been shown that major depression is asignificant risk factor for the development of stroke.

Assessing and Measuring Psychiatric Disability

There is an important and challenging contribution to the literature onthe assessment of disability in a recent communication in the AmericanJournal of Psychiatry (Janca, 2001). Janca has critically evaluated thedisability axis of the Multi-Axial Presentation of ICD-10 for Use inAdult Psychiatry which is an instrument comparable in purpose to the

DSM-IV Axis V scales, ie The Global Assessment ofFunctioning Scale, The Global Assessment ofRelationing Scale and The Social and OccupationalAssessment Scale.

In contrast to the impressively high levels of inter-rater reliability found with the DSM-IV Axis Vscales, Janca found a very low inter-rater reliabilitywhen the World Health Organisations ShortDisability Assessment Schedule was subjected totrials by 274 clinicians from 21 different countries.The question is therefore asked as to whetherDSM-IV Axis V scales have a true inter-raterreliability or whether the claimed satisfactorypsychometric properties are merely a reflection ofextensive instrument administration training andhigh motivation of the clinicians? (I must say thatI have some sympathy for Jancas sceptical viewsince the operational guidelines supplied by

DSM-IV for the determination of disability aredifficult to apply with any degree of confidence, eg on the SOFAS onewould allocate a score of 41-50 serious impairment in....occupational....functioning on the basis of the example unable tokeep a job, when the alleged inability to keep a job might arise from agenuine disability but completely fails to take into accountmotivational and illness behaviour factors).


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a recent metaanalysis of the drug

treatment ofdepression found

response rates to beno better than 50 per cent for active

treatment bycomparison to 32 per

cent for placebo

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Recent studies haveshown that there isan increased riskof ischaemic heart

disease amongdepressed patients.

In assessing disability we tend to set the boundary at ICD-10 orpreferably DSM-IV defined conditions, relying on clinical significancecriteria. Dysthymic disorder which was first introduced as a separatediagnostic category in DSM-IV-R, is found in about 5 per cent of thepopulation. This chronic low grade depressive condition is generally

punctuated by episodes of major depression and thecondition tends to become more severe withincreasing age. The level of functional impairmentin dysthymic disorder equals or exceeds that inmajor depressive disorder.

A prospective 5 year follow-up study has shownthat the course and outcome of dysthymic disorderare rendered unfavourable by a family history ofpsychiatric disorder, adversity in childhood, chronicstress and an avoidant, dependent or obsessive-compulsive personality disorder. Interestingly afamily history of bipolar disorder is associated witha higher probability of recovery.

Although dysthymic disorder has achieved thestatus of a DSM-IV recognised category, there has

been a proliferation of substhreshold disorders over the past few years.Synonyms include minor depression, subsyndromal symptomaticdepression etc. some of these subthreshold conditions lack validity asformal psychiatric disorders and they are often difficult to distinguishfrom common-or-garden unhappiness. It has been suggested that thesesubthreshold conditions should be more precisely defined and studiedon a longitudinal basis, but it is also recognised that providing formalidentifying criteria and quantifying these symptoms might exacerbatethe current tendency to pathologise conditions that may be within thenormal spectrum. Grief would be a case in point.

Antidepressants of all types cause an increase in the release of presynapticmonoamines, which activate a range of post-synaptic receptors. These arecoupled to second messenger signal transduction factors that controlgene expression. This knowledge has been derived from recent researchwith animal models, providing new perspectives on the pathophysiologyof depressive disorder, the biology of stress and the mode of action ofantidepressant drugs.

In summary, antidepressants of different classes all appear to increase theexpression of neuroprotective proteins which are important for thefunction and growth of neurones.


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patients withdepression following

a myocardialinfarction are overthree times more likely to die thannon-depressed

patients

Cost-Effective Psychological Treatment of CommonPsychiatric Disorders

The past few years has seen the consolidation of the role ofpsychological treatment methods in both depression and the anxiety-based disorders. Cognitive-behavioural therapy now has an establishedtrack record in terms of cost effectiveness and its methods can beapplied either in conjunction with medication or without concurrentpharmacological treatment. Post-traumatic stress disorder and chronicfatigue syndromes provide examples of common and often disablingconditions in which the optimal treatment might be cognitive-behaviour therapy administered by a nurse therapist or clinicalpsychologist backed up by antidepressant medication prescribed by ageneral practitioner or psychiatrist. Cognitive therapy has also, perhapssurprisingly, become recognised as an effective way of helping patientswith refractory schizophrenia and chronic paranoid psychoses to learneffective strategies for challenging delusional ideas and for dealing withdistressing hallucinations.

Schizophrenia

The recent application of quantitive methods in schizophrenia researchhas been a first step in identifying an anatomical substrate forschizophrenia. Stereological analysis of the prefrontal cortex has shown

the presence of increased density of neurones inpatients with schizophrenia. This is now known tobe due to a reduction in the elements of neuralconnectivity rather than the actual destruction ofnerve cells. This deficit appears to occur in aspecific area of the prefrontal cortex in patients withschizophrenia suggesting that the large pyramidalcells in that particular area (layer 3c) receive fewersynapses from modulatory dopaminergic andexitatory afferent inputs.

Since the pathology in the prefrontal cortex ofpatients with schizophrenia appears to be confinedto neuronal processes and synaptic connections

rather than actual loss of neurones, it is hoped thathighly targeted pharmacological treatments can be developed which will have a selective action on specific neuronal cells and connections.


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some subthresholdconditions are often

difficult todistinguish from

common-or-gardenunhappiness

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Cognitive-behaviouraltherapy now has an

established trackrecord in terms ofcost effectiveness

Michael Sharpe

Michael Sharpe is Reader inPsychological Medicine atthe University of Edinburghand is an HonoraryConsultant Psychiatrist to theEdinburgh Hospitals. Hisinterests have focused onthe interface betweenpsychiatry and medicine. Heis particularly interested inthe role of depression inphysical illness, in poorlyunderstood syndromes, suchas chronic pain and chronicfatigue and in how biologicaland psychological factorsinteract to cause symptomsand disability. He is currentlychair of the Scottish LiaisonPsychiatry Group, Director ofPsychological MedicineResearch and Teaching atthe University of Edinburghand provides a consultationservice to the Department ofNeurology at the WesternGeneral Hospital in Edinburgh.


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Functional Symptoms and Syndromes: Recent Developments

Michael Sharpe MA MD MRCP MRCPsychReader in Psychological MedicineUniversity of Edinburgh

The Nature and Size of the Problem

It is becoming increasingly clear that the problem of patients who haveillness that is defined only subjectively and not clearly explained bydisease is a large one. Recent research has shown that such presentationsare extremely common in general practice in a range of countries andcultures. They also account for a quarter to a half of all new medicalhospital outpatient consultations. The most common symptoms arepain in various sites (back pain, head pain, chest pain and generalisedpain) and fatigue. Other common symptoms are tingling, dizziness,weakness, breathlessness, bowel disturbance and palpitations. Althoughnot due to any recognised disease these symptoms may nonetheless beassociated with severe and persistent disability.

Terminology and Classification

TerminologyThere is a great deal of confusion about what to call such illness. A widerange of general terms has been used including hysteria, abnormalillness behaviour, somatisation, and somatoform disorders. Recentlythe terms medically unexplained symptoms (MUS) and functionalsymptoms have become popular amongst researchers, as they do notassume any particular aetiology.

ClassificationClassification is also confusing as there are parallel medical andpsychiatric classifications. The medical classification defines functionalsyndromes such as tension headache, irritable bowel, and so on basedon the bodily system or part apparently most affected. Hence, patientsattending gastroenterology with functional symptoms tend to receivethe label of irritable bowel syndrome, those attending rheumatology bediagnosed as having fibromyalgia, those attending infectious disease ashaving (post viral) fatigue syndrome and so on (see Table 1).


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It is becomingincreasingly clear

that the problem ofpatients who have

illness that isdefined only

subjectively and not clearly explained

by disease is a large one.

There has recently been increased awareness that these individualfunctional syndromes are not as separate as they seem. There is notonly overlap in the symptoms patients report but also in associated

characteristics and response to treatment (see below). It hastherefore been proposed that these conditions be consideredtogether as a general functional somatic syndrome. Whilstthis may be too extreme a view, substantial commonalitybetween them is now generally accepted.

The psychiatric classifications provide alternative diagnosesfor the same patients (See Table 2). The majority, but notall patients will meet criteria for depressive or anxietydisorders and most of the remainder of those for the so-called somatoform disorders of which hypochondriasis(severe anxiety about disease) and somatisation disorder (a long term tendency to present repeatedly with a range ofmedically unexplained symptoms) have most clinical utility.


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Table 1: Common medically defined functional syndromes listed by medical speciality

Gastroenterology Irritable bowel syndrome (IBS), non-ulcer dyspepsia (NUD)

Gynaecology Pre-menstrual syndrome (PMS), chronic pelvic pain (CPP)

Rheumatology Fibromyalgia (FMG)

Cardiology Atypical or non-cardiac chest pain; benign palpitation.

Respiratory medicine Hyperventilation syndrome (HVS)

Infectious diseases (Post-viral) fatigue syndrome (CFS)

Neurology Tension headache

Dentistry Temporal-mandibular joint dysfunction,atypical facial pain

ENT Globus syndrome

Allergy Multiple chemical sensitivity

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patients may becomechronically disabled

because of a treatable but

untreated psychiatricdisorder.

Neither classification is ideal. However, the psychiatric classification hasimportant treatment implications. Because patients present somatically(and may not want a psychiatric diagnosis) this may be missed. Hence,patients may become chronically disabled because of a treatable butuntreated psychiatric disorder. This is not an uncommon finding bothin clinical practice and in IMEs. We need better classifications in themeantime, the best practice is to always seek evidence for and recorddiagnoses from both medical and psychiatric systems for exampleirritable bowel syndrome with anxiety.


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Table 2 : DSM-IV and ICD-10 categories for medicallyunexplained syndromes

DSMIV ICD-10

Somatoform disorders Somatoform disorders

Somatisation disorder Somatisation disorder

Undifferentiated Undifferentiated somatoform disordersomatoform disorder

Conversion disorder

Pain disorder Persistent somatoform pain disorder

Hypochondriasis Hypochondriacal disorder

Body dysmorphic disorder

Somatoform disorder NOS Somatoform autonomic dysfunction

Other somatoform disorders

Somatoform disorder unspecified

Dissociative (conversion) disorders

Disorders of movement and sensation

Other neurotic disorders

Neurasthenia

Depressive disorders Depressive disorders

Anxiety disorders Anxiety disorders

The Aetiology of Functional Syndromes

The best ways of understanding such syndromes is to consider a rangeof biological, psychological and social factors. Table 3 illustrates such anapproach to chronic fatigue syndrome.

Biological factorsRecent research using functional brain imaging (PET and fMRI) hasstarted to identify altered brain functioning in patients who havefunctional syndromes (as well as in those with depression and anxiety).This does not mean the patients have brain disease, but that theirexperience of symptoms has a neurophysiological correlate. On the onehand this is merely evidence of mind-brain identity, on the other handit does remind us that these symptoms are not purely psychologicalphenomena but that they have a biological reality, albeit a potentiallyreversible one.

Psychological factorsWhatever their biological basis, there is strong evidence that symptomsand disability are shaped by psychological factors. Especially importantare the patients beliefs and fears about their symptoms. Research inseveral functional syndromes has found that a strong belief andpreoccupation that one has a medical disease and a helpless andpassive attitude to coping is associated with persistent disability (as it isin recovery from acute medical condition such as myocardial infarction).The presence of depression is similarly associated with greater disabilityand worse outcome. Some persons appear to exaggerate symptoms butthis is often hard to prove.Social factors


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Table 3: Possible causal factors in chronic fatigue syndrome

Predisposing Precipitating Perpetuating

Biological Genetic virus HPA axis Previous disturbancedepression inactivity

Psychological Personality response disease (perfectionism) to stress attribution,

avoidant coping style

Social stresses life conflicts,iatrogenic factors

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there is strongevidence that

symptoms anddisability are shaped

by psychologicalfactors.

Although harder to research, social factors are almost certainly of greatimportance in shaping functional illness. Relevant factors include the

information patients receive about the symptoms andhow to cope with them. This information may behelpful or may stress the chronicity of the illness andpromote helplessness. Such unhelpful information isfound in self-help (!) books and increasingly on theInternet (see for example www.meassociation.org.uk).Unfortunately, doctors and especially specialistprivate doctors and complementary therapists maybe as bad. Other social factors that perpetuate illnessare anger with the person or organisation the illness isattributed to, or toward the insurer for not believingthem. It has been pointed out that: if you have toprove you are ill you cant get well. Both State and

private insurers pay people to remain ill. Litigation for poorlyunderstood and functional illness appears to be on the increase and arecent large study from Canada provided evidence that it does increasethe duration of so-called whiplash symptoms.

Treatment

Evidence based treatmentRecent systematic reviews of randomised controlled trials haveconfirmed that psychologically informed rehabilitative treatments (oftencalled cognitive behaviour therapy or CBT) and antidepressant drugshave some effectiveness in treating most functional syndromes. There ishowever a great shortage of skilled providers of CBT in particular andrehabilitative facilities in general.

Obstacles to recoveryIn practice, even if treatment is available, there may be obstacles torecovery. Over time, the patients beliefs may be become entrenched and be driven by anger and the need to explain continuing disability.The current system of state benefits, insurance payments and litigationremain potentially major obstacles to effective rehabilitation. It is oftenunrealistic to expect medical treatment alone to overcome these.Furthermore patient groups who champion the interest of individualswith functional complaints (particularly for chronic fatigue andfibromyalgia) are increasingly influential; they are extremely effective inlobbying politicians and have even been threatening towards individualsand organisations who question the validity and permanence of theillness they champion. Again the ME lobby is the best example.

THE FUTURE


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social factors arealmost certainly ofgreat importance inshaping functional

illness

ref: 059874

The current systemof state benefits,

insurance paymentsand litigation remain

potentially majorobstacles to effective

rehabilitation.

Functional symptoms are not going to go away. They will be driven byfactors such as work stress and disaffection, information about newillness from the media and the Internet and the persisting stigma ofpsychological problems. However, the form that they take is likely tocontinue to change. Although there are a limited number of symptomsthat people can have, there are an almost infinite range of factors thatthese symptom can be attributed to. Such illness attributions tend to beto external factors and often those, which individuals feel fearful of,wronged by and which are outside their control. Possible new functionalsyndromes are likely to include those associated with pollution(chemical, biological and radiological) of the work place and workstress, and perhaps now in relation to terrorism and fear of terrorism.

A shift towards a more consumer-based approach to health is also likelyto increase the prominence if not the prevalence of such syndromes as the authority of medicine to define what is a legitimate illness isdiminished. Indeed, increasingly consumer oriented and privatiseddoctors will collude with the patients views that they have a disablingand permanent disease. In other words, it may be difficult for those whowish to champion rehabilitation and return to work to hold the linewithout seeming to be anti-patient.

The demands such persons make on health service, social benefit systems,and insurers are likely to increase. It is hard to see how an increasinglypressed health service will be able to deal effectively with the demand. Anincrease in insurance claims is to be therefore anticipated.

What can be done?

GenerallyIt will be imperative that health and social policy addresses this problem.Benefits and medical services need to be more rehabilitation orientated.This will not be easy. However, there are glimmers of progress.

An example is recent developments in the politics ofCFS. After a failure of patient organisations to accept areport on the condition produced by the Royal Colleges,the previous CMO for England set up a working partythat included both patient advocates and professionals.The meetings were difficult and there was a failure toagree the final report. Nonetheless, the current ChiefMedical Officer released the report early in 2002(www.doh.gov.uk/cmo/cfsmereport). It is mixed, interms of the relationship of its contents to the research

evidence as opposed to advocacy but does accept theincreasingly strong evidence for rehabilitation. Furthermore, one of the


20

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Possible newfunctional syndromesare likely to include

those associated withpollution of theworkplace... and

work stress

ref: 059874

Benefits and medicalservices need to bemore rehabilitation

orientated.

ref: 059874

The demands suchpersons make on

health service, socialbenefit systems, and

insurers are likely to increase.

major patient charities (Action for ME) is aligning itself with a moreevidence-based approach. These are early days but if this convergence of rehabilitation oriented clinicians and a patient advocacy group issuccessful, there could be very positive implications for patients and for insurers.

There is a major need for effective rehabilitation for treatable patients.Existing pain and rehabilitation services would provide a useful basis.However, their capacity and skills are currently far too limited. Fundingof rehabilitation by commercial bodies has begun in the UK (withorganisations such as PRISMA) and is likely to continue. As long as theeconomy remains strong and skilled workers are sought after, it will bein employers interests to rehabilitate sick but valued employees.

By the insurance industryFrom the insurance point of view, efforts need to be made to minimisethe risk of their policyholders getting ill and to minimise the obstaclesto their recovery. There are implications for pre-acceptance medicalassessment and for the work practices of employers. When policyholdersdo fall sick with a functional syndrome it is likely to help if both insurerand employer maintain a positive relationship with the claimant. Anearly but positively planned return to work (even in a very limitedcapacity) is desirable. If the claimant becomes hostile toward employeror insurer the position is likely to be difficult to retrieve.

Much could be gained from having an early biopsychosocial assessments of patients that ensured the identification of psychiatric as well asmedical diagnoses. There is also a need to minimise iatrogenic harmboth from family doctors who misguidedly encourage the patients totake time off at the insurers expense and from certain specialists.

For those with established disability an increased availability ofrehabilitative treatment facilities is highly desirable. The NHS is notlikely to pay for these.

Summary

The problem of medically unexplained or functional illnessis a large one. It is not going to go away and it is likely toget bigger. Social factors are more likely to influence thetrends in the prevalence, presentation and cost than aremedical developments. Both health services and insurersnow need to take a more positive approach. To those whosay that this will cost money I would reply how much is it costing you doing nothing?DOCTOR, I HAVE A PAIN


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how much is itcosting you doing

nothing?

ref: 059874

If the claimantbecomes hostile

toward employer orinsurer the position

is likely to be difficult to retrieve.

ref: 059874

As long as theeconomy remainsstrong and skilledworkers are soughtafter, it will be inemployers interests to rehabilitate sick

but valued employees.

Anthony K. Clarke

Anthony K. Clarke isConsultant in Rheumatology& Rehabilitation at the Royal National Hospital forRheumatic Diseases in Bath,where he is also Director ofRehabilitation and MedicalDirector. Among his otherappointments, he is CivilConsultant in Rheumatology& Rehabilitation to the Royal Air Force and is a Past President of the BritishSociety of RehabilitationMedicine and the SouthWales, South West andWessex Rheumatology Club.He is also a past member of the Disability LivingAllowance Advisory Boardand helped in the initialtraining of the BenefitsAgency Medical Service for the introduction ofIncapacity Benefit.

Among his clinical interestsare general rheumatology,pain, chronic fatigue andcommunity rehabilitation. He has a particular interest in the injured employee andregularly provides expertopinion in litigation andinsurance disputes.


22


23

Doctor, I have a pain

Anthony K Clarke FRCP Medical DirectorThe Royal National Hospital for Rheumatic Diseases, Bath

Pain is one of the commonest symptoms experienced by human beings.It is extremely difficult to quantify pain and the only way that we knowthat a person is suffering is on the basis of what he or she tells us. Wehave to put the patient on trust to tell us the truth. Compared to, sayheart disease, we do not have an objective test of the type of exercisewith the Bruce Protocol for angina or changes on x-ray to confirm heartfailure. Yet, musculoskeletal pain is among the commonest reasons forpeople to be on long term absence from work. Back pain accounts formore loss of productivity than industrial action and the problemsrelating to work related upper limb pain has threatened to shut downwhole areas of commerce. This short review aims to look specifically atthe problems of low back and upper limb work related pain, with somecomments on inappropriate pain and what steps can be taken to avoidlong term disability.

Aetiology

The majority of patients with low back pain are suffering frommechanical pain, that is pain which arises from relatively minor injury

to the soft tissues in the back, including the ligaments,muscles and joints. The physician should always beaware of the possibility of the rarer and more seriouscauses of pain, such as prolapsed intravertebral disc,osteoporotic collapse, and malignant disease. However,the overwhelming majority of symptoms relate potentiallytreatable and reversible mechanical problems.Experience has shown that if a proper diagnosis is madeand treatment commenced early, then the prognosis isalmost always good. One of the most difficult problemshowever in Britain is the difficulty of early access toadequate diagnostic and treatment facilities.

Upper limb work-related pain consists of a collection ofusually mild and reversible soft tissue problems in thearm or arising from the neck. By definition, theseproblems may be precipitated or worsened by work oroveruse of the limb. Among the recognised causes arecarpal tunnel syndrome, tennis and golfers elbow,

capsulitis of the shoulder, brachial neuralgia and veryoccasionally true tendonitis. The term repetitive strain (or stress) injury

ref: 059874

musculoskeletal pain is among the

commonest reasonsfor people to

be on long termabsence from work.Back pain accounts

for more loss ofproductivity thanindustrial action

(RSI) should be avoided if for no other reason that as a term it isemotive and carries significant diagnostic and social baggage which maymake it difficult to reach an objective decision about treatment.Without a doubt, the most important issue from the upper limb pain isto reach a sustainable diagnosis.

It is important to realise that the incidence of upper limb pain is just ascommon in the general population as it is in, say, keyboard workers. Itis also important to realise that with proper treatment the overwhelmingmajority of patients will get better and be able to return to work,including doing work with keyboards.

History

The taking of an adequate clinical history remains the cornerstone ofany clinical evaluation of the patient. With low back pain it is possiblefor the pain to arise spontaneously. There are a number of red flagswhich should alert the physician to serious causes of pain, such asneurological signs and symptoms and unremitting night pain. It is morecommon for the episode of pain to arise following a specificprecipitating incident, such as lifting an inappropriately heavy object.

With upper limb pain, a careful clinical history will often reveal features,which will direct the physician in the correct direction as far as thediagnosis is concerned. An example might be a story of the pain beingprecipitated when gripping and twisting at the wrist, a frequent story intennis elbow, or the typical history of numbness and tingling in thefingers, sparing the little finger, which is seen in carpal tunnel syndrome.

Examination

As important as a good history is a good examination. In the back itshould be possible to exclude by examination such conditions asankylosing spondylitis or neurological problems related to prolapsedintervertebral disc. General examination will help exclude systemicproblems such as secondary deposits from carcinoma of the lung.

With upper limb pain, again general examination is essential. Inparticular a proper neurological examination is always required lookingfor, among other things, carpal tunnel syndrome and cervical spinenerve root pressure. One needs to be able to identify or exclude suchconditions as algodystrophy or osteoarthritis producing pain referred tothe deltoid insertion and neck related problems. It is most unusual notbe able to make a definitive diagnosis.InvestigationI


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As important as agood history is a good examination.

ref: 059874

the incidence of upperlimb pain is just as

common in thegeneral population as it is in, say,

keyboard workers...with proper treatment

the overwhelmingmajority of patientswill get better and be able to return

to work

Investigation

As long as red flag conditions are excluded on the history andexamination, for the majority of low back pain suffers, investigation isnot indicated. There is virtually no correlation between symptomsarising from the low back and changes seen on plain x-ray. It is onlywhen an acute attack of low back becomes chronic that furtherinvestigation should be considered. As a rule, it is as valuable to get a full blood count and sedimentation rate as a plain x-ray.

Even in patients with long term problems, the value of suchinvestigations as magnetic resonance imaging (MRI) is doubtful.It rarely reveals significant changes that will change clinicalmanagement in the absence of obvious neurological signs. Theone exception to that is in those patients suffering withsignificant complaints of pain in the legs on walking, who maywell be suffering from spinal stenosis. This usually occurs inlater life and is rarely a problem in the working population. Inmany centres in Britain the wait for non-urgent MRI ismeasured in months and waiting for this investigation may wellsignificantly delay proper rehabilitation and the return to work.

In upper limb pain, the presence of neurological signs may welltrigger further investigation. Therefore with evidence of a carpaltunnel syndrome there is an argument for undertaking nerveconduction studies. However, again frequently there is a significantdelay in the performance for this investigation and the majority ofrheumatologists and hand surgeons will be prepared to treat a

patient with a carpal tunnel syndrome if the signs and symptoms aresufficiently clear. MRI may be indicated if there is a suggestion of nerveroot pressure in the neck. Plain x-rays can be helpful in identifyingsignificant osteoarthritis, but as with low back pain frequently the bestway of arriving at a diagnosis is by taking an adequate history andundertaking a proper examination.

Treatment

The Clinical Standards Advisory Group a decade ago showed conclusivelythat with acute low back pain the best approach was to give adequateanalgesia, avoid bed rest, and encourage very early return to work. Thiswould prevent long-term disability in the majority of cases. The evidencecurrently available suggests that a majority of people with back pain willrespond to physiotherapy arrived at muscle strengthening and educationon correct lifting technique. This should leave only a small hard core ofpeople who might require intensive investigation, occasionally surgery andperhaps other forms of therapy such as cognitive therapy.


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In many centres in Britain the wait

for non-urgent MRI is measured in months andwaiting for this

investigation maydelay proper

rehabilitation and the return to work

Even if there is failure to treat the acute episode rapidly and appropriately,as long as the patient receives proper evaluation and treatment withinsix to nine months, then long term disability will frequently be avoided,mainly by the use of physical rehabilitation. Small doses of mildanalgesics can be helpful and of course care attention to workingpractices to avoid a re-injury.

Pain in the arm should be treated on its merits. If there is a positivediagnosis of a carpal tunnel syndrome or De Quervains, for instance,

then injection or possibly decompression should beconsidered. Simple tennis elbow should respond toinjection or to other strategies, such as the use of anepicondylitis splint. Physical therapy for the cervicalspine is always worth considering. Again, it isimportant to pay attention to the work station andwith working practices. Wherever possible, prolongedperiods of rest should be avoided and a positive,attitude both on the part of the employer and employeeis worthwhile. Early treatment is critical. If the problemis allowed to drag on, chronic pain will almost certainlyappear and unnecessary work disability will emerge. Inparticular it appears to be important to avoid a blameculture and the use of terms such as RSI which willencourage workers and their representatives to feel thatthey have a progressive and untreatable disorder whichwill inevitably lead to severe disability. The experience

in Australia, where the so-called kangaroo pawthreatened to bring commerce to a halt, shows that a constructiveapproach by the various interested parties, including the trade unions,employers and government, will lead to a considerable reduction indisability from this group of disorders.

Inappropriate pain and Fibromyalgia

On occasion, we see people who develop pain which appears to be out ofproportion to the insults suffered and which often has a distribution anda nature which is unusual. Fibromyalgia is now a commonly diagnosedcondition. The hallmarks of this problem are a pre-existing painfulcondition, trigger spots that occur at specific sites on the body and sleepdisturbance. It is not a disease in the sense that measles or appendicitis,but rather a syndrome which appears to be due to deconditioning ofmuscle. Some argue that it is in fact depression while others that it doesnot exist at all. However, the consistency of the history and thedistribution of the trigger spots leads most rheumatologists to believethat it is a true entity, although many authors do accept that there is alarge psychological aspect and that it may represent the somatic end of


26

ref: 059874

prolonged periods ofrest should be avoided

and a positiveattitude both on thepart of the employer

and employee isworthwhile. Early

treatment is critical

the fatigue syndrome spectrum. Typically, the history is one of chronicpain from problems such as back or neck pain, which leads to sleep

disturbance and then considerable pain in muscleparticularly across the shoulders.

There is a general consensus that the correct approachto treatment for these patients is to correct sleepdisturbance, usually by using a mild tricyclic such asAmitriptyline and then to put the individual on topaced activities and then a paced exercised programme.Many sufferers report that on good days they try catch-up with things that they have got behind with and thatthey then pay for it over the next day or two. The pointof pacing is to try and prevent over-stressing the

muscles on the good days, producing a steadyimprovement with the physical rehabilitation. If this is undertaken at anearly stage, this is a highly successful strategy.

Inappropriate pain is becoming more common and can be verydisabling. Typically, the story is one of a painful syndrome of somedescription which does not get better within the normal time frameexpected. Pain becomes persistent, usually with disturbed sleep andfrequently is increasingly disabling. Physical examination andinvestigation usually fails to reveal any serious underlying cause. Mostauthors agree that the problem is due to sensitisation of pain fibres.

The reason why this condition is so difficult to treat is that theunderlying cause is almost always settled by the time the patientpresents. The pain bears many of the hallmarks of phantom limb painexperienced by amputees. In both conditions it would appear that thepain fibres have been so severely stimulated that any sensory stimulus tothe skin or underlying tissues in the problem area will produce painsignals in the brain rather than the more appropriate sensations such astickle, heat or propioception. There is some evidence to suggest that thecentral processing of incoming sensory signals is also disordered leadingto the continuing inappropriate pain. The main consequence of thissequence of events is that it is very unlikely that treatment to theoriginal underlying cause will lead to significant reduction in pain.Indeed in many cases the precipitating cause may well have gone awaycompletely, often months or years before.

Treatment therefore should be directed at assisting the patient to copewith the pain. The first task is to properly explain to the patient thenature of their pain and why simple treatments, including things likesurgery and physiotherapy are unlikely to be helpful. It is importantthat the patient understands some of the underlying principles in the


27

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inappropriate painis becoming

more common andcan be very disabling

ref: 059874

the story is one of apainful syndrome of

some descriptionwhich does not getbetter within the

normal time frameexpected

generation of the pain they are experiencing and in particular toappreciate that all sensory experiences are in the end psychologicallygenerated in the brain. This is often a difficult concept, if for no otherreason that many patients when hearing the words brain andpsychological will immediately start to equate the explanation with abelief that the doctor suspects that the patient is malingering or is

psychiatrically unwell, both of which are untrue.

The next task which is frequently more difficult than thefirst, is the need to explain that the pain they areexperiencing does not indicate serious underlying diseaseand that the undertaking of activities which temporarilyincrease the pain is not harming the individual. This is ofcourse counter-intuitive because we used the idea thatpain represents a serious problem, such as putting oneshand on a hot plate or having acute appendicitis. Theindividual has to be convinced that the time the pain theyare experiencing is not useful and therefore it is quite

safe for them to work through the pain. This is particularlyoccupationally important as far as work hardening is concerned. Manylow back pain sufferers are afraid that doing quite simple tasks such aslifting light weights will actually be doing more damage to the backbecause it hurts when they do it. The role of the physiotherapist indemonstrating to the individual that increasing amounts of activity isnot only not harmful, but that the effects are beneficial is veryimportant.

Cognitive behavioural therapy is being increasingly usedto help people with chronic pain from any cause. Thetechniques are reasonably well understood by the generalpublic because they are used as a management for phobiaand have been featured on popular television programmes on more than one occasion. This technique does notabolish pain, but it does help patients to cope with painand get on with a more normal life and in all the studiesthat have been done, there is clear evidence that thetechnique will allow return to work in a significantnumber of patients. Not all individuals are susceptible tothe technique, particularly if they cannot grasp theconcept of the psychological nature of the pain or the fact

that the pain is not particularly dangerous. Outstandinglitigation makes it more difficult to succeed with cognitive behaviouraltherapy because of the secondary gain that is achieved by continuing tobe symptomatic until the legal case is settled.


28

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outstanding litigationmakes it more

difficult to succeedwith cognitive

behavioural therapy

ref: 059874

Cognitive behaviouraltherapy is being

increasingly used tohelp people with

chronic pain fromany cause.

As noted above, inappropriate pain and fibromyalgia appearto becoming more frequent and there is something tosuggest that this group of disorders is related to otherincreasingly common problems like chronic fatigue andallergy syndromes which maybe reflects the increasing stressassociated with modern lifestyles, including the requirementfor increased productivity at work. Malingering as such israre, although it does occur, but exaggeration, particularly ifthere is litigation outstanding, is relatively common. Manypeople have unrealistic expectations of the effectiveness ofmodern medicine. In particular they believe that if theyhave a pain or some other bodily dysfunction, that not onlyshould doctors be able to cure them but that they have aduty to do so. Regrettably that is not true. It would be ofconsiderable benefit to society if an educational programmewas put in place which taught people that it is normal to

expect some pain and discomfort, particularly as we get olderand that there is no magic treatment, nor is treatment necessary in theoverwhelming majority of cases. It would also be of considerable benefitif more people could be convinced of the importance of physical fitnessand the need to take regular exercise to keep muscles strong so thatjoints, including the back, can be protected.

Conclusion

Musculo-skeletal symptoms are common and potentially disabling.There appears to be something of an epidemic of back related andupper limb pain, as well as an increase in inappropriate pain andfibromyalgia. There are reasons for believing that some of theserepresent life-style difficulties but there is also good evidence that rapidtreatment of these problems, coupled with good ergonomic assessmentand modification of working practices and workstations, will lead to asuccessful outcome for the majority of patients. In those patients inwhom chronic symptoms develop such techniques as cognitivebehavioural therapy may be helpful.


29

ref: 059874

rapid treatment ofthese problems, coupledwith good ergonomicassessment andmodification of

working practices willlead to a successful

outcome for amajority of patients.

Geoffrey H Robb

Geoffrey Robb is ConsultantPhysician at Epsom GeneralHospital where he has aparticular interest in diabetes.He is currently ConsultantMedical Officer toUnumProvident and has along and active associationwith the insurance industry.He has been instrumental inshaping UnumProvidentscurrent active approach toclaims management and hasalso had central role inshaping the companysunderwriting policy in relationto a number of diseases andconditions. He is also ChiefMedical Officer for FriendsProvident Life Office and tothe Health Claims Bureau. Hewas president of theAssurance Medical Societyfrom 1999-2001 and was aninvited lecturer at theInternational Congress of LifeAssurance Medicine inSydney in 2001.


30

Recent Advances in General Medicine

Geoffrey H Robb MB ChB FRCP, Consultant Physician, Epsom General Hospital

What we know about the human body and what can go wrong with itincreases all the time. In writing a short article on Recent Advances,inevitably I am reflecting my own interests in medicine, together withthose of the insurance industry and in no way can this article pretend tobe a comprehensive review of such a vast subject. I trained in cardiologyand more recently in diabetes. Over the years I have developed a specialinterest in the management of obesity and also fatigue syndromes asthese were conditions for which the general practitioner frequentlysought my assistance. This article therefore, addresses some of thedevelopments in these areas, together with others which affect principallycritical illness and cancer, some areas of neurology and psychiatry.

Coronary Thrombosis

There has been rapid progress in both the prevention and treatment ofCORONARY THROMBOSIS. Large and well structured studies

using statins (such as 4S and WOSCOPS) have demonstratedimportant reductions in mortality in both primary and secondaryprevention of coronary thrombosis with a statin. In any one who isat risk of having a coronary thrombosis because of adverse familyhistory, diabetes, existing vascular disease or a high cholesterol, thereis a compelling evidence that a statin will reduce the risk of a majorvascular complication. Although one of the five statins available inthe UK (Cerivastatin) has been withdrawn because of muscledamage, the evidence in favour of this group of drugs remainsoverwhelming. There are important economic implications as if allthose who should be on a statin for prevention of coronary diseasewere prescribed them, the cost to the health service would beenormous. The government of Australia have already expressedconcern and other countries where drugs are available either free oron a subsidised basis will also be worried. The potential prolongation

of life may well have an adverse effect on pension funds.

It is not only statins that are proving useful in preventing adverse effectsfrom vascular disease. Aspirin, Clopidogrel and ACE inhibitors have allbeen shown to help those who have had a myocardial infarction.Multiple drug therapy should not necessarily be regarded as an indicationthat disease is severe, but rather that they have a caring and up to datephysician who is aware of how further cardiac damage can be prevented.


31

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while thesedefinitions may be

appropriate forclinical practice, theinsurance industry

will surely needadditional safeguards


32

Acute Myocardial Infarction

The definition of ACUTE MYOCARDIAL INFARCTION haschanged recently, which is of importance to those of us involved in

critical illness policies. The old definition was of characteristiccardiac chest pain, together with ECG changes and an elevationin cardiac enzymes. The new definition as recommended in aconsensus document of the joint European Society ofCardiology and the American College of Cardiology defines amyocardial infarction as a typical rise and gradual fall inbiochemical markers of myocardial necrosis such as Tropinin orCK-MB, together with at least one of the following:

a) Ischaemic symptomsb) ECG changesc) Coronary artery intervention such as angioplasty

A pathological diagnosis is still acceptable.

This will pose a problem for critical illness insurers in that only oneTropinin estimation is usually requested in clinical practice and falsepositives may occur. It would be difficult to refute a claim for anindividual who presented with chest pain who had an isolated hightropinin but no other indication of myocardial infarction and while

these definitions may be appropriate for clinical practice, theinsurance industry will surely need additional safeguards.

There has been further refinement in coronary angioplastyover the past two or three years in that stenting of narrowcoronary arteries is now almost universally practiced. There issome evidence that those who have had either successfulangioplasty or coronary artery surgery can be regarded aspreferred lives as their mortality is lower in the short termthan the general population. Newer forms ofimmunosuppression have improved the prognosis of those

with cardiac transplants and over 50% of such patients areexpected to survive for over 10 years.

There are important lessons here for those underwriting disabilitypolicies or managing claims. The first is that survivors of ischaemiccardiac episodes who have been appropriately treated are likely to have along life expectancy provided left ventricular function as judged byejection fraction is reasonable. There is new objective evidence to showthat depression is extremely common in those who have had cardiac

ref: 059874

there is new objectiveevidence to show

that depression isextremely common inthose who have had

cardiac surgery

ref: 059874

It is possible forsome diabetics to beinsured at ordinaryrates of premium.

surgery and our claims assessors will be all too aware of policy holderswho have had successful cardiac intervention yet are not prepared toreturn to their insured occupation. Sometimes this can be due tocerebral embolism of clots detached or formed during surgery butfrequently the underlying reason is depression, perhaps exacerbated bythe understandable concern of spouses and other family membersfollowing a cardiac event. Such episodes are less likely to occur incentres where there is a vigorous early cardiac rehabilitation programme.

Diabetes

My other major interest is that of DIABETES. Most Type 1 (or insulindependent) diabetes of working age will be on a basal bolus regimewhereby they have an injection of quick acting insulin with each oftheir 3 meals and a long-acting insulin at night the so-called basalbolus regime. This endeavours to reproduce the activity of the normalpancreas and the majority of diabetics can maintain adequate control onsuch a regime. Blood sugar monitoring will still be necessary but that isbeing made easier by the introduction of tissue fluid sugar estimationssuch as the glucowatch. Insulin injections are virtually painless butfinger prick blood sugar testing is painful and measurement of tissuesugar levels which can be painless should enhance blood sugar control.It is possible for some diabetics to be insured at ordinary rates ofpremium, if all their risk factors are controlled but such diabetics arestill a minority.

There are exciting developments for those who have Type 2 diabetes.The mainstay of treatment with Metformin and a sulphonylurea cannow be supplemented by a Glitazone which will reduce insulin resistance(and hopefully reduce the risk of macrovascular disease). The otherrecent introduction is the prandial glucose regulators such as Nateglinide,which stimulate the release of insulin from pancreatic beta cells andreduce post-prandial hyperglycaemia. It has been shown that the risk ofdeveloping complications of diabetes is closely related to the post-prandial blood sugar so in theory these drugs should reduce vasculardisease, but that has yet to be proven.

Insulin pumps and pancreatic cell transplantation are in the process ofdevelopment and are likely to help individual diabetics but are unlikelyto affect the overall burden of vascular disease in the short or mediumterm. Insulin pumps are for those whose blood sugars fluctuate so wildlythat it is difficult to maintain a relatively normal lifestyle. They areintrusive in that the diabetic has a needle in the abdomen and they haveto wear a syringe containing insulin and a small pump at all times. Theycan only be detached for short periods such as bathing or swimming.


33

ref: 059874

It has been shownthat the risk of

developingcomplications ofdiabetes is closelyrelated to the post

prandial blood sugarso in theory thesedrugs should reduce

vascular disease, butthat has yet to

be proven.

They are not for the majority of diabetics, who are best controlled on abasal bolus regime. The problems with islet cell transplantation are three-fold. Firstly, one has to have an adequate supply of the functioning isletcells and in the Edmonton series which has been the most successful sofar, islet cells were taken from two or three donors. The supply of donororgans inevitably is limited so in the absence of some form of stem celltransplant, this can only benefit a tiny minority of diabetics. The otherproblem is that of immuno-suppression, which the Canadian team haveimproved, but the big breakthrough in preventing rejection has yet to occur.

Cancer

In the field of CANCER, the most important development from theinsurance point of view is the increased awareness about cancer of theprostate and the use of the PSA test as a screen for this. Although cancerof the prostate is relatively uncommon in men under the age of 60, itstill occurs sufficiently frequently for many, including myself, to offerthis as a screening investigation when taking blood for other purposes.The prognosis for prostatic cancer has always been rather better thanthat of other cancers, but it is crucial for critical illness policies that arobust definition be accepted. If any presence of neoplastic cells in theprostate is accepted for the diagnosis, then pricing will have to changeappropriately but a more realistic definition might well be that theprocess must be locally invasive in order to trigger payment under acritical illness policy.

Obesity

The management of OBESITY remains a major clinical problem. Thecause is both genetic and environmental and the latter is not oftenamenable to change. When obesity is secondary to depression, then theprognosis is reasonable provided the depression is treated vigorously.Two new drugs have recently been introduced which are proving ofvalue. Orlistat acts by blocking absorption of fat from the small intestineby the inhibition of the enzyme which normally digests fat. It is usefulin those who are able to keep to a low fat diet. Sibutramine acts in thebrain by altering serotonin levels and this can in some cases turn off thefeeling of hunger and desire to eat. The long term place of both thesedrugs in practice remains to be determined.


34

ref: 059874

The management ofOBESITY remains a major clinical

problem. The cause isboth genetic andenvironmental

ref: 059874

in the field ofCANCER,

the most importantdevelopment from theinsurance point of

view is the increasedawareness about

cancer of theprostate and the

use of the PSA test

Depression

As everyone in UnumProvident knows, claims for psychologicalproblems exceed those from any other single cause. DEPRESSION isthe most common underlying disorder and it is indeed very common in

the general population, both insured and non-insured.Pharmaceutical companies have been busy in this areaand there are a whole number of new antidepressantdrugs available. Claims assessors, I am sure, will havenoticed the discouraging frequency with which claims fordepression are submitted where the individual is either onno antidepressant medication or only on a relatively sub-therapeutic dose. Depression is a real challenge for aclinician and the right dose is as important as the choiceof the drug in the treatment of the condition. The

increasing complexity of drug regimes means that specialist psychiatrichelp should be sought with the more difficult cases, but in clinicalpractice, patients are often not referred soon enough or indeed not at alland it is probable that this is leading to much needless suffering. Thediagnosis of depression is sometimes a cover for a breakdown in workrelationships and claims assessors have become adept in sorting out thereal failure for return to work.

Neurology

The most important advance in NEUROLOGY in recent years hasbeen the development of high quality scanning procedures for thecentral nervous system. It is frustrating that scan appearances often donot correlate with the clinical condition but diagnosis of cerebral vasculardisease, multiple sclerosis and brain tumours has been immeasurablyadvanced by these new scanning methods. The treatment of neurologicaldisease remains disappointing, although some patients with multiplesclerosis can be helped by beta-interferon and newer drugs for Parkinsonsdisease and epilepsy will help the majority of sufferers who are severelyaffected. There is tantalising research into the growth of nerve cellswhich, if clinically available, could revolutionise so much neurologicaltreatment but such treatment is probably several years away.

This article has attempted to address a few of the discussion points inmodern medicine, but cannot hope to be comprehensive. Much can belearned about medical advances by reading what is written week byweek in the broadsheet press. Many doctors, as well as their patientskeep up to date in this way!


35

ref: 059874

depression is a realchallenge for the

physician

ref: 059874

Much can be learned about

medical advances byreading what is

written week by weekin the broadsheet

press. Many doctors,as well as their

patients keep up todate in this way!

Charles Pumphrey

Charles Pumphrey isConsultant Cardiologist at St Georges Hospital, Tooting,and Honary Senior Lecturerat St Georges HospitalMedical School. He is directorof the Cardiothoracic Unit at St Georges Hospital. He trained in cardiology inLondon and Edinburgh andhas been a British-AmericanTravelling Research Fellow atthe Mayo Clinic, USA. He haspublished extensively on avariety of issues in cardiology,but particularly in connectionwith ischaemic and valvularheart disease. He is a memberof the British Cardiac Society,the British Pacing andElectrophysiology Group andthe British CardiovascularIntervention Group.


36

Recent Developments in Cardiology

Charles W Pumphrey DM FRCP, Consultant Cardiologist, St GeorgesHospital, London

This report is devoted to identifying those developments in cardiologywhich are likely to reflect on the life assurance industry with particularreference to improving prognosis in various cardiovascular conditionsand diagnosis.

Ischaemic Heart Disease

Myocardial Infarction

Diagnosis of myocardial infarction. With the development of troponin Tas a sensitive measure of evidence of myocardial damage, the diagnosisof myocardial infarction has now been redefined. Patients who havecardiac pain in association with an identifiable level of troponin T inthe blood are considered to have had a myocardial infarct. No changein the creatinine phosphate kinase or other conventional cardiacenzymes are necessary any longer. An elevated troponin T withoutelevation of conventional cardiac enzymes is thought to arise due tomicro-emboli from an active coronary plaque causing infarction in themicro-circulation.

When a patient presents with chest pain and identifiabletroponin T without a rise in cardiac enzymes, they areknown to be at particular risk of developing a substantialinfarct due to occlusion of an epicardial vessel. As a resultpatients presenting with unstable angina are now riskstratified according to their troponin T levels (as well as ongoing ECG changes) and early investigation by angiographywith a view to revascularisation is offered to these patients.

The consequence of the development of troponin T assayas a marker for myocardial damage is that there will be anincrease in the number of patients that can be defined ashaving experienced a myocardial infarct. Once

revascularisation has been undertaken, however, the prognosiswill be as if they have not had a conventional infarct (in the old sense ofthe word) since their heart muscle function will probably appear normalon echocardiography and angiography. The prognosis in coronary arterydisease is, to a large extent, defined by left ventricular function andtherefore not all patients defined as having an infarct by tropinin T willhave the same adverse prognosis as is associated with patients who had amyocardial infarction diagnosed by the old criteria.


37

ref: 059874

off pump coronaryartery surgery isallowing for aspeedier recovery

following open heartsurgery

Coronary RevascularisationThe techniques in coronary surgery are developing: off pump coronaryartery surgery is allowing for a speedier recovery following open heartsurgery with a reduction in the cerebrovascular complications associatedwith coronary surgery.

Minimally invasive coronary artery surgery(midcab) is also developing in specificallydefined types of coronary lesion. However, themajority of coronary operations still involve asternotomy and the use of a cardiopulmonarybypass pump. Surgeons are favouring the processof full arterial revascularisation which is having ameasurable impact on the longevity of asuccessful outcome. Although associated withgreater technical problems at the time of surgery,the use of the radial artery, right internalmammary artery (as well as le

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