Richard Mayou

OUTCOME OF 'WHIPLASH' NECK INJURY

Psychological factors have been alleged to be important in the course and outcome of whiplash neck injury but there is little quantitative evidence. This study uses quantitative methods involving a prospective interview assessment to describe psychological and quality of life predictors, and 3 and 12 month outcome. Consecutive attenders to the Accident and Emergency department of a teaching district hospital with a clinical diagnosis of whiplash neck injury were included and there were follow-up interviews at home. Neck symptoms were recorded, and there was a standard mental-state interview with added questions about post-traumatic symptoms and a semi-structured interview for disability and consequences for quality of life. There was a wide individual variation in course and outcome; the majority of subjects complained of persistent neck symptoms and a sizeable minority reported specific post-traumatic psychological symptoms (intrusive memory, phobic travel anxiety), similar to those described by patients suffering multiple injuries. Social impairment, including effects on travel, were considerable in one-quarter. Reports of persistent neck symptoms were not associated with any baseline psychological variables or with compensation proceedings; psychological factors appeared to be more important in determining the extent of social impairment. We conclude that travel, social and psychological morbidity is substantially greater than previously recognized.

What happens to medical patients with psychiatric disorder

Medical, psychiatric and social outcome were examined in medical in-patients previously identified as suffering from psychiatric disorder. One third of patients with an affective (emotional) disorder on admission were still psychiatrically ill four months after discharge. Persistent disorder was associated with continuing physical illness. During the year following admission those with affective disorder on admission continued to make greater demands on medical, social and psychiatric services than matched controls and had double the mortality rate (not significant). Patients with organic mental states on admission had a high mortality and morbidity, and made considerable continuing use of general hospital social and psychiatric services. Improved recognition of psychiatric disorder during hospital admission could result in better overall care of medical patients psychiatric and social difficulties and more effective use of medical resources.

CONSEQUENCES OF ROAD TRAFFIC ACCIDENTS FOR DIFFERENT TYPES OF ROAD USER

The study aimed to describe the immediate and later physical, social and psychological consequences of a road traffic accident for vehicle occupants, motorcyclists, cyclists and pedestrians amongst consecutive hospital attenders at an Accident and Emergency Department. Physical and accident details were collated from hospital records. Subjects completed questionnaires at hospital attendance, 3 months, 1 and 3 years. There were 1148 respondents from 1441 consecutive attenders over a 1-year period. The main outcome measures were self-report physical status, standard measures of post-traumatic stress disorder, mood, travel anxiety and health status at 3 months, 1 and 3 years. There were marked differences in injury pattern and immediate reaction between road user groups. Pedestrians and motorcyclists suffer the most severe injuries and report more continuing medical problems and greater resource use, especially in the first 3 months. There were few differences in psychological or social outcomes at any stage of follow-up. Despite differences between the road user groups in their injuries, immediate reactions and treatment, there were few longer-term differences. A third of all groups described chronic adverse consequences which were principally psychological, social and legal.

Consultation-liaison psychiatric service delivery: results from a European study

The reported findings of the European Consultation-Liaison Workgroup (ECLW) Collaborative Study describe consultation-liaison service delivery by 56 services from 11 European countries aggregated on a C-L service level. During the period of 1 year (1991), the participants applied a standardized, reliability tested method of patient data collection, and data were collected describing pertinent characteristics of the hospital, the C-L service, and the participating consultants. The consultation rate of 1% (median; 1.4% mean) underscores the discrepancy between epidemiology and the services delivered. The core function of C-L services in general hospitals is a quick, comprehensive emergency psychiatric function. Reasons to see patients were the following. deliberate self-harm (17%), substance abuse (7.2%), current psychiatric symptoms (38.6%), and unexplained physical complaints (18.6%) (all means). A significant number of patients are old and seriously ill. Mood disorders and organic mental disorders are most predominant (17.7%). Somatoform and dissociative disorders together constitute 7.5%. C-L services in European countries are mainly emergency psychiatric services and perform an important bridge function between primary, general health, and mental health care.

Cardiac failure: Symptoms and functional status

The associations between exercise capacity, symptoms and specific aspects of quality of life were examined in subjects participating in a trial of the treatment of heart failure. Patients were assessed on entry and after three months treatment. The principle symptoms were fatigue, breathlessness and chest pain. These limited the extent and speed of physical activities, restricted social, leisure and family life and were associated with emotional distress. There were associations between baseline exercise capacity and measures of quality of life. Change in exercise capacity during three months treatment was correlated with changes in measures of symptoms, limitation of activity and quality of life. The findings confirm the value of change in exercise capacity as a measure of functional status and suggest that it should be supported by a limited number of specific measures of quality of life.

EARLY REHABILITATION AFTER MYOCARDIAL INFARCTION

129 men aged 60 years or less with a diagnosis of myocardial infarction were allocated to one of three programmes of management: normal treatment (control), exercise training, or extra advice. Outcome was evaluated after twelve weeks by exercise testing and standardised assessments of psychological state and social adjustment. There were no differences between the groups in psychological outcome, physical activity, or satisfaction with leisure or work. The exercise patients were more enthusiastic about their treatment and achieved higher work levels on exercise testing than the advice or control groups. Those who did not attend had a significantly worse outcome. At eighteen months the only significant findings were better outcomes, in terms of overall satisfaction, hours at work, and frequency of sexual intercourse, for the advice group. Exercise training increased confidence during exercise in the early stages of convalescence but the overall results show that rehabilitation is of little benefit to cardiac function, everyday life, or emotional state.

CHEST PAIN, PALPITATIONS AND PANIC

Chest pain and palpitations are commonly described in the general population and are frequent presenting symptoms in all medical settings. Although often transient, they can be persistent and are associated with considerable disability, distress, and concern about heart disease and use of medical resources. Both symptoms are associated with panic but also with other psychiatric disorders. It is most useful to consider etiology as multicausal and interactive; psychological factors affect interpretation of bodily perceptions and have deleterious effects on quality of life and use of medical resources. There is evidence that general measures and specific drug and psychological treatments can be effective. There is still uncertainty about the most appropriate ways of providing effective care to large numbers of patients.

TREATING MEDICALLY UNEXPLAINED PHYSICAL SYMPTOMS

Chest pain, back pain, headache, muscular pains, bowel symptoms, breathlessness, dizziness, and fatigue often remain unexplained after medical assessment. 1 Such cases may be referred to as functional syndromes of chronic fatigue, chronic pain, fibromyalgia, and irritable bowel or as somatoform (somatisation) disorders. In many cases the symptoms are severe, persistent, and disabling and cause considerable personal, social, and healthcare costs.1 2 3 Furthermore, the problem is large, accounting for a quarter of general practice consultations, as many as a half of outpatient clinic attendances, and a substantial number of hospital admissions.2nnWhen symptoms are found not to result from “genuine physical illness” they are often believed to be insignificant or attributed to mental illness. Consequently when investigations prove negative, management is commonly limited to reassurance about the absence of disease and occasionally referral to a general psychiatrist. In our experience such referrals are …

PREDICTION OF EMOTIONAL AND SOCIAL OUTCOME AFTER A HEART ATTACK

Data from two prospectively studied series of patients recovering from heart attacks (n = 129 and 100) were analysed to determine the extent to which early findings can predict later psychological and social outcome. Some aspects of early and late outcome can be predicted with modest accuracy by multiple regression analysis of information obtained during the acute hospital admission. More accurate, and therefore clinically more useful, prediction of late outcome is possible in early convalescence. It is suggested that systematic clinical assessment during admission and a few weeks after return home could detect most patients in need of extra specialist rehabilitation.

Whiplash neck injury

Whiplash, or post-traumatic, neck injury is an increasingly frequent clinical problem. Large numbers of patients present with both acute and chronic physical symptoms. It has frequently been alleged that psychological factors and social variables (especially the influence of possible compensation) are major causes of persistent physical complaints and disability. There have been few methodologically satisfactory studies, and very little attention has been paid to mental state and quality of life issues. Epidemiology, clinical features, prognosis, and aetiology are all reviewed with a special emphasis on psychological outcome and variables. It is argued that such factors are as important in relation to whiplash injuries as are other physical conditions, especially musculoskeletal disorders. In addition, specific posttraumatic symptoms are common but usually unrecognized.