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“Wheelchair” patients with nonorganic disease: A psychological inquiry

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Abstract

We studied ten patients referred from the neurology service with severe disability associated with the use of a wheelchair, but with no organic disorder to account for their disabilities. All patients were assessed using rating scales as well as a standardized psychiatric interview (SCID), and all medical and psychiatric case notes were examined. We also interviewed key carers for their views on the information and assistance the patients had received. All but two of the ten patients were women, and the mean age was 45.4 years (sd=5.4). All had current diagnoses of conversion or somatoform disorders and six had previous episodes of major depression. Most patients expressed beliefs about their illness that were not consistent with the medical facts, and only two of the carers were satisfied with explanations they had been given by doctors. The results suggest that requests for psychiatric help once patients have become grossly disabled are unlikely to lead to recovery. The psychiatrist, however, can help the primary care doctor to formulate a plan of management aimed at preventing further deterioration.

Introduction

Patients who present with physical complaints but are found to have no relevant organic disease are commonplace in medical clinics [1]. It has been estimated, for example, that as many as one third of patients attending cardiac, gastrointestinal, and neurology clinics have no ascertainable organic disease [2].

A subgroup of these patients have chronic and enduring symptoms associated with gross disability, despite having either trivial or no relevant organic disease. These patients not only pose formidable management problems but are also an enormous financial drain, both on the state and their families [3]. Furthermore, doctors in both primary and tertiary care settings find these patients difficult to help [4], particularly because many decline referral for psychiatric assessment.

In this study, our aim was to identify patients who were wheelchair bound and to: (1) determine the psychiatric diagnosis, both current and lifetime; and (2) to explore those factors in the patient's previous history (both personal and early family environment) that may have contributed to the development of their chronic disability. Particular attention was focused on those factors found to be of importance in previous studies, namely childhood histories of physical illness, early parenting experiences, and the beliefs of the patients and their carers. We also inquired after the use of state benefits and other disability aids.

Section snippets

Method

Nine of the ten patients were referred from either the neurology out-patient or rehabilitation services in Oxford between 1992 and 1996. The remaining patient was referred from the orthopedic service in 1991, but had been discharged from the neurology clinic in 1986 with no evidence of organic disease. All patients satisfied our criteria for wheelchair dependence, which included being confined to a wheelchair for at least 50% of each day for at least 12 months before the assessment. They also

Patient characteristics

All but two of the ten patients were women, and the mean age was 45.4 years (sd=5.4). The mean duration of wheelchair use was 8.3 years (range 1–23 years, see Table I). None were in gainful employment or involved in compensation claims. Four had acquired their wheelchairs from community occupational therapists, three from their GP, and one each from social services, a local orthopedic hospital, and another was “borrowed.”

None were in gainful employment, but six had been employed previously

Discussion

All our patients were grossly disabled but had no detectable organic disease to account for their symptoms and disabilities. All were in receipt of welfare benefits and all were unemployed. The most common reaction of the patients to referral for psychiatric assessment was surprise, resentment, and sometimes anger. None were involved in medicolegal compensation.

We recognize that these patients are a highly selected sample, all of whom had been referred from specialist tertiary services (all had

Acknowledgements

We thank Ann Day for help with data analysis.

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