Skip to main content Accessibility help
Hostname: page-component-5c569c448b-ph4cd Total loading time: 0.449 Render date: 2022-07-05T07:39:38.798Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "useRatesEcommerce": false, "useNewApi": true } hasContentIssue true

Letter to the Editor

Published online by Cambridge University Press:  08 October 2009

Moorlands, Little Clifton, Workington, Cumbria CA14 1YT, UK
Rights & Permissions[Opens in a new window]


Copyright © Cambridge University Press 2009

Sharpe et al.'s (Reference Sharpe, Stone, Hibberd, Warlow, Duncan, Coleman, Roberts, Cull, Pelosi, Cavanagh, Matthews, Goldbeck, Smyth, Walker, Walker, MacMahon, Murray and Carson2009) study ‘Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome’ presents in declarative statements three interdependent socio-psychological factors as indicative of poor outcome after 1 year of illness: illness beliefs, non-attribution to psychological causes and financial factors.

Whilst patients may be happy to engage with a biopsychosocial model it is the lack of available biological explanations that may well lead to poor outcome rather than illness beliefs per se. Terms such as ‘functional weakness’ and ‘software error’ are semantically vague and as Stone acknowledges elsewhere (see: ‘family and work’) may well need to be re-worded in unhelpful psychological terms as ‘conversion disorder’ on official documents. For patients the biological is important as it provides social legitimacy for a physical illness and an objective entity that they can fight to overcome. Vuilleumier et al.'s (Reference Vuilleumier, Chicherio, Assal, Schwartz, Slosman and Landis2001) study of hysterical paralysis showed poor recovery dictated by the level of activation in the contralateral caudate and thalamus. Yet this study attempts no physiological or objective reassessment of patients. Instead it relies on subjective self-reported assessment. Objective assessment by an experienced physiotherapist or occupational therapist may well produce a different SF-12 score. As such, reported improvement or failure to improve may be merely the result of a cognitive compliance to the demands of the physician or indeed the breakdown and nihilism when faced with a discourse devoid of physical explanations. Kanaan et al. (Reference Kanaan, Armstrong, Barnes and Wessely2009) suggests that neurologists often decide within a few minutes of meeting a patient whether an organic explanation will be forthcoming. Do we assume patients are unaware of this through subsequent manner and rapport? What might the effect of this be on patient morale and presentation, especially those struggling with distressing symptoms?

Rather than work towards a therapeutic relationship of mutual trust and respect Sharpe et al. state that their data lends ‘support to the idea that interventions which change these variables [i.e. state benefits or opposition to physician imposed psychological explanations of physical symptoms] may improve the outcome for this patient group’. Have Sharpe and colleagues considered how patients may interpret the fiscal side of this intervention?

In denying a correlation between SF-12 scored disability and receipt of benefit, Sharpe et al. inadvertently infer that patients with ‘symptoms unexplained by disease’ are guilty of benefit fraud. The DWP does not use SF-12 to allocate benefits such as disability living allowance (DLA) or incapacity benefit. It is therefore erroneous to use data as the authors do to state that: ‘Illness beliefs and financial benefits are more useful in predicting poor outcome than the number of symptoms, disability and distress.’ They also fail to assess the monetary value of any benefit with regard to severity of disability or map this against socio-economic status.

That there is a link has been noted by Rosato & Reilly (Reference Rosato and O'Reilly2006) who in contrast to Sharpe et al. correlate level of benefit with degree of disability. Indeed some studies of families with disabled children have shown that disability benefits actually improve social inclusion and in the long term allow independence within the family unit (Preston, Reference Preston2005).

Of particular note from Preston's study is the improvement in mental health amongst DLA claimants with money spent on cinema trips, social activities as well as contributing to basic costs such as transport.

Sharpe et al. conceivably present a situation in which the most vulnerable within a population are further excluded from society. For the fact remains that in all patient groups socio-economic status is a greater predictor of ill health than the receipt of health-related benefits per se. Furthermore, by denigrating a patient's own perceptions of their illness they deny the therapeutic partnership by which any disease may be overcome, irrespective of aetiology.

Declaration of Interest

The author is a full-time teacher and patient misdiagnosed with ‘multiple functional symptoms’, found after 5 years to have ‘systemic autonomic failure’ and hereditary spastic paraplegia by consultants Yiannakou, Gorman and Newton. Condition improved with baclofen, midodrine and sacral nerve implant.


Kanaan, R, Armstrong, D, Barnes, P, Wessely, S (2009). In the psychiatrist's chair: how neurologists understand conversion disorder. Brain. Published online: 16 April, 2009. doi:10.1093/brain/awp060.CrossRefGoogle ScholarPubMed
Preston, G (2005). Helter skelter: families, disabled children and the benefits system, CASE Paper 92, Centre for the Analysis of Social Exclusion, London School of Economics.Google Scholar
Rosato, M, O'Reilly, D (2006). Should uptake of state benefits be used as indicators of need and disadvantage? Health & Social Care in the Community 14, 294301.CrossRefGoogle ScholarPubMed
Sharpe, M, Stone, J, Hibberd, C, Warlow, C, Duncan, R, Coleman, R, Roberts, R, Cull, R, Pelosi, A, Cavanagh, J, Matthews, K, Goldbeck, R, Smyth, R, Walker, A, Walker, J, MacMahon, A, Murray, G, Carson, A (2009). Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome Psychological Medicine. Published online: 23 July 2009. doi:10.1017/S0033291709990717.Google ScholarPubMed
Vuilleumier, P, Chicherio, C, Assal, F, Schwartz, S, Slosman, D, Landis, T (2001). Functional neuroanatomical correlates of hysterical sensorimotor loss. Brain 124, 10771090.CrossRefGoogle ScholarPubMed
You have Access
Cited by

Save article to Kindle

To save this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the or variations. ‘’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Letter to the Editor
Available formats

Save article to Dropbox

To save this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about saving content to Dropbox.

Letter to the Editor
Available formats

Save article to Google Drive

To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about saving content to Google Drive.

Letter to the Editor
Available formats

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *