This is an HTML version of an attachment to the Freedom of Information request 'Training, briefing and knowledge-base materials for WCA assessors regarding certain conditions'.

 
 

MEDICAL SERVICES 
 
 

PROVIDED ON BEHALF OF THE DEPARTMENT FOR WORK AND PENSIONS 
 
 

 
 
 
Training & Development 
 
EBM 
 
Mental Health Protocols: 
Key Points and Analytical Guidance 
 
MED/S2/CMEP~0054 
 
 
 
Version 2 Final 
 
 
 
 
 
 
 
 
 
 
 

 
 
 

 
 
 
 
 

 
 

Medical Services 
 
 

Foreword  
 
 
This guidance has been produced as part of a Continuing Medical Education 
programme for practitioners approved by the Department for Work and Pensions 
Chief Medical Adviser to carry out medical assessments. 
All practitioners undertaking medical assessments must be registered medical or 
nursing practitioners who in addition, have undergone training in disability 
assessment medicine. The training includes theory training in a classroom setting, 
supervised practical training, and a demonstration of understanding as assessed by 
quality audit. 
This guidance must be read with the understanding that, as experienced disability 
analysts, the practitioner will have detailed knowledge of the principles and practice 
of diagnostic techniques, and therefore such information is not contained in this 
guidance. 
In addition, the guidance is not a stand-alone document, and forms only a part of the 
training and written documentation that a practitioner receives. As disability 
assessment is a practical occupation, much of the training also involves verbal 
information and coaching. 
Thus, although the guidance may be of interest to non-medical readers, it must be 
remembered that some of the information may not be readily understood without 
background medical knowledge and an awareness of the other training given to 
disability analysts. 
 
 
 
 
 
Office of the Chief Medical Adviser 
13 November 2007
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Document control 

Superseded documents  
 
Version history 
Version Date 
Comments 

Final 
13/11/07 
Signed off by Medical Services Contract 
Management Team 
2b (draft) 
23/08/07 
Customer comments incorporated 
2a (draft) 
9/08/07 
Updated to bring the format in line with the other 
key points documents 
1 Final 
04/12/02 
 
 
 
 
Changes since last version 
 
Outstanding issues and omissions 
 
Issue control 
Author: 
Dr Gill Buchanan, Dr Andrew Cohen, Dr Andrea 
Wilkinson, Dr Peter Ellis 
 
Owner and approver: 
Dr A Graham 
 
Signature: Date: 
 
Distribution: 
 
 
 
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 Contents 
Page 
Section Page 
Part A – Key Points 
8 
Introduction 8 
1. 
Depression 9 
1.1 
Definition 9 
1.2 
Aetiology 9 
1.3 
Diagnosis 9 
1.4 
Treatment 10 
1.5 
Prognosis 10 
1.6 
Suicide and Deliberate Self Harm (DSH) 
10 
2. 
Anxiety Disorders 
12 
2.1 
Definition 12 
2.2 
Generalised Anxiety Disorder 
12 
2.3 
Panic Disorder 
13 
2.4 
Agoraphobia 13 
2.5 
Social Phobia 
13 
2.6 
Specific (isolated) Phobias 
14 
2.7 
Treatments for Anxiety Disorders 
14 
2.8 
Main Disabling Effects 
14 
3. 
Alcohol Related Disorders 
15 
3.1 
Introduction 15 
3.2 
Quantifying Alcohol Intake 
15 
3.3 
Consequences of Excess Alcohol Consumption 
15 
3.4 
Diagnosis 16 
3.5 
Treatment of Alcoholic Dependence 
16 
3.6 
Prognosis 16 
3.7 
IB-PCA Considerations 
16 
4. 
Substance Use Disorders 
17 
4.1 
Description 17 
4.2 
Aetiology 17 
4.3 
Prevalence 17 
4.4 
Diagnosis 17 
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4.5 
Treatment 18 
4.6 
Prognosis 18 
4.7 
Main Disabling Effects 
18 
5. 
Schizophrenia 19 
5.1 
Definition 19 
5.2 
Clinical Features 
19 
5.3 
Treatment 20 
5.4 
Prognosis 20 
5.5 
Main Disabling Effects 
20 
6. 
Bipolar Disorders 
21 
6.1 
Description 21 
6.2 
Diagnosis 21 
6.3 
Treatment 21 
6.4 
Prognosis 21 
6.5 
Main Disabling Effects 
22 
7. 
Obsessive Compulsive Disorder 
23 
7.1 
Definition 23 
7.2 
Diagnosis 23 
7.3 
Treatment 23 
7.4 
Prognosis 23 
7.5 
Main Disabling Effects 
24 
8. 
Adjustment Disorders and Post-Traumatic Stress Disorder 
25 
8.1 
Definition 25 
8.2 
Aetiology 25 
8.3 
Diagnosis 25 
8.4 
Treatment 26 
8.5 
Prognosis 26 
8.6 
Main Disabling Effects 
26 
9. 
Learning Disability 
27 
9.1 
Introduction 27 
9.2 
Autistic Spectrum Disorders 
28 
9.3 
Autism 28 
9.4 
Asperger Syndrome 
29 
9.5 
Down’s Syndrome 
29 
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9.6 
Fragile X Syndrome 
29 
9.7 
Attention Deficit Hyperactivity Disorder – ADHD 
30 
9.8 
Education 30 
10. 
Eating Disorders 
31 
10.1 
Description 31 
10.2 
Diagnosis 31 
10.3 
Treatment 31 
10.4 
Prognosis 31 
10.5 
Main Disabling Effects 
32 
11. 
Personality Disorders 
33 
11.1 
Definition 33 
11.2 
Prevalence 33 
11.3 
Diagnosis 34 
11.4 
Treatment 34 
11.5 
Prognosis 34 
11.6 
Main Disabling Effects 
34 
12. 
Organic Disorders 
35 
12.1 
Delirium & Dementia 
35 
12.2 
Head Injury 
36 
12.3 
Cognitive Impairment due to Prescribed Medication 
37 
13. 
Analytical Guidance 
38 
13.1 
Introduction 38 
13.2 
Depressive Disorders 
39 
13.3 
Anxiety 40 
13.4 
Alcohol 41 
13.5 
Substance Abuse 
42 
13.6 
Schizophrenia and other Psychoses 
43 
13.7 
Bipolar Disorders 
44 
13.8 
Obsessive Compulsive Disorder 
45 
13.9 
Adjustment Disorders and Post Traumatic Stress Disorder 
46 
13.10 
Learning Disability 
47 
13.11 
Eating Disorders 
48 
13.12 
Personality Disorders 
49 
13.13 
Organic Brain Disorders 
50 
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14. 
References 51 
Observation Form 
52 
  
 
 
 
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Part A – Key Points 
Introduction 
These evidence based protocols are the result of extensive research by Atos 
Healthcare Medical Services. They contain key points on the aetiology, diagnosis, 
treatment, prognosis, and main disabling features of the mental health conditions 
that are most commonly encountered in the field of Disability Assessment Medicine.  
These key points are intended to be particularly useful as a quick reference guide. 
The full text of the protocols is available on CD. 
The key points that are presented in this section are complemented by the other 
parts of this module, which incorporate original analytical guidance and advice on 
the most relevant assessment techniques. 
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1. 
Depression 
1.1 
Definition 
  Unipolar mood disorders are characterised by recurrent episodes of 
depression without intervening episodes of mania or hypomania. 
  Historically mood disorders were often referred to as affective disorders. The 
term 'affective' has been replaced with 'mood' in both international classification 
systems of mental disorders. 
  The concept of mixed anxiety and depression is now recognised as a clinical 
entity. 
1.2 
Aetiology 
  Adverse life events, especially those characterised by loss increases the risk of 
a major depressive episode for a period of 2-3 months following the event. 
1.3 
Diagnosis 
  The Diagnosis of a mild depressive episode requires at least two of the three 
core symptoms, plus two of the seven other symptoms for a period of more than 
2 weeks. 
  Diagnosis of a major depressive episode requires six of the ten symptoms listed 
below. 
 
Core symptoms are: 
Other symptoms are: 
1.  Depressed mood 
4.  Poor self confidence and self esteem 
2.  Loss of interest and enjoyment 
5.  Ideas of guilt and unworthiness 
3.  Loss of energy, fatigue 
6.  Ideas or acts of self harm or suicide 
 
7. Poor concentration, attention and 
indecisiveness 
 
8.  Psychomotor agitation or retardation 
 9. 
Disturbed 
sleep 
 10. 
Disturbed 
appetite 
  In major depression with psychotic features, hallucinations and/or delusions may 
occur, the content being consistent with the depressive mood. 
  Somatic (or endogenous) depression is characterised by physical symptoms 
such as early waking, psychomotor retardation or agitation, marked loss of 
appetite, weight loss and loss of libido. 
  Mood disorders are commonly co-morbid with other psychiatric disorders. 
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1.4 
Treatment 
  Antidepressants and cognitive behaviour therapy are equally effective in treating 
mild to moderate depression. In severe depression, anti depressant drugs are 
more effective. 
  Patients prefer talking therapies: counselling, cognitive behaviour therapy, group 
therapy, brief focal psychotherapy and family or marital therapy. 
  Most available antidepressants are equally effective if given at an adequate dose 
for a sufficient period.  
  Antidepressant treatment should be continued for 6 months following remission. 
  In those with onset of a major depressive episode after 50 years of age, or with 
three previous episodes of depression, it is recommended that antidepressant 
medication be continued indefinitely. 
  Electroconvulsive therapy is reserved for cases of resistant depression 
unresponsive to pharmacotherapy, especially those with psychotic or marked 
biological symptoms. 
1.5 
Prognosis 
  Co-morbidity is associated with a longer duration of the depressive episode, 
more psychiatric morbidity and more social and occupational impairment.  
  About 70% with moderate to severe illness begin to respond to treatment within 
6 weeks; without treatment, the majority can expect to recover eventually, 
although the natural course tends to be about 1-2 years. 
  12-20% of patients with unipolar depression develop chronic depression: they 
remain symptomatic 2 years after the onset of the initial depressive episode. 
  The lifetime risk of suicide is as high as 15% in those with severe illness. 
1.6 
Suicide and Deliberate Self Harm (DSH) 
1.6.1 
Prevalence 
  Suicide accounts for about 1% of all deaths every year. 
  70% of young suicides in the UK had been diagnosed with a psychiatric 
disorder, commonly depressive disorders (55%), followed by personality 
disorders (29%). 
  The male suicide rate is 2 – 4 times higher than the female rate. 
  DSH is more common in women than men.  
  The highest rates of DSH occur in the 15 – 35 age group. 
1.6.2 
Diagnosis 
  There is no evidence that asking about suicidal thoughts increases the risk of 
subsequent suicide. 
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  Risk factors for suicide following DSH include: a high level of suicidal intent, 
having another psychiatric disorder, a history of previous suicide attempts, social 
isolation, being aged over 45, being unemployed or retired, and suffering from a 
chronic painful illness. 
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2. 
Anxiety Disorders 
2.1 
Definition 
  Anxiety is a normal phenomenon that occurs in response to stress, and at 
optimal levels, it can be beneficial. 
  Anxiety occurs when an individual believes that the demands of the situation are 
greater than their ability to cope with it. The bodily (somatic) effects seen in 
anxiety are caused by activation of the autonomic nervous system, resulting in 
release of adrenalin: “the fight or flight reaction.” 
  Pathological  anxiety is an unpleasant emotional state characterised by 
fearfulness and distressing physical symptoms. It is disproportionate to the 
severity of the stress, continues after the stressor has gone, or occurs in the 
absence of any external stressor. 
2.2 
Generalised Anxiety Disorder 
  GAD is generalised, excessive anxiety, persistent for more than 6 months. 
  Thyrotoxicosis is the commonest physical cause of anxiety. 
  Co-morbidity with other mental health problems is common, and is associated 
with increased disability. 10% of patients with GAD become dependant on drugs 
or alcohol.  
  Other unfavourable prognostic features include: 
  Personality Disorder.  
  Derealisation and Depersonalisation.  
  Poor quality of relationships.  
  Long duration of illness.  
  GAD is a chronic condition. Spontaneous remissions are rare, and relapses are 
common. 
  About 40% of patients will experience full remission after 5 years.  
  Having achieved improvement, 33% of patients will suffer a relapse in the next 3 
years.  
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2.3 
Panic Disorder 
  Panic disorder is recurrent, acute, unprovoked, periods of intense fear (panic 
attacks). 
  The cardinal feature of panic disorder is fear of dying, going mad or losing 
control. During a panic attack, the patient experiences such severe fear that 
they have to ‘flee’, regardless of the consequences. The episode resolves after a 
few minutes. 
  Panic disorder occurs in 1 or 2% of the general population. 
  With treatment, up to half of patients with panic disorder may be symptom-free 
after 3 years. 
2.4 
Agoraphobia 
  Excessive fear of a situation, which leads to avoidance of that situation, is called 
“phobia.” 
  The degree of avoidance is a useful measure of severity. 
  Patients suffer severe anxiety in anticipation of going out, particularly if they are 
unaccompanied. This may result in a restriction of activities such as going to the 
shops, being in crowed places, using public transport or travelling in lifts 
(claustrophobia). 
  Agoraphobics often feel worse the further they are away from home. Symptoms 
tend to escalate gradually over time. In the extreme the patient may become 
housebound, being unable even to open the front door or only able to go into the 
back (not front) garden. 
  In an effort to overcome agoraphobia, the patient may develop alcohol or drug 
dependency. 
  Depression may result from the restriction in lifestyle and social isolation.  
  Agoraphobia occurs in about 1.5% of the general population. 
  Untreated, agoraphobia typically runs a chronic course. 
  20% of patients with agoraphobia eventually achieve spontaneous remission.  
  90% of patients with agoraphobia will experience significant improvement 
with treatment.  
2.5 
Social Phobia 
  Most people admit to social discomfort while under public scrutiny, but social 
phobia is an excessive fear that a performance or social interaction will be 
inadequate, embarrassing or humiliating. 
  The patient has insight that their fear is excessive and unreasonable. 
  Alcohol is often used in an effort to control the anxiety. 
  During an assessmentsocial phobics may appear relaxed. Physical symptoms 
(blushing, inability to speak, shaking or vomiting) may only become apparent 
when they are placed in the stressful social situation. 
  About a third of patients will enjoy a complete remission during long-term follow-
up.  
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2.6 
Specific (isolated) Phobias 
  A specific phobia is the persistent inappropriate fear of a specific object or 
situation. 
  The degree of avoidance is a useful measure of severity. 
  The degree of disability depends on the ease with which the phobic object can 
be avoided. 
  In general, specific phobias are less handicapping than other types of phobias. 
  Behaviour therapy is the most effective treatment. Drugs are of little use. 
  Exposure treatment can achieve long-term cure in about half of patients with 
specific phobias. 
2.7 
Treatments for Anxiety Disorders 
  Psychological treatments aim to teach the skills needed to cope with the physical 
and cognitive aspects of anxiety. They are at least as effective as drug 
treatments. Overall, with psychological treatments, about half of patients regain 
normal functioning. 
  When combined, drug and psychological treatments have a synergistic effect on 
the long-term outcome of anxiety disorders. Psychological treatments seem to 
be particularly effective at preventing relapse when drug treatment is eventually 
withdrawn.  
2.8 
Main Disabling Effects 
  It is important to distinguish common anxiety conditions that have no long-term 
disabling effects from those that cause persistent disability. “Trait anxiety” (a 
lifelong personality characteristic) and “stress reactions” (a self-limiting effect of 
life events) do not cause significant long-term disability. 
 
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3. 
Alcohol Related Disorders 
3.1 
Introduction 
3.1.1 
Definition of Harmful Alcohol Consumption  
  Alcohol consumption damaging to the psychological, physical or social well 
being of the individual. 
3.1.2 
Key Features of Alcohol Dependence  
  Increased tolerance – larger doses are required. 
 Withdrawal 
symptoms. 
 Cravings. 
  Obtaining the next drink becomes the most important part of a person's life.  
  The pattern of consumption (timing, place and substance) becomes rigid. 
3.2 
Quantifying Alcohol Intake 
  The recommended safe limits of weekly alcohol intake are 21 units for men and 
14 units for women, with at least 2 drink free days.  
  Health is seriously at risk when weekly alcohol intake reaches 35 units for men 
and 21 units for women.  
  A unit of alcohol (10ml) is approximately equivalent to: a small glass of wine, a 
pub single measure of spirits or half a pint of ordinary strength beer.   
3.3 
Consequences of Excess Alcohol Consumption 
  80% of patients referred for treatment of alcohol abuse have physical 
complications, including Wernicke - Korsakoff Syndrome, peripheral neuropathy, 
cirrhosis, gastritis, pancreatitis, oesophageal varices, macrocytic anaemia, 
cardiomyopathy and gout.  
  Alcoholic cirrhosis is associated with a 5-year survival of 48% if drinking 
continues, and 77% if it stops.  
  40% of alcohol abusers presenting for treatment have depression. 
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3.4 
Diagnosis 
  Many heavy drinkers do not seek help.  
  A high index of suspicion is required, especially in claimants with medical or 
psychiatric conditions often associated with alcohol.  
  Screening questionnaires have been developed to identify patients who may be 
at risk from their pattern of alcohol consumption. 
  A detailed picture of a typical day gives a good indication of how alcohol affects 
the claimant’s life.    
3.5 
Treatment of Alcoholic Dependence 
  Approximately 70% of all patients achieve a reduction in the number of days of 
drinking and improved health status within 6 months.  
  The majority of patients have at least one relapse during the first year following 
treatment. 
3.6 
Prognosis 
  Alcohol causes about 33,000 deaths per annum in England and Wales.  
  A third of patients manage to recover without professional intervention.  
  The onset of chronic complications of alcohol predicts a poor prognosis. 
3.7 
IB-PCA Considerations 
  With the exception of those cases where it is appropriate to advise exemption 
from the PCA, the mental health assessment should always be applied when 
assessing claimants with alcohol related disability.   
  The most important discriminating factor in assessing the impact of alcohol 
excess on a claimant is to determine whether they are dependent on alcohol.  
 
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4. 
Substance Use Disorders 
4.1 
Description 
  Intoxication is defined as a transient syndrome due to recent substance 
ingestion that produces clinically significant psychological and physical 
impairment. 
  Abuse and harmful use are used to define maladaptive patterns of substance 
use that impair health. 
  Dependence is diagnosed in the presence of well-defined criteria. 
  Tolerance develops after repeated misuse of a drug. 
  Withdrawal state is drug-specific. 
4.2 
Aetiology 
  Important factors are vulnerable personality, adverse social and environmental 
factors, and easy availability of drugs. 
  Approximately 10% of people who experiment with drugs will develop problems 
with them in the longer term. 
4.3 
Prevalence 
  Difficult to estimate as drug misuse often goes undetected. 
  Prisoners tend to show the highest rate of illicit drug use and drug dependence. 
4.4 
Diagnosis 
  Self-neglect may be evident on observation. 
  Physical signs can include needle tracks, thrombosis of veins and subcutaneous 
abscesses. 
  Cognitive impairment, altered mood and psychotic symptoms can all feature. 
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4.5 
Treatment 
  Can be provided through specialist inpatient or outpatient units, or general 
practitioners. 
  Most cases will be offered individual counselling. 
  For most drugs, including opioids, detoxification can be accomplished on an 
outpatient basis. 
  Use of a replacement drug may reduce harmful practices, and facilitate retention 
in a treatment programme. 
  A number of different health professionals may be involved in the rehabilitation 
process. 
4.6 
Prognosis 
  Drug misuse carries a very high morbidity. 
  Drug dependence cannot be cured completely; it can only be effectively 
controlled. 
  Craving and relapses are not the exception, but the rule. A very small dose of 
the drug, years after the last dose can produce intense craving. 
  In those who are dependent on heroin, the mortality at 10 years is 10-15%, with 
a tendency to natural remission in the survivors, the overall abstinence in the 
same group being 50%. 
  Craving in abstinent individuals is caused by the presence, not the absence of 
the drug. 
4.7 
Main Disabling Effects 
  Drug users in employment have a high absenteeism rate and a higher incidence 
of accidents. 
  Employment rates for drug dependent individuals are very low. 
  The disability arising from drug use is highly variable. 
  Effects on the mental state can include altered mood or behaviour, poor 
concentration and self- neglect. The ability to interact with other people may be 
impaired. 
  The mental and physical effects may be of such severity that exemption from the 
IB-PCA can be considered. 
 
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5. 
Schizophrenia 
5.1 
Definition 
  The typical course of schizophrenia is acute episodes of hallucination, delusions 
and florid disorganisation of thought; superimposed on a persistent disorder of 
the initiation and organisation of thought and behaviour. 
5.2 
Clinical Features 
  Schizophrenic symptoms can be seen as an: 
  Excess or distortion of normal function = positive symptoms or  
  A decrease or loss of normal function = negative symptoms
 
Positive Symptoms 
Negative Symptoms 
  Formal Thought Disorder 
  Poverty of thought and speech 
 Disorganised 
behaviour 
 Impaired 
volition 
 Inappropriate 
affect 
  Blunt affect and anhedonia 
 Delusions 
 Social 
withdrawal 
 Hallucinations 
 
  In chronic schizophrenia, the symptoms appear to segregate into three core 
syndromes.  
a)  Negative symptoms appear to cluster together as part of a syndrome: 
psychomotor poverty
b)  Positive symptoms fall into two separate clusters, reality distortion and 
disorganisation. 
  Psychiatric co-morbidity is common. 
  The clinical course of schizophrenia shows significant variability in mode of 
onset, degree of symptom persistence and long-term outcome.  
  The acute phase is characterised by dysphoria, irritability, obsessional thoughts, 
poor concentration and sleep disturbance; followed by the development of 
delusions and hallucinations and a rapid deterioration in occupational and social 
functioning.  
  Lack of insight, auditory hallucinations and ideas of reference are the most 
frequent acute symptoms. 
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5.3 
Treatment 
  Drugs are used for treatment of acute episodes and the prevention of relapse.  
  Psychosocial interventions are used to prevent relapse and disability. 
  Typical antipsychotic drugs are more effective in treating the positive symptoms 
of schizophrenia, but have side effects that are themselves disabling. The 
atypical antipsychotics may be more effective in reducing negative symptoms 
and have a better side effect profile. 
  Patients who have had several psychotic episodes usually require life-long 
maintenance antipsychotic medication. 
  Psychosocial managements that have been shown to be useful in schizophrenia 
include: supportive psychotherapy, cognitive behaviour therapy, family 
intervention and social skills training. 
5.4 
Prognosis 
  The clinical course becomes established within the first five years. 
  In most cases the course follows one of four broad patterns: 
  Complete Remission (22%). 
  Episodic Remittent (35%). 
  Episodic with stable deficit (8%). 
  Episodic with progressive deficit (35%). 
  Death rates of people with schizophrenia are at least twice as high as the 
general population.  
  The leading cause of death amongst schizophrenic patients is suicide. The 
lifetime risk of suicide in schizophrenic patients has been estimated as 10%. 
5.5 
Main Disabling Effects 
  A large proportion of claimants with schizophrenia will fulfil the criteria for 
exemption from the PCA on the grounds of a severe mental illness.   
  The disabling effects are due to a range of abnormalities in psychological 
functioning, such as poor attention and concentration; and failure to recognise, 
and act on, social or affective cues.  
  Disability may also arise as a side effect of the treatment of schizophrenia such 
as the abnormalities of motor function secondary to antipsychotic medication. 
  Persisting moderate to severe disability is present in 40% of males and 25% of 
females. 
 Supported  Employment Programmes have been shown to be effective in 
increasing the rates of competitive employment.  
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6. 
Bipolar Disorders 
6.1 
Description 
  These are severe mental health conditions characterised by marked mood 
swings. 
  Typically both depressive and manic or hypomanic episodes can occur. 
  Swings of mood are pathological and recurrent. 
6.2 
Diagnosis 
  Mood swings usually include episodes of depression. 
  In hypomania, the clinical features are less marked than in mania and psychotic 
features are not seen. 
  Physical appearance may be unusual and speech and thought processes 
abnormal. 
  Lack of insight may mean relevant features are not reported. 
  60% of bipolar patients have psychotic symptoms at some time. 
  Co-morbidity with other mental health conditions is common. 
6.3 
Treatment 
  Most sufferers are likely to have been in contact with specialist mental health 
services. 
  Management of acute mania/hypomania is best undertaken in hospital with the 
use of medication aimed at reducing physical and mental overactivity. 
  Longer-term management is aimed at preventing relapse or recurrence. 
  Lithium remains the prophylactic drug of choice.  
  Poor compliance with treatment is a major issue, particularly for those on lithium. 
6.4 
Prognosis 
  The average manic episode lasts 6 months (treated or untreated) with recovery 
the usual outcome. 
  90% of patients who have had a manic episode will have a manic or depressive 
recurrence. 
  50% of bipolar patients attempt suicide at some point. 
  Less than 20% of bipolar patients are able to achieve a 5-year period of clinical 
stability. 
  The long-term functional prognosis is that high levels of mental health disability 
are likely. 
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6.5 
Main Disabling Effects 
  Disabling mood swings are likely to persist between relapses. 
  All aspects of daily life can be severely disrupted. 
  Motivation, concentration and cognitive ability may be reduced. 
  Long term psychosocial functioning is poor in up to 60% of patients. 
  Many claimants with bipolar disorder will fulfil the exemption criteria for the PCA. 
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7. 
Obsessive Compulsive Disorder 
7.1 
Definition 
  OCD has the characteristics of an anxiety disorder. The anxiety is generated by 
either thoughts or behaviours, to which the sufferer responds by anxiety relieving 
rituals. 
  Obsessions are recurrent thoughts, ideas, or impulses, which are experienced 
as unwanted and distressing.  
  Common obsessions include, contamination, pathological doubt, somatic 
concerns and the need for symmetry. 
  Compulsions are repetitive, purposeful and intentional behaviours, which are 
performed in response to an obsession.  
  Common compulsions include checking, washing, counting and arranging 
objects symmetrically. 
7.2 
Diagnosis 
  OCD sufferers are distressed by their condition, whereas people with obsessive 
personality disorder are not.  
  Depression and anxiety are commonly co-morbid with OCD. 
7.3 
Treatment 
  Behavioural therapy and drug treatments are both effective in treating OCD.  
  The combination of pharmacological treatment with behavioural therapy is likely 
to give the best chance of achieving a good response. 
  First line drug treatments for OCD are the Selective Serotonin Reuptake 
Inhibitors (SSRIs).  
  Discontinuation of drug treatment is associated with relapse rates of 80-90%. 
7.4 
Prognosis 
  If symptoms of OCD have been present for over 1 year then spontaneous 
recovery is unusual. 
  Relapses in OCD may be precipitated by adverse life events. 
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7.5 
Main Disabling Effects 
  Obsessions and compulsions may result in restricted social functioning and 
social isolation.  
  Obsessional thoughts interfere with concentration on study and work.  
  Co-morbid depression may worsen the disabling effects of OCD. 
 
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8. 
Adjustment Disorders and Post-Traumatic 
Stress Disorder  

8.1 
Definition 
  Post-Traumatic Stress Disorder (PTSD) and Adjustment Disorders arise 
because of acute severe stress or continued psychological trauma. 
  A diagnosis of PTSD requires that, “the person experienced, witnessed, or was 
confronted with an event or events that involved actual or threatened death or 
serious injury, or a threat to the physical integrity of self or others,” and that, “the 
person’s response involved intense fear, helplessness, or horror.” 
  Adjustments Disorders (AD) are “states of subjective distress and emotional 
disturbance that interfere with social or occupational functioning, and which arise 
during a period of adaptation to an adverse life event.” 
  PTSD is an anxiety-type disorder with symptoms of: 
  Re-experiencing the event.  
  Avoidance behaviour and numbing of responsiveness. 
  Persistent symptoms of increased arousal. 
  PTSD can occur at any age and may affect children who have been exposed to 
traumatic events. 
8.2 
Aetiology 
  Adjustment Disorder and PTSD result from the failure of the individual’s coping 
strategies. 
  The most common cause of PTSD is road traffic accidents. 
8.3 
Diagnosis 
  Adjustment Disorders lie on the threshold between normal behaviour and 
psychiatric morbidity.  
  Diagnosis of PTSD is sometimes difficult, as the sufferer may be reticent in 
describing their symptoms to avoid recalling the traumatic event.  
  Co-morbidity with other psychiatric illness is very common in PTSD.  
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8.4 
Treatment 
  Treatment of adjustment disorders focuses on psychotherapeutic and 
counselling interventions. The symptoms of anxiety and depression can be 
managed pharmacologically. 
  Prevention, training and pre-selection of individuals likely to be exposed to 
severe stressors reduces the likelihood of development of PTSD. This is 
especially important in occupations such as the armed forces and the 
emergency services. 
  Debriefing immediately following the stressful event does not prevent PTSD and 
may be harmful. 
  Benzodiazepines in the immediate post stressor period are harmful. 
  Selective Serotonin Reuptake Inhibitors (SSRIs) improve symptoms in patients 
with PTSD. 
  Cognitive behaviour therapy is effective, especially if combined with SSRI drug 
therapy. 
8.5 
Prognosis 
  60% of cases of PTSD have a slow natural recovery time over a period of about 
six years; treatment accelerates recovery. 
  Long-term chronicity remains about 40% with or without treatment.        
8.6 
Main Disabling Effects 
  The disabling effects of these conditions are very variable: each case must be 
assessed individually.  
 
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9. 
Learning Disability 
9.1 
Introduction 
  In people of working age, learning disability is the commonest disability in the 
UK.  
  Classification of Learning Disability: 
 
EQUIVALENT MENTAL 
Classification IQ 
Proportion 
AGE 
Mild 
50 – 69 
8 – 12 years 
85% 
Moderate 
35 – 49 
3 – 8 years 
10% 
Severe 
20 – 35 
1 – 3 years 
3.5% 
Profound 
< 20 
< 1 year 
1.5% 
9.1.1 
Mild Learning Disability 
This is not usually associated with abnormalities in appearance or behaviour. 
Language, sensory and motor abnormalities are mild or absent. Adults may have 
difficulty coping with stress, and may need support with complex functioning such as 
parenting and handling their finances. However, the majority are able to live 
independently in the community and manage some form of employment.  
9.1.2 
Moderate Learning Disability 
People with moderate learning disability are rarely able to live independently, but 
they may learn to wash, dress and feed themselves. This group have limited but 
useful language skills. Help is needed with road sense and finances. Challenging 
behaviour is common. Moderate learning disability is often associated with epilepsy, 
neurological, and other physical disabilities. 
9.1.3 
Severe and Profound Learning Disability 
This group of claimants have very limited verbal and self-care skills. Epilepsy affects 
33%, incontinence 10% and inability to walk 15%. Behaviours such as self-harming 
or inappropriate sexual behaviour occur in up to 40% of children and 20% of adults 
in these categories.  
9.1.4 
Prevalence 
  In England, it is estimated that there are 1.2 million people (2% of the 
population) with mild or moderate learning disability, and about 120,000 adults 
with severe or profound learning disability. 
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9.1.5 

Aetiology 
  There is an obvious cause for mild learning disability in about half of cases. In 
the remainder, combinations of social, educational and emotional deprivation are 
the main contributory factors.  
  In severe learning disability, 80% have evidence of organic brain damage.  
9.1.6 
Psychiatric Co-morbidity 
  40% of those diagnosed with learning disability also have a mental illness.  
9.2 
Autistic Spectrum Disorders 
  A group of developmental conditions that affect the way the brain processes 
information. People with autism are severely affected, while Asperger syndrome 
describes people at the higher functioning end of the autistic spectrum. 
9.3 
Autism 
  Autism is a lifelong developmental disability that affects the way a person 
communicates and relates to people around them. An autistic person 
experiences a confusing mass of events, people, places, sounds and sights 
without order or meaning.  
  The range of intellectual ability extends from severe learning disability to above 
average IQ.  
9.3.1 
Core Clinical Features 
  Autism is usually apparent by the age of 3 years.  
  Abnormal social interaction: There is poor grasp of non-verbal social cues and 
avoidance of eye contact, so people with autism may appear aloof and 
indifferent. 
  Impaired language and communication skills. 
  A “rigid routine,” interests and activities that have a preoccupation with dates or 
numbers, and a stereotyped behaviour pattern such as hand flapping, nodding 
or rocking. 
  About 10% of children with autistic spectrum disorders have a special skill at a 
much higher level than the rest of their abilities - for example, music, art, 
numerical calculations or jigsaw puzzles.  
9.3.2 
Prognosis 
  Autism typically runs a steady lifelong course.  
  Although some autistic adults learn to adapt partially to their disability, only 11% 
gain jobs on the open market, and only 15% achieve independent living.  
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9.4 
Asperger Syndrome 
  People with Asperger syndrome can speak fluently, but they may not understand 
the reactions of listeners.  
  They often develop an obsessive interest in memorising facts about a special 
subject.  
  Any unexpected happening or change in the routine can upset them. 
  Children with Asperger syndrome usually have normal or above average 
intelligence, and they attend mainstream school.  
9.5 
Down’s Syndrome 
  The vast majority of cases of Down’s syndrome are caused by trisomy 21. 
  Down’s syndrome is associated with a typical facial appearance and short 
stature. 
  85% have moderate or severe learning disability.  
  Physical health problems are associated with Down’s syndrome: 
  Congenital heart disease – 40%.  
  Visual and hearing impairment – 50%. 
  Hypothyroidism – 30%. 
  Oesophageal and duodenal atresia. 
  Cognitive decline and dementia (similar to Alzheimer’s disease) occurs 30-40 
years earlier than in the general population, and affects 25% of people with 
Down’s syndrome.  
  Life expectancy is approximately 50 years. 
9.6 
Fragile X Syndrome 
  Fragile X syndrome is the second commonest cause of moderate and severe 
learning disability after Down’s syndrome, accounting for 20 - 30% of learning 
disabilities.  
  A milder form affects girls, who may have normal intelligence.  
  Fragile X syndrome is associated with a typical appearance, including an 
elongated face, large ears and blue eyes. Other features include flat feet, macro-
orchidism and hyper-flexible joints.  
  The degree of learning disability is similar to that in Down’s syndrome.  
  The majority of people with Fragile X syndrome need day-to-day supervision. 
They may work in a sheltered environment, and live at home or in supported 
accommodation. 
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9.7 
Attention Deficit Hyperactivity Disorder – ADHD 
  The prevalence of ADHD in the UK is about 1%. 
9.7.1 
Core Clinical Features 
  Inattention 
Easily distractible, forgetful, difficulty sustaining tasks such as play, learning and 
work. 
  Overactivity 
Fidgety, reckless, socially disinhibited, inappropriately active, talking excessively. 
  Impulsivity 
Interrupts and intrudes, unable to “wait their turn”. 
9.7.2 
Treatment 
  Ritalin (methylphenidate) is an amphetamine-like stimulant. It has the 
paradoxical effects of decreasing activity level and improving attention.  
  Medication produces a short-lived improvement after each dose, but it is not a 
permanent cure.  
9.7.3 
Prognosis 
  By the second decade, impulsivity and inattention tend to improve, even without 
medication.  
  The learning difficulties caused by ADHD in childhood have long-term 
consequences. About 60% of adults continue to experience disability.  
9.8 
Education 
  Children with learning disability are usually educated within mainstream schools.  
  The 1995 Disability Discrimination Act protects employees with learning 
disability. 
 
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10.  Eating Disorders 
10.1  Description 
  The three most common eating disorders are anorexia nervosa, bulimia nervosa 
and obesity. 
  These are now recognised to be both disabling and relatively common. 
  There is considerable overlap between anorexia and bulimia. 
  There is usually no underlying psychological causative factor in obesity. 
10.2  Diagnosis 
  Anorexia is characterised by distorted body image, fear of fatness and deliberate 
weight loss to BMI of 17.5 or less. 
  In anorexia, medical complications occur commonly and can be disabling or life 
threatening. 
  Bulimia is characterised by episodes of binge eating, fear of fatness and self-
induced vomiting. 
  Obesity is diagnosed when the BMI exceeds 30, and severe obesity when BMI 
>40.    
10.3  Treatment 
  The majority of anorectic patients can be managed as outpatients. Hospital 
admission may be necessary if the weight falls to a dangerous level. 
  Psychological measures to treat anorexia include cognitive, behavioural or family 
therapy. 
  Treatment for bulimia follows the same general principles. In-patient treatment is 
rarely necessary and the management is usually easier than for anorexia. 
  Patients with bulimia should not be given tranquillisers because of a high 
propensity for addiction. 
10.4  Prognosis 
  In anorexia, 65% have a good outcome and maintain a normal weight.  
  Mortality in anorexia is up to 5% over 4-5 years, and as high as 10% in the long 
term. 
  Two-thirds of deaths are due to the effects of starvation, and one-third to suicide. 
  In bulimia, two thirds have a continued preoccupation with weight and eating, 
and about one third maintain a healthy and regular eating pattern. 
  Obesity roughly doubles mortality risk. 
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10.5  Main Disabling Effects 
  In anorexia, physical function is usually well preserved, but medical 
complications are common and may give rise to symptoms such as fatigue. 
  In bulimia, the likelihood of physical incapacity increases with frequent bingeing 
and purging due to electrolyte imbalance and other complications. 
  Psychological problems are common in anorexia and bulimia. 
  Low mood is particularly common at low weights in anorexia. 
  Unless the BMI is over 40, obesity is unlikely to produce significant impairment. 
 
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11.  Personality Disorders 
11.1  Definition 
  The point at which personality problems become personality disorders is 
generally taken as the point at which the personality disturbance results in 
impaired relationships and reduced social and occupational functioning. 
  The categorical approach to the classification of personality disorder assumes 
the existence of distinct types of personality disorder with distinctive features. 
In reality, few patients fit neatly into any single category and individuals with 
severe personality disorder may satisfy the criteria in all categories. An 
alternative dimensional approach has been proposed which is gaining popularity, 
although it is not yet standard clinical practice. 
  The Diagnostic and Statistical Manual of Mental Disorders (4th edition) (DSM-
IV), groups the different disorders into three clusters: 
 
Cluster A 
The odd and eccentric group 
  Paranoid Personality Disorder 
  Schizoid Personality Disorder 
 Schizotypal 
Personality 
Disorder 
Cluster B 
The flamboyant or dramatic 
 Anti-Social 
Personality 
Disorder 
group 
 Borderline 
 Histrionic 
 Narcissistic 
Cluster C 
The anxious and fearful 
 Avoidant 
group 
 Dependent 
 Obsessive 
compulsive 
11.2  Prevalence 
  In Britain, the prevalence of personality disorder has been estimated as: 
  2% to 13% in the general population. 
  32% in primary care patients. 
  30-40% amongst psychiatric outpatients. 
  40-70% of psychiatric inpatients. 
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11.3  Diagnosis 
  Personality disorder is often a diagnosis of exclusion.  
  The patient's own account of the disorder may be unreliable due to the disorder 
itself or the patient's self-assessment of personality may be distorted by mood 
disorders.  
  Most people diagnosed with a personality disorder are not dangerous. Danger 
(to self and others) is most often associated with a dissocial disorder. 
  People diagnosed as borderline or paranoid personality disorder may be at 
higher risk of self-harm and/or suicide. 
  Personality disorders are commonly co-morbid with other psychiatric illnesses. 
  Dissocial personality disorder is included in the Mental Health Act 1983, and if 
thought to be treatable, can be the basis for compulsory admission to hospital. 
11.4  Treatment 
  There is not much research evidence to support the treatment of personality 
disorder with drugs.  
  Aggressive behaviour has been shown to respond to carbamazepine therapy, 
depot anti-psychotic drugs have been reported to benefit patients who self-harm, 
and SSRIs have been used in patients with borderline personality disorders. 
  Psychosocial treatments aim to provide insight for patients, allowing them to 
understand their emotions and to find more appropriate coping mechanisms.  
11.5  Prognosis 
  Personality disorders are lifelong conditions. 
  There is a high incidence of death by violence and suicide. 
  Obsessional personality disorders are at a high risk of progression to an actual 
Obsessive Compulsive Disorder, or to depression. 
  Paranoid and schizotypal disorders may progress to schizophrenia, but schizoid 
disorder does not. 
  Borderline personality disorder carries a relatively favourable prognosis with 
clinical recovery in over 50%. 
11.6  Main Disabling Effects 
  As there is such an overlap between the different disorders, it is unlikely that 
claimants will fall exactly into neatly defined categories. It is important for the 
examining doctor to assess the claimant’s actual functional capabilities and not 
to assume that particular difficulties exist purely based on the diagnosis. 
 
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12.  Organic Disorders  
12.1  Delirium & Dementia 
12.1.1  Description 
  These are due to some demonstrable abnormality of brain structure or function. 
  Cognition, behaviour or emotions may be affected. 
12.1.2  Aetiology 
  Delirium is more common in those who have reduced cerebral reserve. 
  Dementia has many causes but in the elderly, the commonest are vascular and 
degenerative causes. Alzheimer’s disease accounts for half of all cases. Lewy 
body dementia, 20% of cases. 
12.1.3  Prevalence 
  In the community, 5% of over 65s have dementia.  
  As the ageing population increases the number of people with dementia will rise 
significantly. 
12.1.4  Diagnosis 
  In dementia, the usual mode of presentation is poor memory. 
  Vascular dementia shows a stepwise progression. 
  In Lewy body dementia, cognitive impairment fluctuates. Vivid visual 
hallucinations, Parkinsonism and frequent falls may feature. 
  AIDS dementia complex is usually a later feature of AIDS, occurring in 30% of 
cases. 
  Prion diseases remain extremely rare in the UK. 
  In recent years, a separate entity called mild cognitive impairment (MCI) has 
been recognised. 
12.1.5  Treatment 
  In delirium, the underlying cause is treated. 
  In Alzheimer’s disease acetyl cholinesterase inhibitors can slow the rate of 
deterioration in mild or moderately affected individuals. 
 
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12.1.6  Prognosis 

  In delirium, this is dependent on the underlying cause. 
  The mean life expectancy, from diagnosis, in Alzheimer’s disease is 7 years. 
  Vascular dementia has a shorter life expectancy at 4 to 5 years. 
  The prognosis in AIDS dementia complex is very poor. 
12.1.7  Main Disabling Effects 
  In the majority of cases, the disabling effects of cognitive impairment are very 
significant. 
  More than 30% of those with MCI have difficulty with tasks of daily living such as 
using the telephone. 
  With regard to the IB-PCA, cases of dementia are likely to be exempt. 
12.2  Head Injury 
12.2.1  Description 
  The after-effects and residual disability from head injury can be significant. 
  Long-term effects may include epilepsy, impaired cognition and psychiatric 
syndromes. 
12.2.2  Aetiology 
  The commonest cause is road traffic accidents. 
12.2.3  Prevalence 
  About 20% of all head injuries will need admission to the hospital and 2-3% of 
those admitted will prove fatal.  
12.2.4  Diagnosis 
  The duration of unconsciousness and amnesia are proportional to the severity of 
the injury. 
12.2.5  Treatment 
  Initial recovery may be rapid, but some functions may take a very long time to 
recover. 
  Recovery is not only due to anatomical reorganisation but also due to 
behavioural compensation and functional adaptation. 
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12.2.6  Main Disabling Effects 

  Focal neurological deficits may never recover. 
  Cognitive deficits resolve within 3 months in most individuals who have a minor 
brain injury. 
  Moderate to severe brain injury leads to persistent cognitive and behavioural 
problems. 
  With regard to the IB-PCA, severely affected individuals are likely to fulfil 
exemption criteria. 
  Mental health assessment may show reduced concentration and memory. The 
ability to learn new tasks may be affected. Anxiety, fatigue, behavioural 
problems and difficulty communicating may all feature. 
12.3  Cognitive Impairment due to Prescribed Medication 
  The mental health assessment of the IB-PCA should be applied whenever a 
claimant is taking any medication that impairs cognitive function to a degree that 
causes mental disablement. 
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13.  Analytical Guidance 
13.1  Introduction 
The tables in this section provide guidance concerning the mental health conditions 
that are most commonly encountered when working in the field of Disability 
Assessment Medicine.  
IB approved doctors should always consider Exemption advice on the basis of a 
severe mental illness in those situations where they find evidence of features that 
are described in the tables under the heading of “Severe Disability Likely”. 
 
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13.2  Depressive Disorders 
 
Attempted suicide in the last 6 months. 
Psychiatric hospital admission in the last year. 
History 
Treated with ECT in the last year. 
Attending psychiatric day hospital. 
Severe 
Living in supported accommodation. 
Disability 
Unkempt appearance. 
Likely 
Poverty of speech. 
MH 
Psychomotor retardation.  
Assessment 
Severe mood disturbance. 
Psychotic symptoms.  
Active suicidal thoughts. 
Attending with a CPN, social worker or support worker. 
Co-morbidity with drug or alcohol abuse or another psychiatric 
illness. 
Death of a partner, spouse or first-degree relative in the last 6 
months. 
History 
Numerous recurrent depressive episodes or chronic depression. 
Attending psychiatric outpatient clinic. 
Under the supervision of a CPN. 
Taking a course of antidepressants. 
Significant 
Taking lithium treatment. 
Disability 
Receiving a course of psychotherapy. 
Likely 
Loss of appetite. 
Loss of weight. 
Early morning waking. 
Diurnal variation of mood. 
MH 
Anhedonia. 
Assessment 
Downcast gaze and poor eye contact. 
Hopelessness. 
Unreasonable guilt. 
Impaired concentration and memory. 
Avoids social interaction. 
History 
Not receiving antidepressant or psychological treatment. 
Significant 
Disability 
No biological symptoms of depression. 
MH 
Able to continue with their usual interests and hobbies. 
Unlikely 
Assessment 
Enjoys social contact with friends and family. 
  An individual acute episode of depression is likely to respond to 
treatment. 
  However, in the longer term, further depressive episodes are 
common. 
Prognosis 
 
  Depression may present to the Disability Analyst as chronic 
and intractable. 12-20% of subjects with unipolar depression 
develop chronic depression, and remain fully symptomatic in 
the longer term.   
  For an acute episode of depression, a review after 6 months 
will usually be appropriate. 

Suggested 
 
A severe acute episode of depression that warrants exemption 
review 
advice should be reviewed in 12 months. 
 
  Chronic depression that is not responding to treatment should 
periods for 
be reviewed in no less than 18 months. The most severe and 
IB-PCA 
intractable cases should be reviewed in 2 years or ”the longer 
term” according to the age of the claimant, and duration of the 
illness. 
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13.3  Anxiety 
 
Housebound due to severe disabling anxiety disorder e.g. visited 
History 
Severe 
by GP or psychiatrist at home.  
Disability 
Attending with CPN, social worker or support worker. 
Likely 
MH 
Severe and persistent symptoms of anxiety leading to social 
Assessment 
isolation. 
Taking antidepressant treatment. 
Taking buspirone. 
Taking propranolol specifically for anxiety symptoms. 
Taking benzodiazepines most days for relief of anxiety symptoms. 
(Not for sleep). 
History 
Under the care of a psychiatrist or the community mental health 
team. 
Significant 
Receiving psychological therapy. 
Disability 
Co-morbidity with drug or alcohol abuse or another psychiatric 
Likely 
illness. 
Avoidant behaviour: Only leaves home when it is unlikely that there 
are many people about, does not answer the phone or the door, 
MH 
avoids social interaction. 
Assessment 
Reliant on friends and family to accompany them outside the 
house.  
No social life. 
Specific phobias. 
History 
Trait anxiety. 
Significant 
Short-term “stress reactions.” 
Disability 
Claimant living independently. 
Unlikely 
MH 
Claimant enjoys contact with family and friends. 
Assessment 
No loss of interests or hobbies.  
Can travel unfamiliar routes unaccompanied on public transport. 
The length of history and type of treatment help to predict 
prognosis: 
  Cognitive behaviour therapy is an effective treatment for most 
Prognosis 
 
anxiety disorders. 
  Drug treatments typically last about 6 months. 
  A long history of disabling anxiety and previous unsuccessful 
treatment are associated with a poor prognosis. 
Considerations pertaining to length of history:  
  Acute problems should be reviewed after 6 months. 
  Years of intractable anxiety should be reviewed after no less 
Suggested 
than 18 months. 
review 
 
periods for 
Considerations pertaining to type of treatment:  
IB-PCA 
  Claimants starting psychological treatment should be reviewed 
in 12 months.  
  Simple phobias and panic may respond quickly, so review after 
6 months. 
 
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13.4  Alcohol  
 
Severe chronic physical complications e.g. liver failure, portal 
hypertension, bleeding oesophageal varices, recurrent 
pancreatitis, cardiomyopathy and Wernicke-Korsakoff syndrome. 
History 
Claimants who are habitually intoxicated and would pose a threat 
to themselves or others in the workplace. 
 
Claimants undergoing detoxification and rehabilitation. 
Severe 
Poor self-care and a chaotic lifestyle. 
Disability 
Likely 
Failure of memory, loss of intellectual ability and deterioration of 
MH 
personality. Claimants whose dependence on alcohol has led to 
Assessment 
extreme poverty and neglect and an inability to function socially. 
Signs indicative of the severe chronic physical complications of 
Physical signs 
alcohol excess.  
Claimants who have developed dependence on alcohol. 
Under the care of a specialist alcohol treatment service. 
Taking disulfiram or acamprosate treatment. 
Chronic physical consequences such as peripheral neuropathy or 
atrial fibrillation. 
Hospital referrals for investigation of alcohol related physical or 
History 
mental illness. 
Emergency admissions for fits, delirium tremens, pancreatitis or 
haematemesis. 
Significant 
Co-morbidity with another psychiatric illness. 
Disability 
Alcohol-related social problems such as debt, divorce or 
Likely 
homelessness. 
Social isolation, and the avoidance of people. 
Early features of cognitive impairment.  
MH 
NB: Amnesic “blackouts” due to heavy drinking are not a form of 
Assessment 
epileptic fit. 
Signs including unkempt appearance, the smell of alcohol on the 
Physical signs 
breath, plethoric face, bloodshot conjunctivae, acne rosacea and 
tremor. 
Claimants who are able to continue with their usual interests and 
History 
Significant 
hobbies. 
Enjoy social contact with friends or family. 
Disability 
Unlikely 
MH 
Absence of abnormal findings on mental state examination 
Assessment 
Alcohol dependence is often characterised by periods of 
Prognosis 
 
remission and relapse. 
Length of history is predictive of prognosis. 
Suggested 
  Those with acute problems, or a history of long remissions, 
review 
should be reviewed after 6 months. 
 
periods for 
  Claimants with very long histories of intractable alcoholism 
IB-PCA 
should be reviewed after no less than 18 months. 
 
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13.5  Substance Abuse 
 
Chaotic and disorganised lifestyle 
Poly-substance abuse and dangerous injecting habits 
Compulsive drug seeking behaviour to the exclusion of all other 
activities 
Gross self-neglect 
History 
 
Grossly impaired social interaction 
Currently undergoing detoxification or detoxification planned in the 
Severe 
near future 
Disability 
Overdoses or suicide attempts in the last six months 
Likely 
Suicidal ideation and low self-esteem 
Evident gross self-neglect 
MH 
Co-morbidity due to associated severe mental illness 
Assessment 
Behavioural and/or thought disorders 
Attends with CPN or care worker 
Long history of drug abuse and dependence 
Multiple failed detoxification attempts  
History 
Associated mental disorders such as anxiety 
Intensive input and support from community psychiatric team and 
Significant 
social services 
Disability 
Likely 
Some evidence of self-neglect 
Poor insight and motivation 
MH 
Poor social relationships 
Assessment 
Associated mood disorders 
Impaired concentration 
Recreational drug use only 
Normal social functioning 
History 
Adequate self-care 
Significant 
No loss of interests or hobbies 
Disability 
Well groomed with no evidence of self-neglect 
Unlikely 
Intact insight 
MH 
Normal mood and concentration 
Assessment 
Good inter-personal skills 
Appropriate behaviour 
Drug dependence cannot be cured completely; it can only be 
Prognosis 
 
effectively controlled. 
Length of history is predictive of prognosis. 
  Acute drug related problems with a short history should be 
reviewed in 6-12 months. 
  A short term prognosis of 6-12 months may be used in 
Suggested 
claimants with good motivation, intact insight and good 
review 
compliance with treatment, especially in presence of mild to 
 
periods for 
moderate disability  
IB-PCA 
  Claimants with a very long history of drug abuse should be 
reviewed after no less than 18 months to 2 years. A small 
subset of this group may not show any significant change in the 
longer term. 
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13.6  Schizophrenia and other Psychoses 
 
Positive symptoms such as formal thought disorder, disorganised 
History 
behaviour, inappropriate affect, delusions, hallucinations. 
Multiple psychotic episodes. 
Extrapyramidal side effects, stereotypies or dystonias of tardive 
 
dyskinesia. 
Severe 
Prominent negative symptoms such as flat affect, poverty of 
Disability 
speech and social withdrawal. 
Likely 
MH 
Poor self care. 
Assessment 
Thought disordered. 
Distracted appearance suggestive of active hallucinations. 
Residual cognitive deficit. 
Poor insight and compliance. 
Ongoing contact with mental health services. 
Co morbid substance abuse. 
Significant 
History 
Some reduction in social functioning. 
Disability 
Ability to self care not affected. 
Likely 
MH 
Some residual symptoms evident. 
Assessment 
Compliance and insight may fluctuate. 
History of acute and transient psychotic disorders with full recovery 
History 
following episodes. 
Significant 
Discharged from follow up by mental health services. 
Disability 
Unlikely 
MH 
Mental state examination normal. 
Assessment 
The prognosis of schizoaffective disorders is better than 
schizophrenia and worse than affective disorders. 
Acute and transient psychotic disorders have a better prognosis 
Prognosis 
 
than schizophrenia and schizoaffective disorders. 
Persistent delusional disorders are chronic, probably lifelong 
conditions. 
  First episode of psychosis: do not review in less than 12 
months, further follow up dependent on clinical course. 
  Schizophrenia cases with no cognitive deficit following 
Suggested 
resolution of the psychosis: exemption should be reviewed 
review 
regularly, with exemption review advice of 12-18 months being 
 
periods for 
appropriate. 
IB-PCA 
  Schizophrenia cases with residual cognitive deficit, either 
stable or progressive with time: should be reviewed less 
frequently, review advice of 2 years or “in the longer term” is 
appropriate. 
 
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13.7  Bipolar Disorders 
 
Long duration of illness with a pattern of regular relapse. 
No episodes of full recovery. 
Hospital admission in the previous 12 months.  
Ongoing supervision by a psychiatrist. 
History of suicidal ideation or behaviour. 
 
History 
Poor compliance with treatment or follow up. 
Severe 
History of admission under the Mental Health Act.  
Disability 
History of unpredictable relapses.  
Likely 
Ongoing treatment with mood stabilising or anti-psychotic 
medication. Significantly impaired social functioning. 
Evidence of self neglect, disinhibited or unco-operative behaviour. 
MH 
Overt psychotic features. Labile or abnormal mood.  
Assessment 
Lack of insight.  
Co-morbid substance misuse or alcohol related disorder. 
Difficulty sustaining attempted returns to work.  
History 
Significant 
Sub-optimal response to treatment.  
Continuing treatment with psychotropic medication. 
Disability 
Likely 
Appearance, behaviour and mood likely to show some abnormal 
MH 
features. Thought, speech, insight and perceptions may be normal. 
Assessment 
Intellect and cognition unlikely to be affected. 
In younger age group: short history, full recovery between episodes 
and few or no recurrences. 
History indicates that mental health has been normal for a 
sustained period of several years. 
History 
Significant 
Not being prescribed mood stabilising or psychotropic medication. 
Disability 
No ongoing contact with, or supervision from, mental health 
Unlikely 
services. 
No co-morbid conditions. 
MH 
All aspects of mental state normal. 
Assessment 
Length of history is predictive of prognosis: 
Prognosis 
 
  Recurrent episodes of mood disturbance are common 
  Long duration of illness is associated with poor prognosis. 

Suggested 
 
If mental state examination is normal in all respects, a short 
finite period may be advised, provided other aspects of the 
review 
 
assessment such as history support this. 
periods for 
  Once a bipolar illness has become established, a review period 
IB-PCA 
of 2 years or “in the longer term” will usually be appropriate. 
 
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13.8  Obsessive Compulsive Disorder 
 
Claimant spends so much time performing rituals, such as cleaning 
or checking that their social functioning is severely restricted.  
 
History 
Obsessive ruminations may occupy the claimant to such an extent 
Severe 
that their awareness may be affected.  
Disability 
Past history of neurosurgery for OCD. 
Likely 
MH 
Compulsive slowness. 
Assessment 
Co-morbid depression. 
History 
Significant 
Social interaction reduced. 
Disability 
Likely 
MH 
Abnormal mood. 
Assessment 
Rapport difficult to establish. 
Obsessive personality trait. 
Claimant living independently. 
Significant 
History 
Claimant enjoys contact with family and friends. 
No loss of interests or hobbies.  
Disability 
Can travel unfamiliar routes unaccompanied on public transport. 
Unlikely 
MH 
Mental state examination normal. 
Assessment 
  Treatment resistant cases with functional limitations are likely 
to have the condition long term. 
Prognosis 
 
  Late age of onset, initial severe depression, pre treatment 
anxiety and the obsession having the characteristics of an 
overvalued idea are predictive of treatment failure. 
Suggested 
  A review period of 6 to 12 months is usually indicated following 
review 
the initiation of treatment.  
 
periods for 
  In treatment resistant cases, a review period of 2 years or “in 
IB-PCA 
the longer term” will usually be appropriate. 
 
 
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13.9  Adjustment Disorders and Post Traumatic Stress Disorder 
 
The presence of co morbid conditions, such as major depressive 
 
disorders, alcohol related disorders, substance misuse disorders, 
Severe 
History 
generalised anxiety disorder and phobias may be associated with 
Disability 
 
severe disability. 
Likely 
In IB-PCA, the presence of PTSD alone rarely fulfils the criteria for 
exemption. 
Persistent PTSD symptoms 6 years after the stressor 
History 
Associated major depressive illness, alcohol or substance misuse, 
Significant 
generalised anxiety disorders. 
Disability 
Likely 
Irritability, hypervigilant behaviour, poor concentration and 
MH 
exaggerated startle response. 
Assessment 
Avoidant behaviour. 
Acute stress reactions. 
Claimant living independently. 
Significant 
History 
Claimant enjoys contact with family and friends. 
No loss of interests or hobbies.  
Disability 
Can travel unfamiliar routes unaccompanied on public transport. 
Unlikely 
MH 
Mental state examination normal. 
Assessment 
Length of history is predictive of prognosis: PTSD has a slow 
Prognosis 
 
natural recovery time over a period of about six years, after which 
the condition is likely to remain chronic in about 40% of cases. 
Suggested 
  The slow recovery times indicate that two-year review periods, 
review 
up to a 6-year maximum, are usually appropriate.  
 
periods for 
  After a 6-year interval, those chronically disabled are likely to 
IB-PCA 
remain so.  
 
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13.10  Learning Disability 
 
History 
Co-morbid physical disability, epilepsy or mental illness. 
 
Incapable of living independently.  
Severe 
The need for help with some or all bodily functions. 
Disability 
MH 
A failure to be aware of dangers, thus requiring supervision.  
Likely 
Assessment 
Severe behaviour problems requiring supervision, e.g. self-harm or 
violence. 
In receipt of an educational “Statement of Need.” 
History 
Attendance at a special school. 
Significant 
Living alone, but in supported accommodation. 
Disability 
Likely 
The claimant requires prompting to get up and get dressed in the 
MH 
morning. 
Assessment 
The claimant is unable to initiate and complete household tasks. 
Dyslexia. 
History 
Treated Attention Deficit Hyperactivity Disorder. (ADHD) 
Claimants attending an examination centre assessment on their 
Significant 
own. 
Disability 
Use public transport to travel independently on an unfamiliar route. 
Unlikely 
MH 
Claimants who are living independently in their own home. 
Assessment 
Claimants who can manage their own finances and do their own 
shopping. 
Claimants who are able to plan and prepare a proper meal for 
themselves. 
Learning disability runs a chronic life-long course. Once an 
Prognosis 
 
assessment has been made, it is unlikely that there will be 
significant change in the condition. 
Suggested 
review 
 
A review date “in the longer term” is likely to be appropriate. 
periods for 
IB-PCA 
 
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13.11  Eating Disorders 
 
History 
Hospital inpatient treatment. 
 
Severe 
MH 
Severe co-morbid psychiatric illness. 
Disability 
Assessment 
Likely 
Physical signs   Severe weakness, requiring personal care from another person. 
Frequent episodes of self-induced vomiting or purging. 
Abuse of laxatives or diuretics.  
Amphetamine abuse. 
Excessive exercise. 
History 
Amenorrhoea. 
Co-morbid physical complications. 
Co-morbidity with drug or alcohol abuse or another psychiatric 
illness. 
Significant 
Attending psychiatric day hospital. 
Disability 
Likely 
MH 
Social isolation: little contact with family or friends. 
Assessment 
Severe weight loss: BMI < 17. 
Morbid obesity: BMI > 40. 
Underweight despite treatment. 
Physical signs   Lanugo hair. 
Physical weakness. 
Poor dental hygiene with pitting and acid erosion. 
Significant 
Function is usually well preserved in claimants with eating 
Disability 
 
disorders. 
Unlikely 
  For anorexia nervosa, about 65% have a good outcome and 
maintain a normal weight, whilst 15% have a poor outcome 
with a persistently very low BMI.  
  In bulimia, the prognosis is poor in those individuals with a low 
Prognosis 
 
BMI, and with a high frequency of purging 
  In severe obesity (BMI >40), increased morbidity arises from 
conditions such as arthritis, diabetes and coronary heart 
disease. 
Suggested 
  Claimants starting treatment should be reviewed in 12 months.  
review 
 
  Claimants who have suffered intractable problems for years 
periods for 
should be reviewed after no less than 18 months. 
IB-PCA 
 
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13.12  Personality Disorders 
 
Self-harm in the last 6 months. 
Psychiatric hospital admission in the last 6 months. 
Co-morbidity with drug or alcohol abuse or another psychiatric 
 
History 
illness. 
Severe 
Living in supported accommodation. 
Disability 
Bizarre behaviour towards other people. 
Likely 
Chaotic, unstructured lifestyle. 
MH 
Unkempt. 
Assessment 
Living in social isolation. 
Co-morbidity with drug or alcohol abuse or another psychiatric 
illness. 
Receiving psychotropic medication. 
Receiving psychotherapy. 
Attending psychiatric outpatient clinic. 
Significant 
History 
Attending psychiatric day hospital. 
Under the supervision of a CPN. 
Disability 
Repeated episodes of self-harm. 
Likely 
Repeated episodes of violent behaviour. 
Left previous employment due to excessive anxiety and inability to 
cope. 
MH 
Unable to complete tasks in a timely manner. 
Assessment 
Claimant avoids social contact. 
Not receiving psychiatric care or supervision. 
History 
Not receiving psychotropic treatment. 
Significant 
Able to enjoy interests and hobbies. 
Disability 
Enjoys social contact with friends and family. 
Unlikely 
MH 
The claimant is able to do their own shopping, cooking and 
Assessment 
cleaning. 
Able to manage their own finances. 
  Acute problems or crises may resolve with time or treatment. 
Prognosis 
 
  Personality disorders are lifelong conditions, but the disabling 
effects may abate with the passage of time. 

Suggested 
  Acute problems or crises should usually be reviewed after 6 
months. 
review 
 
  For personality disorders, a review between 18 months and “in 
periods for 
the longer term” may be appropriate, depending on the severity 
IB-PCA 
of the associated disability. 
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13.13   Organic Brain Disorders 
 
 
Any dementing condition. 
History 
Amnesic syndrome or Korsakov’s syndrome. 
Severe 
Disability 
MH 
Significant cognitive impairment. 
Likely 
Assessment 
Physical aggression. 
Psychogenic fugue (loss of personal identity). 
Mild cognitive impairment. 
History 
Head injury resulting in unconsciousness for more than 20 minutes 
and post traumatic amnesia for more than 1 hour. 
Attention deficit / reduced concentration. 
Learning and memory problems.  
Significant 
Impaired planning and problem solving.  
Disability 
Lack of initiative, and inflexibility.  
Likely 
Dissociation between thought and action. 
MH 
Impulsivity, irritability and temper outbursts. 
Assessment 
Communication problems. 
Socially inappropriate behaviour and disinhibition. 
Personality change with self-centred behaviour and egocentricity. 
Changes in affect (flat affect, inappropriate emotions and mood).  
Lack of insight. 
Head injury resulting in unconsciousness for less than 20 minutes 
and post traumatic amnesia for less than 1 hour. 
Significant 
History 
Transient global amnesia. 
Disability 
Independent existence and near normal or normal functioning. 
Unlikely 
MH 
All features of mental state examination normal. 
Assessment 
Prognosis 
 
Long history and significant disability indicate a poor prognosis. 

Suggested 
 
Conditions where exemption has been advised are unlikely to 
undergo significant change.  
review 
 
  Where there is significant disability and the condition has been 
periods for 
present for more than 1-2 years, significant change is also 
IB-PCA 
unlikely. 
  
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14.  References 
1.  Incapacity Benefit Handbook for Approved Doctors (April 2000 Print). 
2. Mental Health Disability – A Generic Approach to Assessment 
(MED/S2/CMEP~0013 and MED/S2/CMEP~0015). 
3.  Exemption Advice at the Examination Stage  (MED/S2/CMEP~0030). 
4. The Assessment of Claimants with Drug or Alcohol Problems 
(MED/S2/CMEP~0036). 
5.  The Conduct and Reporting of the Mental Health Assessment in IB-PCA 
(MED/S2/PS~0010). 
6.  Gelder M, Mayou R et al. Shorter Oxford Textbook of Psychiatry. Oxford 
University Press, 2001. 
7.  Puri BK, Laking PJ et al. Textbook of Psychiatry. Edinburgh: Churchill 
Livingstone, 2001. 
8.  Jacobson J L and Jacobson A M. Psychiatric Secrets. Hanley and Belfus, 2001. 
9.  Smith C, Sell L et al. Key Topics in Psychiatry. Bios Scientific Publishers Ltd, 
1996. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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