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 
 
Neurological and Infections Key Points 
and Analytical Guidance 
 
 
 
MED-EBMNIKPETAG~001 
 
Version: 4 Final 
20 August 2011


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 
Sept 2011 
 
 
 
Neurological and Infections Key Points Analytical Guidance 
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Document control 
Superseded documents  
 
Version history 
Version Date 
Comments 
4 Final 
13 September 2011 
Signed off by HWWD and CMMS 
4b draft   
20 August 2011 
Amended after comments by HWWD 
4a draft 
27 June 2011 
Updated by CT following schedule 28 review 

Final 
22 
December 
2009 
Signed off by Medical Services Contract 
Management Team  
3a draft   
01 December 2009 
Updated to incorporate Epilepsy  

Final 

January 
2009 
Signed off by Medical Services Contract 
Management Team 
2a draft 
18 November 2008 
Updated following schedule 28 review  
Changes since last version 
 Section 1.4 
CFS and Medically Unexplained Symptoms 
Outstanding issues and omissions 
Updates to Standards incorporated 
Issue control 
Author
Medical Training & Development 
 
Owner and approver: 
 
Signature: Date: 
 
Distribution: 
 
 
Neurological and Infections Key Points Analytical Guidance 
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Contents 
Part A - Key Points 
6 
Introduction 

1. 
Multiple Sc
 
lerosis
7 
1.1 
Description 

1.2 
Diagnosis 

1.3 
Management 

1.4 
Prognosis 

1.5 
Disabling E
 
ffects

2. 
Parkinson’s Disease 10 
2.1 
Description 10 
2.2 
Aetiology 10 
2.3 
Diagnosis 10 
2.4 
 10
Treatment
 
2.5 
Prognosis 11 
2.6 
Main Disabling Effects 11 
3. 
 12
Epilepsy
 
3.1 
Description 12 
3.2 
Diagnosis 12 
3.3 
Management 12 
3.4 
Prognosis 13 
3.5 
Disabling E
 13
ffects
 
4. 
 15
HIV and Aids
 
4.1 
Description 15 
4.2 
Epidemiology 15 
4.3 
Diagnosis 16 
4.4 
Management 16 
4.5 
Prognosis 17 
4.6 
Main Disabling Effects 18 
5. 
Chronic Fatigue Sy
 20
ndrome / M.E.
 
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5.1 
Description 20 
5.2 
Aetiology 20 
5.3 
Diagnosis 20 
5.4 
 20
Treatment
 
5.5 
Prognosis 21 
5.6 
Main Disabling Effects 21 
6. 
Medically Unexplained Sy
 22
mptoms
 
6.1 
Description 22 
6.2 
Aetiology 22 
6.3 
Diagnosis 22 
6.4 
 23
Treatment
 
6.5 
Prognosis 23 
6.6 
Main Disabling Effects 23 
7. 
Part C - Analytical Guidance 24 
7.1 
Multiple Sclerosis 24 
7.1.1  Overall analysis 25 
7.2 
Parkinson’s Disease 26 
7.2.1  Overall Consideration 27 
7.3 
Epilepsy 28 
7.4 
HIV and Aids 30 
7.5 
Chronic Fatigue Syndrome 31 
7.6 
Medically Unexplained Symptom  32
s
 
Observation form 33 
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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 neurological and infection 
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 a 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.  Multiple Sclerosis 
1.1  Description 
  Multiple sclerosis is a chronic inflammatory disease of the central nervous 
system. 
  Diagnosis requires evidence of lesions that are separated in time and 
space. 
  The cause is unknown but an immunological abnormality is suspected. 
  It has been linked to the geographical area where the individual spent their 
first 15 years. 
  In Europe and North America MS is the most common cause of 
neurological disability in young adults.  
1.2  Diagnosis 
  The disease is characterised by various symptoms and signs of CNS 
dysfunction. 
  The most common presenting symptoms are:- 
  Parasthesiae in one or more extremities, in the trunk, or on one side of 
the face.  
  weakness or clumsiness of a leg or hand 
  Visual disturbances, e.g., partial blindness and pain in one eye 
(retrobulbar optic neuritis), dimness of vision, or scotomas.  
  Mental symptoms include:- 
  Apathy, lack of judgment, or inattention may occur.  
  Emotional lability is common and may suggest an incorrect initial 
impression of hysteria. Euphoria occurs in some patients.  
  Reactive depression, in others.  
  Magnetic resonance imaging (MRI) is the most sensitive diagnostic 
imaging technique. 
  MS lesions may also be visible on contrast-enhanced CT scans. 
  CSF is abnormal in the majority of patients. 
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1.3  Management 
  Spontaneous remissions and fluctuating symptoms make treatments 
difficult to evaluate. 
  Corticosteroids are the main form of therapy 
  Immunomodulatory therapy with interferon-  reduces the frequency of 
relapses in relapsing remitting MS. 
  Intravenous gamma globulins given monthly may help control relapsing 
MS refractory to conventional therapies.  
  In debilitated patients prevention of bed sores and urinary tract infections 
is essential. The need for self catheterisation has to be carefully 
evaluated. 
  The treatment of mental health problems and depression are strongly 
indicated in the clinical management of multiple sclerosis. 
  The evidence base for the effectiveness of multidisciplinary rehabilitation in 
patients with multiple sclerosis (MS) is not yet established. 
1.4  Prognosis 
  Studies indicate that the rate of progress through disability milestones is 
time related. 
  Neurological relapses in multiple sclerosis (MS) are the clinical counterpart 
of acute focal inflammation of the central nervous system (CNS)  
  Neurological progression is that of chronic diffuse neurodegeneration. 
  After a relapse or exacerbation there may be return to the pre-relapse level 
of problem but there will not be an improvement from that baseline and 
some functional reduction is much more likely. 
1.5  Disabling Effects 
  Weakness of one or more limbs, spasticity, muscle fatigue, unsteadiness 
of gait and difficulties with speech. 
  Difficulty in bladder control is common. 
  As the disease progresses mobility problems become apparent. 
  Visual problems may also increase mobility problems. 
  With further progression these manifestations will give rise to difficulty with 
self care. 
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  It is now considered that if symptoms resulting from a relapse do not remit 
within 6 months they are likely to be permanent. 
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2.  Parkinson’s Disease 
2.1  Description 
Parkinson’s disease is characterised by impairment of movement, muscle rigidity, 
and tremor. 
Idiopathic Parkinson’s disease (PD) is a progressive neurodegenerative condition. 
Parkinson's disease affects about 1% of people ≥ 60 years and 0.4% of those > 40 
years. 
2.2  Aetiology 
The aetiology of Parkinson's disease is unknown, however, a number of factors 
have been implicated. 
 Environmental 
insult 
 Genetic 
factors 
 Ageing 
2.3  Diagnosis 
The diagnosis is primarily clinical based on history and examination. 
The three key features are tremor, rigidity and bradykinesia. 
The tremor is slow and coarse and maximal at rest (pill rolling). 
Rigidity is the raised resistance noted during passive joint movement. 
As rigidity progresses, movement becomes slow (bradykinesia), decreased 
(hypokinesia), and difficult to initiate (akinesia). 
2.4  Treatment 
Treatment should be started when symptoms start to cause disability. 
Definitive treatment of early PD is with levodopa or a dopamine agonist. 
In the elderly, L-dopa is the first line choice as it is better tolerated. 
 
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As a result of autonomic dysfunction, anti-parkinsonian drugs’ patients can have 
problems with constipation, urinary symptoms and postural hypotension. 
Maximizing activity is a goal.  
Patients should perform daily activities to the extent possible. 
Physiotherapy should be available for people with PD. 
Occupational therapy should be available. 
Speech and language therapy should be available. 
Currently three surgical options are available for PD. 
2.5  Prognosis 
Parkinson's disease is a progressive disorder which starts with mild unilateral 
involvement and progresses to complete dependency. 
2.6  Main Disabling Effects 
Patients have difficulty starting to walk, turning, and stopping. 
There is a tendency to fall forward (propulsion) or backward (retropulsion) known as 
postural instability. 
Dementia and depression are common. 
Some patients have difficulty swallowing and are at risk of aspiration. 
 
 
 
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3.  Epilepsy 
3.1 
Description 
  Epilepsy is a group of disorders rather than a single disease.  
  Seizures can be classified as partial or generalised.  
  A person is considered to have epilepsy if they have had two or more 
unprovoked seizures. 
  Epilepsy is common, with an estimated prevalence in the developed world 
of 500-1000/100 000 population. 
  The causes/risk factors include birth/neonatal injuries, congenital or 
metabolic disorders, head injuries, tumours, infections of the brain or 
meninges, genetic defects, degenerative disease of the brain, 
cerebrovascular disease, or demyelinating disease.  
3.2  Diagnosis 
  A clear history from the individual and an eyewitness to the attack give the 
most important diagnostic information, and should be the mainstay of 
diagnosis. 
 Investigations 
EEG  - NICE guidelines for diagnosis and management of the epilepsies 
in adults and children recommend that an EEG should be performed to 
support a diagnosis of epilepsy in adults in whom the clinical history 
suggests the seizure is likely to be epileptic in origin. In children, EEG is 
recommended after the second or subsequent seizure. 
Magnetic Resonance Imaging (MRI) scanning is the current standard of 
reference in the investigation of patients with epilepsy. 
Computed Tomography (CT) scanning has a role in the urgent 
assessment of seizures, or when MRI is contraindicated (e.g.  in patients 
who have pacemakers or metallic implants). 
3.3  Management 
  Antiepileptic drug (AED) therapy is long term, usually for at least three 
years and, depending on circumstances, sometimes for life. 
  Treatment is usually started with a single drug at a small dose. 
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  Full adherence to the drug regimen is essential for the treatment to be 
successful. 
  The goal of AED therapy should be maintenance of a normal lifestyle by 
complete seizure control without drug-related side effects.  
  Drugs are usually chosen according to seizure type 
3.4  Prognosis 
 Outcome for the newly diagnosed patient on carefully monitored 
monotherapy is good, with 70 - 80% entering prolonged remission.  
  Factors that contribute to poor prognosis are the presence of structural 
lesions and associated neuropsychiatric handicaps.  
  Important factors influencing a decision about AED withdrawal in adults 
include:-  
                     Driving 
Employment 
Fear of further seizures 
Risks of injury or death with further seizures 
Concerns about prolonged AED  
3.5  Disabling Effects 
  Mild                                                                                                              
A person with mild epilepsy would normally have a fit frequency of less 
than monthly. He/she may have brief absence seizures or infrequent 
generalised seizures with useful warning and no dangerous post-fit 
behaviour.                                                     
     He/she would normally be able to carry out all self-care activities for most 
of the time.                                                                                                       
The risk of falling would normally be very small.  
A person with mild epilepsy, is physically fit, and would normally be                                            
capable of walking an unlimited distance.                                                                      
He/she would normally be safe outdoors and could find their way                                
around. They may be permitted to hold a driving licence. 
  Moderate                                                                                                      
A person with moderate epilepsy would have a fit frequency of around one 
to two a month.                                                                                    
He/she would normally have useful warning of a seizure, but may have 
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post seizure manifestations such as confusion and drowsiness.                                                   
For the majority of the time a person with moderate epilepsy would be 
able to safely self care.                                                                     
Normally the person would have adequate warning of a fit, and be able to 
remove themselves from danger.                                                                
A person with moderate epilepsy, is physically fit, and would normally be 
capable of walking an unlimited distance.                                           
He/she would normally be safe outdoors and could find their way around.                                   
They are unlikely to be permitted a driving licence.              
  Severe                                                                                                          
A person with a severe degree of epilepsy would normally have frequent 
grand mal attacks, (at least more than twice a month), without warning 
which are manifest with severe convulsions, in which injury may often be 
sustained and which might require hospital care.                                                                           
Because of the absence of useful warning, he /she would normally                                             
require the presence of another person for the majority of the time, to                          
safely carry out activities of daily living (for example when bathing).                             
The person would not normally be able to safely prepare and cook a                           
meal without supervision.                                                                                               
A person with epilepsy, which is not complicated by any other disabling                      
condition, is physically fit, and would normally be capable of walking an                      
unlimited distance.                                                                                                          
They would not be permitted to hold a driving licence. 
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4.  HIV and Aids 
4.1  Description 
  HIV  infection  refers  to  infection  with  the  human  immunodeficiency  virus                                 
(HIV) type 1 or type 2.  Initial infection may produce non-specific febrile           
illness.  
  Asymptomatic carriage of human immunodeficiency virus may continue for           
8 to 10 years. 
  Current treatments interrupt the life cycle of the virus but without affecting             
a cure. 
4.2  Epidemiology 
  Worldwide  estimates  suggest  that  by  December  2005  about  38.6  million          
people  were  living  with  HIV.    In  2005,  there  were  estimated  to  be  4.1               
million new cases of HIV infection and 3.3 million deaths from AIDS. 
  The major risk factor for transmission of HIV is unprotected heterosexual             
or homosexual intercourse. 
  Primary or acute HIV infection is a condition that occurs 2-4 weeks after      
infection with the human immunodeficiency virus (HIV).  
  After an infection with HIV, antibodies to the virus can be detected in the         
blood.  This (seroconversion) usually takes 3 months but can take 1 year. 
  Asymptomatic HIV infection is a phase during chronic infection with HIV      
during which there are no overt symptoms of HIV infection. 
  In some individuals the asymptomatic phase can last 10 years or more. 
  Acquired Immune Deficiency Syndrome death rate has shown a 
marked drop between 1995 and 1998 and a slower but continuing 
decrease  since. 
  About 25 million people worldwide have died from this infection since the         
start of the epidemic, and 40.3 million people are currently living with               
HIV/AIDS globally. 
 
 
 
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4.3  Diagnosis 
  The standard test is an HIV antibody test which becomes positive about 6- 
12 weeks after infection. 
  The HIV viral load is measured since this has prognostic importance. 
  Increasingly tests for HIV drug resistance are carried out before therapy is      
initiated. 
  Test are also indicated to exclude other important infections such as                
Hepatitis B and C, Sexually transmitted diseases (STDs) and 
Tuberculosis. 
  AIDS may present with symptoms of opportunistic infections that do not          
normally develop in individuals with healthy immune systems. 
 
As HIV infection progresses towards AIDS common symptoms may include  
 fevers, 
 
  increasing sweats (particularly at night),  
  swollen glands and splenomegaly 
   oral symptoms such as thrush or ulcers 
 weakness, 
 
 weight 
loss 
 
  Those with HIV infection require regular monitoring of CD4 count, HIV 
RNA  load (viral load), as well as basic screening lab tests.   
  Different AIDS illnesses tend to emerge at different degrees of CD4 cell          
destruction resulting in increasing compromise of the immune system. 
4.4 
Management 
  Intervention aims to reduce transmission of HIV, to prevent or delay the                           
onset of AIDS, (as manifested by opportunistic infections and cancers),           
increase survival and minimise loss of quality of life, with minimal adverse       
effects. 
  Without treatment, about 50% of infected people will die of AIDS over 10         
years. 
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  With treatment, prognosis depends on age, CD4 cell count and initial viral       
load.  
  Antiretroviral therapy is recommended for all patients with a history of HIV       
infection and an opportunistic illness which meets the definition of AIDS, 
or  severe symptoms of HIV regardless of CD4+T cell count. 
  There are currently four classes of antiretroviral drugs in use but several         
new classes are in advanced development, whilst a second generation of        
established classes is emerging. 
  For routine use 3 drugs (in abbreviation :HAART) are used in combination. 
  A number of factors may influence the safety and efficacy of antiretroviral        
therapy 
  Non adherence to therapy 
  Adverse drug reactions 
 Drug/drug 
interactions 
  Development of drug resistance. 
4.5  Prognosis 
  At the present time, there is no cure for AIDS. 
  Without treatment, about 50% of people infected with HIV will become ill         
and die from AIDS over about 10 years. 
  HAART has dramatically increased the time from diagnosis to death. 
  Other independent predictors of poorer outcome were advanced age and        
infection through injection drug use. 
Other poorer prognostic factors include 
 Liver 
disease 
 Cardiovascular 
disease 
 Diabetes 
  The development of non-AIDS related cancers especially lung or 
pancreatic. 
 
 
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4.6       Main Disabling Effects 
  HIV infected individuals under care can typically be expected to remain           
generally well for a long number of years after infection. 
  Those who have developed one or indeed several severe AIDS illnesses 
may be left with general or neurological damage, including cognitive 
impairment. This group is likely to require special support. 
 
Care needs may arise from features such as: 
 Dementia 
  Neurological damage including neuropathy 
 Endocrine 
upset 
  General debility  
  Night sweats (severe) 
  Altered bowel habit (severe diarrhoea) 
 Muscle 
weakness 
 Poor 
balance 
  Psychological sequelae such as depression, anxiety, substance 
abuse and alcoholism 
 
The need for attention and supervision will increase and may become substantial if 
severe manifestations ensue such as: 
  Infection with opportunistic infections such as cytomegalovirus or 
toxoplasmosis   
 Malignant 
disease 
 
In advanced HIV or AIDS the ability to walk can be severely affected by a number of 
factors:  
  Dyspnoea due to respiratory infection (PJP or TB) - though this has 
the potential to improve with appropriate treatment.  
  Peripheral neuropathy or muscle weakness 
   Severe debility 
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   Visual impairment can arise as a result of especially cytomegaloviral               
infection or brain involvement.  
 
If significant, then this can affect the ability to get around independently. 
 
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5.  Chronic Fatigue Syndrome / M.E. 
5.1  Description           
   A long standing disabling fatigue without demonstrable muscle weakness. 
  Substantial reduction of previous levels of occupational, educational, 
social, or personal activities  
   Little evidence that inflammation of the brain and spinal cord occurs. 
5.2  Aetiology   
  the composite term CFS/ME best describes this condition and that it is a 
spectrum of disease 
  Infective agents have been implicated but no clear link with serology 
indicating past viral infection. 
  Environmental factors, abnormal physiological pathways and genetic pre-
disposition are all likely to contribute 
  stressful life events or difficulties may precede development of CFS/ME 
5.3  Diagnosis 
  a diagnosis of “exclusion” 
  Fatigue with specific features and one or more of a defined list of 
symptoms. 
5.4  Treatment 
  There is no specific treatment for CFS. 
  Most people do recover to some extent, if not completely, or adjust their 
lifestyle to improve their symptoms 
  In CFS/ME management may be a more appropriate term than treatment. 
  Cognitive Behavioural Therapy (CBT) and Graded ExerciseTherapy (GET) 
are the currently advocated preferred treatment modalities. 
  If chronic pain is a predominant feature, referral to a pain management 
clinic is appropriate. 
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5.5  Prognosis 
The prognosis is highly variable in this unpredictable condition. 
  People with mild illness may recover spontaneously, or with some general 
advice or a limited treatment programme over a six month period. 
  People with established CFS/ME of moderate severity are likely to need a 
more extensive management programme. 
  Some people will recover fully, but others will not achieve their previous 
level of functioning. Some may not improve. 
  Recovery rates for CFS/ME are unclear as studies have tended to be on 
those attending specialist units and thus being in the moderate or severe 
categories. 
  A median of 40% (in some studies 65%) who do not report full recovery do 
show improvement. 
  Some indicators of a good prognosis and some of a poorer outcome have 
been identified. 
5.6 
Main Disabling Effects 
The disabling effects of CFS/ME in individuals are variable. 
  In mild cases the person is likely to be able to walk short distances on an 
unrestricted basis most of the time. 
  Cognition such as judgment, thought processes and communication are 
not affected. 
  With moderate CFS/ME mobility is likely to be restricted with difficulty 
walking more than 100 metres consistently but severe restriction of 
walking is unlikely.  Judgment, thought processes and means of 
communicating are not affected to the extent that they would be unable to 
find their way around in familiar and unfamiliar places. 
  The ability to maintain personal hygiene and nutrition is likely to be 
unimpaired. 
  75% of those with CFS/ME are in the mild or moderate category.   
  Those with severe functional restrictions may exhibit problems with 
mobility, cognition, particularly tasks requiring concentration and self care, 
and they may only manage minimal tasks such as face washing or 
cleaning teeth. 
  They may be severely restricted in their ability to walk.  
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6.  Medically Unexplained Symptoms 
6.1  Description 
  The common factor among all the syndromes is the lack of a satisfactory 
medical explanation.  Common symptoms include, for example, 
headache,  muscle and joint pain, low back pain, non-cardiac chest pain, 
and bowel discomfort. 
  Somatoform disorders is recognised in both DSM IV where the bodily 
symptoms or concerns also have to result in clinically significant distress 
or impairment in functioning, and in the WHO ICD 10 which has a similar 
description but is more detailed in its exclusions. 
   Somatoform syndromes are quite prevalent in all countries.  According to 
a cross-cultural study by the WHO, nearly 20% of primary care patients 
are affected by multiple somatoform symptoms. 
6.2  Aetiology 
  Evidence supports an interaction of physiological, psychological and 
interpersonal factors.  
   Although the lack of organic pathology is the central feature of the 
'medically unexplained syndromes', current models of somatization 
consider benign psycho-physiological processes to be relevant 
6.3  Diagnosis 
There are specific diagnostic criteria. 
A history of many physical complaints beginning before age 30 years. 
Each of the following criteria must have been met 
  four pain symptoms 
 two 
gastrointestinal 
symptoms 
  one sexual symptom 
  one pseudo-neurological symptom 
 
                     AND Either (1) or (2): 
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1.  after appropriate investigation, each of the symptoms cannot be fully explained by a 
known general medical condition or the direct effects of a substance (e.g., a drug of 
abuse, a medication) 
2.  when there is a related general medical condition, the physical complaints or resulting 
social or occupational impairment are in excess of what would be expected from the 
history, physical examination, or laboratory findings. 
 
Definitions and descriptions of various sub-types of somatoform disorder are detailed 
in Section 3 – Diagnosis in the full protocol.   
(Not all are recognised by ICD – 10) 
6.4  Treatment 
Treatment can be difficult as many do not accept that they have a mental component. 
Many people who have somatoform disease also have other mental health problems 
such as anxiety, depression or substance abuse.  Treatment of the coexisting condition 
may improve their somatoform disorder. 
CBT is the best established treatment for a variety of somatoform disorders. 
6.5  Prognosis 
  Short symptom duration and changed marital status are associated with a 
better prognosis. 
  Pending litigation appears to indicate poor prognosis as does an 
unidentified or untreated psychiatric disorder. 
6.6  Main Disabling Effects 
  In a study patients with somatization had substantially greater functional 
disability and role impairment than non-somatizing patients. The degree of 
disability was equal to or greater than that associated with many major, 
chronic medical disorders. 
  Patients who have anxiety or depressive disorders are particularly limited 
in social functioning, role functioning because of emotional problems and 
subjective health. 
  In patients with comorbidity the impairments are summated. 
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7.  Part C - Analytical Guidance 
The tables in this section are for guidance only, they are not prescriptive and each claimant 
has to be considered on an individual basis.   
7.1  Multiple Sclerosis 
 Significant 
Significant 
Severe disability 
disability unlikely 
disability likely 
likely 
History & 
Fully continent or 
Occasional bowel 
Regularly 
Symptoms 
can manage 
or bladder 
incontinent and 
incontinence 
incontinence 
requiring help 
independently 
requiring help 
Feeds 
Some help needed  Unable to feed self 
independently (with  (e.g. cutting food) 
at all Unable to eat 
aids if needed) 
Feeds in 
or swallow 
reasonable time 
Sits and rises 
Sits without 
Cannot rise without 
independently 
support.  Needs 
support of another 
use of aid to rise 
person 
Restricted to bed 
or chair 
Walks 
Use of aids for 
Cannot walk at all 
independently 
reasonable 
(reasonable 
distance in 
Wheelchair use 
distance and time) 
reasonable time 
Dresses 
Help in some areas  Cannot dress 
independently 
or uses aids 
independently 
Can toilet 
Requires help in 
Cannot toilet  
independently (with  some areas 
independently 
or without aids) 
No problem on 
Requires 
Cannot use stairs 
stairs or uses 
supervision from 
even with 
handrail 
another person 
supervision or 
Support 
 
 
Typical day 
Independent day to  Some restrictions 
Requires help with 
day living and full 
on ADLs and 
most ADLs and 
social interaction 
reduced social 
severe restriction 
interaction 
of social interaction 
 
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 Significant 
Significant 
Severe disability 
disability unlikely 
disability likely 
likely 
Observations 
Informal 
Some restriction in 
Static or intention 
movements within 
upper or lower limb  tremor 
normal limits 
function and gait 
Stiff imbalanced 
gait 
Hemiplegia 
No speech problem Can communicate 
Unable to 
communicate 
Normal mental 
Mild to moderate 
Significant features 
health features 
depression 
of depression 
features 
and/or anxiety 
Clinical findings 
Paraesthesia of 
Muscular 
Major neurological 
one extremity or 
weakness and 
deficits 
one side of the 
spasticity 
face 
Bilateral signs 
 
Increased deep 
Increased 
reflexes 
Vertigo 
fatiguability 
Normal vision 
Partial blindness or  Diplopia 
dimness of vision 
 
7.1.1  Overall analysis 
In relapsing remitting MS spontaneous remission is common in the early stages of 
the disease and indeed may be lifelong.  
However, if symptoms resulting from relapse do not remit within 6 months they are 
likely to be permanent. 
If features suggest there is a mental health component it is essential to carry out the 
standard Mental Health Assessment. 
 
 
 
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7.2  Parkinson’s Disease 
 
 Significant 
Significant 
Severe disability 
disability unlikely 
disability likely 
likely 
History & 
Feeds 
Some help needed  Feeding (and 
Symptoms 
independently (with  (e.g. cutting food) 
writing) impossible 
aids if needed) 
Feeds in 
reasonable time 
 
Sits and rises 
Sits without 
Cannot rise without 
independently 
support.  Needs 
support of another 
use of aid to rise 
person 
Steps out well 
Stride moderately 
Shuffling gait. 
shortened 
Difficulty turning 
Normal stride 
Difficulty initiating 
Tendency to fall 
Turns safely 
walking 
forwards or 
backwards 
Help in some areas 
or uses aids 
Dresses 
Requires help in 
Cannot dress 
independently 
some areas 
independently 
Can toilet 
Requires 
Cannot toilet  
independently (with  supervision from 
independently 
or without aids) 
another person 
No problem on 
Requires to use 
Can only use stairs 
stairs  
handrail or has had  with supervision or 
aids installed 
support 
Typical day 
Independent day to  Some restrictions 
Requires help with 
day living and full 
on ADLs and 
most ADLs and 
social interaction 
reduced social 
severe restriction 
interaction 
of social interaction 
 
Observations 
Pill rolling tremor 
Severe tremor but 
Tremor constant 
not constant 
and severe 
2 cm of tremor 
Some hand control  Full loss of hand 
movement in limbs  retained 
control 
or head 
 
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 Significant 
Significant 
Severe disability 
disability unlikely 
disability likely 
likely 
 
No speech problem  Moderate 
Marked weakness 
or slight 
hoarseness 
hoarseness with 
Very difficult to 
good volume and 
Monotone 
understand 
easily understood 
Difficult to 
understand 
Normal expression  Marked immobility 
Frozen expression 
of expression 
Full animation 
Drooling present 
Mouth remains 
closed 
Normal mental 
Mild to moderate 
Significant features 
health features 
depression 
of depression 
features 
and/or anxiety 
Clinical findings 
No significant 
Detectable cog-
Sever rigidity 
clinical findings 
wheel rigidity 
particularly neck 
and shoulders  
 
Detectable slowing  Severe slowing of 
of pronation / 
pronation / 
supination rate 
supination rate 
 
7.2.1  Overall Consideration 
If features suggest there is a mental health component it is essential to carry out the 
standard Mental Health Assessment. 
 
 
 
 
 
 
 
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7.3  Epilepsy 
For a majority of people with epilepsy, seizures can be substantially reduced or 
completely controlled, enabling people to live normal or close to normal lives. For 
the remaining 20 percent, epilepsy is disabling, marked by frequent seizures, other 
impairments, memory and other cognitive effects, and a highly compromised 
standard of living. 
 Significant 
disability 
Significant disability likely Severe disability likely 
unlikely 
History &  Children and adults in 
Children and adults in 
Children and adults in 
Symptoms 
this category will 
this category will 
this category will 
 have gained control of 
  be more likely to 
 have epilepsy as a 
seizures fairly rapidly 
experience side 
result of brain disease 
effects from 
or injury 
 have no or very 
medication 
infrequent seizures 
  be poorly controlled 
  take higher doses to 
despite the use of 
 experience limited if 
maintain control 
multiple medications 
any side effects from 
and combinations of 
medication 
  experience a greater 
medications 
level of social, 
 be cognitively intact 
emotional, and 
  have impairment of 
educational/ 
learning, memory, 
 have no additional 
employment 
attention, and motor 
physical or mental 
problems 
and emotional function 
impairments. 
 experience 
some 
retardation or slowing 
Typical 
No difficulty with self 
likely to experience a 
require help in 
day 
care. 
greater level of social, 
everyday living 
emotional, and 
Manages routine tasks 
educational/ 
have difficulty in 
including washing, 
employment 
maintaining family 
dressing and cooking. 
problems 
support and social 
relationships 
May hold a driving 
Post seizure 
licence. 
confusion and 
report bouts of 
drowsiness. 
continuous seizure 
Usually aura or warning 
activity (flurries) and 
so injury unlikely. 
Unlikely to hold a 
status epilepticus 
driving licence. 
Observations 
Likely to be normal 
Likely to be normal 
May  appear  depressed 
and withdrawn. 
May exhibit confusion or 
aggression particular in 
post-ictal phase. 
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Clinical 
Likely to be normal 
Possibly mild depression  Depression likely 
findings 
Bruising or other injuries 
Other manifestations of  
brain injury or congenital 
problems 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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7.4  HIV and Aids 
 Significant 
disability 
Significant disability likely Severe disability likely 
unlikely 
History & 
Positive HIV test 
Disease duration >10yrs 
Disease duration >10yrs 
Symptoms 
Disease duration <8yrs 
CD4 count <200µL 
CD4 count <100µL 
CD4 count >200µL 
Therapy problems 
Kaposi’s Sarcoma 
No history of 
•  Non adherence to         Lymphoma 
therapy 
opportunistic infections 
•  Adverse drug                 Lung or pancreatic 
 
reactions 
carcinoma 
•  Drug/drug                      Repeated respiratory 
interactions 
infections (incl. T.B.) 
•  Development of             Uncontrollable diarrhoea 
drug resistance. 
Visual impairment 
Anaemia 
Severe opportunistic 
Diarrhoea 
infections 
Night sweats 
 
Hyperlipidaemia, liver 
 
disease or diabetes 
Typical day 
Independent day to day  Bowel urgency and 
Help with most activities 
living and full social frequency. 
of daily living 
interaction 
Help with medication 
Walking distance < 50m 
 
Walking distance < 800m  
Observations  
Unsteadiness 
Breathlessness 
Hairy leukoplakia 
Muscle wasting 
Facial lipodystrophy  
Clinical 
No significant clinical Muscle weakness 
General debility 
findings 
findings 
Peripheral neuropathy 
Reduced visual acuity 
Cognitive impairment, 
Peripheral neuropathy 
depression, anxiety 
Dementia 
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7.5  CFS / ME 
 
 Significant 
disability 
Significant disability likely Severe disability likely 
unlikely 
History &  Mild illness and recovery  History of 1 – 2 years.  
Long clinical course with 
Symptoms 
over six months.  
Specialist referral and 
severe and unremitting 
Specialist referral 
management programme  symptoms.  Little or no 
unlikely.  No history of 
but likely to have been 
response to a range of 
setbacks or replapses. 
able to attend hospital. 
interventions.  Continuing 
setbacks and relapses. 
Typical 
Can wash, dress, bathe.   Mobility restricted to 
Severe mobility restriction. 
day 
Mobility generally 
100m. but more severe 
Only minimal self care 
unrestricted.  Cognition 
restriction unlikely.  
tasks (teeth, face 
and communication not 
Afternoon rests may be a  washing) may be 
affected.  Fatigue 
feature.  This may have 
managed.  May require 
countered by avoidance 
affected work or 
supervision due to 
of leisure and social 
education.  Normal tasks  cognitive impairment and 
pursuits and sometimes 
may require rest after 
require meal preparation.  
rest. 
completion.  Personal 
Light and noise sensitivity.  
hygiene and nutrition 
May be bed or wheelchair 
unimpaired.  Cognition 
bound. 
and judgement can be 
affected but insight of 
precautions remains 
good. 
Observations 
No limitations 
Mild cognitive, 
Cognition and 
concentration and affect 
concentration problems 
changes may be noted. 
may be evident.   
Clinical 
Normal (unless co-
No specific findings on 
Muscle weakness and 
findings 
morbid conditions). 
examination. 
loss of muscle bulk, 
particularly in lower limbs 
may be evident. 
 
 
 
 
 
 
 
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7.6  Medically Unexplained Symptoms 
Because this covers a huge range of conditions with widely varying clinical features and 
effects, each claimant has to be considered on their own merit. 
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