Every neurology service should have access to specialist liaison psychiatry

EDITOR—Crimlisk et al's report on the outcome of motor symptoms that were medically unexplained in a cohort first identified at the National Hospital for Nervous Diseases is welcomed by those interested in the psychiatry of physical illness.1Slater's work, based on cohorts recruited in the 1950s, overestimated the likelihood of misdiagnosis in modern neurology,2 and his conclusions have dissuaded psychiatrists from becoming involved in the management of hysteria.

O'Brien's editorial on Crimlisk et al's study could have sounded two cautionary notes.3Firstly, the study was not based on a true inception cohort, and it was recruited from a highly specialised centre. Usually, these factors lead to the finding of a worse prognosis than if only incident cases were included and the sample was less prone to recruitment bias. In this case, however, the bias may have been in the other direction. Patients seen at the National Hospital are likely to have been more exhaustively investigated and observed for longer (either in this episode or before referral) than they would be in most hospitals, so that the chances of misdiagnosis are reduced. We should not generalise the study findings to hospitals where initial assessment may be undertaken with little or no access to specialist neurological opinion or investigations.

Secondly, the negative message—that high rates of undetected neurological disease are not seen at follow up—has been allowed to obscure the important positive findings of the study. Even years later, the patients had …