I've got an appeal coming up in a few weeks for a person who is unable to walk. This is a symptom of my client's schizophrenia.

Schizophrenia is treated by drugs that block the activity of dopamine, a neurotransmitter, which is faulty in schizophrenia. Since dopamine has a physical presence and has some physical action in the body, I want to try to argue that this is a physical disability that can give rise to high rate mobility.

I also intend to argue that 'disablement' or 'disability', which appears in the act and regs means the 'inability' of a part of the body to function, rather than relating to the diagnoses - which is what the DWP argue. This is a bit like IIDB where the 'loss of faculty' - inability of the brain to process dopamine, gives rise to a 'disablement' - the inability to walk.

Any and all comments would be appreciated, especially on the first argument.

This may be a relatively easy case to argue if you can get evidence of the drugs prescribed, the doseage and how long your client has been taking them.

It is well recognised that an adverse effect of a number of anti psychotic medications is a condition known as drug induced Parkinsonism.

You need to be clear whether the inability to walk is due to drug induced Parkinsonism, and is not a feature of catatonic schizophrenia where the peason adopts bizarre postures for long periods (from what you say, drug induced Parkinsonism seems likely)

The drugs can actually mimic Parkinson's disease and the mechanism is physical ( a lack of dopamine in the area of the brain that controls voluntary movement). The mechanism is thought to be vitually the same in Parkinson's disease and in drug induced Parkinsonism.

There would be an outcry if people suffering from Parkinson's disease were to be denied DLA mobility because the primary area that is diseased is a part of the brain and not the legs.

You will be entering new ground if you try to argue that your clients inability to walk is a physical symptom of schizophrenia itself, but it will be worth a try if you are not able to show that drug induced Parkinsonism is the likely or possible cause

To be honest, Staninsby, I don't have that much detail about the client's condition - this is an exisiting case I picked up recently in my new employment.

I'm not quite sure of the point you're making with drug-induced Parkinsonism. Are you suggesting that success may be more likely if we can show that the physical symptoms are a side-effect of medication rather than a symptom of the illness?

If you are, then one obvious question arises: if drug-induced Parkinsonism is characterised by low dopamine levels caused by medication and this can give rise to an award, how can increased dopamine levels in schizophrenia, caused by social, biologicial or genetic factors not give rise to an award?

I don't think I've ever dealt with a DLA claim for Parkinson's, but from what you say, there is no problem establishing that the 'disablement' is 'physical' for DLA high mob. It would be a very brave DWP official that withdraws entitlement for Parkinson's patients, so what kind of arguments might they use to differentiate the two diseases in the context of entitlment.

Thanks

I dont think even the DWP would try to differentiate between drug induced Parkinsonism and Parkinson's disease, but they most certainly will differentiate between something due to what they consider to be the claimants mental state (in this case something due to schizophrenia), and something with a more obviously physical cause.

In short, I definitely think you will have more successs with the drug induced Parkinsonism line rather than trying to argue that the inability to walk is a physical symptom of schizophrenia. This is because schizophrenia is still thought of as a mental rather than physical illness

The issue of shcizophrenia and DLA high mobility was considered by Commissioner Rice in R(DLA)3/98 in the context of whether or not shcizophenia could be viewed as an arrested development of the brain. It was held that it could not and DLA mobility was refused.

You have said: "...This is because schizophrenia is still thought of as a mental rather than physical illness..."

You're right of course, but is this an artificial distinction? I don't see the difference. Parkinson's is caused by insufficient dopamine in the brain and a feature of schizophrenia is increased dopamine levels. Both can give rise to an inability to walk.

The biggest difference is that in Parkinson's, the faulty dopamine is caused by dgenerative changes in the 'basal ganglia' (whatever that is!!). That is clearly of physical origin. I don't know the cause of dopamine defficiency in schizophrenia, but there must be one. Even if in science it's not clearly understook, there must be a physical origin. In addition, there are other biological and genetic factors involved in the development of schizophrenia. Are these not also 'of physical origin'?

It would be good to hear other people's views on this. Has anyone tried to run any similiar arguments?

There is an argument that there must be a physical or biological origin in practically all mental illness eg there is thought to be an imablance in 5HT (serotonin) involved in depression. This is why drugs like prozac are thought to work by blocking the re-uptake of serotonin by the neurones in the brain.

Similarly, there is strong evidence of a gerntic component in bipolar disorder (manic depression). The bog standard treatment for bipolar disorder is lithium, which is thought to act by dampening down the wild swings in nervous activity characteristic of the condition.

Dopamine is also thought to be invloved in depression as is acetycholine. The problem is that in mental disorders the imbalances in neurotransmitters in the brain is poorly understood, still less any causal mechanisms, and while the distinction between mental and physical disorders remains in medical science, then social security law will follow.

Incidentally excess dopamine, far from depressing activity will usually increase it (this is thought to be the mechanism of the high someone gets when taking stimulants like cocaine)

I remain of the opinion that the drug induced Parkinsonism argument has far more chance of success

This is really an interesting issue and one that needs testing. I think there's more than an argument that all mental health problems are physical in origin. For example,(according to some of the information I've seen recently) most scientists agree that schizophrenia is a biological disease caused by genetic factors, chemical changes in the brain, abnormalities of brain development or the prenatal environment.

It is of course true that much of mental illness is little understood, but at one stage symptoms of mental illness were seen as signs of demonic possession or some other evil. Nowadays this is not the case (except perhaps for the sufferer), but still society clings to much to the 'mental' in mental illness.

Anyway, having gone through the file with a fine-toothed comb, I see that the client's severe mental illness went untreated for around 30 years and the GP does indeed mention 'catatonic schizophrenia'. This means the drug-induced Parkinsonism is out - she's been on respiradol for only a couple of years.

If you were the DWP, how would you defend my test case? In summary, I would argue that the 'physical disablement' is the client's physical inability to walk and that she has a mental illness which is a disease of physical (biological) origin. So the client has a physical disability in both cause and effect and falls within the qualifying criteria on either one or both counts.

ps. thanks for the discussion.

Re: the Parkinsonism arguement. I seem to recall from a past life working in a mental health team, that there is a drug which is often prescribed along with anti psychotics to combat Parkinsonism.

In terms of the issue of the need for a 'physical' cause, I'm not sure if Commissioner Rowland's decision in CDLA/3323/2003 may be useful.

In CDLA/3323/2003, he upholds an appeal against a tribunal decision that although the claimant was virtually unable to walk, this was due to his mental health condition of hysterical paralysis and as this was not a physical condition he could not satisfy the conditions for the higher mobility rate of DLA.

However, Commissioner Rowland holds -

'Regulation 12(1)(a) makes it clear that disablement is to be regarded as physical for the purposes of section 73(1)(a) if it affects the claimant’s physical condition rather than his mental condition. Thus a distinction can be drawn between a psycho-neurotic disorder that produces symptoms such as pain or paralysis, directly impinging on the claimant’s physical ability to move, and, say, agoraphobia or depression that affect the claimant’s will to make use of such a physical ability …

In my judgment, the tribunal erred in law because the undisputed evidence was that the hysteria affected the claimant’s physical condition by severely limiting the extent to which he could use his legs, and, therefore, the only conclusion they could properly have reached on the evidence before them was that the claimant’s physical condition as a whole was such that he was virtually unable to walk.'

There is a summary of CDLA/3323/2003 in the briefcase area of rightsnet, together with a link to the full decision.

To Sara. The name of the drug you are looking for is procyclidine.

The above discussion is a fascinating one to be sure. I am inclined to agree with Stainsby that the drug induced parkinsonism argument is most likely to succeed at tribunal.

However, I do have some sympathy that there is a physical component to mental illness. For example, schizophrenia is primarily a disorder of thought. Thus the neurobiological or biochemical organisation of the brain may be 'faulty' and therefore provides a physical platform for the disordered behaviour of the patient.

Second, there is a strong school of thought that schizophrenia is genetic in origin. A famous study of twins showed a higher incidence of schizophrenia among twins separated at birth and raised in different social environments, than that found in the general population.

Third, there is also another school of thought, following the ideas of the psychologist R D Laing, that schizophrenia has an environmental cause. That is the 'sane reaction of the individual to an insane world'. Certain anecdotal evidence seems to support this. For example, young black men are more likely to be diagnosed as schizophrenic than their white counterparts, when in reality their behaviour (deemed unacceptable by the authorities) has really been reasonable and understandable pro-active resistance (with resulting patterns of thought) to racism and the actions of racist institutions.

Fourth, are chemical changes in the brain causes of behaviour or products of social and environmental stimuli, which then affect behaviour? Can one be certain one way or the other?

With so much unknown, and so much uncertainty, about the causes of
mental illness then it will always be wise to advance whichever argument suits your client's case. Powerful arguments can easily be made for the various points of view held by all sides. You never know, the reps astute advocacy and reasoned argument may just win the day.

Regards
Paul

From Ken's citation of CDLA 3323/2003

'Regulation 12(1)(a) makes it clear that disablement is to be regarded as physical for the purposes of section 73(1)(a) if it affects the claimant’s physical condition rather than his mental condition. Thus a distinction can be drawn between a psycho-neurotic disorder that produces symptoms such as pain or paralysis, directly impinging on the claimant’s physical ability to move, and, say, agoraphobia or depression that affect the claimant’s will to make use of such a physical ability …

In my judgment, the tribunal erred in law because the undisputed evidence was that the hysteria affected the claimant’s physical condition by severely limiting the extent to which he could use his legs, and, therefore, the only conclusion they could properly have reached on the evidence before them was that the claimant’s physical condition as a whole was such that he was virtually unable to walk.'

From the online medical dictionary(link via toolkit on rightsnet)

Paralysis

<neurology> Loss or impairment of motor function in a part due to lesion of the neural or muscular mechanism, also by analogy, impairment of sensory function (sensory paralysis).
In addition to the types named below, paralysis is further distinguished as traumatic, syphilitic, toxic, etc., according to its cause or as obturator, ulnar, etc., according to the nerve part or muscle specially affected.

Origin: Gr. Lyein = to loosen

Catatonia
<neurology, psychiatry> A syndrome of psychomotor disturbances seen in schizophrenic disorders characterised by periods of either muscular rigidity, excitement or stupor.
(16 Mar 1998)

I dont think that Commissioner Rowland was adopting a strictly medical usage of the word paralysis, but I do think that you could argue that catatonia is a motor disturbance and so affects the person's physical condition making him virtually unable to walk.

I've reviewed the case-law on this issue in some detail over the last few days including the two recent decisions CDLA/3323/2003 and CDLA/3612/2003 and also R(DLA3/98. In the latter case, Commissioner Rice, having heard expert witnesses, accepted that a woman suffering severe schizophrenia was suffering from arrested development of the brain.

CDLA/3612/2003 is generally seen as unhelpful on the argument, whereas CDLA/3323/2003 is seen as helpful. They both have useful reviews of previous decisions and I don't they deviate in their conclusions. It seems that individual circumstances of the claimants involved can change the interpretation.

I've written a long submission for this appeal and reproduce a few paragraphs below so you can get the gist of my argument:


2.8 In reviewing the case-law regarding mental health problems and the mobility component, the arguments seem to fall into one of three camps:
1. that the cause of the disablement must be entirely physical (ie. not a mental health problem);
2. that that it matters not that a mental health problem may be involved so long as there is a causal link with a physical disability (e.g. actual pain, caused by a mental problem, that limits walking);
3. that only the inability to walk, howsoever caused, is relevant.

2.10 Applying the issues in these decisions to Mrs Client’s circumstances, I submit that the statutory test is satisfied because she has a mental health problem which limits her walking in two ways.

2.11 First, and consistent with the view of case-law, I submit that although Mrs Client’s disabling condition is of ‘mental’ origin, she does have physical difficulties with walking (see para 2.7 above). These difficulties are that she has some element of muscle wasting, has poor balance and walks very slowly. I submit that these problems establish the necessary causal link (physiological weakness in her limbs) referred to by the commissioner in CDLA/3612/03 (para 14, quoting R(M2/78) that can lead to the conclusion that Mrs Client’s ‘physical condition as a whole’ (reg 12) is such that she is virtually unable to walk. The tribunal will of course want to make findings of fact to establish that Mrs Client is ‘unable to make progress on foot without severe discomfort’. Mrs Client’s relatives will be able to give further information about this aspect of disablement.

2.12 Secondly, Mrs Client is unable to walk without being told to. This aspect of the disablement generally falls into camp 3 (see para 2.8) and is purely a symptom of her schizophrenia (ie. it is her disordered mental processes that prevents her walking as opposed to a tangible physical problem). The commissioner’s seem generally (but not exclusively) to agree that disablement of this nature does not meet the statutory criteria as there is no physical causal link (CDLA3612/2003 para 14, quoting R(M)2/78).

2.13 With due respect to the commissioners, I submit that there are two reasons why this approach cannot be so easily settled. Firstly, her physical inability to walk, howsoever caused, is part of her ‘physical condition as a whole’ and therefore comes within the criteria (CDLA/3323/2003 para 15). Secondly, having regard to the circumstances of the claimant in R(DLA)3/98 (which are almost identical to Mrs Client) and to the comments of the expert witness in that case (see paragraphs 6-14 of that decision), I submit that Mrs Client’s schizophrenia can in fact be classed as a physical disability. Hearing the evidence of the expert witness, the commissioner concluded that that claimant suffered from a state of arrested development which, I submit, amounts to a physical condition.

2.14 That conclusion is similar to other cases considered by commissioners. R(M)2/78 (referred to at para 15 of CDLA/3612/2003) concerned the case of a boy with Down’s Syndrome. It was found that the mobility needs arose from his erratic behaviour (rather than a physical inability to walk), but since Down’s Syndrome is due to faulty genetic inheritance the tribunal held that that was a physical disability and awarded benefit. The commissioner upheld the tribunal’s decision. Similar changes in opinion have occurred in autism where a chromosomal abnormality was accepted as the physical disablement, even though the cause of the inability to walk is usually brought about by refusing to walk, lying down or holding on to objects.

2.15 I submit that there is little difference between these examples and the circumstances of Mrs Client. From the research I have done, it seems clear that scientists generally agree that the cause of schizophrenia is a combination of genetic, biological and prenatal factors. Even if the nature of mental illness is not fully understood, there are clearly biological and/or chemical changes at work and these can’t be anything other than physical – even of they produce symptoms of a psychological nature. The physical causal link is there.

I would be putting thesame aruments if it was my client, but earlier on you asked how I would defend the decision if I was the DWP.

I think the counter argument is to be found in CDLA 4400/2001 where Commissioner Turnbull cited a number of authorities, and efectively summed up the position at para 14(2)(d) and 14(3)

"...because I find the reasoning of Mr. Commissioner Henty in para. 10 of CDLA/944/2001 particularly convincing:

“The claimant has in this context to show he is mentally disabled. The section says that. By that, as I have already pointed out, I think must mean that he suffers from some mental disorder. What is or is not a mental disorder can only be judged
according to the professionally accepted opinion of the time - and not by mere, and possibly amateur, conjecture.”

(3) The same in my judgment applies to “physical disablement” - i.e. the decision maker or tribunal must be satisfied that the claimant is suffering from a medically recognised physical condition. "

Thanks Derek, I'll take a look at these decisions.

From CPAG's site

CDLA/2870/2004
Higher rate mobility component and test for physical disablement

This case is due to be heard by a Tribunal of Commissioners later this year. In this case the claimant has non-specific back and leg pain. The issue is whether pain which is found to have no identifiable physical cause can be "physical disablement" for the purposes of s.73(1)(a) of the Social Security Contributions and Benefits Act 1992 or a feature of the claimant's "physical condition as a whole" for the purposes of Reg. 12(1)(a) of the Social Security (Disability Living Allowance) Regulations 1991 (higher rate of the mobility component).

The hearing is currently set for 24/05/05

This would be difficult to argue as a physical condition caused by the client having schizophrenia, but yes do agree that the disablement itself could be argued as a physical disablity and I would suggest making that very clear to the tribunal.

You may want to write a very specific letter to the consultant psychiatrist as to the level of physical disability and it cause otherwise the tribunal is unlikely to be swayed too much by the arguement.

I would be very interested to know the outcome

Hi Folks,

Went to appeal today and the tribunal found in my client's favour. Thank you to everyone who contributed to this discussion, which helped in securing this outcome.

This was primarily on the basis of the actual physical problems walking as a result of catatonic schizophrenia and associated muscle-wasting and weakness.

The Chair commented that the members were persuaded by my arguments that schizophrenia could be classed as a physical disablement due to genetic, prenatal or other chemical or biological factors.

In this case, there was sufficient physical factors to avoid a decision on this basis (so hopefully dept. won't appeal), but in a case where the inability to walk is due entirely to psychological symptoms of a mental illness, there may still be some hope.

The mainly relevant bits of my arguments are posted above, but I will email a copy if anyone wants it. Obviously it will have to be adapted to suit the individual factors of each case.