One-stop evaluation of globus pharyngeus symptoms with transnasal esophagoscopy and swallowing function test

OBJECTIVE

To evaluate the feasibility of a one-stop assessment of patients complaining of globus sensation with transnasal esophagoscopy (TNE) and functional endoscopic evaluation of swallowing (FEES).

DESIGN

Prospective, nonrandomized, experimental investigation.

SETTING

Tertiary referral centre.

METHODS

Sixty-three consecutive patients complaining of a lump in the throat were evaluated by this combined approach.

MAIN OUTCOME MEASURES

The safety and feasibility of performing a one-stop TNE plus FEES were explored by subjective measurement of the patients' tolerance and satisfaction and comments from surgeons. The possible therapeutic effects were also assessed 2 months after the procedure.

RESULTS

All 63 patients completed the TNE and FEES without any complications. The average duration of the examination was 6.27 ± 2.52 (95% CI 5.63-6.91) minutes. The findings included arytenoid cyst, epiglottic cyst, vocal cord nodules, vocal cord palsy, esophageal reflux, and foveolar gland hyperplasia. Two patients (3.2%) demonstrated some degree of fluid penetration or aspiration. Nine specialists all scored highly on a visual analogue scale on the manipulation, visualization, and satisfaction of the TNE procedure (median  =  8 of 10). Patients also rated a low pain score (median  =  1 of 10) and a high satisfaction score (median  =  9 of 10).

CONCLUSION

The combined technique of TNE and FEES can be used safely as a one-stop examination tool for patients with globus pharyngeus symptoms.

[Assessment and treatment of conversion disorder: the most fascinating borderline of psychiatry and neurology]

Conversion disorder or functional neurological disorder is a neurological symptom complex originating from psychological factors, which manifests in voluntary motor and sensory functions or as unexplained epilepsy-like seizures. Until the 1980's the disorder was called hysterical neurosis. Later on, various general terms, such as unexplained somatic symptoms, pseudoneurological, somatoformic, psychogenic, or psychosomatic symptoms, have been applied. The latest phrase, functional neurological symptoms, emphasizes the change in the functioning of the nervous system rather than in its structure.

Chronic headaches and the neurobiology of somatization

Pain sensitivity is an adaptive process affected by expectation, mood, coping, operant conditioning, and the preconscious allocation of attention. Underlying mechanisms may include encoding of similar experiences (eg, depression, loss, pain-distress) in overlapping patterns of activation, failure of common regulatory mechanisms, direct top-down activation of the pain matrix, and changes in descending pain facilitatory and inhibitory tone. In theory, the combination of glial cell activation from psychological stress and neural firing from nociceptive input may be particularly likely to lead to pain sensitization and long-term structural changes in pain processing regions of the brain. In these ways, headaches in which chronicity, diffuseness, and distress seem better accounted for by psychological than by medical variables can be understood in neurobiological terms. This can allow psychological treatment of physical distress to be objective, nonthreatening, and relatively precise.

The involuntary nature of conversion disorder

BACKGROUND

What makes a movement feel voluntary, and what might make it feel involuntary? Motor conversion disorders are characterized by movement symptoms without a neurologic cause. Conversion movements use normal voluntary motor pathways, but the symptoms are paradoxically experienced as involuntary, or lacking in self-agency. Self-agency is the experience that one is the cause of one's own actions. The matched comparison between the prediction of the action consequences (feed-forward signal) and actual sensory feedback is believed to give rise to self-agency and has been in part associated with the right inferior parietal cortex. Using fMRI, we assessed the correlates of self-agency during conversion tremor.

METHODS

We used a within-subject fMRI block design to compare brain activity during conversion tremor and during voluntary mimicked tremor in 8 patients.

RESULTS

The random effects group analysis showed that conversion tremor compared with voluntary tremor had right temporoparietal junction (TPJ) hypoactivity (p < 0.05 family-wise error whole brain corrected) and lower functional connectivity between the right TPJ, sensorimotor regions (sensorimotor cortices and cerebellar vermis), and limbic regions (ventral anterior cingulate and right ventral striatum).

CONCLUSIONS

The right TPJ has been implicated as a general comparator of internal predictions with actual events. We propose that the right TPJ hypoactivity and lower TPJ and sensorimotor cortex interactions may reflect the lack of an appropriate sensory prediction signal. The lack of a match for the proprioceptive feedback would lead to the perception that the conversion movement is not self-generated.

Relationship between globus sensation and esophageal clearance

CONCLUSIONS

Videofluoroscopy (VF) in the prone position can diagnose a range of esophageal pathologies in all age groups. These correlate with globus sensation in younger and middle-aged patients in prone and supine positions. Abnormal esophageal clearance appears to be associated with globus sensation in young and middle-aged persons, but not in the elderly.

OBJECTIVES

To assess the correlation between globus sensation and abnormal esophageal clearance by VF in relation to body position and to investigate age-related abnormal esophageal clearance, as well as to confirm the utility of VF in diagnosing globus sensation in patients.

SUBJECTS AND METHODS

This was a prospective study. In 72 patients with globus sensation and 33 controls, esophageal clearance was assessed by VF in the upright, supine, and prone positions, and transfer of barium through the esophagus was classified as normal, esophageal retention, esophageal reflux, or pharyngeal reflux. The detection rate of abnormal esophageal clearance was compared among all subjects by age.

RESULTS

In the upright position, VF detected no significant differences in the detection rate of abnormal esophageal clearance and reflux between the patients with globus sensation and controls; however, the detection rate of abnormal esophageal clearance was significantly higher in the prone than in the upright and supine positions (p<0.001), and in all positions was significantly higher among globus sensation patients (p<0.05). In the supine and prone positions, there were significantly higher detection rates of abnormal esophageal clearance in patients than in controls in the young group (p<0.05). Additionally in the prone position, there was a significantly higher detection rate of abnormal esophageal clearance and reflux in patients than in controls in the middle-aged group (p<0.05). In all positions, no significant differences were observed in the detection rate of abnormal esophageal clearance and reflux in the patients and controls in the elderly group.

[Acute hemiplegia and hemianesthesia together with decreased tendon reflexes mimicking acute stroke representing a conversion disorder]

Acute hemiplegia and hemianesthesia is commonly caused by obstruction of major cortical arteries. Such a presentation secondary to a conversion reaction is very rare, especially in the pediatric age group. The authors report an adolescent presenting with acute complete left-sided hemiplegia and sensory loss together with decreased tendon reflexes mimicking an acute arterial stroke. Examination revealed Hoover's sign was present and the patient was oblivious to his stern neurological state. Movement of his paralytic limbs was observed during sleep. Cortical and spinal CT, cortical MRI, motor and somatosensory evoked potentials and a PET study were all normal. As such, the diagnosis of psychogenic hemiplegia was established, apparently within a period that the patient had experienced severe emotional stress while questioning his gender identity. After three days, the adolescent began to move the paralytic limbs along gradual resolution of sensory deficit, leading to complete clinical recovering within two months. Although extremely rare, a conversion reaction should be taken into account in children presenting with acute hemiplegia and anaesthesia, even accompanied with decreased tendon reflexes, when the patient is oblivious to his alleged grave state, and when clinical observations such as Hoover's sign remain intact, substantiated by normal extensive radiological and neurophysiological investigation. Intact motor evoked potentials serve as a key for the diagnosis of psychogenic hemiplegia and, should therefore be performed in suspected cases.

[Hysteria: an historical entity, a psychiatric condition or a neurological disease?]

It has been suggested that hysteria had waned and was an old-fashioned, stigmatizing and false concept, reflecting the incapacity of the medical community to establish a diagnosis in certain situations. Nowadays, however, those disturbances, now referred to as conversion or dissociative disorders, still remain a frequent and incapacitating condition that every clinician faces. These past decades, several studies have tried to better describe their clinical presentation and their neurobiological mechanisms, with the help of the development of new neuroimaging techniques. If the neurobiological correlates are now better understood, efficient treatments are still lacking and only a multidisciplinary (general practitioners, neurologists and psychiatrists) and individually-tailored therapy might be beneficial to the patients.

Impact of psychogenic movement disorders versus Parkinson's on disability, quality of life, and psychopathology

Patients with psychogenic movement disorders (PMD) often report severe impairment, yet the impact of PMD on disability and quality of life has not been examined. We compared 66 patients with PMD and 704 patients with Parkinson's disease (PD) on measures of disability (Older Americans Resources and Services Scale, OARS); quality of life (QOL; SF-12v2 Health Survey) and psychiatric symptomatology (Brief Symptom Inventory 18, BSI-18). On the total OARS, PMD and PD patients reported similar levels of disability (17.6 +/- 6.6, 19.8 +/- 10.9, P = 0.490 at "best" function and 24.1 +/- 11.2, 26.2 +/- 14.3, P = 0.497 at their "worst" function). PMD patients reported similar Physical Health QOL to PD patients (38.9 +/- 14.5, 39.8 +/- 11.6, P = 0.652) but worse mental health QOL (41.6 +/- 13.4 vs. 48.9 +/- 11.0, P < 0.001). On the BSI-18, PMD patients reported higher levels of distress on the Global Symptom Index (62.03 +/- 9.6 vs. 53.7 +/- 9.9, P < 0.001) and on Anxiety, Depression and Somatization subscales (PMD vs. PD scores: Anxiety 58.9 +/- 12.0 vs. 52.3 +/- 10.1, P < 0.001; Depression 58.8 +/- 11.9 vs. 51.3 +/- 10.3, P < 0.001; Somatization 60.5 +/- 11.0 vs. 54.7 +/- 8.7, P < 0.001). Thus, severity of disability reported by the PMD group was equal to that seen in a progressive neurodegenerative condition. Quality of life and mental health implications of PMD were also evident. PMD impacts several aspects of patient function and daily life.

[Evoked potentials and regional cerebral blood flow changes in conversion disorder: a case report and review]

Conversion disorder is defined as the presence of functional impairment in motor, sensory or neurovegetative systems which cannot be explained by a general medical condition. Although the diagnostic systems emphasize the absence of an organic basis for the dysfunction in conversion disorder, there has been a growing interest in the specific functional brain correlates of conversion symptoms in recent years, particularly by examining neuroimaging and neurophysiological measures. In this case report, regional cerebral blood flow changes and evoked potentials of a patient with conversion symptoms are presented. Somatosensory evoked potentials (SEP) of this patient with conversion disorder who had signs of movement disorder revealed that the latency to N20, P 25 waves were in normal limits while the amplitudes of the P25 and N33 components were extremely high (giant SEP). Regional cerebral blood flow assessment revealed hypoperfusion in the left parietal and temporal lobes of the brain. Three months after the first assessment, the control scans showed that the left parietal hypoperfusion disappeared while the left temporal hypoperfusion was still present. The following SEP evaluations which were repeated twice in three months intervals after the initial recordings, showed the persistence of the abnormalities in somatosensorial measures. The neurophysiological and neuroimaging findings in conversion disorder were reviewed and the results of the evaluations of this case were discussed in this article.

Paul Blocq and (psychogenic) astasia abasia

The Greek term astasia-abasia literally translates to mean inability to stand and to walk. Although today we would classify the syndrome as a conversion disorder, it was considered a separate disease by Paul Blocq (1860-1896), who described this phenomenon as the inability to maintain an upright posture, despite normal function of the legs in the bed. Paul Blocq's original 1888 articles on astasia abasia were read, partly translated from French to English, and the cases were summarized. A review of a selection of the literature following Blocq's description on astasia abasia was performed. Present day literature was consulted as well. Blocq reviewed what was known about astasia abasia in two papers. Although he was the first to use the combined term astasia abasia, he referred to similar descriptions of Charcot, Richer, Mitchell, Jaccoud, Roméi, and Erlenmeyer. Blocq's contribution was in compiling the experiences and observations of preeminent 19th century neurologists. He recognized that paralysis, jumping, fits, tremor, and bizarre behavior could all be associated with the syndrome. He distinguished the disorder from hysteria. Moreover, he presented a formal delineation of the gait disorder and provided a pathophysiologic concept. Prognosis was considered favorable. Paul Blocq directed attention to psychogenic gait disorders by publishing a small case series on astasia abasia. Today, these case descriptions would be likely considered cases of conversion or psychogenic gait disorder, with or without other conversion/psychogenic movement disorders.

How does our brain constitute defense mechanisms? First-person neuroscience and psychoanalysis

Current progress in the cognitive and affective neurosciences is constantly influencing the development of psychoanalytic theory and practice. However, despite the emerging dialogue between neuroscience and psychoanalysis, the neuronal processes underlying psychoanalytic constructs such as defense mechanisms remain unclear. One of the main problems in investigating the psychodynamic-neuronal relationship consists in systematically linking the individual contents of first-person subjective experience to third-person observation of neuronal states. We therefore introduced an appropriate methodological strategy, 'first-person neuroscience', which aims at developing methods for systematically linking first- and third-person data. The utility of first-person neuroscience can be demonstrated by the example of the defense mechanism of sensorimotor regression as paradigmatically observed in catatonia. Combined psychodynamic and imaging studies suggest that sensorimotor regression might be associated with dysfunction in the neural network including the orbitofrontal, the medial prefrontal and the premotor cortices. In general sensorimotor regression and other defense mechanisms are psychoanalytic constructs that are hypothesized to be complex emotional-cognitive constellations. In this paper we suggest that specific functional mechanisms which integrate neuronal activity across several brain regions (i.e. neuronal integration) are the physiological substrates of defense mechanisms. We conclude that first-person neuroscience could be an appropriate methodological strategy for opening the door to a better understanding of the neuronal processes of defense mechanisms and their modulation in psychoanalytic psychotherapy.

Clinical profile and outcome of conversion disorder in children in a tertiary hospital of north India

The clinical profile, commonly involved precipitating factors, comorbid conditions, treatment options and outcome of conversion disorder in 40 children in a tertiary level hospital in North India were studied, retrospectively. Majority of the patients were from rural India. Most common presenting symptom was psychogenic non-epileptic seizures; depression and anxiety were among the commonest comorbid conditions. Precipitating factors were predominantly scholastic problems. Treatment option included either psychotherapy only or combination of psychotherapy and pharmacotherapy. No significant difference was found in terms of outcome between the in-patient and out-patient treatment groups. This observation could be cost effective for developing countries like India, where the resources are very limited.

Increased self-monitoring during imagined movements in conversion paralysis

Conversion paralysis is characterized by a loss of voluntary motor functioning without an organic cause. Despite its prevalence among neurological outpatients, little is known about the neurobiological basis of this motor dysfunction. We have examined whether the motor dysfunction in conversion paralysis can be linked to inhibition of the motor system, or rather to enhanced self-monitoring during motor behavior. We measured behavioral and cerebral responses (with fMRI) in eight conversion paralysis patients with a lateralized paresis of the arm as they were engaged in imagined actions of the affected and unaffected hand. We used a within-subjects design to compare cerebral activity during imagined movements of the affected and the unaffected hand. Motor imagery of the affected hand and the unaffected hand recruited comparable cerebral resources in the motor system, and generated equal behavioral performance. However, motor imagery of the affected limb recruited additional cerebral resources in the ventromedial prefrontal cortex and superior temporal cortex. These activation differences were caused by a failure to de-activate these regions during movement imagery of the affected hand. These findings lend support to the hypothesis that conversion paralysis is associated with heightened self-monitoring during actions with the affected arm.

Conversion disorder presenting as hemiplegia and hemianesthesia with loss of neurologic reflexes: a case report

Conversion disorders can present with a variety of sensorimotor signs and symptoms. We present the case of a young woman who presented with sudden onset hemiplegia and hemianesthesia including unilateral loss of deep tendon reflexes, Babinski reflex, and loss of rectal tone with bladder incontinence. The loss of rectal tone, loss of deep tendon reflexes, and a flaccid Babinski reflex are unusual signs in conversion disorders. A thorough medical workup including x-rays, CT scans, and magnetic resonance imaging revealed no organic causes for the neurologic deficits. Before the onset of symptoms, the patient was emotionally upset during an argument, which may have provided the psychologic stressor necessary for a conversion disorder. The young woman gradually regained full neurologic function over the next 14 hours. Conversion disorders should be considered when the neurologic findings do not correspond to known anatomic or physiologic pathways, although a thorough medical investigation must be performed to search for organic causes.

Abnormal brain activation during movement observation in patients with conversion paralysis

Dissociative paralysis in conversion disorders has variably been attributed to a lack of movement initiation or an inhibition of movement. While psychodynamic theory suggests altered movement conceptualization, brain activation associated with observation and replication of movements has so far not been assessed neurobiologically. Here, we measured brain activation by functional magnetic resonance imaging during observation and subsequent imitative execution of movements in four patients with dissociative hand paralysis. Compared to healthy controls conversion disorder patients showed decreased activation of cortical hand areas during movement observation. This effect was specific to the side of their dissociative paralysis. No brain activation compatible with movement inhibition was observed. These findings indicate that in dissociative paralysis, there is not only derangement of movement initiation but already of movement conceptualization. This raises the possibility that strategies targeted at reestablishing appropriate movement conceptualization may contribute to the therapy of dissociative paralysis.

Evolution of the human fear-circuitry and acute sociogenic pseudoneurological symptoms: the Neolithic balanced-polymorphism hypothesis

In light of the increasing threat of large-scale massacres such as terrorism against non-combatants (civilians), more attention is warranted not only to posttraumatic stress disorder (PTSD) but also to acute sociogenic pseudoneurological ("conversion") symptoms, especially epidemic sociogenic symptoms. We posit that conversion disorders are etiologically related to specific evolutionary pressures (inescapable threats to life) in the late stage of the human environment of evolutionary adaptedness (EEA). Bracha et al. have recently argued that from the neuroevolutionary perspective, medically unexplained efferent vasovagal syncope and medically unexplained craniofacial musculoskeletal pain in young otherwise healthy individuals, may be taxonomized as stress and fear-circuitry disorders. In the present article, we extend neuroevolutionary perspectives to acute pseudoneurological sociogenic ("conversive") symptoms: psychogenic non-epileptic attacks ("pseudoseizures"), epidemic sociogenic disorders (DSM-IV-TR Epidemic "Hysteria"), conversive motor deficits (pseudo-paralysis and pseudo-cerebellar symptoms), and psychogenic blindness. We hypothesize that these perplexing pseudoneurological stress-triggered symptoms, which constitute psychopathology in extant humans, are traceable to allele-variant polymorphisms which spread during the Neolithic EEA. During Neolithic warfare, conversive symptoms may have increased the survival odds for some non-combatants by visually (i.e., "non-verbally") signaling to predatory conspecifics that one does not present a danger. This is consistent with the age and sex pattern of conversive disorders. Testable and falsifiable predictions are presented; e.g., at the genome-transcriptome interface, one of the major oligogenic loci involved in conversive spectrum disorders may carry a developmentally sensitive allele in a stable polymorphism (balanced polymorphism) in which the gene expression mechanism is gradually suppressed by pleiotropic androgens especially dehydroxyepiandrosterone sulfate (DHEA-S). Taxonomic implications for the much-needed rapprochement between the forthcoming Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-V) and the International Classification of Diseases (ICD) are discussed.

Hyperactive action monitoring during motor-initiation in conversion paralysis: an event-related potential study

Conversion paralysis (CP) is featured by a stress-induced tonic immobility. Although the neural correlates of this psychiatric condition remain largely unexplored, previous reports showed CP to be associated with anterior cingulate cortex (ACC) hyperactivity. We examined the ACC action monitoring function by recording event-related potentials (ERPs) when conversion patients (n = 6) with unilateral arm paresis made speeded responses with their affected and healthy arms on a flankers task. During this task, pre-response ACC action monitoring is reflected in the N2 ERP component, which is increased when incongruent stimuli lead to simultaneously activated competing response tendencies. The results showed that the N2 congruency effects were significantly increased for responses with affected hands compared to healthy hands. There were no such results for post-response monitoring. This study is the first to present electrophysiological correlates of action monitoring in CP and suggests ACC to be hyperactive when movements with affected arms are to be initiated.

Conversion disorder revisited

Conversion disorder is defined as a psychiatric illness whose symptoms or deficits, affecting voluntary motor or sensory function, cannot be explained by a neurological or general medical condition. Proposing a strategy in the search for the neural mechanisms underlying conversion disorder is a difficult task, partly because key features of the illness inherently lie on a continuum with other psychiatric disorders, such as depression and posttraumatic stress disorder. Recent brain imaging studies have revealed neural circuits involved in complex mental processes potentially related to conversion disorder. These studies are reviewed, together with neuroimaging work in conversion disorder and brain imaging studies that have enriched the conceptualization of memory and emotion in posttraumatic stress disorder and major depression. Analysis of this information from a symptom-based rather than a disease-category perspective leads to a brain-based cognitive model of conversion disorder. This model suggests that disconnected crosstalk between the individual subdivisions of the anterior cingulate and the prefrontal cortex might provide a neuroscientific basis for the psychodynamic dissociation hypothesis, traditionally the bedrock explanation of the relationship between internal conflict and physical deficit. The model also suggests novel research approaches, as well as opportunities for potential therapeutic interventions.

Hysterical conversion and brain function

Hysterical conversion disorders represent "functional" or unexplained neurological deficits such as paralysis or somatosensory losses that are not explained by organic lesions in the nervous system, but arise in the context of "psychogenic" stress or emotional conflicts. After more than a century of both clinical and theoretical interest, the exact nature of such emotional disorders responsible for hysterical symptoms, and their functional consequences on neural systems in the brain, still remain largely unknown. However, several recent studies have used functional brain imaging techniques (such as EEG, fMRI, PET, or SPECT) in the attempt to identify specific neural correlates associated with hysterical conversion symptoms. This article presents a general overview of these findings and of previous neuropsychologically based accounts of hysteria. Functional neuroimaging has revealed selective decreases in the activity of frontal and subcortical circuits involved in motor control during hysterical paralysis, decreases in somatosensory cortices during hysterical anesthesia, or decreases in visual cortex during hysterical blindness. Such changes are usually not accompanied by any significant changes in elementary stages of sensory or motor processing as measured by evoked potentials, although some changes in later stages of integration (such as P300 responses) have been reported. On the other hand, several neuroimaging results have shown increased activation in limbic regions, such as cingulate or orbitofrontal cortex during conversion symptoms affecting different sensory or motor modalities. Taken together, these data generally do not support previous proposals that hysteria might involve an exclusion of sensorimotor representations from awareness through attentional processes. They rather seem to point to a modulation of such representations by primary affective or stress-related factors, perhaps involving primitive reflexive mechanisms of protection and alertness that are partly independent of conscious control, and mediated by dynamic modulatory interactions between limbic and sensorimotor networks. A better understanding of the neuropsychobiological bases of hysterical conversion disorder might therefore be obtained by future imaging studies that compare different conversion symptoms and employ functional connectivity analyses. This should not only lead to improve clinical management of these patients, but also provide new insights on the brain mechanisms of self-awareness.

Salient findings: A potentially groundbreaking study on the neuroscience of hypnotizability, a critical review of hypnosis' efficacy, and the neurophysiology of conversion disorder

Three papers of special interest to researchers and clinicians alike have recently appeared in the general scientific and medical literatures. Two of these papers are original research studies that employ brain-imaging technologies, one using Magnetic Resonance Imaging (MRI), the other position emission tomography (PET). A third paper is a comprehensive review of the empirical findings on the clinical use of hypnosis in pediatric oncology. The research study using MRI technology is extraordinary, because it is the first to document differences in brain morphology between high hypnotizable and low hypnotizable individuals. Arguably, if its findings replicate, the study could be one of the most important developments in scientific hypnosis since the genesis of the Stanford scales 45 years ago. The PET study notes differences in brain activation during intentionally simulated and hypnotically experienced paralysis. The review article examines empirical work addressing the efficacy of hypnosis for procedural pain in pediatric oncology.

Healing the disembodied mind: contemporary models of conversion disorder

The cartesian separation of body and mind has underpinned medical conceptualization of conversion symptoms over the last four centuries. Eighteenth- and nineteenth-century models explained conversion symptoms on the basis of assumed organic lesions. Subsequent psychological formulations focused on mental phenomena, which were disembodied from underlying neurobiological processes. Contemporary theories challenge this disconnection. They place conversion symptoms within an evolutionary framework, arguing that mind is embodied in physical processes and confers significant survival advantage. Current neurobiological models explain conversation symptoms as part of the human emotional response to threat, reflecting either errors in how information about body state is processes and represented, or the motor component of an automatic emotional response. Patients with conversion disorder experience their body functions in a range of distressing and disturbing ways. In order to understand these phenomena, clinicians require conceptual models that expand the conventional dualistic mind-body paradigm, integrate multiple theoretical perspectives, and take into account environmental factors that shape evolutionary and individual development.