The psychosomatic symptom and the self: a sirens' song

This paper examines the symbolic nature of the psychosomatic symptom. It is suggested that the psychosomatic symptom is an informationally rich symbolic derivative of the Self that serves to focus attention on developmental disturbances in the archetypal processes of constructing body image and interpreting dysphoric somatic sensations. Clinical examples are offered to illustrate the changing nature of the psychomatic symptom in society. The therapeutic importance of monitoring affectual transactions in the transference-countertransference field is stressed.

Twenty-seven venous cutdowns to treat pseudostatus epilepticus

Pseudoseizures are often misdiagnosed. We report a patient with pseudostatus epilepticus who has had 27 venous cutdowns on different occasions when she was admitted to hospital with repeated seizures.

'How can we know the dancer from the dance?': hyperbole in hysteria

In this paper the author discusses histrionic or hyperbolic behaviour, which she regards as specific to a certain type of hysterical character. Histrionic hysteria she sees as a pathological organisation. With the use of two clinical examples she examines the phenomenon of hyperbole or exaggeration and suggests that they convey a picture of the patient's internal objects and his relationship to them. Exaggeration can also be used by the patient to distance himself from what is going on in his mind and yet to make the object--the analyst in the session--aware of unrecognised emotions. To study hyperbolic behaviour the author constructs a model in which she divides manifestations of this type of behaviour into three parts; 'the observing self, the acting self and the audience' and examines the different identifications that are at the basis of each part. She considers that these areas of the personality encapsulate fragmenting processes that are continually active and threatening the patient. An exploration of this division into three areas should facilitate and deepen understanding of the processes involved in histrionic behaviour.

[The dream as a relationship paradigm]

279 dreams were drawn from a sample of 32 reports on psychoanalytic treatments of female patients diagnosed either as hysteric (H) or depressed (D). Depending on the gender of the analyst (female = w; male = m) four groups Dm, Dw, Hm, Hw were distinguished. Content analysis of the manifest dreams as to the occurrence of objects, emotions as well as characteristic object-emotion combinations yielded significant differences between groups. The results indicate that dreams can be viewed as relationship paradigms.

[Hysterical emergencies]

Most probably common in emergency departments, but still not well studied in this context, the disorders formerly called "hysteria" are now included in the group "Somatization, undifferentiated somatoform, conversion and dissociative disorders" (SSCD disorders) DSM IV. Their common presentation is that of idiopathic somatic symptoms linked with mental disorders. In the emergency department these symptoms confront physicians who generally do not have extensive psychiatric training. The symptoms occur, and disappear, undetermined by the patients, who are genuinely ill and not malingering. Aside from the somatisation disorder, which by definition is chronic, invalidating and rare, the other disorders (SCD) can: be contingent on the picture of another acute, easily recognisable mental disorder; or, on the other hand, be highly reactional and transient; or constitute the "somatic presentation" of an anxious disorder, the panic attack, well known in somatic emergencies. Management is based on diagnostic considerations and by the difficulties of the patient to accept a psychic cause of the symptoms whereas he is experiencing an organic disorder. The possibilities of discussing such psychogenesis in the context of the emergency department are slight, and the best course is often to adopt a pragmatic and prudent medical approach. An essential point is respect of the patient and his ideas. The legal provision, which already exists, for the presence of psychiatrists in emergency departments should lead to physician-psychiatrist cooperation that would be beneficial for these patients.

[Treatments of hysteria]

Treatment of hysteria requires establishing a management strategy. The first steps consist of symptomatic treatment (catharsis, counter-suggestion, hypnosis, narco-analysis, relaxation, focused psychoanalytical psychotherapy, drug therapy). Thereafter, an approach aiming to modify the psychic structure of the patient can be considered (supportive psychotherapy, psychoanalysis). Occasionally, a systemic approach is necessary. Although each facet of the treatment must be conducted by a specialist, one physician must supervise the overall strategy; this role falls naturally to the family doctor.

[Suggestion and hypnosis in hysteria]

Suggestive influences allow to resolve ambiguities. Normally they are only accepted if they correspond with the knowledge and believes of the subject. Under hypnosis or under the impact of serious psychic perturbations one may take up reality constructions which are not in conformity with these criteria. The restriction of consciousness and the ignoring of certain functions permitting this are the common basis of hypnosis and hysteria. But suggestions do not cause the later; they may only shape the symptomatology. Hypnosis can create a terrain facilitating the resolution of the problems underlying hysteria but it does not represent the treatment of hysteria.

[Hysteria in children]

Hysteria can be found in childhood but as all nevrotic problems during the life period, it is not a fixed entity and cannot presume for the personality to come. Diagnosis is often difficult and is mostly made in pediatric unit in front of conversions symptomatology. The difference between transitory somatizations (frequent during childhood) and conversions is important to make. As part of the diagnosis, finding the underlying personality is necessary. Hysteria is mostly found during the latency period and around puberty period. Awareness is important when the diagnosis is made, to be sure to recognize all the cases and only the real one. Two common situations could be isolated: 1. when a symptom cannot be related to a somatic disorder; 2. when the seduction behavior of a maiden creates counter-attitudes of the medical team and family.

[The glass woman]

The author recounts the case of history of a woman patient seeking psychoanalytic treatment for a variety of extremely severe symptoms. In the course of treatment the original symptom constellation changed, revealing new facets but never disappearing completely. Discussing the compulsive, phobic symptomatology of the patient in terms of the traumatic sexual conflicts underlying them and the attendant break with outward reality and psychotic fabrication of a world of the patient's own making, Zeul warns against premature nosological classification. She contends that, in a case like the present one, the diagnosis of the disturbance into a neat set of nosological compartments--borderline/hysteria/psychosis etc.--makes little sense and should be supplanted by an attempt to describe the psychic mechanisms of mental illness.

Low back pain and illness behavior (inappropriate, maladaptive, or abnormal)

Patients with low back pain without a sufficient physical cause attract labels such as "hysteria" and "hypochondriasis," often on the basis of exclusion. The concept of "abnormal illness behavior" was introduced to clarify the classification and diagnosis of these conditions, in which the behavior of the doctor plays a particularly important part. Principles of management are discussed.

The concept of 'early triangulation' as a key to a unified model of hysteria

On the basis of a subtle and critical use of the concepts of separation and triangulation, this paper develops a psychodynamically unified model of the multi-faceted phenomenology of hysteria in both women and men. It offers an explanation for the manner in which pre-oedipal and oedipal factors interact in hysteria. The fundamental conflict in malignant and benign hysterias is assumed to have the same content, the severity of the disturbance being determined by qualitative and quantitative factors (specific relational constellations, specific forms of traumatisation, and the subject's age, maturity and ability to cope with the relevant problems). The fundamental conflict common to all hysterias is deemed to lie in the subject's attempt to utilise oedipal triangulation in the context of a sexualised form of relationship with the parent of opposite sex, in order to obtain by force the missing early (pre-oedipal) triangulation (in the case of female hysterics) or to secure a substitute for it (in male hysterics), and thereby to achieve the separation from the mother that could not originally be negotiated. Traumatisations and typical defensive constellations associated with this neurotic attempt at resolution are described. The same theoretical approach makes it possible to understand the interactional function of conversion symptoms, and at the same time to consider their significance for this specific neurotic configuration.

"Hysteria" in clinical neurology

Hysteria is an ancient word for a common clinical condition. Although it no longer appears in official diagnostic classifications, "hysteria" is used here as a generic term to cover both "somatoform" and "dissociative" disorders as these are related psychopathological states. This paper reviews the clinical features of four hysterical syndromes known to occur in a neurologist's practice, viz conversion, somatization and pain disorders, and psychogenic amnesia. The presence in the clinical history of a multiplicity of symptoms, prodromal stress, a "model" for the symptom(s), and secondary reinforcement all suggest the diagnosis, and minimise the need for extensive investigations to rule out organic disease. Psychodynamic, behavioral, psychophysiologic and genetic factors have been proffered to explain etiology. Appropriate treatment involves psychotherapeutic, behavioral and pharmacological techniques. A basic requirement is to avoid errors of commission such as multiple specialist referrals and invasive diagnostic and treatment procedures. Hysteria is a remediable condition if identified early and managed appropriately.

Freud's early clinical work

Freud became a medical practitioner because it was impossible for him to pursue the desired career of a microscopic researcher. His education and training had not prepared him for the task of being a practicing physician. In his private practice he began treating some very intelligent, chaotic, demanding, volatile and disturbed patients. Anna von Lieben was one of these patients whom Freud treated very intensively for a long period of time. Elise Gomperz was another talented and severely pained early patient of Freud. Over a number of years, Freud was her psychiatrist and provided her with attentive care using a variety of treatment methods that were available to him at that time. Emmy von N.'s condition was also fluctuating and very demanding. The dramatic sense and chronic clinical course of these patients is compatible with the contemporary diagnostic category of Borderline Personality Disorder. Freud provided these patients with long-term supportive care while he attempted to cure them. At the same time, Freud committed himself to the theory of radical cure and downplayed the supportive, draining and difficult clinical work that he was doing.

["Functional" disorders--from the viewpoint of the neurologist]

Patients with "functional" neurological diseases, i.e. suffering from nonorganic pseudo-neurological disorders, are common in neurological practice and account for a significant minority of neurological admissions. The nomenclature of these disorders is confusing and there is still no satisfactory system of classification. Many of these patients are misdiagnosed. The diagnostic problems and treatment of these disorders are illustrated by 4 case reports. Pathophysiologically the disorders are ill understood. Many of their bizarre features may serve as a means of nonverbal communication for these patients. Their management requires close collaboration between neurologists and psychiatrists. Behavioural therapy may be a more appropriate treatment for these disorders than classical analytic psychotherapy.

Premature termination of psychiatric contact

Failure to complete psychiatric treatment is an extensive and wasteful problem. This retrospective case note study of 252 patients, suffering from a neurotic disorder, investigated which clinical and sociodemographic factors were associated with premature termination of psychiatric treatment. It was found that a history of deliberate self harm was strongly linked with the patients discontinuing their treatment. Other clinical factors, viz, diagnosis, duration of illness, a history of alcohol abuse and a family history of psychiatric illness were not however associated with premature termination of treatment. Older patients and those who were married were least likely to end treatment in this fashion, but sex of the patient, employment status, and distance from the hospital had no such link. Belonging to socioeconomic group 5 was significantly associated with premature termination although no other associations with social groupings were found.

[Anxiety and adolescence]

Based on a single-case study an adolescent patient with an hysterical anxiety syndrome the importance of the integration of age-specific experiences in the phase of late adolescence is described. Here the separation from primary objects as well as the (renewed) coming-up of transitory objects serve as models for untieing of bonds between adolescent and parents. Further the relevance of anxiety in promoting the development at that threshold is described.

The role of motor evoked potentials in the management of hysterical paraplegia: case report

The role of motor evoked potentials in the management of a case of presumed hysterical paraplegia precipitated by spinal injury in a man with a previous history of surgery for scoliosis is presented. Motor evoked potentials were elicited with magnetic stimulation 12 days after injury and were within normal limits. The presence of normal motor electrophysiology and observation by the patient of involuntary movement of the lower limbs during stimulation greatly facilitated the patient's management. These findings are discussed with reference to current diagnostic investigations in the presence of a suspected diagnosis of hysterical paraplegia.

Neuropsychological and psychiatric correlates of intractable pseudoseizures

Psychogenic seizures can mimic convulsive epilepsy and with repetitive attacks, iatrogenic complications from aggressive treatment of status epilepticus can occur. We studied neuropsychiatric features of 20 patients in whom psychogenic seizures were intractable and at times continuous. Nineteen of 20 patients seen were female, and all but one were under 40 years of age. All had convulsive attacks resistant to various medications, normal neurological examinations, and negative imaging studies and electroencephalograms (EEGs). Sixteen had previous evidence of epilepsy and the other four had epileptic relatives. Seizures were atypically prolonged, included back arching and pelvic thrusting, and persisted despite intravenous diazepam and therapeutic phenytoin and phenobarbital levels. Seizures terminated spontaneously in five, were stopped by suggestion in four, and persisted until respiratory arrest or elective intubation in 11. Ten patients had conversion disorder, six borderline or mixed personality disorder and four mental retardation. Fifteen had had some precipitating stressor and the remainder had histories of exhibiting attention-seeking behaviour. Nine of 10 patients with conversion disorder had 'conversion V' Minnesota Multiphasic Personality Inventory (MMPI) profiles, while personality disorder patients had elevation of several psychopathological scales. Patients with conversion disorder gradually improved with anticonvulsant discontinuation, while retarded individuals were helped by behaviour modification, situational change or neuroleptics. Personality disorder patients continued to have attacks and eventually discontinued follow-up. Clinical evidence of non-epileptic seizures includes clinical atypicality and long duration, exacerbation by medications and frequent attacks despite normal examination and studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Non-epileptic seizures: management and predictive factors of outcome

We report a prospective series of 18 patients with a diagnosis of non-epileptic seizures (NES, pseudoseizures) identified in one unit. Sixteen patients agreed to complete a therapeutic programme. At the end of treatment eight were seizure free, three had only occasional NES and five were unchanged. At 1-year follow-up the situation remained similar regarding seizures, with responders demonstrating an improvement in social functioning and a marked reduction in demands on health service resources. Admission variables significantly associated with a poor outcome were an IQ of less than 80 and a past history of violent behaviour.