Epileptic seizures induced by sexual abuse. Pathogenic and pathoplastic factors

Previous sexual abuse is now thought to be a common cause of non-epileptic seizures (pseudoseizures). However, since sexual abuse is common, a previous history of sexual abuse may also occur in people with actual epilepsy. We present six patients in all of whom sexual abuse may, by acting as a stressor in the already predisposed, have precipitated epilepsy and in some of whom the abuse may have affected the actual experiences of the epilepsy itself: all but one of the patients had partial seizures.

[Somnambulism and pavor nocturnus--review and case report]

A case of night terror with sleepwalking in an adult patient is described. Sleep polygraphic data are presented. The literature related to sleepwalking, night terror and its treatment is reviewed. The psychopathologic patterns of sleepwalking and night terror are illustrated and the differentiations of parasomnias and epileptic seizures discussed. The clinical applications of these findings are described and practical recommendations made for the management of NON-REM parasomnia.

High incidence of esophageal motor disorders in consecutive patients with globus sensation

Thirty consecutive patients with globus sensation who were referred to a psychosomatic clinic prospectively underwent otolaryngological, videokinematographic, and manometric examinations of pharynx and esophagus to evaluate whether morphological abnormalities or motility disorders underlay their symptom. When indicated by findings, 24-hour pH-metry, scintigraphy of bolus transport, and esophagogastroscopy were performed. Seven patients were shown to have achalasia, 10 had "hypochalasia" (lower esophageal sphincter relaxation less than 75% with esophageal contraction abnormalities but no complete distal aperistalsis), and 1 had diffuse esophageal spasms; 2 patients had also hyperplastic lingual tonsils, 1 had tonsillitis, and 1 had a cervical spondylophyte. Nutcracker esophagus and nonspecific contraction abnormalities were found in 7 patients, and gastroesophageal reflux with esophagitis and a low lower esophageal sphincter resting pressure was found in 1; only 3 patients had normal esophageal motility. None had volunteered dysphagic symptoms at primary evaluation. Psychometric investigations in consenting patients showed no higher mean scores for state and trait anxiety, depression, hysteria, and hypochondriasis than in general medical outpatients. Esophageal motor disorders may, before giving rise to dysphagia, be sensed more vaguely and induce the globus sensation. However, only disappearance of the sensation after treatment allows inferring an etiological significance of such a disorder.

Chronic pain patients and the nonorganic physical sign of nondermatomal sensory abnormalities (NDSA)

The nonorganic physical sign of nondermatomal sensory abnormalities (NDSA) is frequently found in chronic pain patients. The presence of NDSA qualifies the patient for a potential DSM-III diagnosis of conversion disorder. DSM-III (Axis I and II) diagnoses and personality styles were assigned to 283 mixed chronic pain patients. Discriminant analysis was used to identify diagnoses and personality styles significantly related to NDSA. The demographic variables of workers' compensation (WC) status, age, sex, and race were used as control variables. The discriminant function comprised all control variable, and psychiatric diagnoses accounted for only 22.1% of the variance. Age and WC status, i.e., the demographic variables, explained most of the variance (16.8%), with psychiatric diagnoses adding little (5.3%). The vast majority of the variance is unexplained, indicating the presence of "unexplained" factors for the presence of NDSA in chronic pain patients.

[A case of conversion disorder analyzed from a psychodynamic, psychophysiologic, and morphodynamic perspective]

This paper presents a case of conversion disorder characterized by sensory paralysis that involved the right half of the body, a motor deficit consisting of permanent contracture in flexion of fingers 2-5 of the right hand (clenched fist syndrome), and a visual alteration compatible with homonymous hemianopia and amblyopia. The patient initially presented a clinical picture of depression as well as frequent gynecological disorders. The author evaluates important aspects of the psychogenesis of the clinical picture and emphasizes the identifying aspects and primary and secondary gains. Consideration is given to the distinct therapeutic strategies used (psychotherapy, autogenous training, hypnosis), and the case is analyzed from a morphodynamic point of view. The author concludes that the organic basis of the clinical picture would be localized in the posterior nuclei of the thalamus.

Childhood conversion reactions in the emergency department: Part II--General and specific features

Unexplained somatic symptoms present difficult problems for the emergency physician. Conversion reactions as etiologies for such symptoms can be assessed by using a biopsychosocial framework that has been previously described. To make the diagnosis of conversion reaction, an assortment of positive psychosocial findings in the face of negative organic findings is usually required. This paper describes general features of childhood conversion reactions and specific discriminative findings between organic and conversion etiologies for some of the more common presentations of conversion reactions.

Upper esophageal sphincter tone and reactivity to stress in patients with a history of globus sensation

Anxiety and abnormal upper esophageal sphincter function have been ascribed ill-defined roles in the etiology of globus sensation. In this study, we examined the psychological profile and effect of acute mental stress (dichotic listening task) on UES tone in seven patients reporting to the clinic with globus sensation and 13 healthy controls. Alterations in heart rate, blood pressure, frontalis EMG, and skin conductance confirmed the effectiveness of the stress test in patients and controls. During resting conditions, UES pressure (mean +/- SE) in patients (40.4 +/- 4.6 mm Hg) did not differ significantly from controls (46.5 +/- 4.7 mm Hg). In response to stress, UES pressure rose by 31% in patients (P = 0.04) and by 25% in controls (P = 0.002). The stress-induced rise in UES pressure in patients (9.5 +/- 3.8 mm Hg) was not significantly different to that observed in controls (11.8 +/- 3.0 mm Hg). Psychological profiles of globus patients presenting to the clinic revealed them to be more introverted, anxious, neurotic, and depressed than normal controls. We conclude that in patients with a history of globus sensation, resting UES pressure and its response to stress is normal. Although individuals presenting to the clinic with globus sensation showed increased levels of psychoneurosis, acute, predictable stress is not a factor in the genesis of globus sensation. UES hyperresponsiveness to other stimuli or subjective intolerance to changes in UES pressure could account for symptoms of globus sensation.

EEG frequency analysis in conversion and somatoform disorder

Patients with "hysterical" neurologic symptoms have long puzzled neurologists and psychiatrists. "Hysteria" has recently been subdivided into conversion and somatoform disorder. We applied computerized EEG frequency analysis to 10 patients with diagnosed conversion disorder, 10 somatoform disorder patients, and 10 control subjects. One minute EEG samples composed of 4 sec epochs were recorded from left frontal (F7-C3), right frontal (F8-C4), left posterior (T5-01) and right posterior (T6-02) derivations. Spectral power was calculated for 4 bands (0.25-4HZ, 4.25-8Hz, 8.25-13Hz, and 13.25-30Hz), and for the full frequency range. Low (0.25-8Hz) and high (8.25-30Hz) frequency bands were compared to determine high/low power ratios on the left and right (PHLL) and (PHLR), ratios of left/right front (PLRF) and posterior (PLRP) power, mean alpha frequency deviation frontally (FLRF) and posteriorly (FLRP), and mobility of left and right frontal power (MOLF and MORF). No significant differences were found between conversion disorder patients and controls in PHLL, PHLR, PLRP, and MORF. PLRF, FLRF and MOLF differed significantly between patients and controls. Power and frequency ratios of right frontal mobilities suggested a decrease in high frequency power, reduction in mean alpha frequency, and lower predominant frequency in the right frontal area in somatoform disorder patients as compared to controls, but significance was not reached. Somatoform and conversion disorder patients differed significantly in these spectral measures. These observations suggest that the two "hysterical" disorders may have distinct pathophysiology, and may be due to eventually identifiable cerebral dysfunction in some cases.

The problem of gastroesophageal reflux

Gastroesophageal reflux is the "postnasal drip" of the 1980s. A large variety of symptoms result from reflux: some are merely nuisances, some are life threatening. This review covers those symptoms and diseases due to acid reflux that are of importance to the otolaryngologist.

The attribution of affect in pain clinic patients: a psychophysiological study of the conversion process

In a study to examine the relationship between the conversion process and physiological correlates of emotional arousal, three key elements of conversion were assessed separately in patients experiencing chronic pain for which no adequate somatic cause could be demonstrated. Thirty-seven patients referred to a pain clinic were categorized as members of either high, intermediate, or low conversion groups on the basis of their scores on the Disease Conviction, Affective Disturbance and Denial scales of the Illness Behaviour Questionnaire (IBQ). All patients scored in the high range on Disease Conviction. High conversion patients acknowledge little dysphoric affect and denied life problems apart from physical illness. Intermediate conversion patients also denied life problems other than somatic, but acknowledged high levels of dysphoria. Low conversion patients reported dysphoria and acknowledged life problems which they did not attribute to physical illness. The prediction that the high conversion group would show lower levels of resting skin conductance than the low conversion group was confirmed. Patients in the intermediate conversion group resembled those in the high conversion group in that their resting skin conductance was significantly lower than that observed in members of the low conversion group. These findings are consistent with those of previous studies of conversion disorders. They point to the importance in these conditions of the interaction between dysphoria and the cause to which it is attributed by the patient.

Lateralization of conversion symptoms in children and adolescents

Of 11 children and adolescents with unilateral conversion symptoms, 10 showed symptoms on the right side of the body. Lateralization was found to be related to a patient's handedness.

Neuropsychological concepts of somatoform disorders

Clinical descriptions of somatoform disorders tend to fall largely into the two main categories of conversion disorder and hypochondriasis. These disorders frequently occur in the context of other psychopathology and also tend to have a significant association with CNS disease. Evidence implicating alterations in brainstem reticular arousal and attentional mechanisms in the etiology of these disorders is reviewed. Relevant studies investigating cerebral asymmetry of function have tended to associate right hemisphere information processing style with the sensory, attentional and affective changes that characterize conversion disorders. It is suggested that brain research in the field of somatoform disorders look to the second somatosensory area (SII), which appears to be especially suited to the types of neurophysiological and neuropsychological dynamics that are generally presumed to underlie this class of maladies. Finally, it is argued that a biopsychosocial approach to the understanding of somatoform disorders requires the incorporation of neuropsychological data into a multidimensional conceptual framework.

Hysterical conversion reactions: some patient characteristics and treatment team reactions

Paralysis due to an hysterical conversion reaction may require an active rehabilitation program to prevent complications such as contractures and adhesions. The delivery of this care can create an emotional burden on the rehabilitation staff due to their awareness of the psychiatric etiology of this condition. Good patient care may be undermined by the thought that the patient is malingering. This paper explores features of hysteria--its relation to emotional stress, absence of organic pathology and symbolism--and contrasts it to malingering. The impact of this condition on the treatment staff is explored with two case studies. An understanding of hysteria could make the delivery of proper care to these troubled patients less stressful.

The relationship of the 'inferior constrictor swallow' and 'globus hystericus' or the hypopharyngeal syndrome

The term 'Globus Hystericus' is considered to be a very bad term for such a common condition and it is recommended that it be replaced by the 'Hypopharyngeal Syndrome'. The normal modified swallow initiated from the lingual tonsil--epiglottis area, called the Inferior Constrictor Swallow, can cause all the symptoms. The epiglottis does not bend. There are two groups of symptoms: the first due to sensation from local irritation of the lingual tonsil; and the second due to vicious circles causing increased muscle tension and strain swallowing. If there is pain or dysphagia or impairment in swallowing, then it is not the Hypopharyngeal Syndrome. The key-note of treatment is the logical explanation of these symptoms and that the vicious circles must be broken.

[Diagnosis and differential diagnosis of hysteric amblyopia using psychophysical and electro-ophthalmological examination methods (author's transl)]

In three patients with psychogenic amblyopia the computerized visual field, the ERG, the flash light (H-EP) and pattern reversal stimulated (M-EP) cortical potentials were recorded. Differential diagnosis between psychogenic amblyopia on the one hand, and functional amblyopia and organic lesions of the retrobulbar visual pathways on the other was shown to be possible. In the cases with organic retrobulbar lesions of visual pathways, visual field defects and pathologic H-EP's and M-EP's were found. In functional amblyopia only the M-EP responses are diminished in amplitude. In psychogenic amblyopia only the computerized visual field shows pathologic changes.

Psychopathology and hemispheric dysfunction: a review

In the past 15 years, investigators have attempted to relate psychiatric disorders to our developing knowledge about the asymmetrical organization of the cerebral hemispheres. This paper summarizes the varied, limited, and often conflicting results. The authors suggest that progress in this fascinating and potentially fruitful area will be improved by: a) more critical evaluation of the current literature with regard to its contradictions and to the techniques and theories utilized; b) systematic study of carefully diagnosed, large groups of patients; c) concurrent attempts to identify and carefully assess unusual patients; d) control of laterality measures for drug effects, institutionalization, and such cognitive and affective states as anxiety, depression, paranoia, and psychosis; and e) validation of the localizing value of neuropsychological tests in psychiatric patients by the study of previously diagnosed psychiatric patients with acquired focal brain disease.

Abnormal esophageal manometry in globus hystericus

Globus hystericus means the "hysterical ball or lump in the throat," and is generally assumed to be of psychic origin. True dysphagia is usually absent. Twelve patients with the globus syndrome were studied at the Esophageal Motility Laboratory of the Saint Luke's Hospital of Cleveland. An organic cause for their symptomatology was ruled out by physical examination, laryngoscopy, esophagoscopy and cineesophagograms. Ten patients showed significant elevations in esophageal resting pressures and nine had evidence of disordered motor activity in the body of the esophagus. Knowing from previous investigations that a suprasternal discomfort may be elicited from stimulation of the esophagus at different levels, we propose that the globus sensation is a referred one coming from the hypertonic and frequently incoordinated body of the esophagus.