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Morimoto K, Sekiguchi K, Matsumoto R. Sensory nerve action potential in patients with functional neurological disorders with sensory manifestations. Front Neurol 2023; 14:1259887. [PMID: 38020646 PMCID: PMC10630917 DOI: 10.3389/fneur.2023.1259887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/30/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Functional neurological disorder (FND) has various clinical manifestations. Even though diagnostic criteria for FND have been proposed, FND characteristics with sensory manifestations have not been elucidated. Therefore, we aimed to investigate the association between sensory nerve action potential (SNAP) amplitudes and FND with sensory manifestations. Methods We included 76 outpatients with FND with sensory manifestations whose nerve conduction studies were performed retrospectively. Additionally, we defined 121 patients with other neurological diseases who did not have peripheral neuropathy as disease controls. The SNAP amplitudes were compared between the two groups. We also explored the relationship between SNAP amplitudes and FND-specific clinical symptoms in patients with FND. Results No differences were observed in SNAP amplitudes adjusted for age between patients with FND who had sensory manifestations and disease control patients. Additionally, no differences were observed between patients with FND who had and did not have FND-specific clinical symptoms. Conclusion The SNAP amplitude in patients with FND who had sensory manifestations was equivalent to that in controls.
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Affiliation(s)
| | - Kenji Sekiguchi
- Division of Neurology, Kobe University Graduate School of Medicine, Kobe, Japan
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Roze E, Hingray C, Degos B, Drapier S, Tyvaert L, Garcin B, Carle-Toulemonde G. [Functional neurological disorders: A clinical anthology]. L'ENCEPHALE 2023:S0013-7006(23)00084-2. [PMID: 37400338 DOI: 10.1016/j.encep.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/06/2023] [Indexed: 07/05/2023]
Abstract
Functional neurological disorders have a broad phenotypic spectrum and include different clinical syndromes, which are sometimes associated to each other or appear consecutively over the course of the disease. This clinical anthology provides details on the specific and sensitive positive signs that are to be sought in the context of a suspected functional neurological disorder. Beside these positive elements leading to the diagnosis of functional neurological disorder, we should keep in mind the possibility of an associated organic disorder as the combination of both organic and functional disorders is a relatively frequent situation in clinical practice. Here we describe the clinical characteristics of different functional neurological syndromes: motor deficits, abnormal hyperkinetic and hypokinetic movements, voice or speech disorders, sensory disorders, and functional dissociative seizures. The clinical examination and the identification of positive signs play a critical role in the diagnosis of functional neurological disorder. Knowledge of the specific signs associated with each phenotype render possible to make an early diagnosis. For that matter, it contributes to the improvement of patient care management. It allows to a better engagement in an appropriate care pathway, which influence their prognosis. Highlighting and discussing positive signs with patients can also be an interesting step in the process of explaining the disease and its management.
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Affiliation(s)
- Emmanuel Roze
- Hôpital Salpêtrière, DMU neurosciences, Assistance publique des Hôpitaux de Paris, Paris, France; Inserm, CNRS, Institut du Cerveau, Sorbonne Université, Paris, France
| | | | - Bertrand Degos
- Hôpital Avicenne, hôpitaux universitaires de Paris-Seine Saint Denis (HUPSSD), Assistance publique des Hôpitaux de Paris, Sorbonne Paris Nord, réseau NS-PARK/FCRIN, Bobigny, France; Centre de recherche interdisciplinaire en biologie (CIRB), Collège de France, CNRS UMR7241/Inserm U1050, Université PSL, Paris, France
| | - Sophie Drapier
- Département de neurologie, CHU de Rennes, CIC Inserm 1414, Rennes, France
| | - Louise Tyvaert
- Centre de psychothérapie du CHRU de Nancy, Nancy, France
| | - Béatrice Garcin
- Inserm, CNRS, Institut du Cerveau, Sorbonne Université, Paris, France; Hôpital Avicenne, hôpitaux universitaires de Paris-Seine Saint Denis (HUPSSD), Assistance publique des Hôpitaux de Paris, Sorbonne Paris Nord, réseau NS-PARK/FCRIN, Bobigny, France
| | - Guilhem Carle-Toulemonde
- Cabinet de psychosomatique et stimulation magnétique transcrânienne, clinique Saint-Exupery, 29, rue Émile-Lecrivain, 31400 Toulouse, France.
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3
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Sonoo M. [Borderline regions between neurology and psychiatry, focusing particularly on the functional neurological disorders]. Rinsho Shinkeigaku 2023; 63:135-144. [PMID: 36843086 DOI: 10.5692/clinicalneurol.cn-001817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
Neurology in Japan did not develop from the separation of neuropsychiatry into neurology and psychiatry, which casts a shadow on the present situation of Japanese neurology. Functional neurological disorder (FND; hysteria) is a typical link between neurology and psychiatry. FND is a common disorder, which has been described from the ancient times and has also been the headstream of neurology. FND is not diagnosed by exclusion or by psychiatric causes, but should be actively diagnosed based on the neurological signs themselves (= positive signs of FND) as early as possible, with minimal ancillary tests. This opinion has been supported by the newest Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Many positive signs have been described. Assessment by a neurologist also becomes a treatment.
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Affiliation(s)
- Masahiro Sonoo
- Department of Neurology, Teikyo University School of Medicine
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Abstract
Functional neurological disorder (FND), previously regarded as a diagnosis of exclusion, is now a rule-in diagnosis with available treatments. This represents a major step toward destigmatizing the disorder, which was often doubted and deemed untreatable. FND is prevalent, generally affecting young and middle aged adults, and can cause severe disability in some individuals. An early diagnosis, with subsequent access to evidence based rehabilitative and/or psychological treatments, can promote recovery-albeit not all patients respond to currently available treatments. This review presents the latest advances in the use of validated rule-in examination signs to guide diagnosis, and the range of therapeutic approaches available to care for patients with FND. The article focuses on the two most frequently identified subtypes of FND: motor (weakness and/or movement disorders) and seizure type symptoms. Twenty two studies on motor and 27 studies on seizure type symptoms report high specificities of clinical signs (64-100%), and individual signs are reviewed. Rehabilitative interventions (physical and occupational therapy) are treatments of choice for functional motor symptoms, while psychotherapy is an emerging evidence based treatment across FND subtypes. The literature to date highlights heterogeneity in responses to treatment, underscoring that more research is needed to individualize treatments and develop novel interventions.
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Affiliation(s)
- Selma Aybek
- Neurology Department, Psychosomatic Medicine Unit, Inselspital University Hospital, Bern, and Bern University, Bern, Switzerland
| | - David L Perez
- Divisions of Cognitive Behavioral Neurology and Neuropsychiatry, Functional Neurological Disorder Unit, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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5
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Eldawlatly AA. Conversion disorder: A mysterious event following general anesthesia. Saudi J Anaesth 2021; 15:375-376. [PMID: 34658721 PMCID: PMC8477777 DOI: 10.4103/sja.sja_139_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 11/21/2022] Open
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Nagasawa H, Ishikawa K, Takahashi R, Takeuchi I, Jitsuiki K, Ohsaka H, Omori K, Yanagawa Y. A case of real spinal cord injury without radiologic abnormality in a pediatric patient with spinal cord concussion. Spinal Cord Ser Cases 2017; 3:17051. [PMID: 28839952 DOI: 10.1038/scsandc.2017.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 07/06/2017] [Accepted: 07/10/2017] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Real spinal cord injury without radiologic abnormality (SCIWORA) is a rare clinical entity. CASE PRESENTATION The patient was a 13-year-old girl whose body was overturned anteriorly after crashing her bicycle into a curb. Following the accident, in which her neck and upper back hit the ground, she could not move due to paralysis. On arrival, she had paresis of the bilateral upper extremities and experienced a painful sensation when her upper extremities were touched. Cervical roentgenography and whole-body computed tomography revealed no traumatic lesions in either the intracranium or the cervical bone. Urgent spinal magnetic resonance imaging (MRI) showed no significant spinal cord lesions or spinal canal stenosis. She was put on complete bed rest with a cervical collar. On the 2nd hospital day (24 h after the accident), her motor weakness had almost completely subsided, and she felt only mild dysesthesia in both forearms. Roentgenography revealed no instability. Her motor weakness completely recovered on the third day after accident and she was diagnosed with spinal cord concussion. DISCUSSION The present case study, in which MRI was performed, showed that an immediate improvement was obtained in a patient who experienced real SCIWORA. The importance of not only spinal cord lesions, but also perispinal soft tissue injury on MRI has been emphasized for predicting patient outcomes. Accordingly, immediate MRI is essential for evaluating patients with signs and symptoms of spinal cord injury, even when plain neck roentgenography and cervical CT are negative.
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Affiliation(s)
- Hiroki Nagasawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
| | - Kouhei Ishikawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
| | - Ryosuke Takahashi
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
| | - Ikuto Takeuchi
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
| | - Kei Jitsuiki
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
| | - Hiromichi Ohsaka
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
| | - Kazuhiko Omori
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
| | - Youichi Yanagawa
- Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan
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Abstract
Functional (psychogenic) sensory symptoms are those in which the patient genuinely experiences alteration or absence of normal sensation in the absence of neurologic disease. The hallmark of functional sensory symptoms is the presence of internal inconsistency revealing a pattern of symptoms governed by abnormally focused attention. In this chapter we review the history of this area, different clinical presentations, diagnosis (including sensitivity of diagnostic tests), treatment, experimental studies, and prognosis. Altered sensation has been a feature of "hysteria" since descriptions of witchcraft in the middle ages. In the 19th century hysteric sensory stigmata were considered a hallmark of the condition. Despite this long history, relatively little attention has been paid to the topic of functional sensory disturbance, compared to functional limb weakness or functional movement disorders, with which it commonly coexists. There are recognizable clinical patterns, such as hemisensory disturbance and sensory disturbance finishing at the groin or shoulder, but in keeping with the literature on reliability of sensory signs in neurology in general, the evidence suggests that physical signs designed to make a positive diagnosis of functional sensory disorder may not be that reliable. There are sensory symptoms which are unusual but not functional (such as synesthesia and allochiria) but also functional sensory symptoms (such as complete loss of all pain) which are most unusual and probably worthy of independent study.
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Affiliation(s)
- J Stone
- Department of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
| | - M Vermeulen
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
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Abstract
The diagnosis of spinal cord disease may be delayed or missed if the presentation does not conform to the expected pattern of a symmetrical spastic paraparesis with sphincter dysfunction and a sensory level. This may occur when a myelopathy has yet to evolve fully, or is highly asymmetrical, as in Brown-Séquard syndrome. Other potential distractions include fluctuating symptoms, as may accompany spinal cord demyelination, and pseudoneuropathic features, as seen acutely in spinal shock and in the chronic setting with some high cervical cord lesions. A second pathology, such as a polyneuropathy or polyradiculopathy, can mask the presence of a myelopathy. The converse situation, of non-myelopathic disease mimicking a cord lesion, arises typically when symptoms and/or signs approximate bilateral symmetry. This may happen with certain diseases of the brain, or of the peripheral nerves, with functional disorders and even occasionally with non-neurological disease. These sources of diagnostic difficulty assume clinical importance when they delay the recognition of conditions that require urgent treatment.
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Affiliation(s)
- Lionel Ginsberg
- Department of Clinical Neurosciences, UCL Institute of Neurology, Royal Free Campus, University College London, London, UK
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9
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Neurologic diagnostic criteria for functional neurologic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2016; 139:193-212. [PMID: 27719839 DOI: 10.1016/b978-0-12-801772-2.00017-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The diagnosis of functional neurologic disorders can be challenging. In this chapter we review the diagnostic criteria and rating scales reported for functional/psychogenic sensorimotor disturbances, psychogenic nonepileptic seizures (PNES) and functional movement disorders (FMD). A recently published scale for sensorimotor signs has some limitations, but may help in the diagnosis, and four motor and two sensory signs have been reported as highly reliable. There is good evidence using eight specific signs for the differentiation of PNES from seizures. Recently, diagnostic criteria were developed for PNES; their sensitivity and specificity need to be evaluated. The definitive diagnosis of PNES can be made by recording typical positive features during the spells, and in a low proportion of cases, where the distinction with an organic etiology cannot easily be done, a normal electroencephalogram suggests the diagnosis. FMD diagnosis relies on diagnostic criteria, which have been refined over time and may be supplemented by laboratory tests in some phenotypes. Rating scales for PNES and FMD could be useful for severity measures, but several limitations remain to be addressed.
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10
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Abstract
Functional (psychogenic) limb weakness describes genuinely experienced limb power or paralysis in the absence of neurologic disease. The hallmark of functional limb weakness is the presence of internal inconsistency revealing a pattern of symptoms governed by abnormally focused attention. In this chapter we review the history and epidemiology of this clinical presentation as well as its subjective experience highlighting the detailed descriptions of authors at the end of the 19th and early 20th century. We discuss the relevance that physiological triggers such as injury and migraine and psychophysiological events such as panic and dissociation have to understanding of mechanism and treatment. We review many different positive diagnostic features, their basis in neurophysiological testing and present data on sensitivity and specificity. Diagnostic bedside tests with the most evidence are Hoover's sign, the hip abductor sign, drift without pronation, dragging gait, give way weakness and co-contraction.
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Affiliation(s)
- J Stone
- Department of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
| | - S Aybek
- Neurology Service, Geneva University Hospitals and Laboratory for Behavioural Neurology and Imaging of Cognition, University of Geneva-Campus Biotech, Geneva, Switzerland
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Ali S, Jabeen S, Pate RJ, Shahid M, Chinala S, Nathani M, Shah R. Conversion Disorder- Mind versus Body: A Review. INNOVATIONS IN CLINICAL NEUROSCIENCE 2015; 12:27-33. [PMID: 26155375 PMCID: PMC4479361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
In this article, the authors accentuate the signs and symptoms of conversion disorder and the significance of clinical judgment and expertise in order to reach the right diagnosis. The authors review the literature and provide information on the etiology, prevalence, diagnostic criteria, and the treatment methods currently employed in the management of conversion disorder. Of note, the advancements of neuropsychology and brain imaging have led to emergence of a relatively sophisticated picture of the neuroscientific psychopathology of complex mental illnesses, including conversion disorder. The available evidence suggests new methods with which to test hypotheses about the neural circuits underlying conversion symptoms. In context of this, the authors also explore the neurobiological understanding of conversion disorder.
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Affiliation(s)
- Shahid Ali
- Drs. Ali, Chinala, Nathani, and Shah are from Meharry Medical College, Nashville, Tennessee; Drs. Jabeen and Pate are from Veterans Affairs, Nashville, Tennessee; and Ms. Shahid is from Georgetown University, Washington, DC
| | - Shagufta Jabeen
- Drs. Ali, Chinala, Nathani, and Shah are from Meharry Medical College, Nashville, Tennessee; Drs. Jabeen and Pate are from Veterans Affairs, Nashville, Tennessee; and Ms. Shahid is from Georgetown University, Washington, DC
| | - Rebecca J Pate
- Drs. Ali, Chinala, Nathani, and Shah are from Meharry Medical College, Nashville, Tennessee; Drs. Jabeen and Pate are from Veterans Affairs, Nashville, Tennessee; and Ms. Shahid is from Georgetown University, Washington, DC
| | - Marwah Shahid
- Drs. Ali, Chinala, Nathani, and Shah are from Meharry Medical College, Nashville, Tennessee; Drs. Jabeen and Pate are from Veterans Affairs, Nashville, Tennessee; and Ms. Shahid is from Georgetown University, Washington, DC
| | - Sandhya Chinala
- Drs. Ali, Chinala, Nathani, and Shah are from Meharry Medical College, Nashville, Tennessee; Drs. Jabeen and Pate are from Veterans Affairs, Nashville, Tennessee; and Ms. Shahid is from Georgetown University, Washington, DC
| | - Milankumar Nathani
- Drs. Ali, Chinala, Nathani, and Shah are from Meharry Medical College, Nashville, Tennessee; Drs. Jabeen and Pate are from Veterans Affairs, Nashville, Tennessee; and Ms. Shahid is from Georgetown University, Washington, DC
| | - Rida Shah
- Drs. Ali, Chinala, Nathani, and Shah are from Meharry Medical College, Nashville, Tennessee; Drs. Jabeen and Pate are from Veterans Affairs, Nashville, Tennessee; and Ms. Shahid is from Georgetown University, Washington, DC
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Daum C, Gheorghita F, Spatola M, Stojanova V, Medlin F, Vingerhoets F, Berney A, Gholam-Rezaee M, Maccaferri GE, Hubschmid M, Aybek S. Interobserver agreement and validity of bedside 'positive signs' for functional weakness, sensory and gait disorders in conversion disorder: a pilot study. J Neurol Neurosurg Psychiatry 2015; 86:425-30. [PMID: 24994927 DOI: 10.1136/jnnp-2013-307381] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Conversion disorder (CD) is no longer a diagnosis of exclusion. The new DSM-V criteria highlight the importance of 'positive signs' on neurological examination. Only few signs have been validated, and little is known about their reliability. OBJECTIVE The aim was to examine the clinical value of bedside positive signs in the diagnosis of CD presenting with weakness, gait or sensory symptoms by assessing their specificity, sensitivity and their inter-rater reliability. PATIENTS AND METHODS Standardised video recorded neurological examinations were performed in 20 consecutive patients with CD and 20 'organic' controls. Ten previously validated sensory and motor signs were grouped in a scale. Thirteen additional motor/sensory 'positive signs', 14 gait patterns and 1 general sign were assessed in a pilot validation study. In addition, two blinded independent neurologists rated the video recordings to assess the inter-rater reliability (Cohen's κ) of each sign. RESULTS A score of ≥ 4/14 on the sensory motor scale showed a 100% specificity (CI 85 to 100) and a 95% sensitivity (CI 85 to 100). Among the additional tested signs, 10 were significantly more frequent in CD than controls. The interobserver agreement was acceptable for 23/38 signs (2 excellent, 10 good, 11 moderate). CONCLUSIONS Our study confirms that six bedside 'positive signs' are highly specific for CD with good-excellent inter-rater reliability; we propose to consider them as 'highly reliable signs'. In addition 13 signs could be considered as 'reliable signs' and six further signs as 'suggestive signs' while all others should be used with caution until further validation is available.
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Affiliation(s)
- Corinna Daum
- Department of Neurology and Clinical Neurosciences, University Hospital (CHUV), Lausanne, Switzerland
| | - Fulvia Gheorghita
- Department of Neurology and Clinical Neurosciences, University Hospital (CHUV), Lausanne, Switzerland
| | - Marianna Spatola
- Department of Neurology and Clinical Neurosciences, University Hospital (CHUV), Lausanne, Switzerland
| | - Vesna Stojanova
- Department of Neurology and Clinical Neurosciences, University Hospital (CHUV), Lausanne, Switzerland
| | - Friedrich Medlin
- Department of Neurology and Clinical Neurosciences, University Hospital (CHUV), Lausanne, Switzerland
| | - François Vingerhoets
- Department of Neurology and Clinical Neurosciences, University Hospital (CHUV), Lausanne, Switzerland
| | - Alexandre Berney
- Psychiatric Liaison Service, Psychiatry Department, University Hospital (CHUV), Lausanne, Switzerland
| | - Mehdi Gholam-Rezaee
- Department of Psychiatry, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Giorgio E Maccaferri
- Psychiatric Liaison Service, Psychiatry Department, University Hospital (CHUV), Lausanne, Switzerland
| | - Monica Hubschmid
- Psychiatric Liaison Service, Psychiatry Department, University Hospital (CHUV), Lausanne, Switzerland
| | - Selma Aybek
- Department of Neurology and Clinical Neurosciences, University Hospital (CHUV), Lausanne, Switzerland
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Gelauff J, Stone J, Edwards M, Carson A. The prognosis of functional (psychogenic) motor symptoms: a systematic review. J Neurol Neurosurg Psychiatry 2014; 85:220-6. [PMID: 24029543 DOI: 10.1136/jnnp-2013-305321] [Citation(s) in RCA: 210] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The prognosis of functional (or psychogenic) motor symptoms (weakness and movement disorder) has not been systematically reviewed. METHODS We systematically reviewed PubMed for all studies of eight or more patients with functional motor symptoms reporting follow-up data longer than 6 months (excluding studies reporting specific treatments). We recorded symptom duration, physical and psychiatric comorbidity, disability, occupational functioning at follow-up and prognostic factors. RESULTS 24 studies were included. There was heterogeneity regarding study size (number of patients (n)=10 491), follow-up duration clinical setting and data availability. Most studies (n=15) were retrospective. Reported symptom outcome was highly variable. Mean weighted follow-up duration was 7.4 years (in 13 studies where data was extractable). The mean percentage of patients same or worse at follow-up for all studies was 39%, range 10% to 90%, n=1134. Levels of physical disability and psychological comorbidity at follow-up were high. Short duration of symptoms, early diagnosis and high satisfaction with care predicted positive outcome in two studies. Gender had no effect. Delayed diagnosis and personality disorder were negatively correlated with outcome. Prognostic factors that varied between studies included age, comorbid anxiety and depression, IQ, educational status, marital status and pending litigation. CONCLUSIONS Existing follow-up studies of functional motor symptoms give us some insights regarding outcome and prognostic factors but are limited by their largely retrospective and selective nature. Overall, prognosis appears unfavourable. The severity and chronicity of functional motor symptoms argues for larger prospective studies including multiple prognostic factors at baseline in order to better understand their natural history.
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Affiliation(s)
- Jeannette Gelauff
- Department of Clinical Neurosciences, University of Edinburgh, , Edinburgh, UK
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Daum C, Hubschmid M, Aybek S. The value of 'positive' clinical signs for weakness, sensory and gait disorders in conversion disorder: a systematic and narrative review. J Neurol Neurosurg Psychiatry 2014; 85:180-90. [PMID: 23467417 DOI: 10.1136/jnnp-2012-304607] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Experts in the field of conversion disorder have suggested for the upcoming DSM-V edition to put less weight on the associated psychological factors and to emphasise the role of clinical findings. Indeed, a critical step in reaching a diagnosis of conversion disorder is careful bedside neurological examination, aimed at excluding organic signs and identifying 'positive' signs suggestive of a functional disorder. These positive signs are well known to all trained neurologists but their validity is still not established. The aim of this study is to provide current evidence regarding their sensitivity and specificity. We conducted a systematic search on motor, sensory and gait functional signs in Embase, Medline, PsycINfo from 1965 to June 2012. Studies in English, German or French reporting objective data on more than 10 participants in a controlled design were included in a systematic review. Other relevant signs are discussed in a narrative review. Eleven controlled studies (out of 147 eligible articles) describing 14 signs (7 motor, 5 sensory, 2 gait) reported low sensitivity of 8-100% but high specificity of 92-100%. Studies were evidence class III, only two had a blinded design and none reported on inter-rater reliability of the signs. Clinical signs for functional neurological symptoms are numerous but only 14 have been validated; overall they have low sensitivity but high specificity and their use should thus be recommended, especially with the introduction of the new DSM-V criteria.
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Affiliation(s)
- Corinna Daum
- Department of Neurology, Clinical Neurosciences Department, University Hospital (CHUV), , Lausanne, Switzerland
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15
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Hysterical paralysis and premature burial: A medieval Persian case, fear and fascination in the west, and modern practice. J Forensic Leg Med 2013; 20:133-5. [DOI: 10.1016/j.jflm.2012.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Revised: 05/18/2011] [Accepted: 05/30/2012] [Indexed: 11/20/2022]
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16
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Hirjak D, Thomann PA, Wolf RC, Weidner N, Wilder-Smith EP. Dissociative paraplegia after epidural anesthesia: a case report. J Med Case Rep 2013; 7:56. [PMID: 23445923 PMCID: PMC3610243 DOI: 10.1186/1752-1947-7-56] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 01/16/2013] [Indexed: 11/29/2022] Open
Abstract
Introduction Clinicians are confronted with considerable difficulties in diagnosing conversion disorders such as dissociative paraplegia. In the literature, there is still no sufficient evidence regarding a typical pattern or general characteristics for this neuropsychiatric syndrome. Over the last decades case reports have described patients with similar personality traits, psychopathological characteristics, history and symptoms. Case presentation We present the case of a 67-year-old Caucasian woman of high economic status and educational level with no psychopathological symptoms and no history of mental disorders who developed dissociative paraplegia after epidural anesthesia. The neurological examination revealed incongruous features, and repeated spine magnetic resonance imaging was normal. Three years earlier the patient had transient paralysis of her left lower limb without detectable cause. Conclusion We identified an association between stressful life events and neurological anomalies. Crucial for the diagnosis of dissociative paraplegia is the neurological examination. Our case demonstrates that lack of psychopathological features and previous psychiatric diagnosis are not sufficient to exclude dissociative paraplegia. In patients with incongruous neurological findings and absent neurobiological correlates, clinicians should consider the presence of conversion disorders such as dissociative paraplegia.
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Affiliation(s)
- Dusan Hirjak
- Structural Neuroimaging Group, Department of General Psychiatry, Heidelberg University Hospital, Voßstraße 4, Heidelberg, D-69115, Germany.
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18
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Hysterical paralysis after spinal surgery. Rheumatol Int 2011; 32:4077-8. [DOI: 10.1007/s00296-011-2257-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 10/22/2011] [Indexed: 10/15/2022]
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Stone J, Warlow C, Sharpe M. The symptom of functional weakness: a controlled study of 107 patients. ACTA ACUST UNITED AC 2010; 133:1537-51. [PMID: 20395262 DOI: 10.1093/brain/awq068] [Citation(s) in RCA: 161] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Functional weakness describes weakness which is both internally inconsistent and incongruent with any recognizable neurological disease. It may be diagnosed as a manifestation of conversion disorder or dissociative motor disorder. Other names include psychogenic or 'non-organic' paralysis. We aimed to describe the incidence, demographic and clinical characteristics of cases with functional weakness of less than 2 years duration, and to compare these with controls with weakness attributable to neurological disease. Both cases and controls were recruited from consultant neurologists in South East Scotland. Participating patients underwent detailed assessments which included: physical examination, structured psychiatric interview (Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders), measures of symptoms, disability and distress [Short Form (36) Health Survey, Hospital and Anxiety Depression Scale], and assessment of their illness beliefs using an augmented version of the Illness Perception Questionnaire. In total, 107 cases (79% female, mean age 39 years, median duration of illness 9 months) were recruited. This number suggests a minimum annual incidence of 3.9/100 000. Forty-six controls (83% female, median age 39 years, duration 11 months) were also recruited. Compared to controls, cases had similar levels of disability but more physical symptoms, especially pain. They had a higher frequency of psychiatric disorders, especially current major depression (32 versus 7%, P < 0.0001), generalized anxiety disorder (21 versus 2%, P < 0.005), panic disorder (36 versus 13%, P < 0.001) and somatization disorder (27 versus 0%, P < 0001). There was no difference in median self-rated anxiety and depression scores. Paradoxically, they were less likely than controls to agree that stress was a possible cause of their illness (24 versus 56%, P < 0.001). Cases were twice as likely as controls to report that they were not working because of their symptoms (65 versus 33%, P < 0.0005). Functional weakness is a commonly encountered clinical problem. Patients with this symptom are as disabled as patients with weakness of similar duration due to neurological disease. There is a paradox between the frequency of depression and anxiety diagnoses and the patient's willingness to accept these as potentially relevant to their symptoms. We discuss the theoretical and practical implications of these findings for the concept of conversion disorder.
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Affiliation(s)
- Jon Stone
- Department Clinical Neurosciences, School of Molecular and Clinical Medicine, University of Edinburgh, Western General Hospital, Crewe Rd, Edinburgh EH4 2XU, UK.
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Morita H, Shimojima Y, Nishikawa N, Hagiwara N, Amano N, Ikeda SI. Size variance of motor evoked potential at initiation of voluntary contraction in palsy of conversion disorder. Psychiatry Clin Neurosci 2008; 62:286-92. [PMID: 18588588 DOI: 10.1111/j.1440-1819.2008.01795.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To investigate the efficacy of transcranial magnetic stimulation (TMS) with a cue signal for the objective diagnosis of palsy of conversion disorder (CD). METHODS Ten patients with palsy of CD, nine with amyotrophic lateral sclerosis (ALS), and eight control subjects were examined. Motor evoked potential (MEP) was recorded from the abductor digiti minimi muscle under three conditions: at rest, during tonic contraction, and with an audio cue signal. In the cue signal paradigm, subjects were asked to perform ramp-and-hold contraction in response to a cue signal. RESULTS MEP size increased in the cue signal paradigm in both controls and patients with ALS, but was not obvious in some CD patients. This was likely due to variance among trials in the cue signal paradigm in each CD patient. The coefficients of variance (CV) among trials in the cue signal paradigm were 15 +/- 4.3 in controls, 25 +/- 11 in ALS, and 70 +/- 40 in CD. CONCLUSIONS CV of MEP size with cue signal was larger in CD than in controls (P < 0.005) and in ALS patients (P < 0.01). The size variance among MEP trials with the cue signal is a supportive parameter for the diagnosis of CD.
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Affiliation(s)
- Hiroshi Morita
- Department of Medicine-Neurology, Shinshu University School of Medicine, Asahi, Matsumoto, Japan.
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Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care professionals. J Spinal Cord Med 2008; 31:403-79. [PMID: 18959359 PMCID: PMC2582434 DOI: 10.1043/1079-0268-31.4.408] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Smith HE, Rynning RE, Okafor C, Zaslavsky J, Tracy JI, Ratliff J, Harrop J, Albert T, Hilibrand A, Anderson G, Sharan A, Brown Z, Vaccaro AR. Evaluation of neurologic deficit without apparent cause: the importance of a multidisciplinary approach. J Spinal Cord Med 2007; 30:509-17. [PMID: 18092568 PMCID: PMC2141729 DOI: 10.1080/10790268.2007.11754585] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE A patient presenting with an acute neurologic deficit with no apparent etiology presents a diagnostic dilemma. A broad differential diagnosis must be entertained, considering both organic and psychiatric causes. METHODS A case report and thorough literature review of acute paraplegia after a low-energy trauma without a discernible organic etiology. RESULTS Diagnostic imaging excluded any bony malalignment or fracture and any abnormality on magnetic resonance imaging. When no organic etiology was identified, a multidisciplinary approach using neurology, psychiatry, and physical medicine and rehabilitation services was applied. Neurophysiologic testing confirmed the absence of an organic disorder, and at this juncture, diagnostic efforts focused on identifying any psychiatric disorder to facilitate appropriate treatment for this individual. The final diagnosis was malingering. CONCLUSIONS The full psychiatric differential diagnosis should be considered in the evaluation of any patient with an atypical presentation of paralysis. A thorough clinical examination in combination with the appropriate diagnostic studies can confidently exclude an organic disorder. When considering a psychiatric disorder, the differential diagnosis should include conversion disorder and malingering, although each must remain a diagnosis of exclusion. Maintaining a broad differential diagnosis and involving multiple disciplines (neurology, psychiatry, social work, medical specialists) early in the evaluation of atypical paralysis may facilitate earlier diagnosis and initiation of treatment for the underlying etiology.
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Affiliation(s)
| | | | | | | | | | - John Ratliff
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | | | | | - Ashwini Sharan
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Zoe Brown
- Rothman Institute, Philadelphia, Pennsylvania
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery
,Please address correspondence to Alexander Vaccaro, MD, The Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107; phone: 267.503.0580; fax: 267.339.3623 (e-mail: )
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Stone J, Smyth R, Carson A, Lewis S, Prescott R, Warlow C, Sharpe M. Systematic review of misdiagnosis of conversion symptoms and "hysteria". BMJ 2005; 331:989. [PMID: 16223792 PMCID: PMC1273448 DOI: 10.1136/bmj.38628.466898.55] [Citation(s) in RCA: 211] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Paralysis, seizures, and sensory symptoms that are unexplained by organic disease are commonly referred to as "conversion" symptoms. Some patients who receive this diagnosis subsequently turn out to have a disease that explains their initial presentation. We aimed to determine how frequently this misdiagnosis occurs, and whether it has become less common since the widespread availability of brain imaging. DESIGN Systematic review. DATA SOURCES Medline, Embase, PsycINFO, Cinahl databases, and searches of reference lists. REVIEW METHODS We included studies published since 1965 on the diagnostic outcome of adults with motor and sensory symptoms unexplained by disease. We critically appraised these papers, and carried out a multivariate, random effect, meta-analysis of the data. RESULTS Twenty seven studies including a total of 1466 patients and a median duration of follow-up of five years were eligible for inclusion. Early studies were of poor quality. There was a significant (P < 0.02) decline in the mean rate of misdiagnosis from the 1950s to the present day; 29% (95% confidence interval 23% to 36%) in the 1950s; 17% (12% to 24%) in the 1960s; 4% (2% to 7%) in the 1970s; 4% (2% to 6%) in the 1980s; and 4% (2% to 6%) in the 1990s. This decline was independent of age, sex, and duration of symptom in people included in the studies. CONCLUSIONS A high rate of misdiagnosis of conversion symptoms was reported in early studies but this rate has been only 4% on average in studies of this diagnosis since 1970. This decline is probably due to improvements in study quality rather than improved diagnostic accuracy arising from the introduction of computed tomography of the brain.
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Affiliation(s)
- Jon Stone
- School of Molecular and Clinical Medicine, University of Edinburgh, Edinburgh EH4 2XU.
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Stone J, Sharpe M, Binzer M. Motor conversion symptoms and pseudoseizures: a comparison of clinical characteristics. PSYCHOSOMATICS 2005; 45:492-9. [PMID: 15546826 DOI: 10.1176/appi.psy.45.6.492] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The authors prospectively studied consecutive neurological inpatients with either motor conversion symptoms or pseudoseizures of recent onset. Patients were administered a structured psychiatric diagnostic interview, a measure of perceived parental care, and a life events inventory. They found that patients with pseudoseizures (N=20, mean age=27 years): 1) were younger than patients with motor conversion symptoms (N=30, mean age=39 years), 2) were more likely to have a borderline personality disorder), 3) were more likely to have a lower perception of parental care and to report incest, and 4) reported more life events in the 12 months before symptom onset. These differences in their characteristics and associated factors raised the question of whether it is helpful to group patients with pseudoseizures and motor conversion symptoms in a single diagnostic category of conversion disorder. An alternative view, that gives primacy to the symptoms rather than a disorder, may enable more precise research questions to be posed.
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Affiliation(s)
- Jon Stone
- Division of Clinical Neurosciences, School of Molecular and Clinical Medicine, Western General Hospital, University of Edinburgh, UK.
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Abstract
STUDY DESIGN A cross-sectional study was performed to elucidate the usefulness of a new clinical evaluation, and a prospective study was performed to detect hysterical paralysis using this evaluation method. OBJECTIVES To make a correct diagnosis of hysterical paralysis, a new clinical evaluation was developed. SUMMARY OF BACKGROUND DATA Hysterical paralysis is a conversion disorder. Its diagnosis must be ruled out when encountering a patient with paralysis, therefore imaging and electrophysiological studies are often necessary, but costly. The principal salient diagnostic features for diagnosing hysterical paralysis are thought to be the preservation of a normal reflex pattern, normal rectal sensation, and normal bladder and bowel functions; however, these features are not always successfully identified. METHODS A new clinical evaluation named the "Spinal Injuries Center" test was developed. The lower extremities of the patients were divided into two groups as follows: in group A, the patients were able to lift up the knee; in group B, the patients were unable to lift up the knee. The 96 legs of the 48 patients who had obvious myelomalacia were randomly chosen. All legs were investigated using the Spinal Injuries Center test, and the association between each group and the Spinal Injuries Center test was examined. The 28 legs of the 14 patients in whom hysterical paralysis was diagnosed were prospectively evaluated using the Spinal Injuries Center test, and the association between the groups and the Spinal Injuries Center test was examined. RESULTS Forty-eight legs were classified as group A, and 48 legs were classified as group B. In group A, 45 legs were judged to be positive for the Spinal Injuries Center test, and 3 legs were negative. In group B, 1 leg was judged to be positive for the Spinal Injuries Center test, and 47 legs were negative. All legs of the patients with hysterical paralysis were classified as group B; however, all legs were positive for the Spinal Injuries Center test. CONCLUSIONS The Spinal Injuries Center test is a new clinical evaluation method that can help make a correct diagnosis of hysterical paralysis. When a patient is unable to lift up his knees by himself, the result of the Spinal Injuries Center test is considered to be positive, and hysterical paralysis is diagnosed in such patients. The diagnosis of hysterical paralysis must be ruled out when encountering patients with paralysis, and as a result, imaging and electrophysiological studies are often necessary. Unfortunately, such tests are costly. Thus, a new clinical evaluation for the diagnosis of hysterical paralysis, named the Spinal Injuries Center test, was developed. When patients who are unable to lift up their knees by themselves test positive using the Spinal Injuries Center test, then they are considered to have ether hysterical or simulated paralysis.
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Affiliation(s)
- Itaru Yugué
- Department of Orthopaedic Surgery, Spinal Injuries Center, Iizuka, Japan.
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Abstract
Psychogenic movement disorders are one of the most challenging conditions encountered by clinicians. Patients with these disorders represent the overlap of psychiatry and neurology and need care from these specialties. Issues within the patient's family, questions about secondary gain, and prejudices among other clinicians often complicate evaluation and treatment. Diagnosis is further complicated by lack of laboratory and other tests to reliably diagnose movement disorders; most movement disorders are diagnosed based on history and clinical phenomena. Treatment is best conducted within the context of a multidisciplinary team experienced in working with these patients and with one another. Identification and treatment of underlying psychopathology, such as major depression or anxiety disorders, is also of great importance.
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Affiliation(s)
- Karen E. Anderson
- Movement Disorders Division, Department of Neurology, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
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Heruti RJ, Levy A, Adunski A, Ohry A. Conversion motor paralysis disorder: overview and rehabilitation model. Spinal Cord 2002; 40:327-34. [PMID: 12080460 DOI: 10.1038/sj.sc.3101308] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
It is important to consider a differential diagnosis between paralysis on an organic basis and paralysis and disability due to psychological mechanisms in people with physical impairment secondary to trauma, without evidence of organic etiology. We review the most dramatic type of conversion disorder (CD)-'Conversion Motor Paralysis'. Recent important medical literature concerning the accepted treatment and rehabilitation management will be reviewed and discussed. The inter-disciplinary in-patient team management approach in a rehabilitation setting offers the benefits of a comprehensive assessment and treatment. The diagnosis is temporary and conditional, since there may be a long delay until the appearance of organic findings. A complete medical assessment is essential in order to rule out any possibility of an organic etiology. In as many as 25% to 50% of patients diagnosed as conversion, an organic medical diagnosis was found.
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Affiliation(s)
- R J Heruti
- Rehabilitation Ward, Reuth Medical Center, Tel-Aviv, Israel
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Heruti RJ, Reznik J, Adunski A, Levy A, Weingarden H, Ohry A. Conversion motor paralysis disorder: analysis of 34 consecutive referrals. Spinal Cord 2002; 40:335-40. [PMID: 12080461 DOI: 10.1038/sj.sc.3101307] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN We present our cumulative experience with patients sustaining the most dramatic type of Conversion Disorder (CD) - Conversion Motor Paralysis. SETTING Rehabilitation departments, Reuth Medical Center, Tel-Aviv and Sheba Medical Center, Tel-Hashomer, Israel. METHODS During the period 1973-2000, 34 patients with neurological symptoms without any anatomical or physiological basis were admitted to both rehabilitation departments. This number consists of less than 1% of the total acute traumatic and non-traumatic spinal cord disorders admitted annually to these centers. RESULTS Twenty-five of the subjects were men (mean age of 30 years) and nine were women (mean age of 31.4 years). Neurological symptoms included: paraplegia (complete or incomplete) (18), hemiplegia or hemi paresis (11), tetraplegia (complete or incomplete) (three), monoplegia (one), triplegia (one). The final diagnosis on discharge was CD in 30 of the 34 cases, the remaining four being diagnosed as malingering. Functionally, nine patients had a complete recovery, 10 a partial recovery and 15 remained unchanged. CONCLUSION Disabled people who experienced traumatic events resulting in various disabilities are admitted usually to a rehabilitation center. However, some of them are later diagnosed as having Conversion Disorder or malingering. We believe that their participation in active regular and integrative rehabilitation process is beneficial to most of them. Most of these patients gain functional independence and return to the main stream of life.
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Affiliation(s)
- R J Heruti
- Department of Rehabilitation, Reuth Medical Center, Tel-Aviv, Israel
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Abstract
Hysterical paralysis is an unusual diagnosis, requiring the physician to infer the intentional stance of the patient when the latter fails to act. This paper argues that the distinction between ''hysterical'' and ''feigned'' disorders cannot be currently justified on the basis of objective criteria. The physical ''signs'' of hysterical paralyses are those of voluntary motor inconsistency. The patient fails to perform certain acts, whereas others, utilising the same muscle groups, are preserved. Hence, hysterical paralyses are essentially disorders of action, themselves the product of abnormalities of mind, ''will'', or the intention to deceive (the ''self'' or the ''other''). The role of the psychodynamic unconscious in the maintenance of hysterical paralyses is problematic; their maintenance requires the patient's conscious attention: They remit with sedation and distraction. Although functional neuroimaging studies of these symptoms have been preliminary, they may eventually reveal an objective pathophysiology of the disordered ''will'', and a contrasting functional anatomy of the intentionally feigned symptom.
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Affiliation(s)
- S A Spence
- Imperial College School of Medicine, MRC Cyclotron Unit, Hammersmith Hospital, London, UK
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Crimlisk HL, Bhatia K, Cope H, David A, Marsden CD, Ron MA. Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms. BMJ (CLINICAL RESEARCH ED.) 1998; 316:582-6. [PMID: 9518908 PMCID: PMC28460 DOI: 10.1136/bmj.316.7131.582] [Citation(s) in RCA: 182] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate psychiatric and neurological morbidity, diagnostic stability, and indicators of prognosis in patients previously identified as having medically unexplained motor symptoms. DESIGN Follow up study. SETTING National Hospital for Neurology and Neurosurgery, London--a secondary and tertiary referral hospital for neurological disorders. SUBJECTS 73 patients with medically unexplained motor symptoms admitted consecutively in 1989-91. 35 (48%) patients had absence of motor function (for example, hemiplegia) and 38 (52%) had abnormal motor activity (for example, tremor, dystonia, or ataxia). MAIN OUTCOME MEASURES Neurological clinical diagnosis at face to face reassessment by a neurologist and a psychiatric diagnosis after a standardised assessment interview--the schedule for affective disorders and schizophrenia--conducted by a psychiatrist. RESULTS Good follow up data were available for 64 subjects (88%). Only three subjects had new organic neurological disorders at follow up that fully or partly explained their previous symptoms. 44/59 (75%) subjects had had psychiatric disorders; in 33 (75%) patients, the psychiatric diagnosis coincided with their unexplained motor symptoms. 31/59 (45%) patients had a personality disorder. Three subjects had developed new psychiatric illnesses at follow up, but in only one did the diagnosis account for the previous motor symptoms. Resolution of physical symptoms was associated with short length of symptoms, comorbid psychiatric disorder, and a change in marital status during follow up. CONCLUSIONS Unlike Slater's study of 1965, a low incidence of physical or psychiatric diagnoses which explained these patients' symptoms or disability was found. However, a high level of psychiatric comorbidity existed.
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Abstract
A literature review of reported cases of intractable sneezing reveals that intractable sneezing typically occurs in children or adolescents and is a manifestation of conversion disorder. Analysis of these cases demonstrates a number of features that are helpful in differentiating psychogenic from organic sneezing. Also discussed are aspects of patient management once a diagnosis of conversion disorder is established.
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Affiliation(s)
- L J Fochtmann
- Department of Psychiatry and Behavioral Sciences, State University of New York at Stony Brook 11794-8101
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Abstract
The incidence of injuries to the spinal cord sustained at rugby in South Africa, New Zealand and Australia is reviewed. Ninety-seven injuries seen at Stoke Mandeville Hospital at the National Spinal Injuries Centre (NSIC) between 1956 and 1993 are analysed in detail. There were 93 accidents at rugby union, two at American football and two at rugby league. The injuries were of the cervical spine apart from four hysterics and one thoracic injury. The thoracic injury occurred after the game when the player fell downstairs. The injuries were analysed according to the mechanism of injury, the neurological condition, the causation, the standard of the player and the position in the field. The injuries caused were the result of force being applied to the skull which was transmitted to the cervical spine resulting in injury to the cervical cord. As a result of this research, representations were made to the appropriate authorities and changes in the laws were made. As a result of these law changes there has been a dramatic reduction in the overall number of injuries and the elimination of the injury from the loose scrum. This paper discusses the historical sequence of how these preventative measures came about to reduce the incidence of injuries and the legal implications whereby the authors took part in two law suits. The legal consequences are analysed in detail.
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Affiliation(s)
- J R Silver
- Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, England
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Meyer BU, Britton TC, Benecke R, Bischoff C, Machetanz J, Conrad B. Motor responses evoked by magnetic brain stimulation in psychogenic limb weakness: diagnostic value and limitations. J Neurol 1992; 239:251-5. [PMID: 1607885 DOI: 10.1007/bf00810346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The latencies and amplitudes of responses evoked by magnetic brain stimulation (magnetic evoked potentials, MEP) in the first dorsal interosseus and the anterior tibial (TA) muscles were investigated in 15 patients with psychogenic limb weakness and in 50 patients with limb weakness due to established organic central nervous system disease. Of the patients with psychogenic limb weakness, 3 presented with upper limb monopareses, 2 with lower limb monoparesis, 4 with hemipareses, 4 with parapareses and 2 with paraparesis. All patients with psychogenic weakness had MEP in arm and leg muscles with latencies within the normal range. MEP amplitudes were also normal except for 1 patient in whom the response amplitude in the TA of the plegic limb was reduced. In patients with limb weakness due to established organic disease, MEP were frequently but not invariably abnormal. In patients with plegic (i.e. completely paretic, MRC grade 0) muscles due to organic disease, MEP always were clearly abnormal. Normal MEP were sometimes elicited from paretic muscles, more commonly in association with cerebral hemisphere lesions than with spinal lesions. We conclude that psychogenic limb weakness is associated with normal MEP. However, normal MEP in mildly paretic muscles do not definitely exclude organic pathology.
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Affiliation(s)
- B U Meyer
- Neurologische Klinik und Poliklinik, Technischen Universität, München, Federal Republic of Germany
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