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.

Globus hystericus--a somatic symptom of depression? The role of electroconvulsive therapy and antidepressants

OBJECTIVE

An association of "globus hystericus" with depressive illness has already been established. Successful treatment with antidepressants has been previously reported but this is the first report of globus symptom responding to electroconvulsive therapy (ECT) followed by long-term remission on maintenance dose with tricyclic antidepressant.

METHOD

A detailed retrospective study of an elderly patient's General Practice medical notes revealed 45-year history of recurrent globus symptom, interspersed with other somatic complaints. Patient's frequency of consultations with her family physician was noted before treatment and during the 5-year follow-up period. Using DSM-III diagnostic categories, the patient was diagnosed as suffering from major depressive disorder with globus symptom. The notes were insufficient to ascertain whether past episodes of globus occurred in a setting of depressive disorder.

RESULTS

A prompt response of globus symptom to ECT was observed with 5-year symptom-free follow-up period as long as the patient remained on a maintenance dose of antidepressant. A marked reduction in frequency of medical consultations for other somatic complaints was noted.

CONCLUSIONS

The case illustrates a strong association of globus symptom with depressive disorder and other somatic concerns. Patients with recurrent globus symptom and family history of depressive illness should be screened for a possibility of depressive disorder. ECT and antidepressants may be successfully used in treatment of globus in a setting of depressive illness. Long-term maintenance with antidepressive medication may keep at least some of these patients symptom-free. It is suggested that globus hystericus could be more appropriately viewed as a somatic symptom of depression rather than a conversion disorder.

Conversion disorders in childhood and adolescence: a psychiatric consultation study in a general hospital

From March 1986 to April 1995, 418 consecutive psychiatric consultations for patients aged 18 or below were completed. Ten of these patients met the Diagnostic and Statistical Manual of Mental Disorders, 4th. edition (DSM-IV) diagnostic criteria for a conversion disorder. The medical and psychiatric consultation records of these patients were reviewed. Chief conversion symptoms included pseudoseizure (four cases), gait disturbance (two cases), abnormal movement (one case), four limbs weakness (one case), aphonia (one case) and tunnel vision (one case). The psychosocial problems of the patients included family problems (seven cases), interpersonal problems (two case) and concurrent physical illness (one case). Six patients (60%) manifested complete remission and others showed improvement of the symptoms.

Psychogenic nonepileptic seizures

Psychogenic nonepileptic seizures (NES) are commonly encountered in clinical practice, and they may pose difficult diagnostic problems. For appropriate evaluation and treatment of NES, a multidisciplinary team approach is needed; typically, a neurologist with expertise in epilepsy, a psychologist or psychiatrist, and a support staff should be involved. Psychogenic NES have no single initial clinical manifestation, and various etiologic factors may contribute to their development. Of importance, psychogenic NES are "real" seizures that may be as disabling as epileptic seizures. Most often, they occur on a subconscious level, and the patient may have no control over their occurrence. Precipitation or termination of a habitual seizure during video-electroencephalographic monitoring has often been used to distinguish NES from epileptic seizures, but the results can sometimes be misleading. Numerous additional diagnostic techniques can be used to assist in making the diagnosis. Treatment is based on the type of psychiatric disorder present. Favorable prognostic factors include being female and having an independent lifestyle, normal electroencephalographic findings, higher intelligence, and no prior psychotherapy.

Conversion disorder after maxillofacial trauma and surgery

Three cases of conversion disorder are reported: one after orthognathic surgery and two after facial trauma. Two of the cases involved facial anesthesia and one case involved facial palsy. It was thought to be important to bring this phenomenon to the attention of oral and maxillofacial surgeons, to consider its management, and to define the patients with a high risk of developing conversion disorder. The prognosis is dependent on the circumstances of the onset of the disorder, the premorbid psychologic health of the patient, and how rapidly treatment is prescribed.

[Diagnosis, symptoms and follow-up of psychogenic tremor]

A total of 21 patients with psychogenic tremor (PT) were asked to take part in a neurologic and psychosomatic assessment; for 17 patients follow-up information was also recorded. Women out-numbered men in the sample. In the majority of patients the tremor was associated with a variety of other conversion symptoms. The clinical picture of the tremor varied. After beginning exclusively in the extremities, it tended to spread to other parts of the body. Other psychopathology (depression and histrionic personality disorder) existed in almost a third of the sample. Many patients had retired from professional life, or planned to do so in the near future, because of PT. At follow up the initial diagnosis was confirmed in all patients although in some patients additional physical illness had developed during the follow-up period. When neurological and psychiatric/psychosomatic criteria are applied the diagnosis of PT can be established reliably. Studies that have questioned the validity of the conversion concept on the basis of frequent misdiagnoses may indicate problems in the diagnostic procedure rather than an invalid theoretical construct.

Management of conversion disorder

Conversion disorder is a psychologically produced alteration or loss of physical functioning suggestive of a physical disorder. Conversion symptoms are often superimposed on organic disease and can be overlooked. Psychological techniques are central to the management of conversion symptoms. Principles of psychological management include the following: avoiding confrontation with the patient; avoiding reinforcement or trivializing the symptoms; reviewing results of tests and exams and creating an expectation of recovery; educating the patient by providing a benign explanatory model of symptoms; evaluating the patient's emotional adjustment and referring for psychotherapy when possible. Use of behavior therapy reinforcement and double-bind psychotherapy strategies may be helpful with more chronic or resistant symptoms, especially when there is a history of vague or excessive somatic complaints or significant secondary gain. Four case studies are presented to illustrate these principles.

Behavioral management of conversion disorder: retrospective study

OBJECTIVE

To assess whether operant behavioral treatment of conversion disorder provides effective and durable symptom resolution, and to evaluate the prognostic value of duration of symptoms, as to the time required to effect symptom resolution.

DESIGN

Retrospective case series (consecutive sample).

SETTING

Inpatient rehabilitation unit in a tertiary care center.

PATIENTS

The first 10 patients with conversion disorder treated by the author. There were 5 men and 5 women, age range 19 to 69 years, mean 32.7 years. The duration of conversion disorder symptoms (all involving gait) ranged from 0.5 to more than 112 weeks (mean 27.8 weeks, median 12 weeks). Follow-up range was 7 to 36 months (mean 20 months).

INTERVENTION

All patients were treated as inpatients using a behavioral approach. A 'pseudo-scientific' explanation of the symptoms was provided, with an explanation that stressors can exacerbate symptoms. patients were in a wheelchair when no in therapy, and a physical therapy program was devised, using a treatment sequence based treatment of the analogous neurological condition. Other therapies were also utilized for positive reinforcement of normal function. All patients had psychological evaluation, with treatment as indicated. Patients were hospitalized long enough to restore normal gait and begin psychological treatment.

MAIN OUTCOME MEASURES

Functional Independence Measure ambulation score at admission, discharge, and follow-up, and descriptive data, including symptom recurrence after discharge, new neurological symptoms after discharge, new treatment since discharge, and new psychiatric or neurological diagnosis since discharge.

RESULTS

All patients attained normal ambulation before discharge (n = 10, Wilcoxon signed rank test p = .002). At followup, 7 of 9 patients maintained normal ambulation (Wilcoxon signed rank test of pretreatment ambulation score versus followup ambulation score p = .1016). Two patients resumed partial dependence on wheelchair use. There was a Spearman correlation coefficient of .68196 (p = .0298) when comparing duration of symptoms against duration of treatment. No patient had symptom substitution or new diagnosis made during the follow-up period.

CONCLUSION

(1) Behavioral treatment of conversion disorder is effective, and appears to provide a clinically (but not statistically) significant long-lasting resolution of symptoms. (2) There is a strong positive correlation between duration of conversion symptoms and the time required to eradicate them.

Metaphor and meaning in conversion disorder: a brief active therapy

The concept of conversion disorder as a change in somatic function that symbolically represents an unconscious conflict is currently challenged in the literature. In this article, the author elaborates on the psychodynamic concept of conversion and defines its characteristics and mode of diagnosis. The usefulness of this approach is demonstrated in a detailed case presentation of a brief, active psychodynamic psychotherapy of six sessions that led to the rapid disappearance of symptoms. In particular, the metaphoric meanings of the physical symptoms were interpreted and followed by an immediate disappearance of symptoms. The logic of this therapeutic approach and its implications as a transference cure are discussed in detail.

"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.

Nonepileptic seizures

The widespread use of video-electroencephalogram monitoring has dramatically increased our recognition of the high prevalence and diversity of nonepileptic seizures. Nonepileptic seizures stand squarely in the interface between psychiatry and neurology, an area that has been both claimed and denied by both sides. Collaborative exploration of this border zone has provided new insights into a disorder that may be as ancient as epilepsy.

Intractable sneezing as a conversion symptom

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.

Course and outcome of conversion and somatization disorders. A four-year follow-up

Although the two disease concepts have very different histories, many previous studies have mixed conversion disorder and somatization disorder and none has made direct comparison between them. The authors applied DSM-III criteria to inpatient and outpatient medical records and attempted to follow 98 patients who met criteria for somatization disorder or conversion disorder. Five of these patients died 4 years later and, of those who survived, 70 (75.3%) were given follow-up interviews by a rater blind to baseline diagnosis. The 32 patients with a baseline diagnosis of conversion disorder were significantly less likely than the 38 patients with somatization disorder to be given the same diagnosis at follow-up. Six of the conversion disorder patients were given follow-up diagnoses of somatization disorder and, in four other cases, subsequent developments revealed medical explanations for the presenting complaint. Of the two baseline diagnoses, somatization disorder predicted substantially more impairment in a variety of domains.

The amobarbital sodium interview in conversion disorders: use of video feedback in therapy

The prognosis in treating acute conversion disorder is good, but it demands considerable time in the form of an intensive, and often extensive, hospital stay. With the increasing trend to limiting hospital stays, the family practitioner working with a psychiatrist in the hospital setting is pressured to find new approaches in order to limit the use of inpatient units. The authors describe a case of classic conversion disorder and outline a successful approach that uses a video recording of the interview, during which the patient is under the influence of amobarbital sodium. The videotape then provides valuable feedback during future therapy sessions in the treatment of this persistent disorder.

Diagnostic concepts, multimodal and multiaxial approaches in psychotherapy and psychosomatics

Basic questions concerning diagnostic models in psychoanalytic psychotherapy and psychosomatics are discussed in this paper. Against the background of the different areas in psychodynamic-oriented diagnoses, the advantages and disadvantages of descriptive multiaxial diagnostical models like DSM-III-R and ICD-10 are examined. These conceptual reflections have been built on the findings from participation in Germany of a great number of psychotherapeutic/psychosomatic institutions in the field trials for the assessment of the Diagnostic Criteria for Research of ICD-10, chapter V. Some of the most important issues this study has raised are discussed.

Clinical facts or psychoanalytic clinical facts?

A clinical fact is defined by the field in which it is situated. In the field of psychoanalysis, the author makes a distinction between psychoanalytic clinical facts arising outside the analytic situation, for example, during interviews or in the applied psychoanalysis, and psychoanalytic clinical facts arising within the psychoanalytic situation, where they find their full value in the transference and countertransference relationship. The author gives two illustrations of this. The characteristics of psychoanalytic clinical facts are that they are observable and communicable, and that they have at the same time a fixed and a transformational aspect. During a preliminary interview it is fruitful to use psychoanalytic clinical facts to open the patient to his/her psychic life through contact with the psychoanalyst.

[Psychogenic thoracic pain attacks. Pathogenesis, follow-up, therapy]

Over a five-month period a 10-year-old girl presented repeatedly with attacks of chest pain that were eventually diagnosed as a conversion disorder (DSM-III-R). A detailed case report of the (just) three sessions with both mother and daughter is given and the process of identifying the conflict constellation (death of a loved one, reproachful attitude toward the mother), aspects of primary and secondary gain, and factors influencing choice and localization of the pain symptoms (models: father and brother) are discussed. The therapeutic lead-in was achieved by noticing and inquiring about the patient's equivocal use of the term "joke" during an interview and in a projective sentence completion test. The therapeutic approach comprised psychoanalytically oriented components, elements of family therapy, suggestive measures, exercises and counseling. Over a follow-up period of two years the patient remained symptom-free and her further development was unproblematic. Aspects of this case that are typical of conversion disorder and factors indicating a good prognosis are discussed with reference to the literature.