Pseudoneurologic syndromes: recognition and diagnosis

Physicians may encounter patients with a collection of psychologic disorders that present with neurologic symptoms or signs, yet have no identifiable structural or functional etiology within the nervous system. These disorders comprise the so-called pseudoneurologic syndromes, which can mimic almost any organic disease. A careful history and physical examination often can identify the psychologic origin of the symptoms. Presenting syndromes can include pseudoparalysis, pseudosensory syndromes, pseudoseizures, pseudocoma, psychogenic movement disorders and pseudoneuro-ophthalmologic syndromes. These presentations may be distinguished from organic disease by observing signs and symptoms or eliciting test responses that are nonphysiologic and incompatible with organic disease. Once a pseudoneurologic syndrome is identified, patients require compassionate and understanding care to resolve underlying emotional problems.     

Is early differentiation between psychogenic and somatogenic lumbago-ischialgia syndrome patients possible by anamnesis? Results of a screening study

Low back pain (LBP) is one of the most frequent causes for early retirement, hospital treatment and loss of days of work (Raspe u. Kohlmann 1993). Further differentiation and earlier diagnosis of psychogenic LBP could significantly reduce health costs. We interviewed 101 patients with LBP in the departments of Neurology and Neurosurgery (Gemeinschaftskrankenhaus Herdecke, University Witten/Herdecke) with the "structured biographical interview for patients with pain" (Egle 1992). This questionnaire has been used successfully differentiating between patients with organic and psychogenic chronic pain syndromes. It is a semi-standardised instrument based on observations, mainly made by Engel (1959), showing that many patients suffering from chronic benign pain syndromes had experienced psychic traumatisation during childhood. We compared a group of patients with clear neurological deficits and organic pain origin (n = 47) with a group of patients with psychogenic LBP (n = 25). Parameters were among others their biographical family constellations, their past medical history (also looking for symptoms of dissociation [conversion]), their present life and their coping with pain. In comparison with other studies examining similar aspects in patients who had pain in other parts of the body (Egle et al. 1991), our groups showed less discriminating results concerning biographical aspects. We found that also 40% of patients with organic pain origin hat traumatic constellations in their childhood. The following factors differentiated best between the both groups and characterised the psychogenic group: Intensity of pain was judged to be significantly higher with the "visual analog scale": age of the patient less than 40 years; distraction does not alter the pain; preceding experiences with physicians had often been negative; pain leads to impairment of familiar contacts; conflicts with parents during childhood could not adequately discussed with them at that time. These seven aspects can very well be part of a clinical history taking in a general medical setting, so that patients with LBP can be differentiated more effectively.     

Quality of life in patients with ankylosing spondylitis

Quality of life encompasses the net effects that a patient perceives an illness to have on his or her life. Quality of life commonly includes symptoms, physical functioning, work ability, social interaction, psychological functioning, treatment side effects, and financial costs. In ankylosing spondylitis, although symptoms of pain, stiffness, and fatigue are common and moderately severe, few patients develop severe functional disability and most remain employed. The limited information available suggests that most patients with ankylosing spondylitis have few problems with social interactions, although depression is not uncommon. Direct medical costs of ankylosing spondylitis are low, compared with those of other rheumatic diseases.     

Do perceived popular adolescents who aggress against others experience emotional adjustment problems themselves?

Aggression is associated with a host of behavioral, social, and emotional adjustment difficulties. However, some aggressive youth are perceived as “popular” by peers. Although these perceived popular aggressive youth appear relatively well adjusted, especially in the social domain, the emotional well-being of these youth is understudied. The current findings indicate that perceived popularity buffers adolescents who hurt others through relational aggression from internalizing symptoms. In contrast, perceived popularity did not buffer adolescents who engaged in overt verbal and physical aggression from internalizing symptoms. The results suggest that relationally aggressive perceived popular adolescents may be especially resistant to intervention if their aggression helps them manipulate their social worlds but does not contribute to internalizing symptoms. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Older spouses' perceptions of partners' chronic arthritis pain: Implications for spousal responses, support provision, and caregiving experiences.

This study of older patients with osteoarthritis and their spouses examined concordance between patients' and spouses' reports of patients' pain severity and the association of concordance with support and caregiving outcomes. Patients and spouses independently viewed videotapes of the patient performing simulated household tasks and provided ratings of patients' pain. Spousal overestimation of patients' pain was the most common type of nonconcordance. Spouses who were accurate in their perceptions of their partner's level of pain during a log-carrying task responded less negatively and provided emotional support that was more satisfying to patients. In addition, spouses who were accurate in their perceptions of their partner's pain during the log-carrying task reported less stress from providing support and assistance. Future research that uses such observational methods may be highly useful for understanding the effects of chronic illness on older couples. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prevalence, Course, and Predictors of Emotional Distress in Pregnant and Parenting Adolescents.

This study examines trajectories and correlates of emotional distress symptoms in pregnant adolescents (n = 203) and nulliparous adolescents (n = 188) from economically disadvantaged communities over an 18-month period. For both groups, the prevalence of significant emotional distress exceeded expectation based on adolescent norms; however, the severity of symptoms did not differ between the 2 groups. Results from growth curve modeling revealed a significant decline in symptoms during the study period for both groups, but pregnant adolescents experienced a different pattern of decline. Also, certain interpersonal factors (e.g., history of physical maltreatment, partner support) appeared to play a more important role in the emotional well-being of pregnant and parenting adolescents relative to nulliparous adolescents. Implications for early identification and intervention are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Conceptualizing and defining psychosomatic disorders.

The concept of psychosomatic illnesses as physical problems resulting from emotional stress is questioned as one that may have outlived its usefulness. A broader definition involving all behavioral concomitants of illness is suggested. The new conception encompasses (a) organic problems created by difficulties in learning and development rather than affect, (b) organic problems created by deviation in personality and character rather than affect, (c) psychological disturbance created indirectly by physical illness, and (d) psychological disturbance created directly by physical illness. Several illustrations of the newly defined types of psychosomatic disorders are given. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Combined medical and psychological symptoms: impact on disability and health care utilization of patients with arthritis

OBJECTIVES: Many reports indicate that patients with combined chronic illness and depressive symptomatology have more disability than those with illness alone, which may influence physician visits. Studies suggest that these combined conditions are unevenly accommodated by the delivery system and nonpsychiatric physicians often fail to recognize or treat these symptoms. To address this need, this study aimed to provide further information on combined conditions and report on relations found among arthritis disease symptoms, depression, and disability. METHODS: The data was derived from a series of statewide surveys assessing the influence of psychosocial factors on disease course and treatment in a community sample of 277 patients under the care of a rheumatologist. A multivariate model was developed to assess these interrelationships, using measures of symptom severity, depression (CESD), disability (activities of daily living, days of restrictive activities, days in bed), service utilizations, and a few personal and health variables. RESULTS: Even after removing somatic items from the CESD to reduce the risk of inflation due to physical disease, evidence was found for additive impact of depression on one measure of disability, days of restrictive activities. Patients with comorbid conditions also were a high-service utilization group. Very few patients reported receiving help in dealing with emotional problems, suggesting presence of substantial unmet need. CONCLUSIONS: Nonpsychiatric physicians need to be aware of the mental health status of chronically ill patients. Although the association between medication use and depression suggests some awareness of the need to treat depression, especially in physically compromised patients, there may be some need to dispense psychological and psychosocial support to those in need.     

Chronic abdominal pain in children as a diagnostic and therapeutic problem

Diagnostic and therapeutical problems associated with chronic abdominal pain in children have been discussed, basing on an analysis of 19 children hospitalized for such a pain. Prevalence of psychic origin has been stressed. However, it may sometimes co-exist with organic disorders as well as maintain pain after successful treatment of the underlying disease. Therefore, diagnostic examination should be repeated in every case in which pain changes its character or the additional alarming symptoms appear. The treatment of the chronic abdominal pain of psychogenic origin requires long-term psychotherapy with the active participation of parents and sick child.     

A case of polyorchidism with embryonal carcinoma

OBJECTIVE: To compare the intraurethral application of liposomal prostaglandin-E1 (PGE1) with intracavernosal injection of PGE1 in patients with organic or psychogenic erectile dysfunction (ED). PATIENTS AND METHODS: Penile tumescence and rigidity were classified by palpation in 25 patients (10 with psychogenic and 15 with organic ED: median age 45 years, range 23-67). All patients were undergoing primary treatment for ED, the median (range) duration of which was 2 3 (2-44) months. After administering PGE1 by each route (1 mg intraurethral and 0.02 or 0.01 mg intracavernosal), the degree of erection was assessed and duplex ultrasonography of the deep penile artery was performed. RESULTS: After the intraurethral application of liposomal PGE1, there was mild penile tumescence in 12 patients with organic ED, the others having no response. In contrast, intracavernosal injection produced sufficient rigidity in 13 patients with organic ED, while two only had a slight increase in tumescence. In patients with psychogenic ED, intraurethral application gave adequate rigidity in six, with four having little or no tumescence, and intracavernosal injection induced sufficient rigidity for intercourse in all. Duplex ultrasonography of the deep penile artery of the penis showed that intraurethral application induced lower flow rates than intracavernosal injection. No patient reported pain after intraurethral application but two of 25 reported severe pain after intracavernosal injection. CONCLUSIONS: The intraurethral application of liposomal PGE1 did not produce sufficient rigidity and was not effective in patients with organic ED. However, it did produce sufficient rigidity in six of 10 patients with psychogenic ED and may thus provide a therapeutic alternative in selected patients.     

Expression of cyclin-dependent kinase 5 and associated cyclins in Leydig and Sertoli cells of the testis

Sixty patients with a sudden onset of motor disability were assessed for illness behavior and depression. In 30 of the patients, etiology was attributed to a definite structural lesion. The remaining 30 patients were diagnosed as having conversion disorder. The Illness Behaviour Questionnaire (IBQ) and the Hamilton Rating Depression Scale (HRDS) were used as instruments for assessment. The mean HRDS score was significantly higher in the conversion group, indicating a higher degree of affective disease in these patients. According to the results of the IBQ, the patients with conversion disorder showed a higher degree of irritability, disease conviction, and phobic preoccupation, and also, to a greater extent, rejected psychological explanations for their symptoms. Denial was high in both patient groups, coexisting with affective symptoms in the conversion patients but not in the neurological patients. Although valuable information could be extracted from the IBQ, it was not found to be a reliable instrument for distinguishing between psychogenic and organic causes of motor disability.     

Electrophysiological aids in distinguishing organic from psychogenic tremor

The clinical differentiation of tremors of organic and psychogenic origin can be difficult. We describe a patient with unilateral upper limb tremor that was initially considered to have a psychogenic cause, but subsequent frequency analysis of EMG signals and accelerometer recordings indicated that the tremor was organic in nature. An ischemic lesion in the contralateral lentiform nucleus found on MRI supported this conclusion. Quantitative electrophysiologic studies may thus be useful in distinguishing organic from psychogenic tremor.     

Psychosocial correlates of recurrent childhood pain: A comparison of pediatric patients with recurrent abdominal pain, organic illness, and psychiatric disorders.

Pediatric patients with recurrent abdominal pain (RAP) were compared with patients with peptic disease, patients with emotional disorders, and well children with regard to (1) emotional and somatic symptoms and (2) theoretically derived variables, including negative life events, competence, family functioning, and the modeling and encouragement of illness behavior. RAP patients had levels of emotional distress and somatic complaints higher than those of well children and lower than those of psychiatric patients, but not different from those of patients with peptic disease. RAP patients had fewer negative life events, better family functioning, and higher competence than children with emotional disorders. In comparison with well children and psychiatric patients, both RAP and peptic disease patients had a higher incidence of illness in other family members and perceived greater parental encouragement of illness behavior for abdominal symptoms. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Emotional and physical intimacy in coping with lupus: Women's dilemmas of disclosure and approach.

This study examined whether self-rated physical and emotional intimacy of 74 women with their heterosexual partner, during an illness episode of lupus, was related to their affect and relationship satisfaction. It was predicted that greater intimacy would be related to better psychosocial adjustment. Women who engaged in physically intimate behavior with their partner more often reported greater relationship satisfaction. Women who frequently avoided or who were often the initiators of physical intimacy, however, reported greater negative affect. Concerning emotional intimacy, women who disclosed more information about illness symptoms and women who concealed more information about their symptoms and feelings experienced the highest levels of negative affect. Results identify dilemmas that women with recurrent illness may face when trying to maintain intimacy during illness periods. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Culture, adaptation, and patterns of disease

The sick patient, rather than the disease process itself, should occupy the central focus of the physician's attention. Such an approach recognizes the interaction of physiologic and emotional forces in the occurrence of disease. It allows for a consideration of the contributory role of emotions in the precipition of physical illness and a recognition that physical illness may produce emotional sequelae of relevance to the total clinical problem. It is an approach which views man as an adapting animal, whose environment may play a crucial role in his adaptation and his disease. Only with such a perspective of man and disease can the principles of medical treatment be realistic.     

Functional (non-ulcer) dyspepsia: unexplained but not unmanageable

Functional dyspepsia--defined as chronic or recurrent pain or discomfort centred in the upper abdomen, with no clinical or endoscopic evidence of known organic disease--is very common and causes considerable morbidity and loss of productivity. A first priority in management is reassuring patients that they do not have a serious disorder. Few drugs have established benefit and the choice depends on which symptoms predominate--prokinetic drugs may be most beneficial in those in whom discomfort (rather than pain), bloating or nausea is the most bothersome complaint and antisecretory drugs in those with predominant epigastric pain.     

Inverse radiotherapy planning for a concave-convex PTV in cervical and upper mediastinal regions. Simulation of radiotherapy using an Alderson-RANDO phantom. Planning target volume

It is a common practice in healthcare to provide comfort and relief from distressing symptoms with the use of intravenous fluids when the patient is no longer able to ingest an adequate amount of fluid. If hydration is not provided to a patient, the medical professional is thought to be negligent of the patient's needs, to consign the patient to a horrible death, and even to shorten the patient's life. On the contrary, dehydration in terminal illness has not been found to produce distressing symptoms or to shorten life span; it may even be beneficial.     

Health patterns of women with fibromyalgia

Using diaries, eight women documented how they were living with their fibromyalgia on a daily basis for 3 months. Aches and pains were the most common symptoms experienced on nine to 81 of the 84 days of data collection. Cross-correlations revealed significant patterns related to pain, sleep and weather conditions for individual women. The narrative portion of their diaries supports that pain is physical and mental, knowing the self helps to control the intensity of the illness, and distraction helps to decrease the associated discomforts. Use of diaries and active listening (validation) are supported as interventions for these women.     

Low back pain in children and adolescents: to treat or not?

Recent cohort data has shown that low back pain is a common symptom in adolescents that, by the age of 16, approaches the level found in adults. The symptoms are frequently recurrent, but are not usually associated with disability. Spells are frequently forgotten, and medical attention is not generally sought. Although the possibility of serious spinal pathology must be considered, the majority of adolescent back trouble may be considered a normal life experience. The efficacy of treatment for non-specific back pain in this age group is undetermined, but the similarities with adult symptoms suggests that management should follow current clinical guidelines for adults (early activation and advice stressing the benign nature of the problem). Persisting root pain may best respond to chemonucleolysis. There is no evidence that treatment or lifestyle changes at this age will reduce symptoms in adult life, but inappropriate medical attention may have detrimental psychosocial consequences.