Refer to: Reynolds MD: Clinical diagnosis of psychogenic rheumatism. West J Med 128:285-290, Apr 1978
Clinical Diagnosis of Psychogenic Rheumatism MICHAEL D. REYNOLDS, MD, Orange, California
Rheumatic symptoms that are a somatic expression of emotional disturbance are common, and often are mistakenly attributed by physicians to organic disease. Psychogenic rheumatism is encountered most frequently among middleaged women. The typical complaint is of widespread pain and stiffness, often with report of swelling and paresthesia, but symptoms characteristically are vague. Overt psychiatric disturbance may be apparent. Distinction from organic disease should not be difficult if physicians recognize the typical presentation, and find that symptoms fail to correspond to patterns of organic disorders. When organic disease coexists with psychogenic rheumatism, as often is the case, the objective abnormalities are insufficient to explain the symptoms. Persons who sifler from psychonieuirotic illness not
inifrequenitly develop a synmptom-complex which includes
pains or aches atnd stigness or limitationi of movement with or without loss of power. Thzis fact has received little emphasis in medical textbooks and has not been systematically disseminated in the teachinzg of under-JAMES L. HALLIDAY' graduates.
IT IS NOW 40 years since Dr. James Halliday called the attention of his colleagues to the frequency with which rheumatic symptoms occur during emotional disorders, warned how often errors in diagnosis and treatment result from neglect of this fact3 and introduced the name "psychoneurotic rheumatism." Halliday and later writers found that from 13 percent to 49 percent of patients with rheumatic complaints cannot be shown to have organic disease which explains their symptoms.'4-9 Despite its frequency, many physicians experience difficulty in recognizing psychogenic rheumatism (PR), or in diagnosing it From the Division of Rheumatology, Department of Medicine, College of Medicine, University of California, Irvine. Supported by a grant from The Arthritis Foundation, Southern California Chapter. Submitted August 15, 1977. Presented in part at the VIII European Rheumatology Congress, Helsinki, Finland, June 5, 1975. Reprint requests to: Michael D. Reynolds, MD, Department of Medicine, 101 The City Dr. S., Orange, CA 92668.
with confidence. Discussions in textbooks,'0 as well as published series of caseS2,C,7,1l-l3 describe many valuable diagnostic features, but do not consider whether characteristics frequently noted in patients with PR are also seen in persons with organic rheumatic disease. Furthermore, these descriptions tend to deal with "pure cases," in which no concurrent organic disorder confuses the clinical presentation. However, structural musculoskeletal disease frequently coexists with PR.4'7'9 For these reasons, an analysis of the clinical features of PR compared with those of common organic articular diseases should be useful.
Materials The records of all consultations by the author during a four year period were reviewed; of these 135 were abstracted with special attention to features that clinical observation and the literature had suggested were frequent in PR. These 135 cases consisted of all in which the principal diagnosis was PR or one of the three most prevalent diseases of joints: rheumatoid arthritis ("definite" or "classical" by criteria of The American Rheumatism Association14), degenerative joint disease THE WESTERN JOURNAL OF MEDICINE
285
PSYCHOGENIC RHEUMATISM
(osteoarthritis) or degenerative intervertebral disk disease. In addition, all cases of predominantly musculoskeletal symptoms, in which no specific diagnosis was made, were analyzed. This was done to examine whether PR was being diagnosed because of specific features or merely by
PR and the other conditions, except disk disease, to a statistically significant degree (p0.05).
0 0 29 15 0 0 38 31*
31*
Undiagnosed
6 3 13 3 3 3 16 3 3
PSYCHOGENIC RHEUMATISM
in the joints and in interarticular areas. Second, these patients are unable to describe the character of pain in terms such as "sharp" or "aching," or by comparison with familiar pains. Sometimes they use uncommon or dramatic terms to describe symptOmS.1"'3"7 Inability of patients to be precise must be distinguished from the effects of impaired memory,'7 and from the difficulty in obtaining definite answers from patients who are circumstantial or perseverating. Generalized Pain.6'7'11"13'17 The feature of generalized pain is well-recognized by most physicians; the patient who "hurts all over" often is mentioned as a prototype of the neurotic patient. When the sites of symptoms are grouped as neck and back (spine), upper limbs and lower limbs, the frequencies with which patients with PR reported involvement of these areas were 83 percent, 93 percent and 100 percent, respectively. The high prevalence of complaints referable to the spine4 differed significantly from the other groups except, of course, degenerative disk disease. Involvement of all three areas is typical of PR (79 percent of cases). Frequently the generalized pain is of a transient and migratory character, changing in intensity and location much more rapidly and irregularly than do the symptoms of persons with arthritis. Some patients' descriptions give the impression of a pattern of symptoms changing almost continuously. Generalized pain should be distinguished from widespread pain. Persons with arthritis or extensive degenerative disease of joints may note pain in many places, but the sites of pain remain discrete, and the patient can easily name places which remain pain-free. Failure of prescribed treatment to reduce symptoms.27""7 Whereas most of the patients in the other groups reported that treatment had given at least partial relief from pain and other symptoms, nearly half of those with PR indicated that they had gotten no benefit from any treatment prescribed. Patients' Manner of Describing the Illness Considering the manner in which patients presented their histories, we noted three features to be characteristic of PR: Presence of several separable rheumatic syndromes. Patients with polyarthritis usually perceive their illness as a single entity whose sites and
intensity vary with time. Persons with degenerative disease of joints may have a few distinct regional syndromes (for example, cervical disk, lumbar disk, knees). But the complaints of those with PR often can be grouped into four, five or more regional sets more or less clearly distinguishable on the basis of their symptoms, temporal patterns, inciting and relieving factors, and the like. This is not just a manifestation of lack of precision in describing symptoms; the patients themselves often perceive their problem as manifold and describe different symptoms in different regions of the body. Prominent nonrheumatic complaints without evident organic basis.7 Most of the patients who did not have PR confined their complaints to the musculoskeletal system, during a rheumatological consultation. But nearly a third of those with PR complained, along with rheumatic symptoms, of problems in other organ systems, whose organic basis was inapparent. The colon was the organ most often featured in these nonrheumatic problems, and in several patients extensive studies of the gastrointestinal tract had been carried out. Use of medical words; self-diagnosis. Patients sometimes offer only a diagnosis when asked to describe their problem. The physician must then ask detailed questions to find out what symptoms lie behind that diagnosis.15 (Patients with genuine arthritis often will give the diagnosis as a chief complaint, but have no hesitation about describing the symptoms.) In cases of self-diagnosis, a history of reading newspaper and magazine articles or books about the supposed illness may emerge. In other cases, a too-hasty attribution of symptoms to "arthritis," "bursitis" and the like by a physician previously visited has been seized upon by the patient.15 Previous Illness and Medical Care of Patients The final aspect of the in'terview which indicated the presence of PR was the history of previous illness and medical care. Previous rheumatic illness or injury. Halliday2 and others4'5 have noted -the importance of previous rheumatic illness or injury in determining the form or the site of a somatic expression of emotional stress. Previous rheumatic illness was fairly frequent in the other groups, but significantly less so than among the patients with PR. Consultation with multiple physicians. Another feature is consultation with several physicians regarding the present rheumatic illness.'5 We defined THE WESTERN JOURNAL OF MEDICINE
287
PSYCHOGENIC RHEUMATISM TABLE 4.-Physical Findings on Rheumatologic Examination Sign
Psychogenic Rheumatism
Tenderness of musculoskeletal structures ..... ......... 90 Generalized tenderness ........ ..................... 24 Inconsistent manifestations ....... ................... 24 Hyperreactivity ................................... 7 Deformityt . ..................................... 0 0 Soft tissue swelling or effusion at joints ..... .......... .................. 21 Bony enlargement of joints ....... Crepitus ......................................... 14 ....................... 34 Pain on motion ............ ..................... 24 Limitation of motion ......... Absence of objective signs of rheumatic disease .... .... 48
Percent Frequency Found with Rheumatoid Degenerative Degenerative Arthritis Joint Disease Disk Disease
51 3 3 0 71 91 26* 66 57 86 0
52 0 0 0 56 41 78 74 48 56 0 significant (p>O.05).
85* 0 8
0 54 8* 62 62 38* 85 0
Undiagnosed
65 0 0 0 3*
29 13 13* 48 35 48*
*Difference between this figure and frequency with psychogenic rheumatism is not tExcluding deformities of the feet, mild degrees of which are frequent in healthy persons.
this as the patient's having, on his or her own initiative, consulted three or more physicians without apparent reason except dissatisfaction. This correlates with the report of failure of treatment to relieve symptoms (above). Patients with disk disease had multiple physician contacts as frequently as did those with PR. Prior psychiatric treatment. Prior psychiatric treatment was usually in the form of tranquilizers or antidepressants provided by the patients' regular physicians, rather than therapy by a psychiatrist. Patients with disk disease also had frequently received such drugs. A high prevalence of past psychoneurotic illness has been reported in some studies of PR.4'6'7"6
Nondiagnostic Features of Histories In this study, some features which have been said to be typical of PR were not found more often with that disease than with organic disorders. Female sex of patient. The proportion of women to men was the same as for the other rheumatic disorders (Table 1). Recognized sexrelated factors, such as willingness to seek medical attention, preclude any valid statement about a predilection of PR for one sex, in the absence of epidemiologic studies of populations. Many cases of PR in men were collected by military physicians during wartime.4-6"' Absence of visible change in symptomatic areas.6 Only 31 percent of the patients with PR did not claim some change in the appearance of affected parts. Nearly half reported that they had swollen joints; this symptom usually was not confirmed by examination.4 Lack of external inciting or relieving influences on symptoms.7 Patients with PR commonly stated 288
APRIL 1978 * 128 * 4
that their pain was influenced by use of the affected part, and often attributed worsening to inclement weather. Absence of disability.13 Report of difficulty in carrying out usual activities was as common among patients with PR as among those with organic disease. Multiple surgical operations.'5 17 A history of more than three operations was not more frequent in the group with PR. Family history of rheumatic disease.4"6 This was very common in all groups. (However, we have seen cases of PR in children in which the symptoms were plainly a pattern of behavior learned from a neurotic mother.) Marital discord.'6 Separation, divorce or expressed unhappiness with the spouse were not significantly more common in the group with PR. (Despite its small diagnostic value, evidence of marital discord should be sought because it is the major environmental factor in the genesis of some cases of PR.)
Findings on Physical Examination The findings on physical examination also provide clues to the presence of PR (Table 4). The most frequent finding was tenderness of musculoskeletal structures. A psychogenic basis for reports of tenderness was indicated by a nonanatomical distribution.7 The sites reported as tender did not correspond to typical sites of individual rheumatic diseases, to specific anatomical structures, to specific tissues or to patterns of pain reference. One form of this is generalized tenderness (the physical analogue of the symptom of "hurting all over"). A second sign of the nonorganic nature of complaints of pain and tenderness was incon-
PSYCHOGENIC RHEUMATISM TABLE 5.-Psychiatric Syndromes Manifested by Patients Psychiatric Syndrome
Depression ...... Anxiety ...... Hysteria ...... Total
......
Psychogenic Rheumatism
Rheumatoid
17* 17 7 41
0 0 0 0
Arthritis
Percent Frequency Found with Degenerative Degenerative Joint Disease Disk Disease
0 0 0 0
0 8 0 8
Undiagnosed
6 3 0 9
*In two (7 percent) of the depressed patients there also were manifestations of anxiety. I
sistent manifestations.13"15 Failure of repeat palpation of previously tender sites to provoke renewed signs of discomfort was associated with PR. A more subtle inconsitstency was normal posture, movement and gait during the interview, or when the patient was unaware of being observed, which changed to painful, abnormal motor activity during the formal physical examination. Hyperreactivity and withdrawal from the examiner'0 (what Boland7 has appropriately called a "touch-menot" response) has been said to be characteristic of PR, but was observed only infrequently in this series. More often, patients with PR reported pain while evincing none of the signs-facial expression, tensing of muscles or withdrawal-which normally accompany a truly painful examination. Such patients might assert "That's very sore" in a completely bland manner. A most important finding was that more than a third of the patients with PR had identifiable joint disease. Degenerative disk disease was present in six and osteoarthritis in four (in one combined with disk disease); one had a "frozen" shoulder and one had congenital disease of a hip. (We have also seen PR occurring with rheumatoid arthritis.) A similar frequency of coexisting organic disease (28 percent to 40 percent) has been noted in previous studies.4'7'9 Important evidence of PR in these cases was that the symptoms did not correspond in their site, character or severity to those expected from the observed lesions; in other words, the observed organic changes do not explain the symptoms of which the patienzt complains.4 Only about half the patients with PR were completely free of objective signs of rheumatic disease. Nevertheless, the prevalence of most objective signs of articular disease (deformity, soft tissue swelling or effusion, crepitus, limitation of motion) was significantly lower among patients with PR than in the other groups. The exception was the bony enlargement of osteoarthritis, which was present with about equal frequency among those with PR, rheumatoid arthritis
and an undiagnosed disorder. The subjective report of pain during motion was significantly less frequent among those with PR than in the other groups. Diagnosis of a specific psychiatric disorder could be made from the patient's behavior in certain cases (Table 5). Depression was considered to be present when there were a history and an appearance of sadness (including weeping) and of psychomotor retardation, sometimes with supporting symptoms such as morning insomnia. Often an explanatory life situation was uncovered. Anxiety was diagnosed on the basis of an appearance of tenseness and restlessness, and expressions of apprehension and concern. This was sometimes combined with a tendency to fidget continuously with some object in the hands. Two patients reported a plethora of symptoms, but exhibited relative indifference to symptoms, and denial of emotional stress. Their behavior toward the examiner had seductive or sexual overtones. They were thought to qualify for a diagnosis of hysteria. Detailed, formal psychiatric investigation was not attempted; presumably it would have led to a larger number of specific diagnoses.06""6 Specific syndromes were noted significantly more often among patients with PR than among those with organic disease.
Report of a Case A 55-year-old woman, a nurse's aide retired because of disability, stated "my spine is going to pieces." Seven years previously she had begun to have pain in the neck and head, with weakness and paresthesias in the upper limbs, which progressed over several years to a "pulsating, throbbing" pain in the "whole spine." Roentgenograms showed minimal degenerative cervical and lumbar disk disease, but an electromyogram was abnormal, and anterior fusion of the 5th and 6th cervical vertebrae was done. This relieved symptoms only for a few weeks; a second fusion operation one level higher was equally unsuccessful. The THE WESTERN JOURNAL OF MEDICINE
289
PSYCHOGENIC RHEUMATISM
patient now complained of pain in almost all regions of the body, paresthesias in the limbs and a multitude of other symptoms. Several relatives and the patient's husband were reported to have disease of the spine. The patient did not readily answer questions about her life situation; she denied any family problems and appeared to have no interests outside her home. During examination she reported tenderness or pain on motion at many sites, but the only objective abnormality was modest limitation of active motion of the cervical spine. Straight leg raising with the patient supine caused pain, but the same maneuver "disguised" while the patient was sitting was painless. Throughout her visit, the patient frequently used medical terms (often incorrectly), and her narrative was burdened with innumerable self-diagnoses and interprotations. There seemed to be considerable latent hostility toward physicians; the patient ascribed some of her symptoms to previous diagnostic procedures and repeatedly mentioned the failure of past treatment to afford her relief. She denied any emotional component to her illness even before any such suggestion was made, and became defensive and uttered a blanket denial when this possibility was mentioned. It may be significant that the rheumatic symptoms began shortly after the patient underwent hysterectomy and oophorectomy; her manner of dress and use of cosmetics were appropriate for a younger woman, perhaps suggesting a sense of loss.
with rheumatoid arthritis indicates unfamiliarity with the features of both diseases. Some physicians have equated PR with the debated clinical entity "fibrositis.""i So labeling patients whose rheumatic symptoms stem from emotional disturbance may comfort physicians or patients by creating an aura of organicity about the psychogenic disorder. But such mislabeling is likely to impair understanding of the actual causes of the symptoms, and to promote continued ineffective treatment with antirheumatic measures. The failure of a neurotic patient's symptoms to correspond to an organic entity, and the manner in which he or she presents those symptoms, should often make evident the diagnosis of PR. The physician's role in the course of the illness can be crucial. By making an erroneous diagnosis of "arthritis," by delaying too long in telling the patient any diagnosis or by subjecting the patient to extensive, unrevealing laboratory testing, the physician can increase in the patient's mind the presumption of organic illness, and fix the neurosis more strongly.12"5 This may have occurred in some of the cases in the present study. Conversely, persons with an organic musculoskeletal disorder and a concurrent neurosis should not be labeled as having PR, in the absence of its characteristic manifestations. Nor should the organic rheumatic disease which often accompanies PR be neglected, although evaluation or treatment of the organic condition may be difficult because of the coexisting psychogenic disorder.
Differential Diagnosis The patients with PR plainly had created problems in diagnosis for their physicians. In only two cases did a referring physician indicate that he or she recognized the symptoms as possibly psychogenic. However, the frequency with which the patients had received tranquilizers and antidepressants suggests that the emotional aspects of their illness did not fully escape the attention of their physicans. Astonishingly 11 (38 percent) of the patients with PR reportedly had received a diagnosis of rheumatoid arthritis from a physician, despite the fact that none of them met well-publicized diag-
1. Halliday JL: Psychosomatic medicine and the rheumatism problem. Practitioner 152:6-15, 1944 2. Halliday JL: Psychological factors in rheumatism-A preliminary study. Br Med J 1:213-217, 264-269, 1937 3. Halliday JL: The psychological approach to rheumatism. Proc Roy Soc Med 31:167-178, 1938 4. Boland EW, Corr WP: Psychogenic rheumatism. JAMA 123:805-809, 1943 5. Heaton TG: Arthralgia. Canad Med Ass J 50:515-520, 1944 6. Flind J, Barber HS: The psychogenic basis of some socalled rheumatic pains. Q J Med 54:57-74, 1945 7. Boland EW: Psychogenic rheumatism: the musculoskeletal expression of psychoneurosis. Ann Rheum Dis 6:195-203, 1947 8. Antonelli F: Die Rheumaneurose. Der psychogene oder funktionelle Rheumatismus in psycho-somatischer Betrachtung. Z Psychosom Med 3:1-7, 1956 9. Auquier L: Les fonctionnels vus par le rhumatologue. Acquis Med Recent 1970, pp 129-144 10. Bayles TB: Psychogenic factors in rheumatic diseases, In Hollander JL, McCarty DJ (Eds): Arthritis and Allied Conditions, 8th Ed. Philadelphia, Lea & Febiger, 1972, pp 229-238 11. Ellman P, Savage OA, Wittkower E, et al: Fibrositis-A biographical study of fifty civilian and military cases, from the Rheumatic Unit, St. Stephen's Hospital (London County Council), and a military hospital. Ann Rheum Dis 3:56-76, 1942 12. Weiss E: Psychogenic rheumatism. Ann Intern Med 26: 890-900, 1947 13. Tegner W, O'Neill D, Kaldegg A: Psychogenic rheumatism. Br Med J 2:201-204, 1949 14. Ropes MW, Bennett GA, Cobb S, et al: 1958 revision of diagnostic criteria for rheumatoid arthritis. Bull Rheum Dis 9:175-176, 1958 15. Cohen H: The diagnostic significance of pain. Ann Rheum Dis 10:221-227, 1951 16. Ellman J, Shaw D: The "chronic rheumatic" and his painsPsychosomatic aspects of chronic non-articular rheumatism. Ann Rheum Dis 9:341-357, 1950 17. Rose TF: The positive signs of neurosis. Canad Med Ass J 84:1132-1135, 1961
nostic criteria for that disease14 and none had objective findings of inflammation of the joints. Another six patients had been said to have unspecified "arthritis." A number of the patients had been given dangerous drugs such as corticosteroids and phenylbutazone. Confusion of PR 290
APRIL 1978 * 128 * 4
REFERENCES
Clinical Diagnosis of Psychogenic Rheumatism MICHAEL D. REYNOLDS, MD, Orange, California
Rheumatic symptoms that are a somatic expression of emotional disturbance are common, and often are mistakenly attributed by physicians to organic disease. Psychogenic rheumatism is encountered most frequently among middleaged women. The typical complaint is of widespread pain and stiffness, often with report of swelling and paresthesia, but symptoms characteristically are vague. Overt psychiatric disturbance may be apparent. Distinction from organic disease should not be difficult if physicians recognize the typical presentation, and find that symptoms fail to correspond to patterns of organic disorders. When organic disease coexists with psychogenic rheumatism, as often is the case, the objective abnormalities are insufficient to explain the symptoms. Persons who sifler from psychonieuirotic illness not
inifrequenitly develop a synmptom-complex which includes
pains or aches atnd stigness or limitationi of movement with or without loss of power. Thzis fact has received little emphasis in medical textbooks and has not been systematically disseminated in the teachinzg of under-JAMES L. HALLIDAY' graduates.
IT IS NOW 40 years since Dr. James Halliday called the attention of his colleagues to the frequency with which rheumatic symptoms occur during emotional disorders, warned how often errors in diagnosis and treatment result from neglect of this fact3 and introduced the name "psychoneurotic rheumatism." Halliday and later writers found that from 13 percent to 49 percent of patients with rheumatic complaints cannot be shown to have organic disease which explains their symptoms.'4-9 Despite its frequency, many physicians experience difficulty in recognizing psychogenic rheumatism (PR), or in diagnosing it From the Division of Rheumatology, Department of Medicine, College of Medicine, University of California, Irvine. Supported by a grant from The Arthritis Foundation, Southern California Chapter. Submitted August 15, 1977. Presented in part at the VIII European Rheumatology Congress, Helsinki, Finland, June 5, 1975. Reprint requests to: Michael D. Reynolds, MD, Department of Medicine, 101 The City Dr. S., Orange, CA 92668.
with confidence. Discussions in textbooks,'0 as well as published series of caseS2,C,7,1l-l3 describe many valuable diagnostic features, but do not consider whether characteristics frequently noted in patients with PR are also seen in persons with organic rheumatic disease. Furthermore, these descriptions tend to deal with "pure cases," in which no concurrent organic disorder confuses the clinical presentation. However, structural musculoskeletal disease frequently coexists with PR.4'7'9 For these reasons, an analysis of the clinical features of PR compared with those of common organic articular diseases should be useful.
Materials The records of all consultations by the author during a four year period were reviewed; of these 135 were abstracted with special attention to features that clinical observation and the literature had suggested were frequent in PR. These 135 cases consisted of all in which the principal diagnosis was PR or one of the three most prevalent diseases of joints: rheumatoid arthritis ("definite" or "classical" by criteria of The American Rheumatism Association14), degenerative joint disease THE WESTERN JOURNAL OF MEDICINE
285
PSYCHOGENIC RHEUMATISM
(osteoarthritis) or degenerative intervertebral disk disease. In addition, all cases of predominantly musculoskeletal symptoms, in which no specific diagnosis was made, were analyzed. This was done to examine whether PR was being diagnosed because of specific features or merely by
PR and the other conditions, except disk disease, to a statistically significant degree (p0.05).
0 0 29 15 0 0 38 31*
31*
Undiagnosed
6 3 13 3 3 3 16 3 3
PSYCHOGENIC RHEUMATISM
in the joints and in interarticular areas. Second, these patients are unable to describe the character of pain in terms such as "sharp" or "aching," or by comparison with familiar pains. Sometimes they use uncommon or dramatic terms to describe symptOmS.1"'3"7 Inability of patients to be precise must be distinguished from the effects of impaired memory,'7 and from the difficulty in obtaining definite answers from patients who are circumstantial or perseverating. Generalized Pain.6'7'11"13'17 The feature of generalized pain is well-recognized by most physicians; the patient who "hurts all over" often is mentioned as a prototype of the neurotic patient. When the sites of symptoms are grouped as neck and back (spine), upper limbs and lower limbs, the frequencies with which patients with PR reported involvement of these areas were 83 percent, 93 percent and 100 percent, respectively. The high prevalence of complaints referable to the spine4 differed significantly from the other groups except, of course, degenerative disk disease. Involvement of all three areas is typical of PR (79 percent of cases). Frequently the generalized pain is of a transient and migratory character, changing in intensity and location much more rapidly and irregularly than do the symptoms of persons with arthritis. Some patients' descriptions give the impression of a pattern of symptoms changing almost continuously. Generalized pain should be distinguished from widespread pain. Persons with arthritis or extensive degenerative disease of joints may note pain in many places, but the sites of pain remain discrete, and the patient can easily name places which remain pain-free. Failure of prescribed treatment to reduce symptoms.27""7 Whereas most of the patients in the other groups reported that treatment had given at least partial relief from pain and other symptoms, nearly half of those with PR indicated that they had gotten no benefit from any treatment prescribed. Patients' Manner of Describing the Illness Considering the manner in which patients presented their histories, we noted three features to be characteristic of PR: Presence of several separable rheumatic syndromes. Patients with polyarthritis usually perceive their illness as a single entity whose sites and
intensity vary with time. Persons with degenerative disease of joints may have a few distinct regional syndromes (for example, cervical disk, lumbar disk, knees). But the complaints of those with PR often can be grouped into four, five or more regional sets more or less clearly distinguishable on the basis of their symptoms, temporal patterns, inciting and relieving factors, and the like. This is not just a manifestation of lack of precision in describing symptoms; the patients themselves often perceive their problem as manifold and describe different symptoms in different regions of the body. Prominent nonrheumatic complaints without evident organic basis.7 Most of the patients who did not have PR confined their complaints to the musculoskeletal system, during a rheumatological consultation. But nearly a third of those with PR complained, along with rheumatic symptoms, of problems in other organ systems, whose organic basis was inapparent. The colon was the organ most often featured in these nonrheumatic problems, and in several patients extensive studies of the gastrointestinal tract had been carried out. Use of medical words; self-diagnosis. Patients sometimes offer only a diagnosis when asked to describe their problem. The physician must then ask detailed questions to find out what symptoms lie behind that diagnosis.15 (Patients with genuine arthritis often will give the diagnosis as a chief complaint, but have no hesitation about describing the symptoms.) In cases of self-diagnosis, a history of reading newspaper and magazine articles or books about the supposed illness may emerge. In other cases, a too-hasty attribution of symptoms to "arthritis," "bursitis" and the like by a physician previously visited has been seized upon by the patient.15 Previous Illness and Medical Care of Patients The final aspect of the in'terview which indicated the presence of PR was the history of previous illness and medical care. Previous rheumatic illness or injury. Halliday2 and others4'5 have noted -the importance of previous rheumatic illness or injury in determining the form or the site of a somatic expression of emotional stress. Previous rheumatic illness was fairly frequent in the other groups, but significantly less so than among the patients with PR. Consultation with multiple physicians. Another feature is consultation with several physicians regarding the present rheumatic illness.'5 We defined THE WESTERN JOURNAL OF MEDICINE
287
PSYCHOGENIC RHEUMATISM TABLE 4.-Physical Findings on Rheumatologic Examination Sign
Psychogenic Rheumatism
Tenderness of musculoskeletal structures ..... ......... 90 Generalized tenderness ........ ..................... 24 Inconsistent manifestations ....... ................... 24 Hyperreactivity ................................... 7 Deformityt . ..................................... 0 0 Soft tissue swelling or effusion at joints ..... .......... .................. 21 Bony enlargement of joints ....... Crepitus ......................................... 14 ....................... 34 Pain on motion ............ ..................... 24 Limitation of motion ......... Absence of objective signs of rheumatic disease .... .... 48
Percent Frequency Found with Rheumatoid Degenerative Degenerative Arthritis Joint Disease Disk Disease
51 3 3 0 71 91 26* 66 57 86 0
52 0 0 0 56 41 78 74 48 56 0 significant (p>O.05).
85* 0 8
0 54 8* 62 62 38* 85 0
Undiagnosed
65 0 0 0 3*
29 13 13* 48 35 48*
*Difference between this figure and frequency with psychogenic rheumatism is not tExcluding deformities of the feet, mild degrees of which are frequent in healthy persons.
this as the patient's having, on his or her own initiative, consulted three or more physicians without apparent reason except dissatisfaction. This correlates with the report of failure of treatment to relieve symptoms (above). Patients with disk disease had multiple physician contacts as frequently as did those with PR. Prior psychiatric treatment. Prior psychiatric treatment was usually in the form of tranquilizers or antidepressants provided by the patients' regular physicians, rather than therapy by a psychiatrist. Patients with disk disease also had frequently received such drugs. A high prevalence of past psychoneurotic illness has been reported in some studies of PR.4'6'7"6
Nondiagnostic Features of Histories In this study, some features which have been said to be typical of PR were not found more often with that disease than with organic disorders. Female sex of patient. The proportion of women to men was the same as for the other rheumatic disorders (Table 1). Recognized sexrelated factors, such as willingness to seek medical attention, preclude any valid statement about a predilection of PR for one sex, in the absence of epidemiologic studies of populations. Many cases of PR in men were collected by military physicians during wartime.4-6"' Absence of visible change in symptomatic areas.6 Only 31 percent of the patients with PR did not claim some change in the appearance of affected parts. Nearly half reported that they had swollen joints; this symptom usually was not confirmed by examination.4 Lack of external inciting or relieving influences on symptoms.7 Patients with PR commonly stated 288
APRIL 1978 * 128 * 4
that their pain was influenced by use of the affected part, and often attributed worsening to inclement weather. Absence of disability.13 Report of difficulty in carrying out usual activities was as common among patients with PR as among those with organic disease. Multiple surgical operations.'5 17 A history of more than three operations was not more frequent in the group with PR. Family history of rheumatic disease.4"6 This was very common in all groups. (However, we have seen cases of PR in children in which the symptoms were plainly a pattern of behavior learned from a neurotic mother.) Marital discord.'6 Separation, divorce or expressed unhappiness with the spouse were not significantly more common in the group with PR. (Despite its small diagnostic value, evidence of marital discord should be sought because it is the major environmental factor in the genesis of some cases of PR.)
Findings on Physical Examination The findings on physical examination also provide clues to the presence of PR (Table 4). The most frequent finding was tenderness of musculoskeletal structures. A psychogenic basis for reports of tenderness was indicated by a nonanatomical distribution.7 The sites reported as tender did not correspond to typical sites of individual rheumatic diseases, to specific anatomical structures, to specific tissues or to patterns of pain reference. One form of this is generalized tenderness (the physical analogue of the symptom of "hurting all over"). A second sign of the nonorganic nature of complaints of pain and tenderness was incon-
PSYCHOGENIC RHEUMATISM TABLE 5.-Psychiatric Syndromes Manifested by Patients Psychiatric Syndrome
Depression ...... Anxiety ...... Hysteria ...... Total
......
Psychogenic Rheumatism
Rheumatoid
17* 17 7 41
0 0 0 0
Arthritis
Percent Frequency Found with Degenerative Degenerative Joint Disease Disk Disease
0 0 0 0
0 8 0 8
Undiagnosed
6 3 0 9
*In two (7 percent) of the depressed patients there also were manifestations of anxiety. I
sistent manifestations.13"15 Failure of repeat palpation of previously tender sites to provoke renewed signs of discomfort was associated with PR. A more subtle inconsitstency was normal posture, movement and gait during the interview, or when the patient was unaware of being observed, which changed to painful, abnormal motor activity during the formal physical examination. Hyperreactivity and withdrawal from the examiner'0 (what Boland7 has appropriately called a "touch-menot" response) has been said to be characteristic of PR, but was observed only infrequently in this series. More often, patients with PR reported pain while evincing none of the signs-facial expression, tensing of muscles or withdrawal-which normally accompany a truly painful examination. Such patients might assert "That's very sore" in a completely bland manner. A most important finding was that more than a third of the patients with PR had identifiable joint disease. Degenerative disk disease was present in six and osteoarthritis in four (in one combined with disk disease); one had a "frozen" shoulder and one had congenital disease of a hip. (We have also seen PR occurring with rheumatoid arthritis.) A similar frequency of coexisting organic disease (28 percent to 40 percent) has been noted in previous studies.4'7'9 Important evidence of PR in these cases was that the symptoms did not correspond in their site, character or severity to those expected from the observed lesions; in other words, the observed organic changes do not explain the symptoms of which the patienzt complains.4 Only about half the patients with PR were completely free of objective signs of rheumatic disease. Nevertheless, the prevalence of most objective signs of articular disease (deformity, soft tissue swelling or effusion, crepitus, limitation of motion) was significantly lower among patients with PR than in the other groups. The exception was the bony enlargement of osteoarthritis, which was present with about equal frequency among those with PR, rheumatoid arthritis
and an undiagnosed disorder. The subjective report of pain during motion was significantly less frequent among those with PR than in the other groups. Diagnosis of a specific psychiatric disorder could be made from the patient's behavior in certain cases (Table 5). Depression was considered to be present when there were a history and an appearance of sadness (including weeping) and of psychomotor retardation, sometimes with supporting symptoms such as morning insomnia. Often an explanatory life situation was uncovered. Anxiety was diagnosed on the basis of an appearance of tenseness and restlessness, and expressions of apprehension and concern. This was sometimes combined with a tendency to fidget continuously with some object in the hands. Two patients reported a plethora of symptoms, but exhibited relative indifference to symptoms, and denial of emotional stress. Their behavior toward the examiner had seductive or sexual overtones. They were thought to qualify for a diagnosis of hysteria. Detailed, formal psychiatric investigation was not attempted; presumably it would have led to a larger number of specific diagnoses.06""6 Specific syndromes were noted significantly more often among patients with PR than among those with organic disease.
Report of a Case A 55-year-old woman, a nurse's aide retired because of disability, stated "my spine is going to pieces." Seven years previously she had begun to have pain in the neck and head, with weakness and paresthesias in the upper limbs, which progressed over several years to a "pulsating, throbbing" pain in the "whole spine." Roentgenograms showed minimal degenerative cervical and lumbar disk disease, but an electromyogram was abnormal, and anterior fusion of the 5th and 6th cervical vertebrae was done. This relieved symptoms only for a few weeks; a second fusion operation one level higher was equally unsuccessful. The THE WESTERN JOURNAL OF MEDICINE
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patient now complained of pain in almost all regions of the body, paresthesias in the limbs and a multitude of other symptoms. Several relatives and the patient's husband were reported to have disease of the spine. The patient did not readily answer questions about her life situation; she denied any family problems and appeared to have no interests outside her home. During examination she reported tenderness or pain on motion at many sites, but the only objective abnormality was modest limitation of active motion of the cervical spine. Straight leg raising with the patient supine caused pain, but the same maneuver "disguised" while the patient was sitting was painless. Throughout her visit, the patient frequently used medical terms (often incorrectly), and her narrative was burdened with innumerable self-diagnoses and interprotations. There seemed to be considerable latent hostility toward physicians; the patient ascribed some of her symptoms to previous diagnostic procedures and repeatedly mentioned the failure of past treatment to afford her relief. She denied any emotional component to her illness even before any such suggestion was made, and became defensive and uttered a blanket denial when this possibility was mentioned. It may be significant that the rheumatic symptoms began shortly after the patient underwent hysterectomy and oophorectomy; her manner of dress and use of cosmetics were appropriate for a younger woman, perhaps suggesting a sense of loss.
with rheumatoid arthritis indicates unfamiliarity with the features of both diseases. Some physicians have equated PR with the debated clinical entity "fibrositis.""i So labeling patients whose rheumatic symptoms stem from emotional disturbance may comfort physicians or patients by creating an aura of organicity about the psychogenic disorder. But such mislabeling is likely to impair understanding of the actual causes of the symptoms, and to promote continued ineffective treatment with antirheumatic measures. The failure of a neurotic patient's symptoms to correspond to an organic entity, and the manner in which he or she presents those symptoms, should often make evident the diagnosis of PR. The physician's role in the course of the illness can be crucial. By making an erroneous diagnosis of "arthritis," by delaying too long in telling the patient any diagnosis or by subjecting the patient to extensive, unrevealing laboratory testing, the physician can increase in the patient's mind the presumption of organic illness, and fix the neurosis more strongly.12"5 This may have occurred in some of the cases in the present study. Conversely, persons with an organic musculoskeletal disorder and a concurrent neurosis should not be labeled as having PR, in the absence of its characteristic manifestations. Nor should the organic rheumatic disease which often accompanies PR be neglected, although evaluation or treatment of the organic condition may be difficult because of the coexisting psychogenic disorder.
Differential Diagnosis The patients with PR plainly had created problems in diagnosis for their physicians. In only two cases did a referring physician indicate that he or she recognized the symptoms as possibly psychogenic. However, the frequency with which the patients had received tranquilizers and antidepressants suggests that the emotional aspects of their illness did not fully escape the attention of their physicans. Astonishingly 11 (38 percent) of the patients with PR reportedly had received a diagnosis of rheumatoid arthritis from a physician, despite the fact that none of them met well-publicized diag-
1. Halliday JL: Psychosomatic medicine and the rheumatism problem. Practitioner 152:6-15, 1944 2. Halliday JL: Psychological factors in rheumatism-A preliminary study. Br Med J 1:213-217, 264-269, 1937 3. Halliday JL: The psychological approach to rheumatism. Proc Roy Soc Med 31:167-178, 1938 4. Boland EW, Corr WP: Psychogenic rheumatism. JAMA 123:805-809, 1943 5. Heaton TG: Arthralgia. Canad Med Ass J 50:515-520, 1944 6. Flind J, Barber HS: The psychogenic basis of some socalled rheumatic pains. Q J Med 54:57-74, 1945 7. Boland EW: Psychogenic rheumatism: the musculoskeletal expression of psychoneurosis. Ann Rheum Dis 6:195-203, 1947 8. Antonelli F: Die Rheumaneurose. Der psychogene oder funktionelle Rheumatismus in psycho-somatischer Betrachtung. Z Psychosom Med 3:1-7, 1956 9. Auquier L: Les fonctionnels vus par le rhumatologue. Acquis Med Recent 1970, pp 129-144 10. Bayles TB: Psychogenic factors in rheumatic diseases, In Hollander JL, McCarty DJ (Eds): Arthritis and Allied Conditions, 8th Ed. Philadelphia, Lea & Febiger, 1972, pp 229-238 11. Ellman P, Savage OA, Wittkower E, et al: Fibrositis-A biographical study of fifty civilian and military cases, from the Rheumatic Unit, St. Stephen's Hospital (London County Council), and a military hospital. Ann Rheum Dis 3:56-76, 1942 12. Weiss E: Psychogenic rheumatism. Ann Intern Med 26: 890-900, 1947 13. Tegner W, O'Neill D, Kaldegg A: Psychogenic rheumatism. Br Med J 2:201-204, 1949 14. Ropes MW, Bennett GA, Cobb S, et al: 1958 revision of diagnostic criteria for rheumatoid arthritis. Bull Rheum Dis 9:175-176, 1958 15. Cohen H: The diagnostic significance of pain. Ann Rheum Dis 10:221-227, 1951 16. Ellman J, Shaw D: The "chronic rheumatic" and his painsPsychosomatic aspects of chronic non-articular rheumatism. Ann Rheum Dis 9:341-357, 1950 17. Rose TF: The positive signs of neurosis. Canad Med Ass J 84:1132-1135, 1961
nostic criteria for that disease14 and none had objective findings of inflammation of the joints. Another six patients had been said to have unspecified "arthritis." A number of the patients had been given dangerous drugs such as corticosteroids and phenylbutazone. Confusion of PR 290
APRIL 1978 * 128 * 4
REFERENCES
