International Journal of Pediatric Otorhinoluryngology, 0 Elsevier/North-Holland Biomedical Press

INTRACTABLE PAROXYSMAL REACTION OF ADOLESCENCE

I. RONALD EVA EBIN

SHENKER,

MICHAEL

SNEEZING:

NUSSBAUM,

1 (1979)

171

171-175

A CONVERSION

ALLAN

L. ABRAMSON

* and

Department of Pediatrics, Division of Adolescent Medicine and the Division of Otolaryngology, Long Island Jewish-Hillside Medico1 Center, New Hyde Park, New York and School of Medicine, Health Sciences Center, State University of New York at Stony Brook, N. Y. (U.S.A.) (Received (Accepted

June 13th, 1979) July 13th, 1979)

SUMMARY

A case of recurrent paroxysmal sneezing in an adolescent girl is reported with a review of the literature. The mechanisms of sneezing are described. Most cases appear to have a psychogenic etiology. We postulate that this is a conversion symptom in which the patient received secondary gain and probably represents a pre-Oedipal conflict.

INTRODUCTION

Sneezing is a self-limited and non-debilitating physiological phenomenon. Paroxysmal sneezing, however, is an infrequently reported clinical entity occurring more commonly in adolescence than at other times of life. The purpose of this paper is to report a case of paroxysmal sneezing and to review the literature of this unusual condition. CASE REPORT

The case was a 13.5-year-old white post-menarchal female, admitted to Long Island Jewish-Hillside Medical Center Adolescent Unit with a one week history of uncontrollable sneezing, with a frequency of once every 7-20 sec. There was no sneezing during sleep. An otolaryngologist, neurologist and a psychiatrist who saw her prior to admission agreed that this sneezing was of non-organic origin. After one dose of haloperidol prescribed by a psychia-

* To whom correspondence should be addressed at: Division of Otolaryngology, Island Jewish-Hillside Medical Center, New Hyde Park, N.Y. 11040, U.S.A.

Long

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trist, a bizarre reaction occurred lasting 1.5 h in which she screamed: “Daniel is inside me trying to kill me” and “MS-31 is trying to kill me.” The patient was admitted at this time for more aggressive therapeutic intervention. There were nose bleeds during childhood. There is no family history of allergies. She comes from an upper middle class background and had been accustomed to generous funds for her own amenities. Eight months prior to the onset of her symptoms, her father lost his business which resulted in curtailment of finances available to her. Although adjustments were made by the parents and other siblings, she was unable to accommodate to a more stringent household budget. School performance declined in the months prior to admission, and she became rebellious and antagonistic at home. She denied the use of drugs and any sexual activity. Physical examination revealed chronic nasal irritation, and she sneezed at the rate of once every 7 set throughout the examination. There was no apparent respiratory distress nor evidence of a foreign body in the nose. The remainder of the physical examination was within normal limits. The laboratory data, including a complete blood count, erythrocyte sedimentation rate, serology, pregnancy test, roentgenograms of the paranasal sinuses and skull, and nasal cultures, were all within normal limits. Otolaryngological consultation revealed no intranasal abnormality other than a minimal septal deviation. In an attempt to eliminate the sneezing, the mucous membranes of the nose were anesthetized with topical 10% cocaine. The sphenopalatine ganglion was anesthetized with 2% xylocaine by injecting this solution through the greater palatine foramen. Sneezing continued throughout this procedure. After the extensive local and regional anesthesia was completed, the patient was topically tested for nasal sensation. Her answers were inconsistent. The patient was interviewed utilizing sodium amytal to uncover possible motivation of these symptoms and to utilize post-amytal suggestions to end the sneezing paroxysms. She received 400 mg of sodium amytal during a 45 min period and became drowsy but non-somnolent. The frequency of sneezing decreased but later returned to the initial rate. During the interview, the patient was asked when the sneezing would cease. Although she stated that it was “not mental”, she indicated that her sneezing would cease in three days. During a second interview under sodium amytal the next day, she appeared more relaxed and revealed that she learned a “fake sneeze” in the second grade. The paroxysmal sneezing continued throughout that day, when the patient’s grandmother, who was always indulgent, arrived from Florida. She offered to take the patient shopping for a new Spring wardrobe if she were discharged, and her symptoms ceased. The next day the patient suddenly stopped sneezing. She was discharged with a recommendation for psychotherapy. Eighteen months following discharge, the parents indicated that the patient had seen a psychiatrist on only two occasions. She has had no recurrence of paroxysmal sneezing, but continues to be a behavior problem at

173

home and a marginal school performer, in spite of a bright, normal level of intelligence. Financial pressures remain in the family which are an apparent trigger for spontaneous antagonistic behavior. One such episode involved her running away to Florida for 24 h. DISCUSSION

Sneezing is a complicated physiologic process which encompasses both nasal and respiratory phases. It begins with sensation of the afferent endings of the fifth nerve of the nasal mucosa. The stimulus is transmitted to centers in the medulla which then send efferent impulses to the mucus glands in the nose resulting in the production of clear fluid. This material, in turn, initiates a second afferent message to the respiratory centers in the medulla which act to produce a forcible expiration of air through the nose by means of the diaphragmatic and rib musculature. This pathway is further complicated by extra nasal afferent impulses such as response to bright light or sudden chill, which may produce a sneeze [ 7,8,13]. The causes of paroxysmal sneezing include organic conditions such as allergy, local disturbances, tabes, mild encephalitis, poliomyelitis, and other central nervous system diseases, and functional disturbances such as hysteria and neuroses [ 131. A review of the literature of report& cases is summarized in Table I. Of the 15 cases reported, 11 were adolescents, 7 females and 4 males. All 11 cases were due to an underlying emotional or psychogenic problem. Characteristically, the sneezing episodes do not occur during sleep and are refractory to a wide variety of medications that are ordinarily used to control sneezing. It has been considered that a prior allergic history may account for this condition [ 7] ; however, only 5 of these patients had a history of atopy. In our patient, the etiology of the paroxysmal sneezing was a conversion reaction. Conversion reaction, conversion hysteria and psychosomatic disorders are all within the group classified as physiologic responses to psychic stress. Psychosomatic disorders most often affect the organs regulated by the autonomic nervous system, whereas conversion reactions appear more frequently in the voluntary motor system. There is, however, crossover between these two groups, since many of the symptoms characteristic of conversion reactions, such as nausea, vomiting, and fainting, are mediated in part at least through the autonomic nervous system. In psychosomatic as well as conversion syndromes, an affect or a drive is rendered unconscious by repression and is converted into a somatic symptom. The unconscious drives are accepted to be of a sexual nature originating in the Oedipal period. Freud [1,4] postulated, and it has been widely accepted, that conversion hysteria is related to the Oedipus conflict with its struggle to surmount incestuous genital sexual and hostile strivings. Symptoms represent a reactive hostility to frustration of genital sexual wishes. Thus, the symptoms offer a “solu-

9 10 11 12 13 14 15

1 2 3 4 5 6 7 8

Case

Shilkert [ 141 Miami News [ 121 Kanner [6] J. Amer. med. Ass. [ 111 Zolov [ 151 Zolov (pers. commun., 1976) Zolov (pers. commun., 1976)

Kofman [ 8 ] Kofman [ 81 Kaplan and Lanoff [ 7 ] Kaplan and Lanoff [ 7 ] Kaplan and Lanoff [ 7 ] Murray and Bierer [lo] Elkins and Milstein [ 21 Kammermeier [ 5 ]

Source/author

REVIEW OF REPORTED CASES

TABLE I

40 17 13 69 15 14 14

11 39 13 15 12 14 13 21

Age (years)

F F F M M F F

F M M F M M F F

Sex

Negative Not reported Not reported Not reported Not reported Not reported Not reported

Not reported Not reported Positive Positive Positive Positive Positive Negative

History of allergy Psychogenic Seizures Psychogenic Psychogenic Psychogenic Psychogenic Psychogenic TB Lymphadenitis Psychogenic Psychogenic Psychogenic Psychogenic Psychogenic Psychogenic Psychogenic

Etiology

Psychotherapy Anti-convulsants Psychotherapy Psychotherapy Conditioned response reflex Hypnosis and psychotherapy Hypnosis Antituberculosis therapy and surgery Suggestion therapy Operant conditioner Psychotherapy Not reported Psychotherapy Psychotherapy Psychotherapy

Treatment

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tion” to this by short-circuiting perceptions of the conflict. This is the patient’s primary gain. Secondary gains are also of importance. These are achieved by the patient using the symptoms to manipulate people or situations. Recent investigators [ 3,9] point out that pre-Oedipal aggressive drives can be expressed through conversion channels as well. Even primitive oral narcissistic drives are the central etiologic factors in some patients. The symptoms provide gratification for strong unconscious dependency needs. The goal in therapy is to translate this “body language” into words through psychoanalysis or other therapeutic modalities. A pre-Oedipal conflict can be postulated in our patient. The patient described in this paper has strong dependency needs which conflict with adolescent sexual strivings. Her reluctance to enter a psychotherapeutic relationship makes a more definitive etiology difficult to determine. However, an Oedipal conflict is also possible in view of the damaged image of her father. Secondary gains were of paramount importance in the etiology of this conversion reaction. ACKNOWLDGEMENT

This work was supported ter Research Grant 3-792.

by the Long Island Jewish-Hillside

Medical Cen-

REFERENCES 1 Bruer, J. and Freud, S., Studies in Hysteria, Nervous and Mental Disease, New York, 1950. 2 Elkins, M. and Milstein, J.J., Hypnotherapy of pseudo-sneezing, a case report. Amer. J. clin. Hypnosis, 4 (1962) 273. 3 Fitzgerald, O., Love deprivation and the hysterical personality, J. ment. Sci., 94 (1948) 701. 4 Freud, S., Introductory Lectures on Psychoanalysis, Hogarth and Institute of Psychoanalysis, London, 1924. 5 Kammermeier, R., HNO 5 (1955) 230. 6 Kanner, L., Child Psychiatry, 4th edn., Charles C. Thomas, Springfield, Ill., 1972, p. 634. 7 Kaplan, J.J. and Lanoff, G., Intractable paroxysmal sneezing. A clinical entity defined with case reports, Ann. Allergy, 28 (1970) 24. 8 Kofman, O., Paroxysmal sneezing, Canad. med. Assoc. J., 91(1964) 154. 9 Marmor, J., Orality in the hysterical personality, J. amer. psychoanal. Ass., I(l954) 656-671. 10 Murray, N. and Bierer, J., Prolonged sneezing. A case report. Psychosom. Med., 13 (1951) 56. 11 Questions and answers, J. Amer. med. Ass., 219 (1972) 1350. 12 School girl still sneezes but feels fine. A.P. Newspaper Report, Miami, Florida, 1967. 13 Shapiro, S.L., Paroxysmal sneezing, Eye, Ear, Nose Thr. Monthly, 46 (1967) 1532. 14 Shilkert, H., Psychogenic sneezing and yawning. Psychosom. Med., 11 (1949) 127. 15 Zolov, B., Intractable paroxysmal sneezing, case report and review of literature. A.M.A. Scientific Session, San Francisco, June 1972.

Intractable paroxysmal sneezing: a conversion reaction of adolescence.

International Journal of Pediatric Otorhinoluryngology, 0 Elsevier/North-Holland Biomedical Press INTRACTABLE PAROXYSMAL REACTION OF ADOLESCENCE I...
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