Refer to: Morrison JR: Management of Briquet syndrome (hysteria). West J Med 128:482-487, Jun 1978

Management of Briquet Syndrome (Hysteria) JAMES R. MORRISON, MD, La Mesa, California

The common psychiatric disorder Briquet syndrome (hysteria) has no specific treatment, but it can be managed effectively. Careful diagnosis and differentiation from other psychiatric and medical disorders is the important first step. Surgical intervention should be kept to a minimum; medicines are given cautiously and controlled carefully. The treatment of choice is supportive psychotherapy which ignores physical symptoms and encourages the patient to change the method she uses of coping with her environment. A GENERATION AGO there was no problem; a diagnosis of hysteria meant a patient with a conversion reaction (a symptom with no evident physical cause). Either placebos were prescribed or the patient was shipped off to an analyst for psychotherapy. Neither approach benefited the patient much, but both helped the physician rid his practice of "crocks" so he could concentrate on "treating sick people." Simple. That is the way it was for decades, until an American named Guze resurrected the work of a Frenchman named Briquet. Since then a physician facing the often thankless challenge of the hysteric patient has had a few more options in treating this tricky illness.

Diagnosis First Any plan for management must lie upon the bedrock of a careful diagnosis. The trouble is that too many psychiatric diagnoses are too unreliable to permit planning. Conversion reaction, for example, is all but useless as a diagnosis-a third of all women have had such an experience at some time or other.' Investigators who follow Dr. Morrison is in private practice. Submitted, revised, December 19, 1977. Reprint requests to: James R. Morrison, MD, 5131 Garfield Street, La Mesa, CA 92041.

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up cases of patients with conversion reaction2 find a variety of outcomes, including multiple sclerosis, schizophrenia, brain tumors and manic depressive disease-plus a number of perfectly healthy people, and more with "hysteria." Even the value of hysteria as a diagnosis is diminished by the whim of individual interpretation. Some physicians equate it with conversion reaction; others relate it to a personality pattern that is dramatic, excitable and ingratiating. But many use it as a pejorative to describe unwanted behavior in their patients (or relatives). Clearly, a rational approach to treatment had to await a valid, reliable definition of the illness. That began to come together about 20 years ago. Following earlier work of Purtell and co-workers,3 Guze24 identified an illness characterized by multiple somatic and psychiatric complaints, frequent visits to physicians and a proclivity for polysurgery, often done unnecessarily. Many of the patients involved also have the typical hysterical personality, and many have had conversion reactions as well-but neither is necessary to the diagnosis. Rather, the syndrome is described in easily understood operational terms which produce excellent agreement among independent observers (see Table 1 and accompany-

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ing explanation). Defined in this way, years later 90 percent or more of the patients involved retain the same diagnosis, a vast improvement over other classifications.2 Although Briquet described this polysymptomatic disorder 100 years ago,5 his insight was ignored until recently. Recognizing the need to differentiate this condition from the other meanings of the term hysteria, Guze proposed the eponymous Briquet syndrome. Succinct and clinically meaningful, this term has gained some currency over the past few years, and will be used hereafter to describe these cases. Of course, the diagnosis will never be made unless the physician is suspicious enough to ask

the right questions. This should happen whenever he encounters a patient who has multiple (often vague) complaints, who bears the badge of doctor shopping (a paper bag containing a potpourri of pills), who appears to cling to ill health no matter how expert the treatment or who, with one symptom successfully treated, triumphantly returns with two more. Family practitioners and internists probably see the bulk of these patients, although many are eventually referred to psychiatrists-in my own practice, 6 percent of adult women (in men, Briquet syndrome is virtually never diagnosed") carry this diagnosis. Surgeons, too, are heavily patronized: in one study7 hysteric patients had

TABLE 1.-Diagnosing Briquet Syndrome

II

III

IV

V

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 This

sickly most of life headaches blindness paralysis anesthesia

aphonia convulsions or fits unconsciousness amnesia deafness hallucinations urinary retention (requiring catheterization) ataxia other pseudoneurological symptoms fatigue lump in throat fainting spells visual blurring weakness dysuria dyspnea palpitations of heart anxiety attacks chest pain dizziness

anorexia abrupt weight loss frequent weight fluctuations nausea

abdominal pain vomiting VII dysmenorrhea menstrual irregularity amenorrhea (2 months or more) excessive bleeding with menses VIII sexual indifference ("If I never had sex again I wouldn't care") 41 dyspareunia 42 other sexual problems 43 frigidity (absence of orgasm with regular interVI

34 35 36 37 38 39 40

course) 44 hyperemesis gravidarum (all 9 months of pregnancy, or hospital admission for vomiting) IX 45 back pain 46 joint pain 47 extremity pain 48 burning pains of mouth, rectum, genitalia 49 other body pains X 50 nervousness 51 phobias 52 depression 53 unable to work because of being sick 54 crying spells 55 hopelessness 56 frequent thoughts of death 57 death wishes 58 ideas of suicide 59 suicide attempts

abdominal bloating food intolerance (3 or more) diarrhea

constipation chronic illness begins by age 35, but usually in the early teens. It is diagnosed in the absence of organic pathologic conditions sufficient to explain symptoms, and if no other psychiatric diagnosis (for example, manicdepressive disease) is more likely. For a definite diagnosis of Briquet syndrome the patient must have a dramatic, chronic illness with 25 or more symptoms in at least nine of the ten categories in the table: 20 or more symptoms in eight categories qualifies as probable Briquet syndrome. This symptom review covers the patient's lifetime, not just the present illness. A symptom is scored positive only if the patient has seen a physician for it, taken medicine other than aspirin for it, or if it has significantly interfered with her life. Occasionally, a symptom may be scored as positive even if it does not meet one of the three foregoing criteria provided it is sufficiently impressive: a 10-minute episode of tunnel vision or paralysis may qualify, for example. THE WESTERN JOURNAL OF MEDICINE

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had three times more operations than controls. This illness, beginning in adolescence and persisting throughout life, probably affects 1 to 2 percent of all women and girls.' So from pediatricians to gerontologists, every physican can expect to encounter a number of these patients. Having decided that his patient's symptoms are not physiological, a physician still faces a major diagnostic problem-depression. Confusion arises not only because depression plays a significant role in Briquet syndrome, but also because in some patients with depression, multiple somatic symptoms develop. In a patient in good health before an episode of depression ("this is really a change from her normal self, Doctor") tricyclic antidepressants should be tried to rule out primary affective disorder. If the patient's condition does not respond to an adequate trial (up to 300 mg per day of amitriptyline for three weeks), or if a patient bitterly complains of drowsiness after the first 25 mg tablet-a typical, but by no means pathognomonic reaction-and if the criteria for Briquet syndrome otherwise are met, then administration of antidepressants should probably be stopped. Although other treatments for endogenous depression abound, to ring the changes on all of them would take months. And by that time the patient would be thoroughly incapacitated by all the attention. No single effective treatment exists for this condition. But with attention to the detail of a

carefully thought-out plan, a physician can manage these patients effectively.

Management Management by a physician (rather than physicians) is the first and in some ways the most important principle. It helps solve several problems. One doctor, thoroughly familiar with his patient, can more easily judge whether a new symptom requires investigation, thereby avoiding multiple workups and inappropriate treatment. It also avoids the secondary gain-attention-the patient experiences each time she retells her story. And limiting the number of physicians curtails the patient's scope for manipulation. There is a corollary of "one patient, one doctor": the family physician or internist may be best able to provide continuing evaluation and care, using surgeons and other specialists (psychiatrists included) as consultants-sparingly. 484

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Upon assuming care of the patient with the newly diagnosed condition, one of the physician's first tasks may be to reevaluate the forest of pill bottles with which the patient festoons his desk. Most will be unnecessary, a few potentially harmful. The latter should be discarded at once; the remainder may be eliminated outright, phased out or replaced. Suddenly stopping administration of psychotropic drugs can'backfire. Aside from the psychological dependence these people develop towards their medications, which would surely cause them to seek another physician if the drugs are discontinued abruptly, withdrawal syndromes can occur, particularly with barbiturates and tricyclics. When withdrawing medication the doctor should point out that despite the drugs the symptoms have continued, some of which may be caused by too many pills rather than too few. The patient should be told that she will not be refused medicines she really needs, but that they will be consolidated. The transition to no medicine can be eased by playing upon the pride all people feel at "doing it themselves" without pills; during this phase, more frequent visits (perhaps weekly) may be necessary. Of course, we have to live with reality. In Briquet syndrome this means accepting the fact that some patients will continue to need medication for a while. Then it becomes the physician's job to find a drug which, above all, offers the smallest chance for abuse and side effects. Several drugs can be excluded right away. Barbiturates and certain other hypnotics like glutethimide and. chloral hydrate should be avoided because of their low safety margin and high potential for addiction. Lithium has no place in the treatment of Briquet syndrome. Antidepressants can be tried if the diagnosis is not clear, but because they are potentially lethal they should be carefully monitored or issued in small quantities (no more than a seven-day supply at a time). Phenothiazines have been popular for patients with neuroses and anxiety, but their potential for extrapyramidal side effects and tardive dyskinesia, combined with their very questionable benefit in this condition, suggests that they be used with extreme caution, if at all. The benzodiazepines come closest to fulfilling our requirements for efficacy and safety. When given at bedtime they promote sleep, and their long half-life in the body allows the anxiolytic effect to persist well into the next day. But in

BRIQUET SYNDROME (HYSTERIA)

patients who need to feel more direct control over anxiety smaller doses may be required on a carefully controlled basis during the day according to circumstances. Prescriptions should be written for exact amounts needed between appointments, without refills; most patients should do reasonably well on a regimen of 20 mg per day or less of diazepam or equivalent, and the total dose should never exceed 40 mg per day. And the medication should be phased out as quickly as possible.

Dealing With Symptoms Most symptoms can be handled best by adopting a learning theory paradigm which applies a rational system of selective attention and reward. Symptomatic behavior persists only as long as it continues to be reinforced; withdrawal of the reinforcement must be accomplished to extinguish the symptom. Hyperventilation attacks will continue as long as the family caters to the patient's wishes, rushes her to an emergency room or berates her for her misbehavior. They will diminish when ignored. This approach, which involves both hospital staff and family, may require some coordination by the physician to get underway. This approach avoids fruitless confrontation with the patient as to whether symptoms are real or imaginary (polemics centered about this issue are not only not useful but, because they involve a reward of sorts, may reinforce the pathologic condition they seek to dismantle). It is sufficient for the patient, and should be for the physician, that her pain seems real; raising the issue that it is "all in your head" only produces mistrust or anger at the doctor. A more practical approach accepts as fact the perceived pain, but emphasizes the interpretation that anxiety (nervousness) can worsen symptoms of any stripe. The physician points out that attacking symptoms directly has not proven effective, and suggests that dealing with the problems that produce stress may be more helpful. Not all patients respond negatively to the concept of psychosomatic causality. Some actually feel relief when given an explanation more understandable than vague viral syndromes or intangible internal disorders. A few, undeniably those with milder symptoms, are so willing to accept this explanation that they later can say, "Yes, I have anxiety attacks, pain, hyperventilation (or whatever), but the doctor told me it was just nervousness, so I don't worry about it

anymore." This attitude may be fostered during psychotherapy by presenting the psychological interpretation in a positive light: "You'll feel relieved to learn that your headaches don't mean that anything is seriously wrong." Another useful approach to symptoms is to assume that the patient will continue to have them for some time. As Jay Haley8 explains, the perversity of human nature is such that patients try to confound physicians' expectations. If the doctor says "I suspect you will continue to be bothered by this for a while yet," she may try to defeat this prediction, too, by improving. In this manner the physician can avoid being put on the defensive, a maneuver at which his patient may be adept. If the patient continues symptomatic he can in all honesty respond, "Yes, I thought this problem might continue." For a patient in hospital, a variant of the reward and punishment system may be used to control symptoms. A method has been described by Dickes9 in which patients with conversion reactions are isolated and given privileges contingent upon symptom reduction. The doctor defines this approach as therapy, and tells her he is limiting her activities so she will not hurt herself. Because of this structure the patient cannot view her experience as punishment, so she must accept it without becoming angry at the physician. As affect brightens and she stops talking of suicide, she can be moved off the locked unit; further privileges accrue as improvement continues. The disadvantage of this method is that the patient must be admitted to hospital, and that contradicts one of the overall goals of therapy in Briquet syndrome: avoid hospital admission and medical procedures. However, the magnitude of behavior in this syndrome occasionally becomes so intolerable to patient and family that a brief hospital stay must be permitted. Sterile saline injections and sugar pills have been traditional favorites, particularly among interns and residents who find it a source of interest (and mirth) to heal the lame, the halt and the blind with briny injections. Placebos work by suggesting health to the patient so she will quickly recover from her symptom, but often unrecognized is their power to reinforce the idea that she is sick. With the possible exception of their onetime use as a diagnostic test, use of placebos should be avoided. The attention which has now been withdrawn from somatic symptoms must be refocused elseTHE WESTERN JOURNAL OF MEDICINE

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where. At the same time that the patient is learning to ignore symptoms about which she can do nothing, her physician should begin to focus attention upon factors she can change: the way she deals with her alcoholic husband,10 the rearing of her hyperactive children1' or her own drinking problem. By degrees she will learn to seek attention for talking, and recognize that she does not need somatic symptoms as a ticket of admission to the doctor's office. Use praise early and often. At first the doctor may have to search diligently to find praiseworthy behavior, but as the patient learns to respond to verbal rewards alone she will begin to change to please her doctor. "You can be proud," he may say, "of what you have accomplished. Many patients cannot develop self-control as you have done." The physician can unabashedly use this "tincture of soft soap" approach to establish a relationship which will encourage his patient to modify her behavior. In effect, she becomes addicted to him, rather than to pills. Later he may encourage her to exercise, to enroll in classes, to find a job-all appropriate outlets for the energy which she once channeled into symptoms. The doctor makes no attempt to control his patient's emotions; instead, he agrees with (or suggests to) her that no one can successfully control feelings. He may acknowledge her right to have feelings by saying "It is frightening to have an anxiety attack-and you are entitled to one after what you have been through." He will then go on to consider something she can change: her self-defeating behavior. Although she may be angry at her husband, she can learn not to throw dishes at him (and be praised when she reports her forbearance). As she earns praise and privileges, improvement in her self-esteem follows and she becomes eager to make further changes. Some types of behavior must be met vigorously, and carefully. Suicide threats or attempts are foremost among these: although hysterical patients represent a small minority of completed suicides,12 the sheer volume of attempts'3 makes an occasional success inevitable. Take no chances. Any doubt as to a patient's intentions should be resolved by hospital admission or close watch at home. Threatened or gestured suicide should be met with the same firm restrictions as any other self-defeating behavior. Seclude her "for your own good" away from activities and television, if possible on a closed ward until behavior changes for the better. Long-term inpatient care will rarely 486

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be necessary, though the promise of conservatorship or other loss of rights may be needed to rein in acting out. The threat that a patient will change doctors if demands are not met is a ploy often used, sometimes effectively. This type of manipulation can only be met head on. First, acknowledge her power to terminate the relationship if she wishes, adding the opinion that this step would be a regrettable error, but one which the doctor would have to accept. Then leave the next step up to the patient. Occasionally, a patient will carry through her threat and depart the fold-this attrition, generally low, is necessary to avoid compromising important standards of care. Many patients who have made careers of manipulating physicians actually feel relieved when they find one who insists upon setting limits.14 The seductiveness often noted in these patients may present problems for a male physician who feels tempted to overreact, becoming hostile or sarcastic as he tries to maintain distance. He should carefully avoid physical contact other than a handshake, especially early in the relationship; using her title and last name (Mrs., Miss, Ms. Jones) helps maintain distance. More direct expressions of sexual interest can be met effectively by acknowledging that many patients have harmless fantasies about their doctors. With "You don't need to be afraid that I will take advantage of you," the physician permits her to have the fantasies (she will anyway) and avoids overt rejection while he informs her he will not be seduced.

The Family Relatives can help enormously with management, provided they are educated to understand the problem. A private conference with the physician can help the spouse, parents or grown children appreciate the fact that the patient's illness, while chronic, need not be incapacitating. Although already aware that medicine does not help, many families have felt powerless to stem the flow of drugs prescribed by others. They will most likely eagerly cooperate with the "rescuing" physician as he lays out his program of drug management as described earlier. He should be cautious in interpreting the cause of this condition (although a genetic factor is suspected,'0 the complete cause remains unknown), and he should avoid using pejorative terms like hysterical and manipulation. If the family insists upon a diagnosis, Briquet syndrome does nicely. In counsel-

BRIQUET SYNDROME (HYSTERIA)

ing the family, stress should be laid on working with the patient for everyone's mutual benefit; punitiveness except in the sense of the therapeutic bind ("for your own good we must take away your privileges") must be avoided. Although dramatic alterations in the patient's environment should be postponed (avoid abrupt changes of jobs, houses and husbands), some situations at home can be attacked directly. Alcoholism in her husband may be interrupted with family therapy and disulfiram (Antabuse®). Therapy with psychostimulants or providing reading material'5 may help a patient's hyperactive child. The physician should encourage relatives to deal consistently with the patient, permitting no mixed messages. It may take time to learn that pills left about the house invite abuse. Relatives can most comfortably help the doctor set limits if they follow his lead in avpiding direct refusal of requests. "I can't do that (give you more medicine than is prescribed), but I can do this (talk with you about some of your anxieties)." In working with the family, keep in mind the enormous frustrations relatives face. Living with someone who must be hauled around from doctor to doctor, who takes 15 or 20 pills a day, who cannot care for herself let alone the house or the children, and who requires frequent trips to the emergency room for overdoses and suicide gestures is enough to try the patience of a saint. The complete physician should therefore be' ready to support the family in moments of crisis and to retain his perspective when relatives behave less than therapeutically. The physician should brace himself for some pretty unpleasant feelings of his own. Conditioned

as doctors are to the concept of cure, they have trouble tolerating the patient who never improves. Week after week of continuing complaints which fail to yield to his best therapeutic efforts inevitably raise feelings of inadequacy and guilt in the most competent and conscientious physician. Uncertainty as to the next therapeutic step adds to his anger, and his instinctive reaction will be to excise the patient from his practice. But if he can remember that his mission with these patients is to contain and not to cure, if he expects that for every symptom struck down two will spring up to take its place, if he can learn to expect trouble and not be disappointed when his expectations are met, then with some equanimity he can face the challenge of managing a patient with Briquet syndrome. REFERENCES 1. Farley J, Woodruff RA Jr, Guze SB: The prevalence of hysteria and conversion symptoms. Br J Psychiatry 114:1121-1123, Sep 1968 2. Perley MJ, Guze SB: Hysteria-The stability and usefulness of clinical criteria. N Engl J Med 266:421-426, Mar 1, 1962 3. Purtell JJ, Robins E, Cohen ME: Observations on clinical aspects of hysteria. JAMA 146:902-909, Jul 7, 1951 4. Guze SB: The diagnosis of hysteria: What are we trying to do? Am J Psychiatry 124:491-498, Oct 1967 5. Briquet P: Traite clinique et therapeutique de l'hysterie. Paris, J B Balliere & Fils, 1859 6. Robins E, Purteli JJ, Cohen ME: 'Hysteria' in men. N EnglI J Med 246:677-685, May 1, 1952 7. Cohen ME, Robins E, Purtell JJ, et al: Excessive surgery in hysteria. JAMA 151:977-986, Mar 21, 1953 8. Haley J: Strategies in Psychotherapy. New York, Grune and Stratton, 1963 9. Dickes RA: Brief therapy of conversion reactions. Am J Psychiatry 131:584-586, May 1974 10. Woerner PI, Guze SB: A family and marital study of hysteria. Br J Psychiatry 114:161-168, Feb 1968 11. Morrison JR, Stewart MA: A family study of the hyperactive child. Biol Psychiatry 3:189-195, 1971 12. Robins E, Murphy GE, Wilkerson RH Jr, et al: Some clinical considerations in the prevention of suicide based on a study of 134 successful suicides. Am J Public Health 49:888-899, Jul 1959 13. Schmidt EH, O'Neal P, Robins E: Evaluation of suicide attempts as guide to therapy. JAMA 155:549-557, Jun 5, 1954 14. Murphy GE, Guze SB: Setting limits. Am J Psychotherapy 14:30 47, Jan 1960 15. Stewart M, Olds SW: Raising a Hyperactive Child. New York City, Harper & Row, 1973

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Management of Briquet syndrome (hysteria).

Refer to: Morrison JR: Management of Briquet syndrome (hysteria). West J Med 128:482-487, Jun 1978 Management of Briquet Syndrome (Hysteria) JAMES R...
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