Psychogenic disorders in neurology: frequency and clinical spectrum Lempert T, Dieterich M, Huppert D, Brandt T. Psychogenic disorders in neurology: frequency and clinical spectrum. Acta Neurol Scand 1990: 82: 335-340. Among 4470 consecutive neurological inpatients presenting “with typical neurological symptoms” 405 (9 %) were found to have psychogenic rather than neurological dysfunction of the nervous system as the primary cause of admission. This probably represents a conservative figure, since secondary and minor pseudoneurological symptoms were not included. Retrospective analysis of these cases showed that pain was the most common psychogenic symptom, followed by motor symptoms (in particular stance and gait disturbances), dizziness, psychogenic seizures, sensory symptoms, and visual dysfunction. Unilateral motor and sensory symptoms were equally distributed to the left and right side of the body. Psychiatric abnormalities in these patients were heterogenous. Depressive syndromes were most common (38 %), whereas hysterical features were less frequent than expected (9 % ). On discharge, improvement was significantly better for patients with recent onset of symptoms (2 weeks or less) than for those with longstanding disturbances. Short-term outcome was best for motor symptoms and worst for pain. Improvement was independent of psychiatric findings, I coexistence of a neurological disease, age, and sex.

There is a widely held belief that the frequency of ‘hysterical‘ symptoms has been steadily declining since the times of Charcot and Freud. Recent surveys of psychogenic disorders in neurological settings have been mostly reported by psychiatrists (1-4), thus relating to a selected subgroup of patients who were referred for psychiatric consultation. There are two studies from neurologists which both reported an incidence of ‘hysteria’ of 1% among neurological inpatients ( $ 6 ) . Our aim was to assess retrospectively the frequency and clinical presentation of psychogenic disorders in a large neurological inpatient series. Neurologists may hesitate to explore these borderlands of neurology and psychiatry for good reasons: nomenclature is still confusing, with overlapping use of terms such as hysteria, conversion, functional and psychogenic disorder, all of which are not clearly defined. Several authors have argued against the use of each (6-9). Frequently a psychogenic disorder coexists with an organic neurological disease in the same patient (3, 10-12), as in patients with epilepsy who may suffer from additional psychogenic seizures. A considerable proportion of patients initially diagnosed as ‘hysterical’ later prove to have an organic disease of the nervous system, which explains most of the signs and symptoms (7, 13-15). Even the most careful neurological and psychiatric

T. Lempert, M. Dieterich, D. Huppert, T. Brandt Neurologische Klinik, Klinikum Grosshadern Ludwig Maximilians University, Munich, Germany

Key words: conversion; hysteria; pain; paresis; gait; dizziness; seizures; hypesthesia Thomas Lempert, Neurologische Abteilung, Universitatsklinikum Rudolf Virchow Spandauer Damm 130, 1000 Berlin 19, Germany Accepted for publication June 14, 1 9 9 0

investigation leaves a heterogenous group of seemingly healthy but symptomatic patients which may include undiagnosed psychogenic as well as undiagnosed organic disorders. Large samples of patients can only be evaluated retrospectively. This reduces the reliability of the data, which is based on the individual physician’s competence and sensitivity to psychogenic disorders. In spite of these drawbacks our study may indicate the share of psychogenic disorders among neurological inpatients and delineate their various clinical features. Methods

We reviewed the files of all patients admitted to the Neurological Clinic of the University of Munich between 1985 and 1987 ( n = 4470). The identification of a psychogenic disorder was based on the following criteria which are listed with an example of each for clarification : obvious psychogenic dysfunction of the nervous system unrelated to neurological disease (e.g. florid forms of psychogenic seizures with exhibitionism and dramatism or bizarre ataxia of gait after lumbar disc surgery), neurological dysfunction contradicted by normal physical and diagnostic findings (e.g. sustained paraplegia with normal reflexes, EMG, and central motor pathway conduction time), subjective complaints with normal 335

Lempert et al. neurological but pathological psychiatric findings (e.g. atypical facial pain and depression). We specifically excluded : minor and ill-defined complaints (e.g. insomnia, fatigue, nervousness), subjective symptoms without relevant psychiatric findings (e.g. tension headache, backpain), and cases which remained doubtful after discussion among all authors or with the physician involved. For all identified patients we recorded age, sex, the leading psychogenic symptom (if the patient had more than one), its duration before admission and outcome at the time of discharge from the hospital, accompanying psychogenic symptoms, current neurological and other diseases, and psychiatric findings. Classification of psychiatric abnormalities was based on clinical findings as documented in the files, either by a neurologist (75%) or a psychiatrist (25%). We found that is was often not possible to establish retrospectively diagnoses which met the standards of DSM I11 (1 6) so we did not attempt this in any cases.

Accompanying disease

In 56% of the 405 patients psychogenic dysfunction was the sole medical problem recognized. 28 % had an additional neurological disorder and 20% had a non-neurological disease. Symptoms

Pain was encountered most frequently as the leading symptom. It was followed by motor disturbances, vertigo and dizziness, psychogenic seizures, sensory, and visual dysfunction (Fig. 2). The category of patients presenting with motor symptoms includes a subgroup of 33 patients with astasia/abasia, a ‘nonparetic’ severe impairment of stance and gait; 54% Table 1. Signs and symptoms (n= 7 17) of 405 patients with psychogenic dysfunction of the nervous system’

trunk and extremities headache atypical facial pain

Results

Frequency, sex and age distribution

Among the 4470 neurological inpatients we found 405 (9.0%) in whom psychogenic rather than organic dysfunction was the major cause for admission. The proportion of women was higher (64%) as compared with a random sample of neurological inpatients (n = 2042, 51 % female). Psychogenic dysfunction preferentially affected young and middle aged patients with a peak in the age group between 40 and 50 (mean: 41 years), whereas the random sample of neurological patients was evenly distributed over all age groups (chi2 = 90.3; P < 0.001) (Fig. 1).

vertigo /dizziness

pain

89 61 13

47 38

ocular symptoms

motor symptoms astasia / abasia monoparesis hemiparesis tetraparesis paraparesis paresis of both arms recurrent head drop tremor localized jerking stereotyped motor behavior hypokinesia akinesia foot contracture isolated ataxia of the upper extremities

attacks of phobic postural vertigo continuous dizziness

52 31 20 18 10 2 1 11 1 1

amblyopia amaurosis visual field defects color blindness double vision other visual phenomena pfosis convergence spasm unilateral gaze paresis

1

alimentary symptoms

1 1 1

dysphagia vomiting

10 6 6

2 2 6 1 1 1

4 4

speech disturbances sensory symptoms hyp-/ anesthesia par-/ dysesthesia Sensation of generalized vibration sensation of fever pressure in the ears

81 63 1 1 1

neuropsychological symptoms

41 34

cognitive impairment amnestic aphasia apathy coma

seizures with motor phenomena other lamnestic episodes, mental and emotional alterations)

5

10

20

30

40

50

60

70

80

336

++

9 1 2 1

2 1 2 1

other symptoms bladder dysfunction stool incontinence cough

ye2:s

Fig. 1. Age distribution of 405 neurological inpatients with pSychogenic dysfunction as the chief complaint as compared 102043 random neurological inpatients (shaded area).

dysarthria slow speech aphonia mutism

Note: Several patients had more than one psychogenjc symptom.

11 1 1

Psychogenic disorders

5

10

15

20

I

I I

I

I

t

I

1

n 95

pain motor

82

I

I I

I

trunk and extremities

I

25 %

I face

head

1

paresis

astasialabasia I

vertigo dizziness

75

continuous

I

paroxysmal

I

A

I

62

seizures

I

motor

other

I I

56

sensory visual

8

other

27

paresthesia

I thesis hypesI

I

1

Y - l I

I

5

10

I

I

15

20

.25%

Fig. 2 . Leading psychogenic signs and symptoms in 405 neurological inpatients.

of patients had multiple psychogenic disturbances. Altogether we recorded 717 signs and symptoms which covered almost the entire phenomenological spectrum of neurology (Table 1). The distribution of unilateral motor and sensory symptoms was not conclusive. In 28 of 51 patients

..................ii

eprcssive syndrome (n =14R)

................................

anxiety I compulsion emotional stress hysterical features hypochondria mental deficiency I dementia

w

(9)

non-organic psychosis

(5)

other

(5)

normal

Short term outcome.

(70)

I

I

20

30

I

10

Psychiatric findings

Psychiatric evaluations were sufficientlydocumented in 390 out of 405 patients. A depressive syndrom (38%) was by far the most frequent abnormality followed by anxiety or compulsion (13 %) and hysterical personality features (9%). One third of the patients, however, appeared normal or had current emotional stress as the only apparent psychological factor (Fig. 3). We did not observe a close association of specific psychiatric abnormalities with particular symptoms except for a strikingly high proportion of anxiety and compulsion (60%) in patients with paroxysmal vertigo.

._.. -.....

.-:.:.:.:.:..._. :.:.:.:.r.r.-.:.:.:.:

with unilateral paresis it was the right side of the body which was involved. The distribution of unilateral sensory symptoms was 44 on the right to 38 on the left.

%

Fig. 3. Psychiatric abnormalities in 390 neurological inpatients presenting with psychogenic symptoms.

The short-term outcome of psychogenic dysfunction was simply classified as recovered, improved, or unchanged according to the clinical findings at discharge from the hospital. Paroxysmal symptoms such as psychogenic seizures or episodic vertigo with

337

Lempert et al.

0

recovered

Discussion

improved

4470 patients were admitted to the Neurological Clinic of the Munich University between 1985 and 1987. Of these 9% had psychogenic rather than organic dysfunction of the nervous system as the primary cause of admission. This is a much higher proportion than the 1% reported by Trimble (5) and Marsden (6) from neurological clinics in England. Though this may reflect different referral patterns in different countries, differences in data acquisition seem to be more important: in contrast with previous studies we did not simply extract patients with an established diagnosis such as ‘hysteria’ or ‘conversion disorder’ but reevaluated the files of all patients. Accordingly, we found patients with psychogenic symptoms spread over a variety of diagnostic labels ranging from ‘masked depression’ and ‘anxiety neurosis’ to ‘conversion’ and ‘psychogenic’, whereas the term ‘hysteria’was applied rather reluctantly in our clinic. That our data give a realistic reflection of the frequency of psychogenic symptoms in neurological inpatients is supported by two studies in progress at our clinic: A follow-up of 42 patients with psychogenic seizures which included detailed interviews with patients, relatives and treating physicians confirmed the diagnosis in 41 after two years. For a video-based prospective analysis of psychogenic gait and stance disturbances we identified 20 patients within 12 months, which equals the number expected from our data. The frequency of psychogenic symptoms is further substantiated by reports from psychiatric settings, where conversion was the final diagnosis in 3.4% (17), 4.5% (3), and 5% (4) of cases. Guze et al. found one or more conversion symptoms in 24% of psychiatric patients with different diagnoses (18). In another study 33 of 100 consecutive postpartal women had experienced conversion symptoms at some time in their lives (19). The female preponderance in psychogenic disorders, which was 1.8 : 1 in our study, is a constant finding, spanning from 1.6 : 1 to 4.1 : 1 in previous samples (3, 10, 17, 18, 20). Nevertheless, it is too small to be helpful in the diagnosis of individual cases. Patients with psychogenic dysfunction had a peak frequency in the fifth decade and tended to be younger than neurological patients in general. This allows for two interpretations ; either the elderly develop less often psychogenic symptoms or unexplained symptoms in this population are more easily ascribed to unspecific age-related disorders such as vascular or degenerative changes, even if a causal relationship cannot be demonstrated.

60

40

20

symptom

C 2

duration

weeks

2 weeks-6 months

n=38

n=68

6 months n=151

Fig. 4. Short term outcome of psychogenic dysfunction in neurological inpatients in relation to symptom duration (total n = 257, recovered l l % , improved 3 2 2 , unchanged 57%).

spontaneous symptom free intervals therefore had to be excluded. Of 257 patients 11% recovered completely, 32% were improved, and 57% remained unchanged. Outcome was strongly correlated with the duration of the symptom: patients with recent onset of symptoms (duration less than two weeks) did better than those with long-standing disturbances (chi2 = 90.62, P < 0.001) (Fig. 4). Furthermore, patients with motor symptoms had a somewhat better prognosis (19% recovered, 35 improved, 47% unchanged) than the remainder (chi2 = 12.5, P < 0.01). Patients with sensory symptoms and dizziness ranked second and third, whereas those with pain did worst (6% recovered, 3 1% improved, 63 % unchanged). Outcome was not correlated with psychiatric findings, accompanying neurological disease, age, or sex (Table 2).

Table 2. Clinical criteria related to short term outcome Relation Criterion

to outcome

Duration of symptom

tt

Type of symptom

t

Psychiatric findings Combination with neurological disorder Age Sex

0 0

t t = P < 0,001; t = P < 0,Ol;

338

0 0

O = P > 0,05

Comment the shorter the better (see fig. 4) best for motor dysfunction, worst for pain

Psychogenic disorders

Additional neurological disease was observed in 28 % of our ‘psychogenic’patients. In similar studies on psychogenic dysfunction additional neurological disorders were less frequent in a general hospital (10%) (4), but more frequent in a psychiatric setting (63 %) (1 1). A smaller study of neurological patients with psychogenic symptoms reported coexisting cerebral or systemic disease which possibly compromised cerebral function in 48 % of patients (12). Concurrence of both conditions may be accidental, but may reflect an abnormal psychic reaction to physical disease as well. We recorded a wide spectrum of psychogenic symptoms which did not differ substantially from the various manifestations of hysteria as they were described in the 19th and early 20th centuries (21-23). Pain was the most common symptom, although nonspecific pain of unknown cause such as tension headache was not included. Similarly, previous studies found pain to rank first (3, 24) or second (5) among conversion symptoms. Other studies excluded pain (4,17, 18,20), which does not appear to be justified, since psychogenic pain coexists with other psychogenic symptoms in many patients (3, 25). It has been repeatedly observed that unilateral motor and sensory symptoms of psychogenic origin affect preferentially the left side of the body (4, 21, 26-28), although equal distribution (29) and right sided preponderance (3, 30) has been reported as well. Hypothetical factors influencing the choice of symptom side include cerebral dominance, previous trauma, imitation of a model, and iatrogenic suggestion. In our study 133 unilateral symptoms occurred with about the same frequency on each side of the body. Thus, the assumption of a pathophysiological mechanism which favours one side cannot be supported. Psychiatric findings were heterogenous in our patients. Hysterical personality features were recorded in only 9%, which is even less than the 20 to 50% reported earlier (3, 14, 20, 24, 31, 32). This confirms current diagnostic concepts which separate conversion disorder from histrionic personality disorder (16, 3 1,33). The high proportion of depressed patients is in accordance with previous studies which noted depression in 30 to 50% of cases (3, 10, 24). Recognition of masked depression is especially important since somatic complaints often improve with appropriate antidepressant medication. We found a striking negative correlation of short term improvement with symptom duration, which agrees with the general clinical experience but has as yet not been reported. Further, patients with motor dysfunction had a more favourable prognosis than others. More than half of our ‘psychogenic’ patients left the hospital unimproved. This may be explained

by the short hospital stay which usually lasted five to ten days with completion of therapy on an ambulatory basis. The overall prognosis of psychogenic symptoms, however, seems not unfavorable : the proportion of symptomatic patients decreases with length of follow up. In Ljungberg’s patients it fell from 38 to 23% between the first and fifth year of follow up (20). Finally, it should be emphasized that it is the neurologist who has to establish the diagnosis of psychogenic dysfunction and initiate appropriate treatment, which may or may not include psychiatric support. Diagnostic criteria based on extensive clinical and electrophysiological studies have been worked out for psychogenic seizures (34-39), visual and oculomotor disturbances (40-44), and vertigo (45). Other psychogenic symptoms such as paresis, astasia/abasia, and sensory dysfunction have been described in detail (22,23,26,46,47) but systematic clinical and electrophysiological studies are still lacking. Acknowledgements We thank Drs. P.D. Steckl and D.H. Reisch for critical reading of the manuscript and R. Tobola for secretarial help.

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Psychogenic disorders in neurology: frequency and clinical spectrum.

Among 4470 consecutive neurological inpatients presenting "with typical neurological symptoms" 405 (9%) were found to have psychogenic rather than neu...
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