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Psychogenic disorders

Psychogenic disorders

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    Psychogenic disorders Psychogenic disorders Presentation Transcript

    • PSYCHOGENIC DISORDERS Dr. B. PRAKASH. MD. DM. FAGE., Professor of Neurology (PSG IMS& R) Kasturi Neuro Diagnostic Centre 89-A, East Lokamanya Street, RS Puram. COIMBATORE 978-948-11-79. prakashneuro@yahoo.co.in 29th September 2012
    • INTRODUCTION• Some challenging neurological patients do not have Neurological disorders• They have Neurological symptoms and abnormal findings but arise from Psychiatric distress• We often tend to make Neurological Diagnosis in the fear of not missing it• A skillful Neurologist can make out Psychogenic illness during first interview 2
    • • Psycho disorders are not ∆ed by “Ruling-out” organic – Hx & Examn that are incompatible to neurologic Disorders – Positive psychogenic findings can be demonstrated• History itself may reveal the underlying cause – Past history / Personal history – Sexual abuse / Personality disorder – Escapism / Compensation – Mood disorder / Attention seeking• Convincing the pt is difficult – Do not tell that they are “Malingaring” or “Hysterical” – Tell it is “Involuntary” or “Stress related” – “Usually you will improve” , “May need psychiatrist help” 3
    • PROGRESS• Depends on Doctor - Patient relationship – Make them understand that you could feel their illness – In fact they are ill in a way• Further Prognosis – Counseling – Medication – Psy. Follow-up 4
    • DIAGNOSIS OF PSYCHOGENIC DISORDERS IN NEUROLOGICAL PATIENTS• 1/3 of new Neuro OP Symptoms couldnt be explained – Status Epilepticus : 50 % – Psychogenic seizures : 10-20% – Movement disorders : 5%• Psychogenic symptoms costs 10% – Annual US expenses : 100 billions• Neuro + Psycho Problems in same patient – Difficult challenge – Needs diagnosis and treatment of both illnesses 5
    • PSYCHOGENIC DISORDER: DEFINITION (DSM IV)• Somatoform disorders – Somatisation disorder – Conversion disorder blindness, paralysis, or other nervous symptoms that cannot be explained medically – Undifferentiated somatoform disorder – Pain disorder – Hypochondrias belief that physical symptoms are signs of a serious illness, even when there is no medical evidence – Body dysmorphic disorder – Unspecified somatoform disorder 6
    • Hx SUGGESTING PSYCHOGENIC DISORDER1. Abrupt onset 5. Multiple previous evaluation – Exact day & hour – Usually with negative results – Relate exact event (death) – Fear of missing diagnosis – Especially for mov. disorder 6. Multiple previous surgeries2. Paroxysmal – Hysterectomy – Vary in severity – Appendicetomy – Coming in spells – Laproscopy – Depends on surrounding 7. Change of symptoms (place, person, time) – Change of site of symptoms – Move from one to other body part – Change of nature of symptoms – Unusual accompaniment • Tremor memory loss  GI 8. Similar family history3. Minor causes – Members of family act as model – Minor injury gross neu. Prob 9. Presence of addl psy. co-4. Pending compensation morbidity – Symptoms resolve when case if over – Neu. Disease + anxiety 7
    • NON-ANATOMIC ACCOMPANIMENTS• Intermittent blurring of vision in the ipsilateral eye (asthenopia)• Ipsilateral LMN facial palsy• Ipsilateral hearing impairment• Sternomastoid weakness with hemiparesis 8
    • EXAM’N SUGGESTING PSYCHO’C DSIORDER• Multiple symptoms: not corresponding to anatomy• Multiple signs: not corresponding to symptoms• Distractibility – Features improve on diverting attention • Serial subtraction / rapid alternative movement • Organic chorea may also improve 9
    • EXAM’N SUGGESTING PSYCHO’C DSIORDER• Entrainment – In tremor: ask to move non involved limb in • same/ different /changing  rhythm/rate – Tap at slower frequency (3 Hz)• Variable nature – Some recede which others emerge• Excessive startle• False weakness / sensory symptoms Complete clinical picture is needed to make a psychogenic diagnosis, not on the basis of single 10
    • PSYCHOGENIC WEAKNESS
    • FUNCTIONAL WEAKNESS• No organic pattern (Root, Plx, etc )• Recognized as early as 1800 by Sigmund Freud• Neurologic expertise is needed to rule out organic lesions, like MG, MS, Apraxia etc., 12
    • MOTOR DISABILITYPREDICTORS – Low educational back ground – Personality disorder – Associated depressionDOCUMENTATION – Paralytic limb movement - during sleep or sedation • Observation • EMG • Video recording – To explain to relatives and also to pt regarding the condn 13
    • ARM DROP TEST• Hold the arm above the face (in supine)• Drop it suddenly – Functional – Pt will move away – Organic – May fall (need to hold)• Drop the extended arm in sitting – Initial hesitation in functional pt 14
    • BABINSKI THIGH-TRUNK TEST (JOSEPH BABINSKI 1896)Supine with arms crossed  Asked to sit up1. Normal – Both legs extended into the bed or motionless2. Organic Hemi paresis – Paretic leg involuntarily flexes & elevates off the bed3. Functional weakness : – Normal leg only flexes & elevates off the bed 15
    • HOOVER’S TEST (Charles Hoover – 1908)• PRINCIPLE: – In supine, when one foot is elevated, the other foot gets pressed down into bed• TEST: – Examiner stands at the foot end – Keeps both hands under the feet – Ask to press each leg alternatively down – Failure of normal leg to push down  poor effort 16
    • HOOVER’S TEST TEST ORGANIC WEAKNESS FUNCTIONAL WEAKNESS Good downward force by Weak Downward force byAsked to Normal leg Normal leg lift (Real upward effort of weak (Pt acts as if he is lifting, but actually leg  Good down force by not making effort  Normal limbPARETIC doesn’t get pressed down) normal leg) leg Weak downward pressure in Good downward pressure inAsked to Paretic leg Paretic leg lift (Pt lifts normal leg well and the paretic leg goes down by the law)NORMAL leg 17
    • 18
    • HOOVER’S TEST• Do the test against resistance Discrepancy gets maximized• Both tests should be performed 19
    • (A) Hip extension is weak when tested directly.(B) Hip extension is normal when the patient is asked to flex the 20 opposite hip
    • Sonoo Abductor test (Masahira Sonoo -2004)TEST• Stand at foot end of the bed• Place both hand at lateral ankle• Ask the pt to abduct both legs simultaneously as stronger as he can• Give equal opposing force to both legs 21
    • SONOO ABDUCTOR TEST (Organic Lt weakness) Limb moves Limb Static Pt asked is to move Paretic Limb• A 49 year old man with multiple sclerosis presenting with left leg paresis (organic).(A) Pt abducts sound Rt leg; unabducted paretic leg moves in hyperadducting direct’n(B) Pt abducts paretic Lt leg; unabducted sound leg remains in its original position 22
    • SONOO ABDUCTOR TEST (Functional Lt weakness) Limb moves Limb Static Pt asked is to move Paretic Limb45 year old woman with hysterical paresis overlaying radicular injury presenting with left leg paresis (non-organic).(C) Pt abducts the sound Rt leg; the unabducted ‘‘paretic’’ leg remains in its original position.(D) Pt abducts the paretic Lt leg; the unabducted ‘‘sound’’ leg moves in the 23 hyperadducting direction.
    • (A) and (D): abduction of both legs; grey hand mark, examiner’s hand;(B) and (E): abduction of the sound leg; grey arrow, adducting power by the examiner’s hand(C) and (F): abduction of the paretic leg, White arrow, direction of movement of the leg;left leg paresis white circle, a leg that does not move;Black arrow, abducting power exerted bold white arrow, movement of the unabducted leg by the patient’s leg 24 bold white circle, non-movement of unabducted leg
    • OTHER TESTS• Dynomometer test• EMG – Submaximal voluntary contraction – Fluctuation in interference 25
    • + VE FINDINGS FOR PSYCH. WEAKNESS• On attempting to move a limb – Facial grimacing – Grunting or puffing – Forcible eye closure – Fluttering of eyelashes• “Collapsing” or “give-way weakness”• Large variation in peak power (>20%)• Variation over time or with suggestion• Transiently normal power with encouragements 26
    • • Slow and laborious movements possible – Limb elevation or deep knee bends, which require greater strength when done slowly• Contraction of antagonists with passive movement• Normal or improved function with autonomic movements – Latissimus dorsi contraction with cough but not voluntarily• Apparent task – dependent paralysis – Quadriceps weak : But able to stand• Difference in functional ability on entering and leaving the office 27
    • - VE FINDINGS FOR PSYCHOG WEAKNESS• Normal tone and cutaneous reflex despite profound weakness• Absence of wasting, trophic skin changes, pressure sores, and contractures• Lack of hemispheric concomitants with dense hemi paresis – Facial weakness, Aphasia, Neglect, Hemianopia, or gaze preference• Lack of sphincter disturbances in paraparesis or quadriparesis 28
    • • “ Wrong-way” deviation of the tongue (i.e., away from a hemiparesis)• Globus hystericus( functional subjective sensation of a lump in the throat)• Aphonia• Monoparesis with proximal muscles more severely affected than distal muscles• Dragging a paretic leg behind the body while ambulating• Functioanl sensory abnormalities 29
    • PSYCHOGENIC SENSORY LOSS 30
    • PSYCHOGENIC DISORDERS SENSORY LOSS• All modalities of one side are affected• Inconsistent on serial exam• Abrupt sensory loss at joint level• Midline splitting sensory loss• Variation in vibration across midline in same bone (frontal / sternum)• Loss of JPS in ankle and toes but able to stand /walk with eyes closed 31
    • YES –NO TEST• Simple procedure in unsophisticated patients• Ask to respond as – “Yes” if they feel a stimulus and – “no” if they do not• Apply stimuli at varying interval• Apply below threshold stimuli to unaffected area• Apply above threshold stimuli to impaired area• Usually says “no” immediately after high threshold stimuli to affected area• Organic pt will keep mum on stimulating affected area• Make unequal pauses• Less intensity stimuli should be reported as “Yes”, in affected area 32
    • BOWLUS – CURRIER TEST (WILLIAM BOWLUS: Resident, ROBORT CURRIER – 1963)• For functional hemi-sensory loss in one arm/hand• Inter digitate the fingers & rotate the arm• Ask the patient to close eye• Randomly, rapidly, at various interval apply stimulus (touch / pinprick) to rt / lt fingers• Ask to reply whether touched or not, quickly• Delay in the reply makes it functional 33
    • PSYCHOENIC VISUAL DISORDERS 34
    • FUNTIONAL BLINDNESS• Blind person look straight when talking / Walking – Psy.blind look to other direction• Asked to put his signature • Organic blindness can sign • Functional blindness cannot sign 35
    • Asked to touch tips of index fingers with each other NORMAL FUNC. BLIND – BOTH EYES FUNC. BLIND – LEFT EYE FUNC. BLIND – LEFT EYE (Left Covered) (Right Covered) 36
    • • Optokinetic Nystagmus (OKN) – Elicited if vision is 20/400 37
    • • If total blindness in one eye – Cover normal eye suddenly during OKN test  – Nystagmus continue if blindness is psychogenic 38
    • • Hold a mirror in front of face  ask the patient look into • Twist mirror back of forth  Convergence 39
    • PSYCHOGENIC VISUAL FIELD• Non specific field constriction 40
    • HYSTERICAL HEMIANOPIA• “Missing half” field defect :• Binocular hemifield with complete “blindness” in affected eye and full fields in “unaffected”eye 41
    • FIELD CONSTRICITIONS• A “tubular” field deficit is inconsistent with the laws of optics and eye physiology• Near & away field examination – Tubular in psychogenic – Cone like in organic condition 42
    • CONVERGENCE INSUFFICIENCY• May have associated paralysis of accomodation• Ask to read a paragraph with eyes alternatively covered• Ask the pt to tell time from his wrist watch 43
    • UNILATERAL PTOSIS• Mild spasm• Elevation of lower eyelid• Mild brow ptosis• This man presented with photophobia and difficulty elevating the right side of his forehead. The photograph shows his normal resting state (upper panel) and normal movement of his forehead with his eyes shut (lower panel). There is overactivity of his orbicularis oculis which had been incorrectly interpreted as ptosis. It improved with gradual exposure to light. 44
    • PSYCHOGENIC SEIZURES 45
    • INTRODUCTION• Most common & serious• Common age group : 15-35 yrs• Male: Female ratio = 25:75• Sexual abuse – important risk (up to 25%)• Mild head injury is another factor (20%)• Incidence of Psychogenic Seizures – 20 % of “Intractable seizures” – 5 to 20% of Epilepsy OP – 10 to 40% of Epilepsy ward pts• Diagnostic challenge despite advances (VEEG)• More frequent / severe / more disabling• QOL – Poor 46
    • HISTORY• Initially seizures were considered as a form of functional disorders• Later during 1930s the difference between seizures and pseudoseizures were well made out• Nowadays many psychogenic seizures were found to be organic and originated from frontal lobe 47
    • EPILEPTIC VS NON-EPILPEPTIC SEIZURES EPILEPTIC NON EPILEPTICAGE AT ONSET Children and adolescents 15 to 35 most commonSEX Male and female about equal Female common: 3 to 1ratioPREVIOUS PSY Hx Occasionally present Commonly noted Flailing, thrashing, andMOTOR Bil. synchronous Movements asynchronous / pelvic thrustingVOCALISATION ATONSET Vocalizations or cry Weeping or screamingINCONTINENCE Frequent OccasionalSEIZURE DURATION Usually less than 2-3minutes Often more than 2-3 minINJURY Frequent tongue biting Uncommon Variable, sometime consciousAMNESIA Commom, LOC during seizure during seizurePROVOKED BY No OftenSUGGESTION 48
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    • FEW POINTS• Clinical Characters of psychogenic seizures – Longer duration – Distractible with external stimuli – Semi purposeful movements – Tip of tongue bite – VEEG documentation – Provoke by suggestions• Epileptic + Non-epileptic seizures  makes the ∆ difficult• Good clinical observation is the basis for diagnosis• VEEG monitoring is the gold standard• Sr Prolactin, SPECT, Neuro Psychological testis are addl tools 50
    • PSYCHOGENIC AMNESIA 51
    • INTRODUCTION• For lay people Amnesia means total loss of memory including personal identity• Acute stress may precipitate to subnormal memory function• Psychogenic Amnesia: – Severe retrograde amnesia including important events – Global impairment of memory including general intelligence – Not even islands of memory • New RETROGRADE Well Learning : AMNESIA Normal 52 EVENT VISIT
    • FUNCTIONAL AMNESIA• Amnesia for a salient life event without detectable Neu. cause• Tied with an emotionally traumatic event• R/O seizure, TIA, Head injury that may Amnesia• R/O Alcohol / Drug intoxication• Triggers: – Adult rape – Disasters, Accident & combat (act of fighting) – Attempted suicide – Criminal acts – Violent death of parent in childhood – First visit of hospital EMD – Sexual abuse in childhood• Imaging / EEG / Lab investigations may be helpful 53
    • ORGANIC & FUNCTIONAL AMNESIA ORGANIC AMNESIA FUNCTIONAL AMNESIASTRESSFUL PRECIPITANT Absent Typically presentTYPICAL CAUSES OR CVA, Viral Encephalitis, Surgical Mild Head trauma, Victim ofPRECIPITANTS lesions, anoxia, Alzhiemer’s emotionally traumatic eventAUTOBIOGRAPHICAL Mildly impaired Severely impairedMEMORYPERSONAL IDENTITY Preserved Often lostNEW LEARNING ABILITY Severely Impaired Typically normalEVERYDAY FUNCTIONING Impaired Typically normal High prevelance of traits withPREMORBID Unremarkable borderline and dependentPERSONALITY personality disorderLEGAL INVOLVEMENT(CRIMINAL, CIVIL,OR Rare FrequentDISABILITY) 54
    • MANAGEMENT 55
    • MANAGEMENT• Recognition of distress – Pts are not malingering, but they are sufferers – Do not start with : telling diagnosis, starting treatment, becoming angry• Validation of distress & delivering the diagnosis – Diagnosis is not by exclusion: but by relevant findings – Make the pt aware that - you know “he is suffering”• Removing associated factors 57
    • MANAGEMENT• Explain why symptoms cannot be fit• Supportive non confrontational approach rather than antagonistic / aversive / painful methods• Assure that you do not feel, they are “Crazy”• Assure that the symptoms will “get better with time”• Convey “Good News” – Not a progressive neu. deg. disorder / life threatening• Pt who consulted several doctors are difficult to console• Supportive psychotherapy• Antidepressants• Hypnosis / Amobarbitol/ Placebo Injection 58
    • SUMMARY• Traditional approach to diagnosis & treatment is inadequate• Each individual was different combination of each perspectives – Diseases / Life stories / Dimension / Behavior• The theoretical diagnosis need not fit into the patient• Treatment has to be designed for each patient• If no relief consider – Other ∆s / Other etiology / Other Tt plan / Combination Tt 59
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