Transcript Hysteria - Peninsula MRCPsych

Hysteria
John O’Donovan
History of hysteria
• Conversion disorder
• In general neurological type presentation
without evidence of a neurological cause.
• The presentation tends to conform to ideas of
the patient about how parts of the body or
mind malfunction. (patient’s concept of an
illness)
History
• Ancient Greece, part of the Hippocratic
Corpus delineating certain disease states
including what we would now describe a panic
attacks and also epilepsy as secondary to the
uterus being misplaced. “hysterix pnix”
• Came into recent european writings with
Cullen.
• 1600s possession by demons.
Posssession?
Salem Witchcraft Trials 1697
Sydenham from “discourse on
hysteria” 1624-1694
• When the mind is disturbed by some grevious
accident, the animal spirits run into disorderly
motions; the urine appears sometimes limpid,
and in great quantity; the sick person casts off all
hope of recovery…. In the head the Apoplexy…..,
sometimes they are seized with convulsions that
very much resemble the epilepsy… and are
commonly called the suffocation of the womb; at
other times they are miserably tormented with
the hysterical clavus in which there is a most
vehement pain in the head, which you may cover
with your thumb…………
Charcot 1880s
made the link between
paralysis and idea.
First noted by Reynolds
Freud: the basic concept of
repression into the
unconsious and the
underlying battle between
drives and aspects of the
minds structures becomes
apparent in a physical
presentation.
WAR
American Civil War; “Da
Costs syndrome”
WW1- shellshock
2 schools of thought
“psychological” versus
“short sharp shock”
The army: “insufficient
moral fibre” but yet set up
military psychiatry.
Strongly urge all trainees
to read the history of
psychiatry in this period
Looking good Sigmund
Important to compare
primary and secondary
gain.
Primary gain is the
resolution of the
subconcious conflict with
development of the
symptom.
Secondary gain is a
completely different
process, sick role etc,
nothing to do with
Freudian dynamic theory.
Currently
ICD-10
•
•
•
•
•
•
•
•
•
•
•
Conversion is under dissociative
disorders
F44 “all tend to remit after a few weeks
or months”, really that’s news to me.
44.0 dissociative amnesia
44.1 dissociative fugue
44.2 dissociative stupor
44.3 trance and possession disorders
44.5 dissociative convulsions
44.6 dissociative anaesthesiae and
sensory loss
44.7 mixed conversion
44.8 others, includes Ganser’s
syndrome
44.81 multiple personality disorder
DSM-4
• Classified under
“somatoform disorders”
• Note in ICD-10 F45 is
somatoform disorders
Common exam theme!
• Distinction between the following
conversion/dissociation, somatization disorder,
hypochondriacal disorder and malingering
• Conversion is classical neurological type presentation,
post acute event, psychological trauma
• Somatisation is multiple physical ailments and
presentations
• Hypochondriacal is concern with one or two serious
ailments
• Malingering is production of symptoms for clear and
immediate gain.
Ganser’s Syndrome
• First described in 1898, 3 prisoners in Halle by
Sigbert Ganser.
• Approximate answers
• Sometimes personal identity loss
• Regarded often as a variant of malingering as
much as dissociative, classed under
dissociative.
• Arguably very rare
Conversion disorder
• Not all that rare
• Common enough in neurology wards
• 5-10% of neurology OPD patients, no
neurological explanation for symptoms
• Up to 33% of patient evaluated in specialist
centres for treatment refractory epilepsy have
non epileptic seizures
• Younger patients 3:1 female to male as they
get older becomes a 1:1 ratio.
Conversion disorder basics
• Sometimes there is a recent precipitant,
sometimes there is not.
• Frequently it can be difficult to decide how much
voluntary awareness is present and how much is
unconcious
• There is an overlap with somatisation
• There is marked cultural variation.
• There is only very seldom an organic problem
when a good physician says that there is not.
Dissociative amnesia
•
•
•
•
Loss of autobiographical memory
Anterograde memory preserved
No focal neurology
Note: the memory loss from ECT arguably affects
autobiographical memory
• Kopelman has developed a psychological
schedule for autobiographical memory loss
• Case reports of autobiographical memory loss
post epilepsy surgery
Dissociative stupor
•
•
•
•
Unresponsive
Normal EEG
Walking, respiring etc
NOT CATATONIC
Dissociative anaesthesia or weakness
Neurological examination and investigations do
not reveal a cause for symptoms.
Presentation does not respect neuroanatomy
Hoover’s Sign
Other signs
•
•
•
•
•
•
Give way weakness
Vibration sense splitting the midline
Wrong pattern of weakness
Inconsistent examination
Speed the patient up
For movement disorders, use entrainment
Astasia abasia
Psychogenic seizures
epilepsy
•
•
•
•
•
EEG changes
Frequently hurt
Events occur out of sleep
When alone
If tonic clonic can bite tongue,
sides of cheek, big lacerations
• Prolactin elevated
• Lasts a brief time
• Nearly always responds to
treatment, BDZs and IV AED
NEAD
• EEG normal during event
• Can be hurt in event
• Rarely out of sleep
• With a wittness
• Bites tip of tongue
• Can last hours
• Does not respond to
treatment, AEDs
NEAD
Epilepsy
• History is normally very
clear
• Personality Normal?
• Frequently will have
psychiatric problems but
different types of problems,
depression.
NEAD
• History is vague, does not
describe the seizure well.
• Strong association with Axis
2 disordes, in particular BPD
and childhood abuse
• Self harm other features of
psychiatric illness
• Teddy Bears
Fugue
•
•
•
•
Loss of memory and travel
Sometimes associated with alcohol
Some with psychosis
Some are probably transient global amnesia
which is not psychiatric
Others
• Blindness
• Aphonia-note paradoxical adduction of vocal
cords
• Dissociative identity disorder- hard to believe
that it truly exists, it is however in ICD-10.
Treatment
•
•
•
•
•
Be clear about diagnosis in your own mind.
Non judgmental.
Explanation to patient.
Look for depression, TCAs are better.
Psychotherapy, different approaches CBT,
psychodynamic
• Specialist in patient treatment units
• Avoid excess investigations
Prognosis?
• Very few top class
studies with sufficient
length of follow up.
• My old boss who had
perhaps 30 plus years
as a consultant dealing
with these patients felt
that they frequently
represented.
Prognosis
Good
• Acute onset
• Early presentation
• well developed personality
• Specialist treatment early
• Is the natural course for
them to get well?
• Psychologically minded.
Poor
• Long standing problems
• Personality disorder
• “secondary gain”
• Reluctance to understand
problem in psychological
way.