The Massachusetts General Hospital Handbook of Neurology
Authors: Flaherty, Alice W.; Rost, Natalia S.
Title: Massachusetts General Hospital Handbook of Neurology, The, 2nd Edition
Copyright 2007 Lippincott Williams & Wilkins
> Table of Contents > Adult Neurology > Psychosomatic Neurology
Psychosomatic Neurology
A. Definition of psychosomatic
Here used broadly to include:
1. Somatic manifestations of mood disorders.
2. Somatoform disorders: Somatization, conversion dis., chronic pain dis., hypochondriasis, body dysmorphic dis., factitious dis.
3. Compliance problems that cause or perpetuate physical sx.
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B. Psychosomatic sx are real
We just understand their physiology less. E.g., fMRI shows R parietal activation, opposite of neglect syndromes. Bereavement activates brain regions that regulate physical pain. Stress causes itching in part because endorphins are as pruritic as morphine.
C. Psychosomatic sx are treatable
E.g., conversion paralysis on average causes more disability than an organic one but has a better prognosis.
D. H&P
Ask tactfully about recent or childhood severe illness or trauma; stress, litigation. While female sex is a risk factor, somatization is greatly underdiagnosed in men.
1. MADISON scale for emotional overlay. (There is often an organic underlay.)
M = Multiple unrelated sx
A = Authenticity of sx emphasized
D = Denial of any association with stress
I = Interpersonal interactions visibly worsen symptoms
S = Singularity sx are worst imaginable
O = Only you doctor as savior
N = Nothing makes it better, yet things make it worse
2. Maybe it's you: An MD's breezy or dismissive reassurance may make a pt. exaggerate real sx in order to be heard, making the MD more dismissive.
Table 27. MD characteristics influence who gets called psychosomatic.
Your Perception of Patient Alternate Possibility Too many complaints Pt. is very ill Reads too much med lit Pt. reads more than you Personality disorder You don't like them Nonanatomic deficit Results confuse you Noncompliant Treatment is worse than the dz 3. Physical signs of conversion disorder: In general, conversion sx are more common on the nondominant side. Some pts may overgeneralize or misreport a complicated real deficit, e.g., a crossed face and body numbness, as in brainstem syndromes or MS. None of the following tests are perfectly sensitive or specific.
a. Psychosomatic paralysis:
1) Give-way weakness: May see jerky relaxation in weak limb when test both limbs together. But this is also seen with poor proprioception, e.g., MS.
2) Hoover's sign: Have pt lie down; hold your hand under the good heel while pt. raises the weak leg against resistance. In psychosomatic weakness, pts. do not push down into your hand with the good leg. In somatic weakness, they do.
b. Psychosomatic numbness: Numbness may stop at hairline. Pt. may feel vibration more strongly on one side of forehead than the other, or have normal manipulation in numb hand.
c. Psychosomatic blindness: Pt. may blink to threat or have normal nystagmus to a moving optokinetic strip (successive black and white squares).
d. Psychosomatic vertigo: Very often a med SE, or panic disorder. Ask about palpitations, paresthesias; see if you can reproduce the sensation with hyperventilation or treat it with rebreathing.
e. Psychosomatic gait (AKA astasia-abasia): See Table 17.
f. Nonepileptic spells: No abnormal EEG during the spell. 30%-50% of pts. with pseudoseizures also have real seizures.
Table 28. Differentiating epileptic and pseudoseizures.
Epileptic Seizure Nonepileptic Spell Clonic limb mvt. In phase bilaterally Out of phase Vocalization type Epileptic cry Moans, screams Vocalization timing Mid-seizure Start of seizure Head turning Unilateral Violent side-to-side Eyes Open Closed Postictal Disoriented, HA Weeping, anxious EEG during spell Epileptiform EEG Muscle artifact only
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4. Somatic signs of mood disorder:
a. Not strictly somatoform: These resolve when the mood sx do. But in some pts. (e.g., Parkinson's and the elderly) and cultures, depression more often presents with somatic sx than mood sx.
b. Common organs: Heart, gut, and skin are the organs most directly influenced by limbic tone.
c. Thorough ROS is crucial: The more positives, the firmer the dx. Ask about dizziness; blurry or spots in vision; memory loss; fatigue; change in sleep, weight, bowel; N/V; belly pain; migraines; back pain; palpitations; dyspnea; tremor; weakness; numbness (especially bilateral lips and hands).
d. Pseudodementia of depression/anxiety: Typically, pts are disturbed by their cognitive sx much more than family/coworkers. Attention is the primary impairment. Recall cues help (vs. Alzheimer's); naming is intact. Pseudodementia in the elderly is a risk factor for true dementia, but best not to emphasize that fact to depressed pts.
e. R/o bipolar II: Pts. with bipolar depression are more likely than unipolar depressives to have migraine, back pain, and other somatic sx. Probe for hypomanic episodes ( Was there ever a time when, despite your health, you managed to start many new projects or go without sleep? ). Consult a psychiatrist; avoid SSRIs; favor mood-stabilizing pain meds, e.g., gabapentin, lamotrigine.
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E. Dx
1. DDx: SLE, MS, dystonia, and thyroid dz often cause sx that appear nonneurological. Rarer examples include porphyria, carcinoid.
2. Avoid dismissive reassurance: Rather than telling the pt., It's just anxiety, consider how severe that anxiety must be to cause such sx.
3. Explain psych sx medically: E.g., You have excess adrenaline release that causes your palpitations and lightheadedness. Clonazepam can decrease this.
F. Rx
1. Treat potential psych issues early: Addressing them while medical workup continues feels less dismissive to patients.
2. Do not turf: Many pts. who will not see a psychiatrist will accept an antidepressant if it is also prescribed for a neurological indication.
3. Use medications with dual indications: Pts resist psych meds less when they also have somatic indications. See also Table 25, which lists choice of antidepressants by comorbid condition (p. 100). The belief that we should treat only conditions with known etiology contributes to the relatively low success rate of neurological rx compared with other specialties ( Diagnose, adios ).
Table 29. Treating comorbid psychiatric and somatic sx. See also Table 26.
Comorbid Conditions Treatment Suggestions Pain Depression Somatization Mood lability, mania Cymbalta, perhaps TCA Cymbalta ACDs, e.g., Depakote Fatigue Medication SEs Anxiety Apathy Depression + sleepiness Depression + insomnia Provigil SNRIs (Effexor, Cymbalta) Dexedrine, Wellbutrin Wellbutrin, Effexor Remeron, Paxil Tremor Mood disorder see p. 79 4. Referral to psychotherapy: Present this as a way to help the pt manage the stress of their illness, not as treatment for their psychosomatic sx.
5. Compliance: Selecting the right rx is only 1/3 of the battle; the other 2/3 is helping the pt to adhere to it.
a. Time course noncompliance: Can be a clue to its cause. Often these are mixed, however.
1) Rx stopped within days for a soft SE: If cause is a soft SE (dizzy, felt like a zombie, etc.), pt. may be anxious and hypervigilant.
2) Rx stopped within weeks to months for no benefit: Suggests nocebo effect.
3) Rx taken erratically: Attentional/cognitive problems, or barely tolerable SEs.
b. DDx of noncompliance:
1) Poor access to medications.
2) Confusion: Dementia, delirium, or poor understanding of rx.
3) Self-medication of psychiatric and other problems.
a) Depression/anxiety/stress attempt at chemical coping.
b) Personality disorder impulsive, emotionally driven drug taking. see p. 101.
4) Pseudo-addiction: I.e., inadequate symptom relief.
5) Addiction.
6) Criminal intent: Not common.
c. Rx of compliance problems:
1) Treat the true chief complaint.
2) Fight nocebo effect: Previous med failures make pt. expectations negative, blocking even powerful drug effects.
a) Use distinctly new Rx modality, e.g., a transdermal rather than oral analgesic; may block nocebo effect.
b) Nocebo wears off just as placebo does, so urge pt. to continue.
3) Warn pt of discontinuation syndromes: Pts. who stop meds suddenly are at risk for rebound sx, esp. from ACDs, SSRIs, SNRIs, benzodiazepines.
4) Encourage pt's sense of control: Do not fight pts. who self- experiment; rather, guide them to help you fine tune their regimen. However, self-experimentation and prns work poorly for demented and psychotic pts.
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