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Nancy E. Epstein
  1. Clinical Professor of Neurosurgery, School of Medicine, State University of NY at Stony Brook, NY and c/o Dr. Marc Agulnick 1122 Frankllin Avenue Suite 106, Garden City, NY 11530, USA.

Correspondence Address:
Nancy E. Epstein MD, Clinical Professor of Neurosurgery, School of Medicine, State University of NY at Stony Brook, NY and c/o Dr. Marc Agulnick 1122 Frankllin Avenue Suite 106, Garden City, NY 11530, USA.

DOI:10.25259/SNI_278_2022

Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Nancy E. Epstein. Review/perspective on hysterical paralysis: A diagnosis of exclusion for spinal surgeons. 29-Apr-2022;13:172

How to cite this URL: Nancy E. Epstein. Review/perspective on hysterical paralysis: A diagnosis of exclusion for spinal surgeons. 29-Apr-2022;13:172. Available from: https://surgicalneurologyint.com/surgicalint-articles/11572/

Date of Submission
21-Mar-2022

Date of Acceptance
24-Mar-2022

Date of Web Publication
29-Apr-2022

Abstract

Background: Hysterical paralysis (HP) and/or conversion disorders (CD) are diagnoses of exclusion for spine surgeons. Before assigning this diagnosis to a patient, they must first undergo a full neurodiagnostic evaluation (i.e., X-rays, MR, CT/Myelo-CT) to rule out organic spinal pathology. Here, we reviewed select articles highlighting how to differentiate HP/CD patients from those with spinal disease.

Methods: Several case studies and small series of patients with HP/CD were included in our analysis. Notably, prior to being assigned the diagnoses of HP/CD, patients had to first undergo X-ray, MR, CT, and/or Myelo-CT evaluations to rule out spinal disorders; typically, their neurodiagnostic studies were normal.

Results: Patients with HP/CD often presented with varying clinical complaints of motor paralysis despite intact reflexes, normal sensory examinations, and lack of sphincter disturbance (i.e. intact rectal tone). Further, go and nogo functional MRI (fMRI) examinations demonstrated inconsistencies in areas of brain activation for patients with HP/CD complaints.

Conclusions: HP/CD are diagnoses of exclusion, and patients should first undergo a full panel of neurodiagnostic studies to rule out organic spinal disease. While those with HP/CD should not have unnecessary operations, those with real “surgical pathology” should have appropriate spine surgery performed in a timely fashion.

Keywords: Computed Tomography (CT), Conversion Disorder (CD), Diagnosis of Exclusion, Functional MRI (fMRI), Hysterical Paralysis, Magentic Resonance Imaging (MR/MRI)

INTRODUCTION

Hysterical paralysis (HP) or conversion disorders (CF) are diagnoses of exclusion [ Table 1 ].[ 1 - 17 ] Therefore, before assigning patients the diagnosis of HP/CD, spine surgeons must first complete full evaluations (i.e., X-rays, MR, CT, Myelo-CT studies) to rule out organic spinal disease that may warrant surgical intervention. Further, if and when fMRI is available, these studies may further supplement and differentiate between organic spinal pathology and HP/CD.[ 4 , 10 , 16 ]


Table 1:

Review/perspective of hysterical paralysis/conversion disorders.

 

MULTIPLE FACTORS ASSOCIATED WITH HYSTERICAL PARALYSIS/ CONVERSION DISORDERS

Maxion et al. (1989) identified multiple factors in patients with “classical conversion syndromes” and/or psychogenic seizures/paralysis [ Table 1 ].[ 11 ] Out of 172 patients, 55% had psychogenic fits, and 45% had hysterical paralysis. The age at presentation was bimodal; ages 15-25 vs. 45-55 years of age. Two-thirds of the patients were females who mostly had “relationship problems”, while the 1/3 who were males mostly complained of “professional problems”. Eighty percent of both children and adults had severe social problems. Fifty percent were unskilled workers. Just 12% of younger patients had a history of perinatal brain damage. Of interest, an additional 25% had undergone prior gastric/ duodenal ulcer surgery.

CLASSIFICATION SYSTEMS FOR PSYCHOLOGICAL/MENTAL DISORDERS

In 2019, Blashfield analyzed 16 different classification systems using 22 common terms to describe psychological/ mental disorders that had been used since the 19th century [ Table 1 ].[ 2 ] Three of these descriptions included mania, general paralysis, and senile dementia [ Table 1 ].[ 2 ]

HISTORY OF HYSTERICAL PARALYSIS (HP)/CONVERSION DISORDERS (CD)

Several studies highlighted how inconsistencies in clinical evaluations and ultimately normal neurodiagnostic studies helped differentiate between HP/CD vs. organic spinal disorders [ Table 1 ].[ 1 , 5 , 13 ] In 1989, Apple et al. evaluated 17 patients presenting with different complaints/patterns of motor paralysis, sensory loss, and sphincter dysfunction; 15 of 17 had normal reflexes despite motor paralysis, and all 17 had intact sphincter control (i.e. despite some complaints of incontinence) [Table1].[ 1 ] Sixteen of 17 spontaneously improved over an average 3.8 day hospital stay, with 13 recovering full normal function over this period. They recommended obtaining X-ray/other studies early in the work-up of patients with potential HP/CD diagnoses, and that inconsistencies in the neurological examinations were extremely helpful in differentiating between HP/CD and organic spinal disorders. Okun and Koehler (2007) cited Paul BLocq’s (1860-1896) definition of astasia-abasia; “… the inability to maintain an upright posture, despite normal function of the legs in…bed”, while further differentiating this syndrome from typical hysteria [ Table 1 ].[ 13 ] DeBustos (2014) et al. reassessed the inconsistent clinical presentation of patients with HP/CD, and broke hysteria down into several main groups [ Table 1 ].[ 5 ] These included; “…paroxysms, attacks, acute manifestations, long-lasting functional syndromes, and visceral events.” The first group included minor/major hysterical attacks, while the second group included “…focal hysterical symptoms, paralyses, contractures and spasms, anesthesia, and sensory disorders.”

DIFFERENTIATING HYSTERICAL PARALYSIS/ CONVERSION DISORDERS FROM ORGANIC SPINAL PATHOLOGY

The incidence of HP/CD is 5-22/100,000 in the overall population. Here we have summarized how the diagnoses of HP/CD can be differentiated from organic spinal pathology [ Table 1 ].[ 6 , 8 , 9 , 12 , 14 , 17 ] Gould et al. (1986) observed that 30 patients with organic brain lesions demonstrated at least one of 7 “pathognomonic” findings of hysteria, while many exhibited 3-4.”[ 6 ] These criteria included a; “….history of hypochondriasis, secondary gain, la belle indifference, nonanatomic sensory loss, splitting of midline by pain or vibratory stimulation, changing boundaries of hypoalgesia, and giveaway weakness”. Their observations invalidated using these findings to differentiate HP/CD from organic disease.[ 6 ] Additionally; “…movement disorders and paralysis are most often mislabeled as hysteria”, and, “A diagnosis for hysteria must be made with great caution as it so often proves incorrect”.[ 6 ] Further, they showed how major biases impacted who was misdiagnosed with HP/CD; those typically misdiagnosed included women, homosexual men, and those with psychiatric illnesses. Letonoff et al. (2002) evaluated 3 females who presented with complaints of complete paralysis/sensory/sphincter loss in the lower extremities, but had intact reflexes/rectal tone, normal laboratory studies, electrodiagnostic evaluations, and imaging studies [ Table 1 ].[ 9 ] Interestingly, all were from low income groups with little education, 2 patients had histories of trauma, and a third patient had prior “hysterical” seizures. Once they were told that they had no “organic disease”, all 3 patients recovered within 6 months during which time they typically required psychiatric help and physical therapy. Zhu et al. (2012) cited 2 males who presented with inconsistent neurological deficits that led to the diagnoses of HP/CD; both patients spontaneously fully recovered. Nguyen et al. (2013) reported a 29 year-old female who, 4-6 hours following a cesarean section performed under general anesthesia once a spinal anesthetic had failed, developed bilateral lower extremity weakness [ Table 1 ].[ 12 ] Following the normal lumbar MR, she was diagnosed with psychogenic paresis (HP/CD). Interestingly, she had experienced a similar episode several months earlier after a lumbar puncture. Kanchiku et al. (2017) used motor evoked potentials (MEP) to rule out organic disease and rule in hysterical motor deficits in 11 teenagers averaging 16.5 years of age [ Table 1 ].[ 8 ] Osman et al. (2020) diagnosed 40 functional neurological disorders (FND) out of 1000 new admission to a neuropsychiatric clinic [ Table 1 ].[ 14 ] Those with FND were typcially females (60%) with; “…psychogenic nonepileptic seizures (82.5%), speech abnormalities (47.5%), limb paralysis or weakness (35%)…”. About 95% of these patients improved on anti-depressant medication and/or with psychotherapy.

CONVERSION PARALYSIS AFTER SPINE SURGERY

Few papers focused on episodes of HP/CD “paralysis” immediately following spine surgery [ Table 1 ].[ 7 , 17 ] In 2010, Hsieh et al. reported a 37 year old female who, one hour after a left L5S1 laminotomy, newly developed left leg weakness; the immediate reoperation showed no significant hematoma or other pathology.[ 7 ] Ten hours following the second surgery, the patient developed recurrent left leg weakness. This time, however, normal neurodiagnostic studies (i.e. including somatosensory evoked (SEP) and motor evoked potentials MEP)), led to the correct diagnosis of HP/CD.

CONVERSION PARALYSIS AFTER LEG INJURY

In 2012, Stone reported his own experience with transient psychogenic paralysis of a leg following a fall resulting in a torn quadriceps muscle [ Table 1 ].[ 15 ] He developed transient hysterical paralysis postoperatively that required him to regain the ability to walk.

FUNCTIONAL MRI OF PARALYSIS

fMRI, performed in patients with unexplained/inconsistent neurological deficits and normal neurodiagnostic studies, helped identify/differentiate patients with HP/CD vs. organic spinal disease [ Table 1 ].[ 4 , 10 , 16 ] In 1997, Marshall et al. had a patient with no organic lesion to explain her intermittent left-leg paralysis/sensory loss [ Table 1 ].[ 10 ] On the fMRI, the request to prepare to move the right leg, and actually move the good right leg, resulted in appropriate activation of the left motor/premotor cortex. However, when asked to move the paralyzed left leg, there was just activation documented in the right orbito-frontal and right anterior cingulate cortices. In 2005, Vuilleumier used fMRI to assess the locations of brain activation during HP/CD-related motor paralysis, sensory disturbances, and “blindness”; rather than showing activation in the motor/premotor, somatosensory, and visual cortices respectively, they typically demonstrated increased activity in the cingulate and orbitofrontal areas [ Table 1 ].[ 16 ] Cojan et al. (2009) used the go-nogo fMRI tests to demonstrate activation in the precuneus, ventral lateral frontal gyrus, and ventromedial prefrontal cortices rather than the motor/premotor cortex in patients presenting with HP/CD paralysis [ Table 1 ].[ 4 ]

MEDICOLEGAL IMPACT OF MISDIAGNOSING HYSTERICAL PARALYSIS

The diagnoses of HP/CD are diagnoses of exclusion, and should not be established without first obtaining appropriate neurodiagnostic tests and other studies [ Table 1 ].[ 1 - 17 ] Too frequently females are misdiagnosed with HP/CD, where in fact, they have real spinal pathology. In these cases the failure to “diagnose and treat”, especially in a timely fashion, can lead to irreversible neurological deficits that should have been avoided. Reviewing a case decades ago from a major academic medical center involved a middle aged female who, following a lumbar laminectomy, was “paralyzed.” Rather than obtaining a MR, she was dismissed as exhibiting “hysterical paralysis”; the next day, the MR showed a hematoma that was then removed. Nevertheless, by that time, her paralysis was permanent/irreversible. There are likely many similar medicolegal cases out there where spine surgeons/other specialists have failed to rule out organic disease and differentiate patients’ real organic complaints (i.e. attributable to spinal-surgical disease) from HP/CD.

CONCLUSION

Patients should not be labeled with HP/CD paralysis until neurodiagnostic/other studies (i.e., variously including MR, CT-Myelo-CT, fMRI, SEP/EMG/ MEP) have ruled out the presence of organic disease.

Declaration of patient consent

Patient’s consent not required as there are no patients in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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