2023-07-01 14:27:27
Freud would probably have ascribed them to the category of hysteria. Today it is known that they are instead a neurological problem, even if with psychic repercussions, which is expressed in different ways and which is often not recognized
In 1895 Sigmund Freud published his book on hysteria with Josef Breuer Studien ber Hysterie which in the 19th century had a much wider meaning than today, including most of the psychopathological conditions then known. Freud, who was a neurologist before becoming the father of psychoanalysis, gave this disorder an organic explanation by describing it as an involuntary somatization of a mental discomfort linked to factors such as stress, tension and emotional conflicts or psycho-physical traumas, all situations with such an impact as to hidden from consciousness so as not to renew the psychic pain of the event, but which re-emerged in the form of somatic disturbances which he called conversion syndrome.
New diagnostic categories
Over time, psychiatrists have evolved their diagnostic categories and the latest edition of their bible, the DSM 5-TR, has put conversion disorder in brackets: in fact, insiders use it less and less, preferring now to speak of FND, an acronym of Functional Neurological Disorder, i.e. functional neurological disorder or more correctly functional neurological symptoms, to indicate how it is not a single disorder with a well-defined origin, but a series of symptoms that the doctor observes and where the old criteria of Freud survived until 2013 in the fifth edition of the DSM have now become only risk factors in a complex match between psychological, physiological and socio/cultural issues.
Neurological evaluation
Today psychiatrists underline the importance of the maladaptive experience of these patients, but they emphasize the importance of neurological evaluation because at a first examination of the patient it is often difficult for them to discover the psychological factors that underlie the clinical manifestations. For their part, neurologists, thanks to the latest neuroimaging tools such as functional magnetic resonance, CT, SPECT, etc., are now able to better define the origin of these manifestations. Two years ago, for example, a study published in Neurology by Italian authors using spectroscopic magnetic resonance demonstrated how Freud had already guessed a century ago that hysteria has a biological cause that we now know is a lack of the neurotransmitter glutamate. At the beginning of May of this year, other Italian neurologists gathered in Padua for the Congress of the Italian Society of Parkinson’s and Movement Disorders (LIMPE) indicated how it has become possible to exclude by single photon tomography (SPECT with DaTSCAN tracer) the impairment of dopaminergic nerve pathways in patients resembling those of Freud: presenting with Parkinsonian-like symptoms, but none of the other features of Parkinson’s disease. These are the so-called cases of FMD, an acronym for Functional Movement Disorders, particular functional neurological disorders where the M defines that they are motor-type disorders related to movement. With the SPET-DaTSCAN an altered activity at the level of the temporo-parietal junction, the brain area involved in the awareness of actions, was highlighted.
Executive purpose
The so-called sense of agency of Anglo-Saxon authors is involved, i.e. the executive purpose for which we don’t think about what to do for a coffee, we just do it, automatically. In these patients, however, the executive purpose is altered and, as they themselves assure, their strange movements are involuntary due to the loss of control over the actions and their consequences. We can thus resolve the diagnostic doubts for cases of anomalous movements that do not fall within the classic manifestations. of typical movement disorders such as Parkinson’s and parkinsonisms, essential tremor, dystonias, etc. explains Professor Angelo Antonini who directs the Movement Disorders Center of the University of Padua.
Not just movements
But these patients represent only half of the pie of functional neurological disorders and not all have tremors or jerky or rhythmic movements. Some have symptoms such as weakness or numbness in the limbs, balance and gait abnormalities, often associated with chronic pain, depression and anxiety. Furthermore, the cases in which these symptoms occur simultaneously in the same subject are not infrequent. One of the most well-known FNDs is epileptic pseudo-seizure which Freud probably would have classified as hysteria: it is a condition similar to epileptic seizure, but in the absence of cerebral electrical alterations which can be documented with an electroencephalogram which had not yet been invented in his time.
Lack of recognition
What in a century that has not yet changed is that 80% of at least 50,000 Italian subjects with these disorders before arriving at a correct diagnosis and appropriate treatment, continues, sometimes for years, what the Anglo-Saxon doctor-shopping, a veritable odyssey from one doctor to another with multiple consultations and mostly useless and above all ineffective investigations. Beyond the possibility of using ever more complex instrumental techniques by super-specialists, the real problem lies in the area: in 2017, Professor Michele Tinazzi, President of LIMPE, set up a center in Verona that is now a national reference connected to international centers to define clinical characteristics that help identify these patients even before having to resort to the imaging techniques of super-specialists. In Veneto, FND are estimated to be around 3,637 cases – the neurologist specifies – and FMD are 2,000, representing, after senile tremor and Parkinson’s disease, the third most common cause for which a patient goes to the doctor for of the movement. The levels of disability and impairment of the quality of life of these patients are completely comparable to those of those suffering from real movement disorders and the social-welfare costs are perhaps even greater due to their endless medical pilgrimage with the heavy use of resources, even instrumental completely superfluous.
Especially women
These are mainly adults aged between about 28 and 40 years. Women and those belonging to less well-off social classes and with a low level of education are more affected. Other risk factors are unemployment, living alone especially in large urban centers and having an unsatisfactory job or emotional relationship.
From the onset of symptoms, these patients took an average of 6.63 years before arriving at the Verona center where they found a correct diagnosis. Meanwhile, more than half of them turned to a doctor on average six times a year for diagnostic tests and specialist visits. They also underwent 7 physical or psychological rehabilitation sessions and in some cases ended up in the emergency room with subsequent hospitalization. The annual cost for each of them is estimated at 2,302 euros, of which 1,524 is borne by the NHS and 778 by the patient. Faced with this situation – underlines the specialist – we have activated a training plan in our Region not only for general neurologists, but also for general practitioners by developing a special brochure with SIMG and FIMMG of Verona (Italian Society of General Medicine and Primary Care and Italian Federation of General Medicine, ed) in order to intercept these patients already at the first levels of consultation because the time between onset and fundamental diagnosis to avoid the chronicity of the disorder. Some diagnostic problems also seem to be linked to the difficulties of neurologists in understanding the mechanisms underlying these symptoms which may seem to be the result of simulations that are very difficult to resolve medically. According to a large survey by Randolph and Richard Evans of Cornell University in New York, their degree of satisfaction with treating these patients would in fact be the lowest, even below that for low back pain and insomnia, known for their low success rates.
National Register
The neurologists of the University of Verona have also activated the Italian Functional Motor Disorders Register to collect information on FMD subjects from all Italian regions and are collaborating with an international Task Force which follows almost five thousand. The key to understanding FMD is a multidisciplinary intervention with a team made up not only of the neurologist, but also of the psychologist, psychiatrist, rehabilitation therapists (physiotherapist, speech therapist, etc.) —Tinazzi says— In this way the patient is treated on several fronts (verbal, sensory, motor, etc.) with significant improvements, sometimes reaching a complete remission after months or years of illness. Based on the Veneto model, it would be appropriate to set up dedicated clinics throughout Italy – confirms from Lombardy Carlo Dallocchio, who directs the Neurology Complex Structure of the ASST of Pavia – We have learned that the first step of treatment is to make the patient understand that we consider his real disorder and not a simulation. Feeling accepted as sick helps him to accept the treatment that is proposed to him even if it will not give an immediate solution, but a slow correction that will improve the symptoms over time and with application. For example, simple physical exercise, if regular and of medium-low intensity, is a safe, adequate and pleasant intervention that can relieve many patients of a suffering from which they saw no way out despite the medical wanderings they were forced to undergo. From ongoing studies, the positive effect of this practice is preserved for at least 2 years.
Psychic responses
It has become clear that this pathology lies at the crossroads of neurology and psychiatry and suggestions from both disciplines are needed to solve the enigma it represents. For example, two characteristics of these neurological patients are purely psychological:
1) their surprising response to the placebo, i.e. to the inert drug passed off as the ideal pharmacological solution for his ills;
2) the effectiveness of distracting manoeuvres: if during the intensive rehabilitation cycles they are subjected to to reprogram the movement they seemed to have lost, asking them distracting tasks such as catching the ball that I throw at you while you are walking causes an immediate improvement in gait. If we manage to distract the brain from its unconscious belief that it is ill, the disturbance disappears, probably because the sense of agency circuits of the temporo-parietal junction are reactivated.
Even if not exactly the same mechanism, this phenomenon cannot fail to recall the unforgettable scene in the film Awakenings where Robin Williams awakens from her Parkinsonian-like catatonic apathy a patient for years immobilized in a wheelchair for lethargic encephalitis who catches a ball that Williams alias Sacks had suddenly thrown at her.
July 1, 2023 (change July 1, 2023 | 14:27)
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