Chasing the Chameleon: Psychogenic Paraparesis Responding to Non-Invasive Brain Stimulation

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Abstract

Neurologic symptoms that develop unconsciously and are incompatible with known pathophysiologic mechanisms or anatomic pathways belong to Conversion Disorder (CD). CD diagnosis is based on the clinical history and the exclusion of physical disorders causing significant distress or social and occupational impairment. In a subgroup of CD, called functional weakness (FW), symptoms affecting limbs may be persistent, thus causing a permanent or transient loss of limb function. Physiotherapy, pharmacotherapy, hypnotherapy and repetitive transcranial magnetic stimulation (rTMS) have been proposed as treatment strategies for FW-CD. Herein, we report a 30 year-old male, presenting with lower limb functional paraparesis, having obtained positive, objectively, and stable effects from a prolonged r-TMS protocol associated to a multidisciplinary approach, including psychological and sexuological counseling, and monitored by gait analysis. We postulate that our rTMS protocol, combined with a multidisciplinary approach may be the proper treatment strategy to improve FW-CD.

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Most cited references 14

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Aberrant supplementary motor complex and limbic activity during motor preparation in motor conversion disorder.

Cécile Gallea, Valerie Voon, Christina Brezing … (2011)

Conversion disorder (CD) is characterized by unexplained neurological symptoms presumed related to psychological issues. The main hypotheses to explain conversion paralysis, characterized by a lack of movement, include impairments in either motor intention or disruption of motor execution, and further, that hyperactive self-monitoring, limbic processing or top-down regulation from higher order frontal regions may interfere with motor execution. We have recently shown that CD with positive abnormal or excessive motor symptoms was associated with greater amygdala activity to arousing stimuli along with greater functional connectivity between the amygdala and supplementary motor area. Here we studied patients with such symptoms focusing on motor initiation. Subjects performed either an internally or externally generated 2-button action selection task in a functional MRI study. Eleven CD patients without major depression and 11 age- and gender-matched normal volunteers were assessed. During both internally and externally generated movement, conversion disorder patients relative to normal volunteers had lower left supplementary motor area (SMA) (implicated in motor initiation) and higher right amygdala, left anterior insula, and bilateral posterior cingulate activity (implicated in assigning emotional salience). These findings were confirmed in a subgroup analysis of patients with tremor symptoms. During internally versus externally generated action in CD patients, the left SMA had lower functional connectivity with bilateral dorsolateral prefrontal cortices. We propose a theory in which previously mapped conversion motor representations may in an arousing context hijack the voluntary action selection system, which is both hypoactive and functionally disconnected from prefrontal top-down regulation. Copyright © 2011 Movement Disorder Society.

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Validity of the Optogait photoelectric system for the assessment of spatiotemporal gait parameters.

Karin Lienhard, David Schneider, Nicola Maffiuletti (2013)

The purpose of this study was to evaluate the discriminant and concurrent (criterion-related) validity of a recently introduced floor-based photocell system (Optogait, Microgate, Bolzano, Italy) with a validated electronic walkway for the assessment of spatiotemporal gait parameters. Fifteen patients (mean age±standard deviation: 65±7 years) with total knee arthroplasty and 15 healthy matched control subjects were asked to walk at different velocities while gait variables were recorded simultaneously by the two instruments. The Optogait and the criterion instrument detected the same differences in walking parameters between patients and controls. Intraclass correlation coefficients ranged between 0.933 (swing time) and 0.999 (cycle time, cadence and walking speed). Cycle time and stance time were significantly longer, while swing time, step length, cadence and walking speed were significantly lower for Optogait (p<0.001) compared to the criterion instrument. The Optogait system demonstrated high discriminant and concurrent validity with an electronic walkway for the assessment of spatiotemporal gait parameters in orthopedic patients and healthy controls. However, the two measuring instruments cannot be used interchangeably for quantitative gait analysis, and further validation of floor-based photocell technology is warranted. Copyright © 2012 IPEM. Published by Elsevier Ltd. All rights reserved.

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Functional (conversion) neurological symptoms: research since the millennium.

Alan J Carson, Richard Brown, Anthony David … (2012)

Functional neurological symptoms (FNS) are commonly encountered but have engendered remarkably little academic interest. 'UK-Functional Neurological Symptoms (UK-FNS)' was an informal inaugural meeting of UK based clinicians in March 2011 with a variety of research and clinical interests in the field. This narrative review reflects the content of the meeting, and our opinion of key findings in the field since the turn of the millennium.

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Author and article information

Journal

Journal ID (nlm-ta): Psychiatry Investig

Journal ID (iso-abbrev): Psychiatry Investig

Journal ID (publisher-id): PI

Title: Psychiatry Investigation

Publisher: Korean Neuropsychiatric Association

ISSN (Print): 1738-3684

ISSN (Electronic): 1976-3026

Publication date (Print): April 2018

Publication date (Electronic): 30 March 2018

Volume: 15

Issue: 4

Pages: 428-431

Affiliations

[1 ]IRCCS Centro Neurolesi “Bonino-Pulejo”, Messina, Italy

[2 ]Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, Messina, Italy

Author notes

Correspondence: Rocco Salvatore Calabrò, MD, PhD IRCCS Centro Neurolesi “Bonino-Pulejo,” Via Palermo, SS 113 C.da Casazza Messina, Italy Tel: +39 09060128840, Fax: +39 09060128854, E-mail: salbro77@ 123456tiscali.it

Article

Publisher ID: pi-2017-10-16-2

DOI: 10.30773/pi.2017.10.16.2

PMC ID: 5912486

PubMed ID: 29593207

SO-VID: de6f355a-4be5-429b-b1f5-d55d3412bb57

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 12 June 2017

Date revision received : 29 September 2017

Date accepted : 16 October 2017

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