Michael Binzer

Clinical characteristics of patients with motor disability due to conversion disorder : a prospective control group study

OBJECTIVES Previous studies have suggested associations between conversion and many different clinical characteristics. This study investigates these findings in a prospective design including a control group. METHODS Thirty consecutive patients with a recent onset of motor disability due to a conversion disorder were compared with a control group of patients with corresponding motor symptoms due to a definite organic lesion. Both groups had a similar duration of symptoms and a comparable age and sex profile and were assessed on a prospective basis. Background information about previous somatic and psychiatric disease was collected and all patients were assessed by means of a structured clinical interview linked to the diagnostic system DSM III-R, the Hamilton rating depression scale, and a special life events inventory. RESULTS The conversion group had a higher degree of psychopathology with 33% of the patients fulfilling the criteria for psychiatric syndromes according to DSM-III-R axis I, whereas 50% had axis II personality disorders compared with 10% and 17% respectively in the control group. Conversion patients also had significantly higher scores according to the Hamilton rating depression scale. Although patients with known neurological disease were not included in the conversion group, a concomitant somatic disorder was found in 33% of the patients and 50% complained of benign pain. The educational background in conversion patients was poor with only 13% having dropped out of high school compared with 67% in the control group. Self reported global assessment of functioning according to the axis V on DSM IV was significantly lower in conversion patients, who also registered significantly more negative life events before the onset of symptoms than controls. Logistic regression analysis showed that low education, presence of a personality disorder, and high Hamilton depression score were significantly associated with conversion disorder. CONCLUSION The importance of several previously reported predisposing and precipitating factors in conversion disorder is confirmed. The results support the notion that conversion should be treated as a symptom rather than a diagnosis and that efforts should be made in diagnosing and treating possible underlying somatic and psychiatric conditions.

Recent onset pseudoseizures—clues to aetiology

PURPOSE To examine associations of potentially aetiological significance for the development of pseudoseizures by comparing patients with recent onset pseudoseizures with patients with recent onset epilepsy. METHODS A prospective study of consecutive patients with recent onset pseudoseizures and epilepsy presenting to two Swedish hospitals. Demographic characteristics, somatic symptoms, depression severity, personality disorder, potential childhood aetiological factors and recent life events were elicited from clinical data and a research interview, which included a structured clinical interview for DSM-IV, a measure of perceived parental care and a life events inventory. RESULTS Twenty patients with pseudoseizures of duration less than 12 months (mean 5.4 months) were compared with 20 patients with recent onset epilepsy. There was no statistically significant difference in the rate of current psychiatric disorder. Patients with recent onset pseudoseizures were however more likely to have a borderline personality disorder (P<0.05), and to recollect less parental warmth and more paternal rejection (P=0.0001) in childhood. They had no more life events in the 3 months prior to onset but did report more when the whole year before onset was assessed (P<0.001). CONCLUSIONS Perceived childhood neglect, borderline personality, and an excess of life events over the preceding year is associated with pseudoseizures of recent onset more than with epilepsy. The study was limited by the small sample size making type two errors likely. However, by selecting both cases and controls with recent onset symptoms, the potential bias of differing illness durations and complicating factors of chronicity that have affected previous studies was avoided.

Motor Conversion Disorder: A Prospective 2- to 5-Year Follow-Up Study

In this prospective study, 30 patients with motor conversion disorder were assessed for key psychiatric and demographic variables. At reassessment 2 to 5 years later, 19 patients had completely recovered and 8 patients had improved, whereas only 3 were unchanged or worse. Contrary to other follow-up studies, none of the patients received a rediagnosis of neurological disease. The presence of a personality disorder and overall personality pathology, particularly within cluster C, the presence of a concomitant somatic disease, low DSM-IV Axis V score, and high score on the Becks Hopelessness Scale proved to be associated with poor outcome.

Cerebrospinal fluid biomarkers for Parkinson's disease - a systematic review.

Diagnosis of Parkinsons disease (PD) relies on clinical history and physical examination, but misdiagnosis is common in early stages. Identification of biomarkers for PD may allow early and more precise diagnosis and monitoring of dopamine replacement strategies and disease modifying treatments. Developments in analytical chemistry allow the detection of large numbers of molecules in plasma or cerebrospinal fluid, associated with the pathophysiology or pathogenesis of PD. This systematic review includes cerebrospinal fluid biomarker studies focusing on different disease pathways: oxidative stress, neuroinflammation, lysosomal dysfunction and proteins involved in PD and other neurodegenerative disorders, focusing on four clinical domains: their ability to (1) distinguish PD from healthy subjects and other neurodegenerative disorders as well as their relation to (2) disease duration after initial diagnosis, (3) severity of disease (motor symptoms) and (4) cognitive dysfunction. Oligomeric alpha‐synuclein might be helpful in the separation of PD from controls. Through metabolomics, changes in purine and tryptophan metabolism have been discovered in patients with PD. Neurofilament light chain (NfL) has a significant role in distinguishing PD from other neurodegenerative diseases. Several oxidative stress markers are related to disease severity, with the antioxidant urate also having a prognostic value in terms of disease severity. Increased levels of amyloid and tau‐proteins correlate with cognitive decline and may have prognostic value for cognitive deficits in PD. In the future, larger longitudinal studies, corroborating previous research on viable biomarker candidates or using metabolomics identifying a vast amount of potential biomarkers, could be a good approach.

Illness behavior in the acute phase of motor disability in neurological disease and in conversion disorder : a comparative study.

Sixty patients with a sudden onset of motor disability were assessed for illness behavior and depression. In 30 of the patients, etiology was attributed to a definite structural lesion. The remaining 30 patients were diagnosed as having conversion disorder. The Illness Behaviour Questionnaire (IBQ) and the Hamilton Rating Depression Scale (HRDS) were used as instruments for assessment. The mean HRDS score was significantly higher in the conversion group, indicating a higher degree of affective disease in these patients. According to the results of the IBQ, the patients with conversion disorder showed a higher degree of irritability, disease conviction, and phobic preoccupation, and also, to a greater extent, rejected psychological explanations for their symptoms. Denial was high in both patient groups, coexisting with affective symptoms in the conversion patients but not in the neurological patients. Although valuable information could be extracted from the IBQ, it was not found to be a reliable instrument for distinguishing between psychogenic and organic causes of motor disability.

Conversion symptoms: What can we learn from previous studies?

Conversion symptoms are psychogenic disturbances of bodily function, usually produced by emotional stressors of which the patient is unaware. The psychodynamic concept is still strongly associated with conversion, although psychoanalytic assumptions do not always appear to be valid. Due to ill-defined terminology and differences in inclusion criteria, comparison of data in previous studies is extremely difficult, and it is unclear what relative contributions are made by a range of variables to its precipitation and the form it takes. This review attempts to summarize predisposing, precipitating, and maintaining factors of conversion symptoms and also speculates on possible etiologic factors and suggests fields for further research.Conversion Disorder—DSM IV, Review of research, Somatoform disorders.

Changes in kynurenine pathway metabolism in Parkinson patients with L-DOPA-induced dyskinesia

L‐3,4‐Dihydroxyphenylalanine (L‐DOPA) is the most effective drug in the symptomatic treatment of Parkinsons disease, but chronic use is associated with L‐DOPA‐induced dyskinesia in more than half the patients after 10 years of treatment. L‐DOPA treatment may affect tryptophan metabolism via the kynurenine pathway. Altered levels of kynurenine metabolites can affect glutamatergic transmission and may play a role in the development of L‐DOPA‐induced dyskinesia. In this study, we assessed kynurenine metabolites in plasma and cerebrospinal fluid of Parkinsons disease patients and controls. Parkinson patients (n = 26) were clinically assessed for severity of motor symptoms (UPDRS) and L‐DOPA‐induced dyskinesia (UDysRS). Plasma and cerebrospinal fluid samples were collected after overnight fasting and 1–2 h after intake of L‐DOPA or other anti‐Parkinson medication. Metabolites were analyzed in plasma and cerebrospinal fluid of controls (n = 14), Parkinson patients receiving no L‐DOPA (n = 8), patients treated with L‐DOPA without dyskinesia (n = 8), and patients with L‐DOPA‐induced dyskinesia (n = 10) using liquid chromatography‐mass spectrometry. We observed approximately fourfold increase in the 3‐hydroxykynurenine/kynurenic acid ratio in plasma of Parkinsons patients with L‐DOPA‐induced dyskinesia. Anthranilic acid levels were decreased in plasma and cerebrospinal fluid of this patient group. 5‐Hydroxytryptophan levels were twofold increased in all L‐DOPA‐treated Parkinsons patients. We conclude that a higher 3‐hydroxykynurenine/kynurenic acid ratio in plasma may serve as a biomarker for L‐DOPA‐induced dyskinesia. Longitudinal studies including larger patients cohorts are needed to verify whether the changes observed here may serve as a prognostic marker for L‐DOPA‐induced dyskinesia.

Chronic pain disorder associated with psychogenic versus somatic factors: A comparative study

Fifty-one consecutive non-depressed patients with chronic pain referred to a multidisciplinary pain clinic were assessed. In 32 patients, pain was judged to be associated with psychogenic factors only, while pain in 19 patients could be attributed solely to a general medical condition. The methods of investigation comprised visual analogue scales (VAS) and pain drawings, the Dysfunctional Attitude Scale (DAS), the Karolinska Scales of Personality (KSP), locus of control (LOC) and EMBU (for assessing perceived parental rearing practices). Mean age, gender distribution, analgesic consumption, pain duration, percentage of body area pain as well as body localization of pain were comparable in both groups. Patients with psychogenic pain reported higher levels of general bodily discomfort but less concentration difficulties and memory disturbances compared with the somatic pain patients. There were no significant intergroup differences on any of the LOC, DAS, KSP or EMBU items. LOC turned out to be extremely external, whereas DAS, KSP and EMBU scores were comparable to normal controls in earlier work. The paucity of differences between the two patient groups and the unremarkable personality structure of patients led to somewhat conflicting conclusions, and the results of the study pose one more piece of evidence for the futility of the dichotomous organic vs. psychogenic distinction of chronic pain disorders.

Psychological Defense Strategies According to the Defense Mechanism Test Among Patients with Severe Conversion Disorder

Nineteen patients with a diagnosis of conversion disorder (according to DSM-IV criteria), and 32 healthy nonpatients, were assessed using the Defense Mechanism Test (DMT), which is a projective perception test that examines psychodynamic defense operations according to psychoanalytical theory. The conversion group was significantly separated from the non-patient group. The nonpatients showed better reality testing and the ability to perceive the negative affective element of the stimulus picture when compared to the patient group. The conversion group was characterized by a lateness of perception, specific constellations of defensive maneuvers, and a much more nonemotionally adapted pattern compared to the control group. This supports the notion that conversion symptoms are non-verbal communications inhibiting more articulated verbal expressions of emotions. The results lend support to the theories of psychodynamic self psychology, where the organization of affect experience is believed to constitute an e...

Cerebrospinal fluid levels of catecholamines and its metabolites in Parkinson's disease: Effect of L‐DOPA treatment and changes in levodopa‐induced dyskinesia

Levodopa (l‐DOPA, l‐3,4‐dihydroxyphenylalanine) is the most effective drug in the symptomatic treatment of Parkinsons disease (PD), but chronic use initiates a maladaptive process leading to l‐DOPA‐induced dyskinesia (LID). Risk factors for early onset LID include younger age, more severe disease at baseline and higher daily l‐DOPA dose, but biomarkers to predict the risk of motor complications are not yet available. Here, we investigated whether CSF levels of catecholamines and its metabolites are altered in PD patients with LID [PD‐LID, n = 8)] as compared to non‐dyskinetic PD patients receiving l‐DOPA (PD‐L, n = 6), or not receiving l‐DOPA (PD‐N, n = 7) as well as non‐PD controls (n = 16). PD patients were clinically assessed using the Unified Parkinsons Disease Rating Scale and Unified Dyskinesia Rating Scale and CSF was collected after overnight fasting and 1–2 h after oral intake of l‐DOPA or other anti‐Parkinson medication. CSF catecholamines and its metabolites were analyzed by HPLC with electrochemical detection. We observed (i) decreased levels of dihydroxyphenylacetic acid (DOPAC) and homovanillic acid in PD patients not receiving l‐DOPA (ii) higher dopamine (DA) levels in PD‐LID as compared to controls (iii) higher DA/l‐DOPA and lower DOPAC/DA ratios in PD‐LID as compared to PD‐L and (iv) an age‐dependent increase of DA and decrease of DOPAC/DA ratio in controls. These results suggest increased DA release from non‐DA cells and deficient DA re‐uptake in PD‐LID. Monitoring DA and DOPAC in CSF of l‐DOPA‐treated PD patients may help identify patients at risk of developing LID.