Movement disorders can be expressed, on the one hand, by paresis and paralysis, contractures, the inability to perform complex motor acts, and on the other hand, by various hyperkinesis.
Hysterical paralysis and contractures usually cover a part of the body corresponding to the generally accepted division (arm, hand, finger, etc.), often sharply limiting the lesion along the articular line, regardless of whether this part of the body is innervated by one or more nerves. However, if the patient has suffered organic paralysis in the past (for example, ulnar or radial nerve palsy) or has observed this disease in others, hysterical paralysis may spread to the same muscle groups that were affected by organic paralysis. Hysterical paralysis may involve one limb (monoplegia), both limbs on one side (hemiplegia), both arms or both legs (paraplegia), or all four limbs (tetraplegia). Most often, paralysis of the muscles of the limbs is observed. Paralysis of the muscles of the tongue, neck, or other muscle groups is rare.
Hysterical contractures most often affect the muscles of the limbs, neck (hysterical torticollis) or torso (hysterical camptocormia). Sometimes hysterical spasm of the orbicularis oculi muscle occurs (hysterical blepharospasm). Often, hysterical contractures fix the body in an elaborate pose that is not observed with organic contractures. Tendon reflexes, as well as muscle tone, do not change during hysterical paralysis, paresis and contractures. When examining tendon reflexes, a somewhat deliberate flinch of the whole body or a demonstrative strengthening of the reflex is often noted. It can also be observed when the doctor, after 1-2 studies of the reflex, having made the gesture of hitting the tendon with a hammer, unexpectedly holds the hammer without touching the patient. Cutaneous reflexes that can be voluntarily delayed (plantar) are sometimes not evoked, while reflexes that cannot be voluntarily delayed (m. cremaster reflex) are preserved. Trophic muscle disorders are insignificant even with prolonged hysterical paralysis, and are not accompanied by qualitative disorders of electrical excitability. During sleep, as well as in a state of passion, hysterical paralysis and contractures may disappear.
Paralysis and paresis are usually selective, elective in nature. They appear in one situation and may suddenly disappear in another. So, for example, a “paralyzed” muscle can suddenly contract in a friendly manner when maintaining body balance, during defensive or facial movements, and also if the raised paralyzed limb is lowered (falls smoothly, and not like a whip). All this suggests that with hysteria we are not talking about paralysis in the literal sense of the word, but about the impossibility of voluntarily performing movements, about “not moving.” As S.N. Dotsenko and B.Ya. Pervomaisky (1964) rightly note, there are no isolated hysterical muscle paralysis, for example, m. biceps brachii with intact function of t. brachio-radialis.
In hysterical hemiplegia, unlike organic hemiplegia, paralysis does not extend to the muscles of the face and tongue. It is also not accompanied by a speech disorder, even if the right limbs are affected in right-handed people, and the left limbs in left-handed people. There are no synkinesis, no defensive reflexes, or the characteristic Wernicke-Mann pose. The paralyzed body part usually drags or dangles, like a tethered prosthetic limb (“Todd gait”). The leg is often more massively affected than the arm. Unlike spinal paralysis, hysterical lower paraplegia does not impair the function of the pelvic organs.
Often, hysterical paresis and paralysis are layered on mild residual, organically caused dysfunction, i.e. there is a combination of mild organic paresis with massive hysterical paralysis, which can significantly complicate diagnosis.
S. A. Chugunov, having examined 8 patients with hysterical hemiplegia and paraplegia electroencephalographically, found that in all patients the uneven amplitude and frequency of the alpha rhythm was noticeable. Often there were single fast discharges of high amplitude, reminiscent of “epileptic discharges.” Sometimes, usually in the temporal and frontal leads, groups of frequent low amplitude rhythms (“swirling”) were encountered.
According to E. A. Zhirmunskaya, L. G. Makarova and V. A. Chukhrova, the electroencephalographic picture in hysterical hemiparesis and organic hemiparesis after strokes is fundamentally similar. With organic hemiparesis, pathological potentials may appear in the affected lobe of the brain, just as with hysterical ones; At the same time, destructive brain disorders are not always accompanied by the appearance of shifts in the electrical activity of the brain. We observed 2 patients with hysterical hemiparesis, in whom no deviations from the norm were detected on the electroencephalogram.
The data presented show that hysterically and organically caused central paralysis can give a similar electroencephalographic picture. Lack of detectable pathological changes on the electroencephalogram does not exclude the possibility of both organic and hysterical paralysis.
Hysterical paralysis sometimes occurs as a phase of recovery from a hysterical stupor, less often directly after the action of traumatic stimuli.
Thus, a student expelled from school (the son of respected parents) opened the door to the classroom during a lesson and, standing in the doorway, began to smoke, spitting on the floor. N. did not respond to the teacher’s demand to immediately stop the outrage. Then the teacher, turning pale, approached him and hit him in the face with his right hand. Immediately N. felt general weakness. He slept restlessly at night and, waking up in the morning, noticed that his right arm was completely paralyzed. The muscles of the hand were tense and did not obey him. Disorder of all types of superficial and deep sensitivity affected the hand and forearm to the elbow.
At the clinic, N. was depressed because he “raised his hand” against a student, and was generally burdened by working at school with children. The comrades who came to visit him treated him sympathetically. On the third day the treatment was carried out essential mask Hysterical paralysis was immediately eliminated, all types of sensitivity were restored. N. went to work at a technical school and was healthy in subsequent years. The emerging disease helped him find a way out of the current situation.
Most often, hysterical paralysis and contractures arise gradually, by fixing one or another temporary violation motor function. Even during the First World War, the following typical occurrence of hysterical paralysis was often described in French and German literature. A soldier wounded in the leg or arm was initially unable to move the injured limb due to pain. He was evacuated to the rear. In the rear hospital the wound was healing. Movements in this limb should have already been restored, but they were not restored - hysterical paralysis developed (Binswanger hospital hysteria). Similarly, sometimes the forced position of the body after a bruise in the lumbar region became the starting point for the development of hysterical camptocormia.
The dysfunction caused by the injury, in these cases, coincided in time with the stay in the rear hospital, in a non-life-threatening environment, acquired the character of “conditional pleasantness or desirability” and in the subject, weak or weakened due to exhaustion, intoxication, etc., was fixed according to the mechanism of conditional communication. I.P. Pavlov called this a case of fatal physiological relationships, pointing out that there is no sufficient reason to talk about deliberate feigning of a symptom.
As noted by English and American authors (Sands, Hill, Harrison, etc.), during the Second World War, hysterical paralysis was not observed in persons on ships. This is explained by the fact that paralysis makes it difficult for a person to escape in the event of an enemy attack on a ship, and therefore ideas about its occurrence were not of the nature of “conditional pleasantness or desirability.” At the same time, there were hysterical symptoms that could not prevent the patient from being saved under these circumstances.
Hysterical paralysis and contractures can occur only if their development is “conditionally pleasant or desirable” for the patient. In this case, either the mechanism of hysterical fixation described above, or suggestion and self-hypnosis, plays a role in the pathogenesis of the disease.
The issue of so-called physiopathic or reflex paralysis, first observed by Mitchell (1864) during the American War and further described by Babinski and Froment during the First World War, is controversial. These paralysis occurred in persons who received minor skin wounds. They were most often combined with contracture of the muscles of the hand, in which it took on the appearance of an obstetrician’s hand, and were accompanied by sharp autonomic disorders, sensitivity disorders in the form of a “stocking” or “glove”. Electrical excitability usually changed slightly and only quantitatively; chronaxy increased slightly. With sufficiently deep ether anesthesia, these paralysis disappeared. A number of neurologists (V.K. Khoroshko, S.N. Davidenkov, P.M. Sarajishvili, etc.) join the opinion of Babinski and Froment about the physiogenic, non-hysterical nature of these functional paralysis. However, their occurrence only in war time and only in military personnel, in the absence of these paralysis in peacetime, including with injuries to the nerve trunks, does it give reason to assume the role of “flight into illness” and, therefore, speaks in favor of their hysterical nature. In our opinion, in these cases we are talking about a special group of severe hysterical paralysis, characterized by a sharp severity of autonomic disorders.
S. N. Davidenkov draws attention to the fact that hysterical paralysis should be differentiated from concomitant paralysis, which is expressed in the inability to make any movement only because the usual synergists have fallen out and the patient does not yet know how to use this muscle in a new motor combination. If, due to the destruction of the tendon, it becomes impossible, for example, for active extension of the main phalanx of the finger, then all other movements of the finger may also fall out, due to a general lack of development of motor skills. The resulting disorder may be mistaken for hysterical.
Impaired ability to perform complex motor acts can lead to hysterical astasia-abasia - the impossibility or impairment of the act of standing and walking while all other leg movements are intact. The following observation is typical.
The young woman, active, powerful, and energetic by nature, gave in to her husband’s persistent requests and moved to live with her three children in the house of his relatives. She was received very well and formally treated well, but in this house she felt like a “poor relative.” At night she cried and dreamed of returning to the village, to her mother’s house. Soon she became seriously ill infectious disease and entered the clinic. When the temperature dropped and her physical condition improved, it was discovered that in bed the patient could move her legs freely, but as soon as she tried to get up, her legs gave way and she fell. Hysterical astasia abasia developed. Along with it, increased fatigue was detected, especially when reading, and emotional lability, which was absent before the illness.
Ideas about illness became “conventionally pleasant or desirable,” since illness relieved the patient of the need to return to a house she hated. These ideas led, through the mechanism of self-hypnosis, to the emergence of astasia-abasia. The patient was explained the nature of her illness. The husband was told that “due to his wife’s health” he needed to move to live in the village with her mother. After receiving consent to move, the phenomena of astasia-abasia began to quickly pass.
Hysterical hyperkinesis is very diverse. They can be expressed in the form of trembling of varying amplitude and frequency of both the whole body and its individual parts and are often combined with pseudospasm of the muscles that produce the trembling. This trembling intensifies with excitement and can disappear in the absence of a doctor in a calm environment. As a rule, it disappears during sleep. It should be noted that intensification under the influence of emotions and disappearance during sleep is also characteristic of choreic hyperkinesis and athetosis, caused by organic damage to the subcortical nodes. The absence of hyperkinesis in an affectively charged situation (for example, during an argument with comrades) is uncharacteristic of either hysterical or organically caused hyperkinesis and speaks of their attitudinal nature. Hyperkinesis is often observed during hysteria. right hand and rotatory movements of the head.
N.K. Bogolepov and A.A. Rastvorova emphasize that hysterical and organic excessive movements are often so similar in form to each other that even with careful clinical observation it is difficult to differentiate them. This difficulty is further enhanced by the fact that hysterical hyperkinesis can sometimes occur against an organic background and that, in turn, organic hyperkinesis in 29% of cases occurs suddenly and is associated with excitement or fear. In general, in their opinion, hysterical hyperkinesis, more than organic ones, is characterized by the emergence in connection with mental trauma of dependence on the emotional state and disappearance at rest, the originality of the hyperkinesis itself, manifested in a form unknown to the doctor; insufficient severity of organic symptoms; the presence of exaggerated movements - unusual postures - and other neurotic symptoms; reduction or temporary disappearance of hyperkinesis under the influence of treatment, in particular psychotherapy, as well as under the influence of changes in a traumatic situation.
Hysterical hyperkinesis also includes some tics - rapid coordinated clonic convulsive contractions of a certain muscle group, stereotypically repeated. Most often, this involves the muscles of the face, but sometimes other muscle groups are involved, for example, with tics in the form of a sharp bending of the torso, which has a cartoonish character, a “sniffing” movement, throwing up the head with gaze upward, etc.
Management
Hysterical neurosis
Ancient Greek doctors associated the occurrence of hysteria in women with dysfunction of the uterus. Hysterical neurosis (hysteria; from the Greek hystera - uterus) is a neurosis manifested by polymorphic functional mental, somatic and neurological disorders and characterized by great suggestibility and self-hypnosis of patients, the desire to attract the attention of others at any cost. This explains the diversity and variability of hysterical disorders. “Hysteria is a proteus that takes on an infinite number of different forms; a chameleon that constantly changes its colors” (T. Sydenham). The symptoms of hysteria usually resemble manifestations of a variety of diseases, which is why J. M. Charcot called it “the great malingerer.”
Persons with signs of mental infantilism with emotional lability, affective immaturity, spontaneity of emotional reactions, impressionability and liveliness are prone to hysterical disorders. Hysterical disorders are more common in women.
In hysterical neurosis, three main groups of symptoms are observed: autonomic, motor and sensory. All of them resemble somatic and neurological diseases.
Autonomic disorders often occur in the form of fainting, vegetative crises with palpitations, dizziness, nausea, vomiting, stomach cramps, etc.
Movement disorders usually observed in the form of hyperkinesis or involuntary movements (trembling, shuddering) and symptoms of loss of movements - akinesia (paresis and paralysis). Hyperkinesis is of the nature of tics, rough rhythmic tremor of the head and limbs (which intensifies with fixation of attention), blepharospasm, choreoform movements and twitching, more organized and stereotypical than with chorea. Hysterical hyperkinesis depends on the emotional state; they temporarily weaken or may disappear when switching attention or under the influence of psychotherapy.
Hysterical paralysis can have the character of mono-, hemi- and paraplegia and in some cases resemble central spastic paralysis, in others - flaccid peripheral paralysis. The topography of hysterical paralysis usually does not correspond to the location of the innervation or localization of the focus in the central nervous system. They cover either the entire limb or its part limited by the joint. Pathological reflexes or changes in tendon reflexes are not detected in hysterical paralysis. Muscle atrophy is usually minor and is caused by inactivity.
Sensory impairments manifested by sensitivity disorders (anesthesia, hyper- and hypoesthesia) and painful sensations in various parts of the body. Sensory disturbances in the extremities are most often observed. The distribution of these disorders is often arbitrary and depends on how the patient imagines this disorder, therefore, for patients with hysteria, anesthesia in the form of socks, stockings, gloves, a vest, a belt, half the face, etc. is typical.
Hysterical algia (pain) can be observed in any part of the body (headaches, pain in the back, joints, limbs, heart, tongue, abdomen). There are descriptions of the “chessboard” appearance of the abdomen, characteristic of patients with hysteria, deformed by scars after numerous laparotomies. Similar conditions are described under the name Munchausen syndrome. Patients with these disorders migrate from one surgical clinic to another for the sole purpose of undergoing surgery. Each time they are admitted to the hospital, they provide fictitious information about their lives and medical history. In addition to anesthesia and algia, with hysterical neurosis there is a loss of functions of the sensory organs: deafness, blindness, concentric narrowing of the field of vision (while patients see their surroundings as if through a pipe), hysterical scotoma, amaurosis.
In hysterical neurosis, when exposed to acute mental trauma, generalized convulsive movements may occur, accompanied by autonomic disorders and a disturbance or narrowing of consciousness, which take on the picture of a hysterical attack. Unlike an epileptic seizure, in these cases consciousness is not completely lost and the patient falls, without receiving damage and maintaining the ability to perceive and evaluate what is happening around. In this regard, the more anxiety a seizure causes in others, the longer it can last.
Due to the pathomorphosis of hysterical disorders, it is now rarely possible to observe the clinical picture of a full-blown hysterical attack.
A hysterical attack in modern manifestations of hysterical neurosis more often resembles a hypertensive crisis, a heart attack or some other vegetative-vascular paroxysm that occurs in connection with a traumatic situation. In the structure of hysterical seizures, total tremor is often observed - “shaking of the whole body” or twitching of parts of the body, which general practitioners often do not evaluate as manifestations of hysterical symptoms.
In the pathomorphosis of hysterical disorders, popular lectures on medical topics, raising the general educational level of the population, and drawing attention to the most serious and dangerous diseases undoubtedly play a large role.
Instead of the loss of sensation such as socks, gloves, vests, etc., which were previously described by psychiatrists, there is now numbness of the limbs, a crawling sensation, tingling, a feeling of heat or cold in one or both limbs. These sensations can be similar to organic disorders and make timely diagnosis difficult.
Typical paralysis and paresis, astasia-abasia are rarely observed. In patients, weakness in the arms and legs predominates, usually occurring during anxiety. Patients note that their legs become weak, they give way, one leg suddenly becomes weak, they become braided, or heaviness and swaying appear when walking. These disorders contain an element of demonstrativeness: when the patient is observed, they become most distinct.
Instead of mutism (inability to speak), stuttering, hesitations in speech, difficulties in pronouncing certain words, etc. are now more often observed.
Difficulties in correctly assessing the condition are also due to the fact that after repeated conversations with the doctor, especially if the latter made deontological errors, the patient begins to deny the psychogenic nature of the disorders.
With hysterical neurosis, patients, on the one hand, always emphasize the exceptionality of their suffering, talk about “terrible”, “unbearable pain”, “shaking chills”, emphasize the unusual, previously unknown nature of the symptoms, etc., on the other hand, they seem to indifferent to the “paralyzed limb”, not burdened by “blindness” or mutism.
Affective disorders characterized by lability of emotions, rapid mood changes, and a tendency to violent affective reactions with tears, often turning into sobs.
The course of hysterical neurosis can be wavy. Under unfavorable circumstances, hysterical neurotic symptoms intensify and gradually affective disorders begin to come to the fore. In intellectual activity, features of emotional logic appear, in behavior - elements of demonstrativeness, theatricality with the desire to attract attention at any cost, an egocentric assessment of oneself and one’s condition.
Patients have increased sensitivity to external stimuli, impressionability with a tendency to react directly to current events.
The psychogenic nature of vegetative-somatic disorders in hysterical neurosis gave grounds to evaluate them as conversion disorders. Conversion (from the Latin conversio - turning, directing) is spoken of in cases where changes in physical well-being occur under the influence of emotional factors.
Conversion symptoms are divided into three groups: disturbances of motor acts, sensitivity disorders and all forms of behavior and assessment of the environment. In Russian literature, the term “conversion” is used relatively rarely. Most often, when assessing vegetative-somatic disorders in neuroses, they use the explanation of P.K. Anokhin, who, referring to Lange and criticizing the term “detained emotions,” wrote that an emotion, an emotional charge, if it arose in a person, cannot be delayed - it is possible to delay only external manifestations of emotions, for example, facial expressions, etc., otherwise it will still be resolved, including the most peripheral apparatuses, finding a way out along vegetative pathways, creating vegetative-somatic disorders characteristic of neuroses.
Paralysis, paresis
Paralysis, paresis (Greek paralysis; synonyms of plegia; Greek paresis weakening, relaxation) - loss (paralysis) or weakening (paresis) of motor functions with the absence or decrease in muscle strength as a result of various pathological processes in the nervous system, causing disruption structures and functions of the motor analyzer.
Types of paralysis and paresis. There are organic, functional and reflex paralysis and paresis. Organic paralysis or paresis can develop as a result of organic changes in the structure of the central or peripheral motor neuron (brain or spinal cord or peripheral nerve) that occur under the influence of various pathological processes (trauma, tumors, cerebrovascular accidents, inflammatory and other processes). Organic paralysis or paresis includes, for example, traumatic (including postpartum, obstetric and others), eclamptic (see full body of knowledge: Eclampsia), bulbar palsy (see full body of knowledge), recurrent paralysis (see full body of knowledge). The occurrence of functional paralysis or paresis is associated with the influence of psychogenic factors that lead to neurodynamic disorders of the central nervous system and occur mainly in hysteria (see full body of knowledge). Reflex paralysis or paresis is caused by neurodynamic functional disorders of the nervous system, arising under the influence, as a rule, of an extensive lesion that is not topically related to the developed paralysis or paresis.
According to the prevalence of the lesion, monoplegia (monoparesis) - paralysis (paresis) of the muscles of one limb and diplegia (diparesis) - paralysis (paresis) of the muscles of two limbs are distinguished. Among diplegias, a distinction is made between upper and lower paraplegia (see full body of knowledge), when the muscles of both arms or legs are paralyzed; partial paralysis of the muscles of both arms or legs, called upper or lower paraparesis. Paralysis or paresis of the muscles of one half of the body is called hemiplegia (see full body of knowledge) or hemiparesis, respectively. Triplegia (triparesis) is paralysis (paresis) of the muscles of three limbs. Tetraplegia (tetraparesis) is paralysis (paresis) of the muscles of both arms and both legs.
Based on the nature of the tone of the affected muscles, flaccid, spastic and rigid paralysis and paresis are distinguished.
Depending on the level of damage to the motor analyzer, paralysis and paresis are divided into central, peripheral and extrapyramidal. In addition, there are traumatic and eclamptic paralysis and paresis, which can be of both central and peripheral origin.
Central paralysis or paresis by the nature of the tone of the affected muscles, as a rule, is spastic and develops as a result of organic damage to the central motor neuron in any part of the corticospinal (pyramidal) tract (in the cerebral cortex, internal capsule, brain stem, spinal cord ). Central paralysis is also called pyramidal palsy. The causes of central paralysis or paresis can be circulatory disorders, trauma, tumors, demyelinating and other processes of the brain or spinal cord that disrupt the structure of the pyramidal tract. Central paralysis is sometimes observed in children due to various brain lesions - in utero, during childbirth, and also during the newborn period (see full body of knowledge: Infantile paralysis). Most characteristic features central paralysis or paresis are muscle hypertension, hyperreflexia, the presence of pathological and protective reflexes, pathological friendly movements, decreased or absent skin reflexes.
Muscle tone in central paralysis and paresis is increased according to the spastic type. Muscle resistance is determined to a greater extent at the beginning of the movement, then sharply decreases (the “jackknife” symptom). With pronounced muscle hypertension, muscle-joint contractures develop. With hemiplegia (hemiparesis), muscle tone increases in the adductor muscles of the shoulder, flexors and pronators of the forearm, flexors of the hand and fingers, extensors of the hip and leg, adductor muscles of the thigh and plantar flexors of the foot. As a result, patients have a characteristic Wernicke-Mann position: the arm is brought to the body, pronated and bent at the elbow and wrist joints, the fingers are bent, the leg is extended at the hip and knee joints, the foot is bent in the plantar direction.
As a result of lengthening contracture of the leg, the gait of patients takes on the character of a mower's gait (the affected leg describes a semicircle with each step). With lower paraparesis, patients walk mainly on their toes, crossing their legs. At acute diseases brain or spinal cord (cerebrovascular accidents, injuries, infectious diseases), accompanied by central paralysis, muscle tone can be reduced due to the switching off of the influence of the reticular formation (diaschisal paralysis).
An increase in tendon and periosteal reflexes is accompanied by an expansion of reflexogenic zones, the appearance of clonus of the patellas, feet, and hands (see full body of knowledge: Clonus). Pathological reflexes are evoked on the paralyzed hand: an analogue of the Rossolimo reflex (see full body of knowledge: Rossolimo reflex), carpal ankylosing spondylitis reflex (see full body of knowledge: Bekhterev's reflexes, symptoms) and Bitch's symptom (involuntary spreading of the fingers of the paralyzed hand when passively raising it upward); on the paralyzed leg - pathological reflexes of Babinsky (see the complete body of knowledge: Babinsky reflex), Gordon (see the complete body of knowledge: Gordon's reflexes), Oppenheim, Schaeffer, Zhukovsky and others (see the complete body of knowledge: Pathological reflexes); Protective reflexes also arise (see full body of knowledge) and synkinesis (see full body of knowledge).
The level of damage to the central motor neuron is established based on the localization of paralysis or paresis and its combination with others neurological symptoms. Thus, with damage to the precentral gyrus of the cerebral cortex, hemiplegia of the opposite limbs develops with muscle atonia in the initial period, followed by slow recovery and increased muscle tone, moderate revitalization of tendon and decreased abdominal reflexes, and the presence of pathological extensor reflexes. When the premotor area is damaged on the side opposite to the pathological focus, spastic hemiplegia occurs with severe muscle hypertension, a sharp increase in tendon reflexes, clonus, coordination synkinesias, pathological reflexes of the flexion type and preservation of abdominal reflexes. When the lesion spreads to the area of the postcentral gyrus of the cerebral cortex, sensitivity disorders occur, recovery of impaired motor functions slows down, and decreases. muscle hypertonicity, imitative synkinesis appears.
If the upper part of the precentral gyrus is damaged, monoplegia of the leg occurs; if its middle part is damaged, monoplegia of the arm occurs (on the side opposite to the lesion). Hemiplegia, observed when the pyramidal tract is damaged in the area of the internal capsule, is usually combined with hemianesthesia, central paresis of the facial and hypoglossal nerves. When the lesion is localized in the brain stem, central paralysis of the limbs opposite to the lesion is combined with dysfunction cranial nerves on the affected side and with sensory conduction disorder in paralyzed limbs (see full body of knowledge: Alternating syndromes, Gaze paralysis, convulsions).
If there is a lesion in the pons or in the medulla oblongata, the alternating syndrome can be combined with respiratory distress, disturbances in cardiac function and vascular tone, and vomiting (see full body of knowledge: Bulbar palsy, Pseudobulbar palsy). Damage to the pyramidal tract in the spinal cord is accompanied by central paralysis or paresis that develops below the level of the lesion on the side of the pathological focus. Damage to half the diameter of the spinal cord is manifested by Brown-Séquard syndrome (see full body of knowledge: Brown-Séquard syndrome).
Peripheral paralysis or paresis, by the nature of the change in the tone of the affected muscles, is flaccid and is observed with damage to the peripheral motor neuron (cells of the anterior horns of the spinal cord or nuclei of the cranial nerves, anterior roots of the spinal nerves, plexuses, spinal or cranial nerves). The causes of peripheral paralysis or paresis can be infectious, infectious-allergic, degenerative pathological processes (see full body of knowledge: Myelitis, Neuritis, Polyneuritis, Poliomyelitis), as well as traumatic injuries of the spinal cord, plexuses and peripheral nerves. The main symptoms of peripheral paralysis or paresis are muscle atrophy (see the full body of knowledge: Muscular atrophy), their hypotonia (see the full body of knowledge: Tone, pathology of muscle tone), areflexia (see the full body of knowledge:). Peripheral paralysis and paresis are characterized by changes in the electrical excitability of muscles (the so-called degeneration reaction). Depending on the location of the lesion along the neuron, peripheral paralysis has other features. Thus, when cells of the anterior horn of the spinal cord are damaged, fibrillary twitching is observed; damage to the anterior roots of the spinal nerves causes movement disorders of the radicular type; movement disorders that occur when a peripheral nerve is damaged are combined with sensory disorders in the area of innervation of the affected nerve, as well as vasomotor and trophic disorders, especially in connection with damage to the nerves containing a large number of autonomic fibers (for example, median, sciatic nerves).
Extrapyramidal paralysis or paresis, by the nature of the change in the tone of the affected muscles, is rigid and is observed when the pallidonigral system of the brain is damaged. It is caused by a change in the influence of this system on the reticular formation (see full body of knowledge) and a violation of the cortical-subcortical stem neural connections. Extra pyramidal paralysis and paresis, in contrast to the central (pyramidal) one, is characterized mainly by the absence or decrease in motor activity or initiative (see the full body of knowledge: Hypokinesia, Movements), a decrease in the tempo of movements (see the full body of knowledge: Bradykinesia), loss of friendly and automatic movements . As a result, there is a lack of movement (oligokinesia), slow speech, gait in small steps with the absence of accompanying hand movements (acheirokinesis). Muscle tone in extrapyramidal paralysis and paresis is increased according to the plastic type and is not springy (as in pyramidal paralysis), but waxy in nature (muscle resistance, determined by studying their tone, remains uniformly increased in all phases of movement due to its simultaneous increase in flexors and extensors , pronators and supinators). Often the “gear wheel” phenomenon can be observed (a jerk-like rhythmic resistance to passive flexion and extension of the limbs), and freezing of the limb in a given position can be observed (see full body of knowledge: Catalepsy). In contrast to pyramidal paralysis or paresis, there are no pathological reflexes and there is no sharp increase in tendon and periosteal reflexes. At the same time, an increase in postural reflexes appears (see full body of knowledge).
Hysterical paralysis may have an external resemblance to peripheral paralysis, as well as hemiplegia, paraplegia or monoplegia of organic origin. But unlike them, with hysterical paralysis, the lack of movements and decrease in strength in the limbs are not accompanied by changes in muscle tone and reflexes, trophic disorders, changes in electrophysiological, morphological and biochemical parameters.
Traumatic paralysis or paresis develops as a result of injury to the central or peripheral nervous system and can be central or peripheral in nature, respectively. The most common cause of central traumatic paralysis or paresis is contusion or compression of the brain and spinal cord. Due to diaschisis (see full body of knowledge) - a special type of shock that develops in nerve centers, in the acute period of injury - this paralysis may have the character of diaschisal paralysis.
Peripheral traumatic paralysis is observed with injuries to the spinal cord, spinal nerve roots, plexuses, and peripheral nerves. In cases related to birth trauma, it is called obstetric paralysis. Obstetric paralysis occurs as a result of injury, most often to the brachial plexus and the roots that form it, in the fetus, when traction is performed by the hand while providing manual assistance during childbirth. Obstetric arm paralysis can be unilateral or bilateral; in this case, they distinguish between upper Duchenne-Erb palsy (see the complete body of knowledge: Duchenne-Erb palsy), lower Dejerine-Klumpke paralysis (see the complete body of knowledge: Dejerine-Klumpke paralysis) and total paralysis. Obstetric paralysis of the arm is often accompanied by Bernard-Horner syndrome (see full body of knowledge: Bernard-Horner syndrome).
Peripheral traumatic paralysis or paresis can be observed in women in postpartum period(postpartum paralysis or paresis). It occurs, as a rule, after a long complicated labor due to compression of the lumbosacral plexus or its individual branches. In most cases, postpartum paralysis or paresis is unilateral, less often bilateral, but the lesions are asymmetrical. It manifests itself as weakness in the legs, gait disorder, impaired sensitivity in the area of innervation of the affected branches of the plexus and is characterized by a tendency to rapid restoration of impaired functions.
Eclamptic paralysis or paresis can be central or peripheral and develops in late pregnancy or during childbirth. Central eclamptic paralysis is caused by acute disorder blood circulation of the brain, more often as a hemorrhagic stroke, less often paralysis is a consequence of thrombosis of the cerebral vessels and sinuses of the dura mater. In this case, paralysis in most cases has the character of hemiplegia. Peripheral paralysis in eclampsia is a consequence of the effects of impaired metabolism products on the peripheral nervous system. More often, these paralysis are observed in late pregnancy, occur as polyneuritis and are characterized by predominant damage to the distal muscles of the extremities, accompanied by sensory disturbances and trophic disorders in the area of innervation of the peripheral nerves.
Diagnosis. Determining the nature of paralysis or paresis and identifying their cause is closely related to establishing the diagnosis of the underlying disease that caused the development of paralysis or paresis. Diagnosis uses various methods of clinical, laboratory, radiological, electrophysiological and other types of special studies.
Treatment of paralysis and paresis is part of the complex treatment of the underlying disease. It includes the use of drugs that improve metabolism in nervous tissue, increase the speed of nerve impulses, increase synaptic conductivity, and normalize muscle tone. Physiobalneotherapy, exercise therapy, massage, and orthopedic treatment are widely used.
Physiobalneotherapy helps restore the motor function of affected muscles, has an anti-inflammatory and analgesic effect, stimulates regeneration processes, prevents the development of atrophy of the affected muscles, the formation of contractures, and helps normalize muscle tone.
For peripheral paralysis and paresis, in the first days of treatment, UHF therapy (see full body of knowledge) and microwave therapy (see full body of knowledge), pulsed currents (see full body of knowledge), ultrasound (see full body of knowledge), electrophoresis are used on the affected limb (see full body of knowledge) drugs that have an analgesic effect - calcium, novocaine, etc. (see full body of knowledge: Electrophoresis), UV irradiation in erythemal doses (see full body of knowledge: Ultraviolet radiation). Subsequently, in order to improve the conductivity and excitability of the affected neuromuscular system, electrophoresis of anticholinesterase substances (proserine, galantamine), high-frequency alternating magnetic field, paraffin and ozokerite treatment in combination with electrical stimulation of the affected muscles and corresponding segments of the spinal cord are used. Electrical stimulation (see full body of knowledge), causing muscle contraction, improves blood supply and trophism, prevents muscle atrophy, enhances afferent impulses, which helps restore impaired motor function of muscles. For electrical stimulation, various pulse currents are used, the parameters of which are selected depending on the severity of the lesion and the state of excitability of the neuromuscular system.
In late recovery and residual periods They use mud therapy (see full body of knowledge) and mineral baths (sulfide, radon, sodium chloride, nitrogen-siliceous thermal and others), which have a stimulating effect on regeneration processes.
For central paralysis and paresis, physiobalneotherapy is administered in complex treatment in the early recovery period: for injuries of the brain and spinal cord - at 2-3 weeks, inflammatory lesions of the central nervous system - at 3 weeks, cerebrovascular accidents - at 3-5 weeks. It is aimed at improving blood circulation in the area lesions, stimulation of the activity of nerve elements. For this purpose, electrophoresis of drugs (aminophylline, no-shpa, novocaine, magnesium, iodine, calcium) is used on the collar and sinocarotid zones using the general exposure method or the orbital-occipital method. The technique is chosen depending on the nature of the stroke or injury, the state of the cardiovascular system and the age of the patients. For inflammatory lesions of the central nervous system, UHF and microwave therapy are also prescribed.
Physiotherapy is used to restore impaired motor function, reduce spasticity, eliminate pain and contractures that impede movement. Electrical stimulation is used with pulses of low and high frequencies generated by single and multi-channel devices. Antagonists of spastic muscles are stimulated predominantly. In this case, it is important to carefully select motor points, parameters and force of influence during the procedure in order to avoid increased spasticity. For mild spasticity, 1-2 courses are recommended, for moderate and severe spasticity - 2-3 courses of electrical stimulation at intervals of 3-6 weeks. With a slight increase in tone, electrical stimulation can be combined with electrophoresis of prozerin or dibazol using the method of local influence on muscles. With an early increase in muscle tone, as well as in the late recovery and residual periods, electrical stimulation is carried out with the simultaneous use of muscle relaxants. To reduce muscle tone, before electrical stimulation, treatment is carried out with heat (mud, paraffin, ozokerite applications) or cold in combination with treatment by positioning the paralyzed limb. Cryotherapy (see full body of knowledge) is especially indicated for severe spasticity with contractures in patients aged no more than 60-65 years.
To relieve pain, sinusoidal modulated or diadynamic currents and electrophoresis using novocaine are used locally. For joint and muscle contractures, thermal procedures are prescribed (paraffin, ozokerite, mud applications, local warm baths), electrophoresis medicinal substances, ultrasound, pulsed currents.
Sanatorium-resort treatment of patients with paralysis and paresis is carried out in local neurological sanatoriums, at mud and balneological resorts with sulfide, radon, sodium chloride, nitrogen-siliceous thermal waters (Evpatoria, Kemeri, Odessa, Pyatigorsk, Sochi-Matsesta, Tskhaltubo, etc. ) or in specialized sanatoriums for patients with spinal cord lesions. For peripheral paralysis and paresis, sanatorium-resort treatment is indicated 2-6 months after the end of the acute period; for central paralysis and paresis - after 4-6 months (see full body of knowledge: Sanatorium-resort selection).
Therapeutic exercise and massage for central and peripheral paralysis and paresis improve blood circulation and muscle trophism in the affected limbs, prevent the development of contractures, restore movement, develop compensatory motor skills, and have a healing effect on the patient’s body. Exercise therapy and massage are indicated in the early stages of the disease. From the first days they begin to use special placement of paralyzed limbs. For hemiplegia and hemiparesis resulting from ischemic stroke, treatment with positioning begins on the 2-4th day of illness; for cerebral hemorrhage - on the 6th-8th day (if the patient’s condition allows this treatment). Laying on the back is carried out in a position opposite to the Wernicke-Mann position: the shoulder is moved to the side at an angle of 90°, the elbow and fingers are extended, the hand is supinated and held on the palm side with a splint; the entire limb is fixed in position using sandbags. The paralyzed leg is bent at the knee joint at an angle of 15-20°, and a roll of cotton wool and gauze is placed under the knee. The foot is placed in dorsiflexion at an angle of 90° and held in this position with a wooden stand. Laying on the back is periodically alternated with laying on the healthy side; in this case, the paralyzed limbs are bent at the elbow, hip, knee and ankle joints and placed on pillows. The position of the patient on the back and healthy side is changed every l½-2 hours. Simultaneously with positional treatment, massage is prescribed. Among the massage techniques (see full body of knowledge), stroking, rubbing, light kneading and continuous vibration are recommended. Massage for central paralysis should be selective: muscles with increased tone are massaged using stroking at a slow pace, and their antagonists - by stroking, rubbing and light shallow kneading at a faster pace. In case of peripheral paralysis, the entire limb is first stroked, then the paralyzed muscles are massaged, and their antagonists are only stroked. The massage begins with the proximal limbs and is carried out daily for 10-15 days, and its duration gradually increases from 10 to 20 minutes; course of treatment - 30-40 sessions (if necessary, it can be repeated after 2 weeks). Acupressure and reflex-segmental massage are also shown. Passive movements are used simultaneously with the massage. They are carried out separately for each joint (5-10 movements in full range and at a slow pace), starting from the proximal parts of the limbs on both the healthy and the affected side. Passive movements are carried out by the methodologist or the patient himself with the help of a healthy limb.
To restore motor function, active gymnastics is of primary importance. In case of central paralysis and paresis, it is started on the 7-10th day from the onset of the disease in case of ischemic stroke, in case of cerebral hemorrhage - on the 15-20th day. It is advisable to begin with exercises in holding the limb in its given position. After the patient learns to perform these exercises and hold the limb, active gymnastics is performed first for those muscles whose tone is not increased. The development of active movements is carried out with the help of lightweight exercises using special devices: frames with a system of blocks and hammocks, slippery surfaces, spring traction, gymnastic apparatus. Then active free exercises are prescribed for healthy and affected limbs, including the use of special devices for fastening and unfastening buttons, tying and untying ribbons, and others.
Teaching patients to sit begins in case of ischemic stroke 10 days from the onset of the disease, and in case of cerebral hemorrhage - after 3-4 weeks. Preparing the patient for walking begins in a lying position, and then sitting, and exercises that simulate walking are practiced. When the condition of patients allows them to get out of bed, they begin to teach them to stand on both legs, alternately on a healthy and a sick leg, walk in place, with an instructor, then in a special wheelchair, using a three-legged crutch, along a track, stairs. During the entire course of exercise therapy for central paralysis, a set of exercises is also carried out aimed at eliminating pathological synkinesis. It is advisable to perform gymnastic exercises for peripheral paralysis in a bath or pool with warm water. The duration of the exercise therapy course in each individual case is individual and can vary from 3-4 weeks to 2-3 months or more, and sometimes several years, depending on the nature pathological process, causing the occurrence of paralysis or paresis.
Orthopedic treatment can be conservative or surgical. Conservative treatment as an independent treatment is usually indicated in the absence of evidence of interruption or compression of the nerve trunk and is carried out using prosthetic and orthopedic devices, shoes, plaster, plastic and other removable splints, special beds and other means. Its goal is partial compensation of lost motor function. Surgical treatment paralysis is carried out mainly in case of anatomical interruption of the nerve (partial or complete), compression or crushing of the nerve trunk and in case of ineffectiveness conservative treatment. Surgical interventions are performed directly on the nerves with the application of a primary or secondary nerve suture (see full body of knowledge), performing neurolysis (see full body of knowledge); on tendons and muscles - grafting, muscle plasty, transosseous tenodesis (see full body of knowledge); on joints - operations to secure the joint in a constant fixed position (see the full body of knowledge: Arthrodesis) and to form an artificial bone brake in order to limit mobility in the joint (see the full body of knowledge: Arthrosis).
For persistent severe loss of nerve function more than 2 years after injury and the impossibility or ineffectiveness of surgical intervention on the nerves, orthopedic surgery is indicated. For example, in order to replace the function of a paralyzed deltoid muscle in children over 6 years of age, trapezius muscle myolavsanoplasty is performed. The operation consists of cutting off the trapezius muscle from the clavicle and scapular spine along with the periosteum, suturing a Mylar prosthesis to it, the other end of which is fixed in the upper third humerus. Pronation contracture of the limb is eliminated using detorsion osteotomies of the shoulder and forearm bones. For peripheral paralysis of the limb, tenodesis of the wrist joint is sometimes performed.
With high damage sciatic nerve the function of the muscles innervated by the tibial and common peroneal nerves is lost. In this case, the ligamentous apparatus of the foot is weakened, pronounced bone atrophy and excessive mobility in the ankle and small joints of the foot occur. To restore the weight-bearing ability of the limb, arthrodesis, arthrorrhiza, and tenodesis of the foot joints are used. For example, in case of pronounced valgus or varus position of the foot, arthrodesis of the ankle joint is used, in some cases combined with subtalar arthrodesis.
Wreden's bridging arthrodesis involves the simultaneous closure of the ankle joint and the transverse tarsal joint (Shopard's joint) while maintaining mobility in the tarsometatarsal joints (Lisfranc joint) using a sliding bone graft from the tibial crest. Oppel-Dzhanelidze-Lortiuar arthrodesis consists of closing the ankle, subtalar and talocalcaneal-navicular joints. To limit excessive mobility with a dangling cauda equina, Campbell's posterior arthrorrhiza is recommended; with a calcaneal foot - anterior arthrorrhiza according to Mitbreit.
Damage to the superficial peroneal nerve leads to loss of function of the peroneal muscle group. In these cases, transplantation of the tibialis anterior tendon to the outer edge of the foot is indicated. Damage to the deep peroneal nerve leads to loss of function of the muscles that extend and supinate the foot. To compensate for them, transplantation of the peroneus longus tendon to the inner edge of the foot is indicated. Damage to the common peroneal nerve entails loss of function of the muscles that extend, supinate and pronate the foot. In this case, they most often resort to tenodesis using the tendons of the same paralyzed muscles, which are fixed in the lower third of the tibia. Split transplant operation calf muscle on the dorsum of the foot consists of isolating the tendon of the soleus muscle, cutting it off at the place of attachment to the tubercle of the calcaneus and fixing the second or third to the rear metatarsal bones. The tendon of this muscle is lengthened using Dacron tape.
In cases of radial nerve palsy, the flexor carpi ulnaris tendon can be transplanted onto the extensor digitorum tendon, and the flexor carpi radialis tendon can be transplanted separately into the extensor and abductor pollicis tendons. This operation was first performed by F. Frank in 1898. One of its modifications is the Osten-Sackena-Dzhanelidze operation: cross-transplantation of the flexor carpi ulnaris tendon onto the extensor pollicis longus and abductor longus muscle. thumb hands, and the tendons of the flexor carpi radialis - to the extensor digitorum.
In the postoperative period, the limb is immobilized using splints, splints, functional orthopedic devices (see full body of knowledge), and in some cases - distraction-compression devices (see full body of knowledge). A feature of immobilization is the fixation of the limb in a position that ensures minimal tension on the operated nerves, muscles or tendons. Its duration is determined by the timing of fusion of these formations or the timing of the formation of ankylosis or callus (during operations on bones).
The prognosis depends on the nature of the pathological process, the depth and extent of damage to the motor analyzer and the compensatory capabilities of the body. With central paralysis and paresis that developed as a result of circulatory disorders, the range of movements increases as blood flow is restored. With central paralysis and paresis caused by a cortical lesion, movements are restored faster and more fully compared to paralysis caused by damage to the internal capsule. In case of peripheral paralysis and paresis that developed as a result of injury to the brachial plexus during childbirth, movements in the affected limbs are restored within 1 - 2 years.
In case of peripheral paralysis and paresis caused by damage to the peripheral nerves, if conservative treatment is ineffective, reconstructive surgery is resorted to. After operations on nerves, restoration of their conductivity occurs no earlier than after 5-6 months
Orthopedic operations on joints, muscles and tendons provide only partial restoration of the function of a paralyzed limb.
Antropova M.I.; Badalyan L.O.; Volkov M.V.; Fedorova G.S.; Fitsenko P.Ya.
Psychogenic (hysterical) paralysis, occurring under the influence of psychotraumatic influences (see Neuroses), may outwardly resemble both central and peripheral paralysis. However, there are no changes in muscle tone, tendon-periosteal and skin reflexes, no pathological reflexes, trophic disorders, changes in electrical excitability of nerves and muscles.
P.'s diagnosis does not present great difficulties and is based on the results of a clinical examination. In the differential diagnosis of spastic and flaccid P., along with clinical data, a significant role is played by the study of electrical excitability of nerves and muscles, as well as the bioelectrical activity of muscles (see Electromyography). Hysterical P. is differentiated from similar conditions of organic origin. An essential role is played by the absence of signs of organic damage to the nervous system in hysterical P., as well as the presence of emotional and behavioral characterological disorders.
For the diagnosis of hemiparesis, comparison of muscle strength on both sides is of great importance. This is achieved by comparing the scores of symmetrical movements, as well as using various additional techniques. The essence of the latter is to perform voluntary movements in a physiologically uncomfortable position. In this case, they can be used the following techniques and functional tests.
Venderovich's motor ulnar defect is a technique that reveals the strength of the adductor muscles of the IV-V fingers. Method of determination: with the hands in an extended position, the person being examined with maximum strength presses the fingers together, the doctor moves the little finger away, taking it by the first interphalangeal joint. If ulnar nerve function is impaired or the pyramidal tract is mildly affected, less force is required to abduct the little finger.
Rusetsky's symptom. Make maximum extension of the hands, which are at the same level; on the P. side, extension is limited.
Babinski's symptom of automatic pronation. The patient extends his arms forward in a state of supination; there is a tendency to pronate on the affected side.
Mingazzini's sign - lowering of the outstretched arm on the P side.
Panchenko's technique (Buddha phenomenon). The subject raises his arms up and brings his hands together above his head, palms turned upward, almost until the fingers touch. On the P. side, pronation of the hand is observed, and the hand drops down.
Mingazzini-Barre sample. In the prone position, the patient bends his legs in knee joints at an angle of 90° and holds them for 1-2 minutes. If there is mild weakness in one of the lower limbs, it begins to droop. The test is more demonstrative if the shin is bent at an angle of 30-45° (leg drop test). You can offer the patient in a prone position to bend his legs as much as possible: on the P. side, the flexion is less pronounced (Vitek’s symptom).
Early signs of mild P.: muscle weakness, impaired tempo of movements. If there is even slight weakness of the hand, it is difficult for the patient to perform fine movements, the hand becomes tired (tired) while writing, and handwriting may change. Weakness of the hand is also determined by studying the strength of spreading or bringing together the fingers, contrasting the first finger with the others. Very early sign weakness of the hand - the inability to touch the tip of the first finger to the fifth finger on the palmar surface of the hand. To study the pace of movement, it can be recommended to quickly perform maximum flexion - extension of the feet, opposing the first finger of the hand to the rest.
In newborns and infants, attention should be paid to the presence of asymmetries of movements, for which, in addition to simple observation, it is recommended to use special diagnostic techniques carried out with the child lying on his back.
Traction test. The doctor takes the child's wrists with one hand and slowly pulls him towards himself. In healthy children, uniform resistance to extension is determined.
Withdrawal reflex. Alternate tingling of the soles causes uniform flexion of the hips, legs and feet.
Cross extensor reflex. The child's leg is extended and fixed, then several injections are made into the sole of the fixed limb. In response, extension and slight adduction of the other leg occur.
Lower limb abduction test. With a quick movement, the child’s bent legs are moved to the sides, while moderate resistance to abduction is felt.
P. must be differentiated from movement disorders that occur when muscles are damaged, osteoarticular system, ligamentous apparatus, as well as from restriction of movements due to ataxia, apraxia, sensitivity disorders (including severe pain).
P.'s treatment depends on the location and nature of the damage to the nervous system. Prescribed medications, physiotherapeutic agents, exercise therapy, massage. Carry out orthopedic measures and, if necessary, neurosurgical operations (see Obstetric paralysis, infantile cerebral paralysis, stroke, neuritis, polyneuritis).
Hysterical neurosis (hysteria) can manifest itself as a variety of functional mental, neurological and somatic disorders against the background of increased suggestibility of a person.
Hysteria gets its name from the Greek word “hystera,” which means uterus. The fact is that symptoms of hysterical neurosis occur more often in women, so ancient Greek doctors thought that the manifestations of hysteria were associated with dysfunction of the uterus.
Causes of the disorder
Some people are predisposed to developing hysteria. Among them are persons suffering. However, this is not the only personality disorder against which hysterical reactions may appear. They can form in people with, with, among narcissistic personalities.
People with an immature psyche are prone to hysterical reactions - characterized by increased suggestibility, lack of independence of judgment, impressionability, easy excitability, emotional swings, and egocentrism.
Freud believed that the development of hysteria is based on two factors - mental trauma from early childhood and sexual complexes. From the point of view of the well-known Freud, the germs of our adult problems lie in childhood, and hysteria is no exception to this rule.
The immediate causes of hysterical neurosis are sudden stressful situations, conflicts, problems that a person cannot cope with on his own.
Clinical picture of the disease
Hysteria is also called the “great malingerer,” because it can manifest itself with a wide variety of symptoms, and serious deviations in the functioning of internal organs, which could be confirmed using laboratory or instrumental examinations, while absent.
There are 3 groups of symptoms of hysterical neurosis: motor (motor), sensitive (sensory) disorders and disorders of autonomic functions that imitate somatic or neurological diseases. Autonomic symptoms, observed during hysteria -.
Motor disorders in hysteria
Hysteria can manifest itself as motor disorders in the form of partial or complete paralysis of the limbs, impaired coordination, and the inability to move independently while maintaining all movements within the bed. With hysteria, the voice may disappear, its sonority may be lost while whispered speech is preserved, speech may become slurred and incomprehensible. Stuttering, difficulties in pronouncing certain words, and hesitations in speech may appear.
Various involuntary muscle twitches (tics), rough rhythmic trembling of the head and limbs, which intensifies with fixation of attention, may also occur. Some patients complain that their legs become entangled, or that they feel heavy and stagger when walking. With anxiety, instead of paralysis, weakness in the arms and legs may appear.
The area of paralysis that occurs with neurological diseases always depends on the location of the brain lesion. Also, over time, with neurological paralysis, signs of circulatory disorders appear in the paralyzed areas of the body. In hysterical paralysis, there is no relationship between the affected area of the limb and the location of a specific focus in the central nervous system.
If hysterical neurosis is accompanied by the occurrence of paralysis, then clinical picture will be slightly different. With this pathology, most often motor disturbances will spread either to the entire limb or are strictly limited to the articular line (for example, leg to knee, arm to elbow), and there will be no signs of trophic disorders.
The severity of involuntary movements (hyperkinesis) is closely related to emotional state person. During stressful situations they can be pronounced, and in calm state may pass. They may also weaken or disappear completely when the patient’s attention switches. The nature of hyperkinesis can change against the background of new information received (by the type of imitation).
Hysterical attack
Hysteria can manifest itself as seizures. In response to psychological stress during hysterical neurosis, widespread convulsive phenomena resembling an epileptic seizure may develop.
Unlike epileptic seizures, seizures in hysterical neurosis always occur in the presence of “spectators”; a person falls to the floor “successfully” without receiving any injuries; demonstrativeness is one of the main features of hysteria.
A hysterical seizure is accompanied by a narrowing of consciousness, however, such that a person does not understand at all what is happening to him, where he is, and what happened during the seizure, as happens with epileptic seizures, never happens.
Unlike epileptic seizures, during hysterical seizures there is never involuntary urination, tongue biting, severe injuries, the pupillary reaction to light is preserved.
Sensory disorders
Hysteria may be accompanied by sensory disturbances. The most commonly observed sensitivity disorders are:
- complete loss of sensation (anesthesia);
- decreased sensitivity (hypesthesia);
- strengthening (hyperesthesia);
- pain in various parts of the body and organs.
Hysterical neurosis most often manifests itself as anesthesia (lack of sensitivity) or hypoesthesia (decreased sensitivity) in the form of socks (the affected area is the area of the leg on which socks are usually worn), gloves, a vest, a belt, half the face.
Hysteria in women often manifests itself as hysterical pain, which can appear in any part of the body - pain in the joints, back, headaches, pain in the heart, in the abdomen, etc.
Hysterical neurosis, in addition to loss of sensitivity or pain, can be manifested by loss of function of the sensory organs - deafness or blindness. Quite often, with hysteria, a narrowing of the visual field and a distortion of color perception occur. However, even a pronounced narrowing of vision does not prevent such patients from orienting themselves in space.
Autonomic disorders
In addition to all of the above, hysteria can manifest itself as vegetative disorders: multiple somatic complaints are observed. Most often, vegetative signs of hysteria are disorders of the gastrointestinal tract (nausea, vomiting, pain, belching, feeling of transfusion in the abdomen) and skin sensations (burning, itching, numbness). Autonomic disorders can manifest themselves in the form of dizziness, fainting, and rapid heartbeat.
Distinctive signs and course of the disorder
Appearance and further development symptoms of the disease are always closely related to unpleasant life events and conflicts, but the patients themselves deny such a connection. The inability to convince doctors and relatives of the seriousness of one’s illness and the need for further examination and treatment provokes the emergence of demonstrative behavior aimed at attracting the attention of others to one’s personality. Hence the appearance of fainting, seizures, and attacks of dizziness.
Such disorders are characterized by variability under the influence of new information, sudden onset and disappearance of symptoms. For the patients themselves, the symptoms of hysterical neurosis are a means of manipulating others. They may disappear completely once the goal is achieved.
Hysteria is not mental disorder, which shows the disability group. However, many patients still hope for social support, and therefore very vividly describe the severity of their mental and somatic condition, although no objective signs of this are determined.
Hysterical reactions caused by psychogenic influence can be short-term and disappear spontaneously, without concomitant treatment. In some patients, symptoms of hysterical neurosis can persist for several years.
Treatment and prevention
Drug treatment of hysterical neurosis is carried out with tranquilizers (diazepam, phenazepam), prescribed in small doses and short courses.
If the symptoms of hysteria become protracted, in such cases tranquilizers are combined with antipsychotics that have a corrective effect on human behavior (neuleptil, eglonil, chlorprothixene).
To be frank, hysteria is very difficult to treat, because the whole problem lies not so much in the presence of some serious pathology, but in personal characteristics, in a person’s need to be in the center of attention.
Psychotherapy should occupy a central place in the treatment and prevention of hysteria. During the sessions, the doctor will try to gently find out exactly what events provoked the appearance of symptoms of hysterical neurosis, the exacerbation of the existing personality disorder, will help the patient deal with existing problems in his social environment. However, therapy should be long-term; quick results cannot be counted on.
Interesting article
Case 4. Hysterical paralysis
The psychiatrist made a phone call and asked for a consultation. He wanted to undergo couples therapy and receive supervision about his case at the same time. The therapist replied that he was going on a long-distance business trip in three weeks, so there would not be enough time for either therapy or supervision. The young man insisted on the need for urgent consultation for him and his wife. So the meeting was set up.
When the couple arrived for their first session, the young man was holding the book Strategies of Psychotherapy (Haley, 1963). He introduced his wife, a psychology student. They looked like an attractive couple: a blue-eyed wife with straight blond hair and a handsome brunette husband. He said that he and his wife had a serious problem that other therapists had not been able to solve. The wife suffered from hysterical paralysis of the tongue, which at times refused to obey her. In an attempt to be understood, she could only moo and make strange sounds. The symptom went away when the wife took Valium, after which she rested for about an hour. Over the past six months, a strange illness has overtaken her quite often, but now the young woman will have to work with patients, she will have to present cases publicly, and the young woman is afraid of a sudden onset of paralysis: she will not be able to speak, and then everyone will know about her illness. The therapist noted that the symptom was very interesting, even exotic: it may coincide with the last case of hysterical paralysis that occurred in Western Europe and described by Freud. The husband and wife smiled, agreeing with the therapist without much pride.
The husband then reported that psychoanalytic therapy and psychoanalysis had not been successful. He read Haley's book and is now convinced that strategic marital therapy, through the use of paradox, will help resolve the problem. He knew that the symptom was without any doubt related to marriage.
The therapist inquired about what had happened during previous therapy and learned that the wife's last therapist was an employee of the husband who acted as his supervisor. The nature of the symptom aroused his great interest, and he studied the patient during therapy. The wife added: according to the psychiatrist, the symptom is caused by a feeling of guilt, which is born of her fantasies about oral sex. She stopped therapy after he tried to seduce her. The young woman almost gave in to his proposals when she suddenly realized that despite all his assurances of love, he was cunning and deceiving her. She ran away from the psychotherapy office and never returned there again. This episode became a source of enormous difficulties and troubles for my husband, since he continues to work in a team where this same psychiatrist continues to be his supervisor.
The therapist asked when the symptom first appeared. Both husband and wife remembered that day clearly. Then they were not yet married and went to visit the groom’s parents. The future mother-in-law told them that she was leaving her husband and in an hour she was flying with her daughter to another country. She would like to say goodbye to her son and his bride, but she asked not to tell her father anything until the plan was realized - so that he could not stop her. The young people promised to fulfill the request. And after her husband’s mother left, the girl for the first time felt that she could not utter a word. She was very scared, and the young man gave her a Valium tablet to calm her down. About an hour later the speech returned.
The therapist commented that the experience was indeed quite painful for both of them, especially for the husband. His wife turned out to be unusually sensitive to his difficulties. Then the young woman admitted: she had a difficult relationship with her own parents, and her father suffered from alcoholism.
It appears that the wife's symptom was an important aspect of the husband's career. It gave a reason to involve teachers in the discussion, for whom the unusual case aroused professional interest. During the first phone call, the young man did not even know exactly what was more important to him - supervision or his wife’s recovery. He already felt like an expert on her problem when he discussed with the therapist what approach should be taken in this case. And although he has so far failed to help his wife, the reason for his failure was not a cowardly flight from difficulties, but the originality of the problem. So, in order to succeed in working with this case, the first thing that is required is to strip the symptom of its exoticism.
In order to better understand the presented symptom, according to the therapist, it should be compared with what she herself suffers from. When the therapist is upset or anxious about something, she experiences abdominal pain, which is the result of contraction of the stomach muscles, or spasm. The stomach becomes rigid, tense, and she feels pain. Doesn't it seem to the husband, who is a doctor, that the tongue is also a kind of muscle, and its rigidity can also be considered as a consequence of a muscular spasm, similar to a spasm of the stomach? The husband recognized the legitimacy of this line of thought. And then the therapist noticed that the symptom seemed to her not to be hysterical paralysis, but to be a phenomenon of psychosomatic spasm of one of the parts digestive system- language. As for the causes of the spasm, most likely they lie in the patient’s anxiety. The husband and wife were forced to agree with this argument.
Psychosomatic spasm is, of course, not nearly as interesting and unusual as hysterical paralysis. The therapist redefined the symptom and forestalled a possible confrontation by teaming up with the wife, whose illness was likened to the therapist's, and enlisting the support of the husband as a medical specialist.
The therapist then said that she had to evaluate the symptom in the light of all the terrible things that a person in her profession had to encounter in her therapist's office. Such as, for example, uncontrollable vomiting, forcing a person to quickly hide in the bathroom, loss of consciousness, etc. Of course, when your tongue stops moving, it's terrible, but there are many other equally terrible things that can happen to anyone. And even more terrible than those that the therapist managed to remember. The husband and wife accepted this argument as well.
The symptom has now been defined not only as a psychosomatic disorder instead of the exotic hysterical paralysis, but also as one of the various organic phenomena that occur in abundance in the practice of any therapist.
Then, during the conversation, questions arose regarding the patient’s professional career. The young woman complained about her insecurity, her situation of involuntary competition with her husband, and her uncertainty about whether she could become a good therapist if she herself had such serious emotional problems.
Next, the therapist asked the couple to describe their life together and the difficulties they faced in their marriage. It turned out that the husband, compared to his wife, is not only more passionate about his profession, but also superior to her in sociability: as a rule, he spends his weekends at the club, where he plays tennis and plays other sports. At this time, the wife sits at home, unable to find a place for herself from anger and resentment. At night she is often overcome by anxiety, and she cannot fall asleep or wakes up, overtaken by the same anxiety in the middle of the night. At such moments, she wakes up her husband, needing his support, although he often does not know what needs to be done to calm her down. Then the wife begins to cry and behave like a child, switching to the speech of a little girl. It happens that the tongue refuses to obey it, becoming wooden. She usually falls asleep on Valium, but neither of them likes it that way. The couple fears that addiction may arise. In a word, both of them think that not everything is going well with their communication, and would like their mutual understanding to improve.
The therapist concluded by noting that she needed to see if she could help them in the short time she had and made an appointment with them in a few days.
At the beginning of the next interview, the therapist stated that she had thought a lot about the meaning of the symptom. In her opinion, the version that sees the basis of the symptom in fantasies about oral sex does not stand up to criticism. The couple agreed. And then the therapist proposed her hypothesis: the rigidity of the tongue, in her opinion, is associated with the difficulty of keeping secrets. The wife has probably always been open and sincere, the therapist continued, and that is why it is difficult for her to keep secrets. This peculiarity of hers reached its highest point when her husband’s mother asked the young girl to keep her daring plan a secret. The girl’s tongue seemed to become stiff, as if helping to keep that secret, initiation into which caused a storm of conflicting feelings in her soul. Thus, the therapist summed up, the problem of communicative contact between husband and wife comes down not to a lack of communication, but to its redundancy. Those nights when anxiety attacks did not allow the girl to sleep, long nights filled with conversations and emotional outpourings are convincing evidence of the validity of this conclusion. The therapist was sure that the wife had never had even one little secret. The young woman confirmed that this was indeed the case. Therefore, the therapist concluded, it is very important to increase the distance between husband and wife, limiting the intensity of communications between them. The symptom is a purely individual problem, affecting only the wife and having nothing to do with the husband. Therefore, everything that happens in therapy must remain a secret between the patient and the therapist. It seemed to the latter that through such a decisive and short intervention it would be possible to bring relief to her wife. Right after her conclusion, the therapist rose from her chair and, walking the stunned husband to the door, invited him to leave them alone.
The interaction between husband and wife, the center of which was the symptom, served as a metaphor for the system of their interaction as a whole, where the wife occupied a subordinate and helpless position in relation to her husband, which at the same time constituted her strength, derived from this weakness. Compared to his wife, the husband looked more competent in professional matters, and more adequate, helping her overcome the symptom, but... to no avail: the symptom not only did not disappear after their marriage, but even intensified, requiring more and more attention and energy from both. By connecting the symptom to the episode when it first made itself felt, and defining its meaning as difficulty in keeping secrets, the therapist was able to change the metaphor of which it served as an expression: the marital problem was now seen not in a lack of communication between husband and wife, but in their excessiveness. Previously, the metaphor, finding expression in the system of marital interaction around and about the symptom, spoke, firstly, about the strength and helplessness of the husband, who, trying to understand his wife and help her, suffered one defeat after another, and secondly, about the helplessness and the power of a wife begging her husband to help her, but deep down understanding that it is not in his power to fulfill this request. In other words, the symptom-based interaction system served as a metaphor for hierarchical incongruity in a marriage in which both husband and wife were simultaneously in positions of subordination and superiority in relation to each other. Incongruity was a misguided way to achieve greater equality in her relationship with her husband and an equally misguided attempt to neutralize his superiority in social life. By defining the patient’s problem as a result of excessive communication and excluding her husband from the therapy process, moreover, surrounding her with an aura of the strictest secrecy, access to which is prohibited for him, the therapist radically changed the intra-family hierarchy. The wife became stronger and less helpless, since she alone was now the owner of the symptom. In addition, the opportunity to seek help from her husband was blocked, and finally, left alone, the woman received the advantage of participating in this so-called “strategic paradoxical psychotherapy.” The husband lost a significant amount of his power because he was excluded from helping his wife. But at the same time, he became less helpless, since he ceased to be part of the problem, which means he was freed from responsibility for solving it.
The therapist continued to convince the client that paradoxical intervention was the most appropriate remedy in this case. She opened Strategies for Psychotherapy to a page that talked about Frankl's paradoxical intentions and asked the young woman to read the text. When she looked up from the book, the therapist suggested that she try her best and make sure that right here, in the session, the tongue became clumsy and inactive. The patient tried as best she could, but to no avail. Well, it’s okay, the therapist relented, but within next week the girl should cause the symptom in herself three times a day, lasting no less than fifteen minutes in each individual case. The therapist then began a conversation with the young woman about her business career and what field she was most interested in. She replied that she needed supervision and a deeper study of practice.
At her next appointment, the woman stated that she had followed the directive exactly and that she no longer had the symptom. She kept the therapist's prescription a secret from her husband. Then the therapist remarked that something needs to be done about her nightly anxiety attacks, and offered one more instruction. The patient should have a desk near the bedroom where she could keep paper, pencil, notes from therapy sessions, as well as textbooks and books on therapy in which she found something useful. In cases where the state of anxiety reaches such a strength that it does not allow her to fall asleep, or forces her to wake up from sleep, when her tongue becomes rigid again, there is no need to wake up her husband. Moreover, he should not talk about anything. Instead, she should rise quietly, go to her desk, and spend an hour at it, taking notes on a therapeutic meeting she had with a patient last week or this week. It is necessary to write down everything that the patient said. If the patient is a child with whom she was doing play therapy, record everything that he did during their play. You should describe your therapeutic intervention in detail, reveal its meaning, and provide arguments in favor of its use. You can use books to explain what has been done or to justify your understanding of a case. When the hour is up, the woman should return to the bedroom and lie down. If she fails to fall asleep after fifteen minutes, she can return to her desk and resume the task. It is necessary to act in accordance with these instructions, even if you have to spend the whole night at your desk. The patient can come to the next session with all the material that she has compiled due to insomnia. The therapist will review the notes and discuss them to help her grow professionally. If an anxiety attack strikes the patient not at night, but during the day, she can set her alarm clock for three in the morning, get up when the bell rings, and write down the results of the session for an hour. All this must be kept strictly secret from her husband and under no circumstances should she inform him that her actions are related to therapy. The young woman, with apparent reluctance, gave in to the therapist's demands, expressing doubts about how she would feel the next day if she didn't get enough sleep, and whether it was possible to carry out work while in the grip of anxiety.
The phenomenon of tongue rigidity was blocked by a paradoxical symptom-prescribing intervention. The anxiety attacks also ceased as a result of the prescription of difficult nightly ordeals through which the patient would have to go if the symptom suddenly reappeared. The trial was designed in such a way that, regardless of the outcome, it was doomed to success: either anxiety attacks would become a rare occurrence in her life, or she would advance in the case thanks to a detailed description of the cases and subsequent supervision. Previously, her anxiety was a test for her husband; now her anxiety has become a test for herself.
At the next meeting, the young woman reported that nothing special was happening with her tongue. As for anxiety, I did have one attack. She brought several pages of text describing the case. After working for an hour, the woman went to bed. The notes brought in contained a number of hateful remarks about the therapist, interspersed with fragmentary comments about playing with the child. The client admitted that while filling out these pages, she was filled with anger and hatred because she had to go through the ordeal instead of sleeping. The therapist replied that this was understandable, and began to discuss the notes, explaining what should have been done to make the author’s thoughts clearer, the description more accurate, etc. The same instructions remained for the coming week.
Over the next week, the patient remained asymptomatic. This was the last interview since the therapist was leaving the country. In parting, she said that the patient needed to follow the previous instructions regarding anxiety attacks. If they recur, the woman should show her notes to another therapist with whom a supervisory consultation has been arranged in advance. In order to discourage her from waking up at night, it was agreed with the therapist that he would charge the girl double for each hour of supervisory work.
At a follow-up meeting two years later, the young woman reported that the tongue spasm had never recurred. She had several meetings with her supervisor, then there was no longer a need for them. Although the woman feels anxious from time to time, there was no case when anxiety attacks overtook her at night. Husband and wife are still together, both actively work as therapists, but each in their own field. They can't decide whether they should have a child. Although their relationship has noticeably improved, it seems to them that the limit has not yet been reached: there is room for change and improvement.
The therapeutic intervention contained the following stages:
1. The therapist reconstructed the system of marital interaction that had developed on the basis of the symptom, transforming the diagnosis of hysterical paralysis into psychosomatic spasm and changing the metaphor expressed by the symptom from sexual fantasies and lack of communication to difficulties in keeping secrets and redundancy of communication between husband and wife.
2. The husband was excluded from the therapy process, and the wife received instructions requiring her to keep the content of the therapeutic process secret from her husband, which deprived him of the opportunity to use the symptom as a source of strength and weakness.
3. A paradoxical instruction was successfully used, instructing the wife to voluntarily induce a spasm of the tongue in order to achieve its complete immobility.
4. In dealing with a symptom of anxiety, the therapist prescribed an ordeal through which the patient would go every time she had an outburst of anxiety, and which was calculated to make the young woman either less helpless or, as a result of the new experience, given test - more competent.
5. Therapist, forced ahead of schedule to finish working with the patient, he transferred this case to another therapist, whose functions included supervision, making it possible to ensure that the patient adhered to the instructions blocking outbursts of anxiety for some time.
In this case, the incongruent hierarchy in the marriage manifested itself at the moment when the wife's dependence and uncertainty became fertile ground for the emergence of her “hysterical” symptom. The so-called “hysterical paralysis” was for her a source of power over her husband, while simultaneously remaining a position of weakness in relation to him. The “wife’s hysteria” allowed the husband to establish himself in a position of superiority, while simultaneously placing him in a position of dependence, since all attempts to help ended in failure, although the symptom was within the scope of his professional competence. The therapist organized the couple in such a way that strength and weakness were no longer centered on symptomatic behavior; he also used a paradoxical instruction and a difficult test to overcome the symptom.
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Hysterical paralysis, contractures and hyperkinesis
Paralysis and contractures cover a group of muscles involved in performing some purposeful motor act, for example, chewing, sucking, closing your eyes, etc., regardless of whether this group is innervated by one or more nerves. Paralysis of the facial muscles and especially the tongue is uncommon.
Hysterical blepharospasm manifested by spasm of the orbicularis oculi muscle. Usually occurs after significant neuropsychic stress. The orbital and zygomatic reflexes do not change. When reflexes are evoked, deliberate shudders of the whole body or demonstrative strengthening of the reflex are often observed. It can also be observed when, after several evocations of the reflex, they only make a striking gesture (holding the hammer) without touching the patient. During sleep and in a state of passion, the spasm of the orbicularis oculi muscle disappears.
If the patient has hysterical hemiplegia, then the paralysis does not extend to the muscles of the face and tongue. Such patients do not have speech disorders, synkinesis, protective reflexes, etc.
Hysterical paralysis of the facial muscles manifested by immobility of one half of the face. Occurs if it is “conditionally pleasant or desirable” for the patient. In its development, either hysterical fixation, or self-hypnosis or suggestion is important.
Hysterical hyperkinesis. Among functional hyperkinesis, tics occupy an important place. These are short-term, monotonous, stereotypical violent clonic twitches of a certain group of muscles, often having a deliberate appearance: various grimaces, protruding the tip of the tongue, involuntary blinking of both eyes or simultaneous winking, frowning of the eyebrows, wrinkling of the forehead, repeated movements of the head to the sides and stretching of the neck, reminiscent of gestures , as if the patient is trying to free himself from a tight collar, sucking a finger, the tip of the tongue, lips, convulsive stretching of the lips with the trunk, biting nails (onychophagia), puffing out the cheeks, moving the tongue to remove a lump of food from the gums, chewing, tic spitting, snorting, snorting, sniffing, snoring, forced coughing, etc.
They arise in connection with negative emotion, mental trauma, and also as imitation.
The disease is chronic, periodically worsening, in rare cases it occurs as an episodic manifestation.
Hysterical glossoplegia occurs under the influence of negative emotions, manifested by a violation of active movements of the tongue. Patients have difficulty speaking and moving food in the mouth. However, more often voluntary movements of the tongue are possible. The patient moves his tongue in his mouth very slowly, but sticks it out oral cavity can not. There is hypoesthesia of the tongue, pharynx and skin in the tracheal area, which does not correspond to the zone of innervation of nerves or nerve roots, i.e. hysterical type hypoesthesia. The cough of patients is loud. Patients prefer to explain themselves in writing.
The prognosis is usually favorable, movements can be restored immediately, or recovery is slow, leading to hysterical stuttering.
Hysterical aphonia develops under the influence of mental trauma. In patients, the sonority of the voice disappears, and in contrast to aphonia caused by organic lesions of the nervous system, the cough in patients remains sonorous.
During the examination, hysterical hypoesthesia of the tongue and pharynx may be noted; the glottis remains open with significant tension on the vocal cords. Hysterical aphonia is very difficult to treat and can develop into hysterical stuttering.
Emergency and specialized assistance. Typically, hysterical symptom complexes arise acutely, and in cases where medical assistance rendered untimely, can be fixed for many years. The main method of treatment in this case is psychotherapy in combination with medications. In very severe cases, hypnosis with explanation is used. The method of self-hypnosis and autogenic training are important.
During psychotherapy, patients with hysterical prosopalgia are prescribed tranquilizers: diazepam (Seduxen), chlordiazepoxide (Elenium), trioxazine, meprotan (Andaxin), etc., among which diazepam is the most effective. It is prescribed 0.005 g 2-3 times a day. It is advisable to select the dose individually, starting with the minimum and gradually increasing it. Valerian root, bromine preparations, barbital sodium (medinal) and motherwort tincture in combination with small doses of caffeine are also used.
Treatment of hysterical paralysis, paresis and sensitivity disorders can also be successful only if psychotherapy is combined with drug therapy and electrical procedures.
Patients with hysterical trismus and hysterical glossoplegia (glossoparesis) are prescribed a course of treatment with caffeine and barbamyl: 1 ml of a 20% caffeine solution is injected subcutaneously and then 5-10 minutes later very slowly - 3-5 ml of a 5% barbamyl solution. The patient is told that his existing disorders will gradually smooth out. The course of treatment is 6-10 sessions.
Patients with mild and moderate forms of the disease are recommended to do daily morning exercises. Shown physiotherapy followed by warm baths, preferably in a sanatorium (change of scenery).
