Movement disorders can be expressed, on the one hand, by paresis and paralysis, contractures, the inability to perform complex motor acts, 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 in the past organic paralysis (for example, paralysis of the ulnar or radial nerve) or has seen this disease in others, hysterical paralysis can spread to the same muscle groups to which organic paralysis extended. Hysterical paralysis can affect an isolated limb (monoplegia), both limbs on one side (hemiplegia), both arms or both legs (paraplegia), and all four limbs (tetraplegia). Most often, paralysis of the muscles of the extremities 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 trunk (hysterical camptocormia). Sometimes there is a hysterical spasm of the circular muscle of the eyes (hysterical blepharospasm). Often, hysterical contractures fix the body in a pretentious posture, which is not observed in organic contractures. Tendon reflexes, as well as muscle tone during hysterical paralysis, paresis and contractures, do not change. In the study of tendon reflexes, a somewhat deliberate start of the whole body or a demonstrative increase in the reflex is often noted. It can also be observed when the doctor, after 1-2 studies of the reflex, having made a gesture of hitting the tendon with a hammer, unexpectedly delays the hammer without touching the patient. Skin reflexes that can be arbitrarily delayed (plantar) are sometimes not triggered, while reflexes that cannot be arbitrarily delayed (reflex to m. Cremaster) are retained. Trophic disorders of muscles 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 can disappear.
Paralysis and paresis are usually selective, elective. They show up in one situation and may suddenly disappear in another. So, for example, a "paralyzed" muscle can suddenly contract in a friendly manner while maintaining the balance of the body, during defensive or mimic movements, and also if the raised paralyzed limb is lowered (falls smoothly, and not like a whip). All this suggests that in hysteria we are not talking about paralysis in the literal sense of the word, but about the impossibility of voluntary performance of movements, about “non-movement”. As SN Dotsenko and B. Ya. Pervomaisky (1964) rightly note, there are no isolated hysterical muscle paralysis, for example, paralysis of m. biceps brachii with intact function of T. brachio-radialis.
In hysterical hemiplegia, unlike organic paralysis, 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-handers are affected, and the left-handers - the left limbs. There are no synkinesis, no protective reflexes, or the characteristic Wernicke-Man posture with them. The paralyzed part of the body usually drags or dangles like a tethered prosthesis ("Todd's gait"). The leg is often more severely 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 superimposed on light residual, organically caused dysfunctions, that is, there is a combination of mild organic paresis with massive hysterical paralysis, which can significantly complicate the diagnosis.
SA 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 attracted attention. Often there were single, high-amplitude, fast discharges, reminiscent of "epileptic discharges." Sometimes, usually in the temporal and frontal leads, there were groups of frequent rhythm of low amplitude ("dimness").
According to EA Zhirmunskaya, LG Makarova and VA 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, as well as with hysterical ones; at the same time, destructive disorders of the brain 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 abnormalities were found on the electroencephalogram.
These data show that hysterically and organically caused central paralysis can give a similar electroencephalographic picture. The absence 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 immediately after the action of traumatic stimuli.
Thus, a student expelled from school (the son of respected parents) opened the door to the classroom during the lesson and, standing at the door, began to smoke, spitting on the floor. N. did not immediately respond to the teacher's demand to stop the disgrace. Then the teacher, turning sharply pale, went up to him and hit him in the face with his right hand. N. immediately felt a general weakness. He slept anxiously 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 sensation covered the hand and forearm up to the elbow.
In the clinic, N. was deprived of the fact that he "raised his hand" to the student, and generally weighed down the work at school with children. Comrades who came to visit him treated him sympathetically. On the third day, treatment with an ether mask was carried out. Hysterical paralysis was immediately eliminated, all types of sensitivity were restored. N. went to work in a technical school and in subsequent years was healthy. The emerging disease helped him find a way out of this 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, at first could not move the injured limb due to pain. He was evacuated to the rear. In the rear hospital, the wound was healing. The movements in this limb should have already recovered, but they did not recover - hysterical paralysis developed (Binswanger hospital hysteria). In a similar way, sometimes the forced position of the trunk after a contusion of the lumbar region became the starting point for the development of hysterical camptocormia.
The dysfunction caused by trauma 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 by the mechanism of conditional communication. I.P. Pavlov called this a case of fatal physiological relations, pointing out that there is no sufficient reason to speak of deliberately simulating a symptom.
As noted by the 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 the ideas about its occurrence were not of the nature of "conditional pleasantness or desirability." At the same time, there were such hysterical symptoms that could not prevent the patient from saving under these circumstances.
Hysterical paralysis and contractures can occur only if their development is "conditionally pleasant or desirable" for the patient. At the same time, either the mechanism of hysterical fixation described above, or suggestion and self-hypnosis, plays a role in the pathogenesis of the disease.
Controversial is the question of the 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. These paralysis occurred in persons who received light skin wounds. They were most often combined with contracture of the hand muscles, in which it took the form of an obstetrician's hand, and were accompanied by severe autonomic disorders, sensory disorders in the form of a "stocking" or "glove". Electroexcitability usually changed insignificantly and only quantitatively; chronaxia increased slightly. With a sufficiently deep ether anesthesia, these paralysis disappeared. A number of neurologists (V.K.Khoroshko, S.N.Davidenkov, P.M.Saradzhishvili and others) subscribe to the opinion of Babinski and Froment about the physiogenic, non-hysterical nature of these functional paralysis. However, their occurrence only in wartime and only in military personnel, in the absence of these paralysis in peacetime, including with injuries of nerve trunks, gives 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.
SN Davidenkov draws attention to the fact that hysterical paralysis should be differentiated from friendly paralysis, which are expressed in the impossibility of making any movement only because the synergists familiar to them have fallen out and the patient still does not know how to use this muscle in a new motor combination. If, due to the destruction of the tendon, it becomes impossible, for example, active extension of the main phalanx of the finger, then all other movements of the finger may also fall out, with a general undeveloped motor function. The resulting disorder can be mistaken for hysterical.
Violation of the ability to perform complex motor acts can lead to hysterical astasia-abasia - the impossibility or violation of the act of standing and walking, while all other leg movements are preserved. The following observation is characteristic.
The young woman, active, domineering, energetic by nature, yielded to her husband's insistent requests and moved to live with her three children in the house of his relatives. She was very well received 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. She soon fell ill with a severe infectious disease and entered the clinic. When the temperature dropped and the somatic state improved, it was found that in bed, the patient can move her legs freely, but barely tries to get up, as her legs give way and she falls. Hysterical astasia abasia developed. Along with it, increased fatigue was found, especially when reading, and emotional lability, which was absent before the illness.
The concept of illness became “conventionally pleasant or desirable,” since the illness relieved the patient of the need to return to the house she hated. These ideas led by 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 it was necessary for "the wife's health" to move to live in the village with her mother. After obtaining consent for the move, the phenomena of astasia-abazia began to pass quickly.
Hysterical hyperkinesis is very diverse. They can be expressed in the form of tremors of various amplitudes and frequencies, both of the whole body and of its individual parts, and are often combined with pseudospasm of the muscles that carry out the tremors. This tremor increases 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 amplification 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 colored situation (for example, in a dispute with comrades), which is uncharacteristic for either hysterical or organically conditioned hyperkinesis, and speaks of their attitudinal nature. Hyperkinesis is often observed in hysteria. right hand and rotatory head movements.
NK Bogolepov and AA 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 occurs suddenly in 29% of cases and is associated with excitement or fear. In general, in their opinion, hysterical hyperkinesis, more than organic ones, are characterized by the emergence of dependence on the emotional state in connection with mental trauma and disappearance at rest, the originality of hyperkinesis itself, which manifests itself 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 the traumatic situation.
Some tics also belong to hysterical hyperkinesis - rapid coordinated clonic convulsive contractions of a certain muscle group, which are stereotypically repetitive. Most often, this involves the muscles of the face, but sometimes other muscle groups, for example, with tics in the form of a sharp bending of the torso, which is caricatured in nature, "sniffing" movement, throwing up the head with the gaze upward, etc.
Management
Hysterical neurosis
Ancient Greek doctors associated the occurrence of hysteria in women with dysfunctions of the uterus. Hysterical neurosis (hysteria; from the Greek. Hystera - uterus) is a neurosis that manifests itself in polymorphic functional mental, somatic and neurological disorders and is characterized by great suggestibility and self-hypnosis of patients, the desire at any cost to attract the attention of others. This explains the variety and variability of hysterical disorders. “Hysteria is a proteus that takes on an infinite number of different kinds; a chameleon that constantly changes its colors ”(T. Sydenham). Symptoms of hysteria usually resemble the manifestations of a variety of diseases, so J. M. Charcot called her "the great simulator."
Persons with signs of mental infantilism with emotional lability, affective immaturity, immediacy of emotional reactions, impressionability and liveliness are prone to hysterical disorders. Hysterical disorders are more common in women.
In hysterical neurosis, there are three main groups of symptoms: autonomic, motor and sensory. They all resemble somatic and neurological diseases.
Autonomic disorders often in the form of fainting, vegetative crises with palpitations, dizziness, nausea, vomiting, in the form of stomach cramps, etc.
Movement disorders usually observed in the form of hyperkinesis or involuntary movements (trembling, flinching) and symptoms of loss of movements - akinesia (paresis and paralysis). Hyperkinesis are in the nature of tics, rough rhythmic tremors of the head and extremities (which intensifies with fixation of attention), blepharospasm, choreoform movements and twitching, more organized and stereotyped than with chorea. Hysterical hyperkinesis depends on the emotional state, they are temporarily weakened or may disappear with a switch of attention or under the influence of psychotherapy.
Hysterical paralysis can have the character of mono-, hemi- and paraplegia and resemble in some cases central spastic, 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 bounded by the joint. There are no pathological reflexes or changes in tendon reflexes in hysterical paralysis. Muscle atrophies are usually mild, due to inactivity.
Sensory impairment are manifested by disorders of sensitivity (anesthesia, hyper- and hypesthesia) and painful sensations in different parts of the body. Most often, there are violations of the sensitivity of the extremities. The distribution of these disorders is often arbitrary and depends on how the patient imagines this violation, therefore, anesthesia in the form of socks, stockings, gloves, vest, belt, half of the face, etc., is characteristic for patients with hysteria.
Hysterical algias (pains) can be observed in any part of the body (headaches, pain in the back, joints, limbs, heart, tongue, in the abdomen). There are descriptions of the type of abdomen ("checkerboard") characteristic of patients with hysteria, deformed by scars after numerous laparotomies. Similar conditions are described under the name Munchausen syndrome. Patients with these disorders wander from one surgical clinic to another with the sole purpose of undergoing surgery. Each time they are admitted to the hospital, they provide fictitious information about their life and medical history. In addition to anesthesia and algia, with hysterical neurosis, there is a loss of functions of the sense organs: deafness, blindness, concentric narrowing of the visual field (while the 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 impairment or narrowing of consciousness, which acquire a picture of a hysterical seizure. Unlike an epileptic seizure, in these cases, consciousness is not completely lost and the patient falls without injury and retaining the ability to perceive and evaluate what is happening around. In this regard, the more excitement in others causes a seizure, the longer it can last.
In connection with the pathomorphosis of hysterical disorders, it is now rare to observe a clinical picture of a detailed hysterical seizure.
A hysterical seizure in modern manifestations of hysterical neurosis 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, there is often a total tremor - "shaking all over the body" or twitching of body parts, which are often not assessed by general practitioners as manifestations of hysterical symptoms.
In the pathomorphosis of hysterical disorders, undoubtedly, popular lectures on medical topics, raising the general educational level of the population, and drawing attention to the most serious and dangerous diseases play an important role.
Instead of loss of sensitivity like socks, gloves, vests, etc., which were previously described by psychiatrists, numbness of the limbs, a feeling of crawling, tingling, a feeling of heat or cold in one or both limbs is now observed. These sensations can be similar to organic disorders and make timely diagnosis difficult.
Typical paralysis and paresis, astasia-abasia are rare. In patients, weakness in the arms and legs prevails, usually arising from excitement. Patients note that the legs become wadded, give way, one leg suddenly becomes weak, braids or appears heaviness, staggering when walking. These disorders contain an element of demonstrativeness: when the patient is observed, they become most pronounced.
Instead of mutism (inability to speak), stuttering, stuttering in speech, difficulty in pronouncing certain words, etc. are now more common.
Difficulties in the correct assessment of the condition are also due to the fact that after repeated conversations with the doctor, especially if the latter made deontological mistakes, the patient begins to deny the psychogenic nature of the disorders.
With hysterical neurosis, patients, on the one hand, always emphasize the exclusiveness of their sufferings, talk about "terrible", "intolerable pains", "shaking chills", emphasize the unusual, previously unknown nature of the symptoms, etc., on the other, they seem to be they are indifferent to the "paralyzed limb", they are not burdened by "blindness" or mutism.
Affective disorders characterized by lability of emotions, rapid mood swings, a tendency to violent affective reactions with tears, often turning into sobs.
The course of hysterical neurosis is undulating. 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 to oneself at any cost, an egocentric assessment of oneself and one's condition.
Patients have increased sensitivity to external stimuli, impressionability with a tendency to respond directly to events.
The psychogenic nature of vegetative-somatic disorders in hysterical neurosis gave grounds to evaluate them as conversion disorders. Conversion (from 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: disorders of motor acts, disorders of sensitivity 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. 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 the 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 a lack or decrease in muscle strength as a result of various pathological processes in the nervous system, disturbing structures and functions of the motor analyzer.
Types of paralysis and paresis. Distinguish between 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), arising under the influence of various pathological processes (trauma, tumors, disorders cerebral circulation, 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 paralysis (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 are found mainly in hysteria (see the complete body of knowledge). Reflex paralysis or paresis is caused by neurodynamic functional disorders of the nervous system, arising under the influence of, as a rule, an extensive lesion that is not topically associated with the developed paralysis or paresis.
According to the prevalence of lesions, 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, upper and lower paraplegia are distinguished (see the complete body of knowledge), when the muscles of both arms or legs are paralyzed; partial paralysis of the muscles in both arms or legs, called upper or lower paraparesis. Paralysis or paresis of the muscles of one half of the body is called hemiplegia, respectively (see the complete body of knowledge) or hemiparesis. Triplegia (triparesis) - paralysis (paresis) of the muscles of three limbs. Tetraplegia (tetraparesis) - paralysis (paresis) of the muscles of both arms and both legs.
By 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, traumatic and eclamptic paralysis and paresis are distinguished, 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 cortical-spinal (pyramidal) pathway (in the cerebral cortex, internal capsule, brain stem, spinal cord ). Central paralysis is also called pyramidal palsy. Central paralysis or paresis can be caused by circulatory disorders, trauma, tumors, demyelinating and other processes of the brain or spinal cord that disrupt the structure of the pyramidal pathway. Central paralysis is sometimes observed in children due to a variety of brain lesions - in utero, during childbirth, and also during the neonatal period (see full body of knowledge: Infantile paralysis). The most characteristic signs of central paralysis or paresis are muscle hypertension, hyperreflexia, the presence of pathological and protective reflexes, pathological friendly movements, a decrease or absence of skin reflexes.
Muscle tone in central paralysis and paresis is increased in a spastic manner. Muscle resistance is determined to a greater extent at the beginning of the movement, then sharply decreases (the "jackknife" symptom). With pronounced muscle hypertension, muscular-articular contractures develop. With hemiplegia (hemiparesis), muscle tone increases in the adductors of the shoulder, flexors and pronators of the forearm, flexors of the hand and fingers, extensors of the thigh and lower leg, adductors of the thigh and plantar flexors of the foot. As a result, patients have a characteristic Wernicke-Mann posture: the arm is brought to the body, pronated and bent at the elbow and wrist joints, the fingers are bent, the leg is unbent in the hip and knee joints, the foot is bent in the plantar direction.
As a result of lengthening leg contracture, the gait of the patients acquires the character of a mower's gait (the affected leg describes a semicircle with each step). With lower paraparesis, patients walk mainly on toes, crossing their legs. In acute diseases of the brain or spinal cord (cerebrovascular accidents, trauma, infectious diseases), accompanied by central paralysis, muscle tone can be reduced due to the exclusion 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 clonuses of the patella, feet, hands (see the complete body of knowledge: Clonus). On the paralyzed hand, pathological reflexes are triggered: an analogue of the Rossolimo reflex (see the complete body of knowledge: Rossolimo reflex), the ankylosing spine reflex (see the full body of knowledge: Ankylosing spondylitis reflexes, symptoms) and the Bitch symptom (involuntary spreading of the fingers of the paralyzed hand while passively lifting it up); on a 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 full body of knowledge: Pathological reflexes); there are also protective reflexes (see the complete body of knowledge) and synkinesis (see the complete body of knowledge).
The level of damage to the central motor neuron is established on the basis of the localization of paralysis or paresis and its combination with other neurological symptoms. So, with damage to the precentral gyrus of the cerebral cortex, hemiplegia of the opposite limbs develops with muscle atony in the initial period, followed by slow recovery and increased muscle tone, moderate revitalization of tendon reflexes and a decrease in abdominal reflexes, and the presence of extensor pathological reflexes. When the premotor region is damaged on the side opposite to the pathological focus, spastic hemiplegia occurs with pronounced muscle hypertension, a sharp increase in tendon reflexes, clonuses, coordinator synkinesis, pathological reflexes of the flexion type, and preservation of abdominal reflexes. When the focus spreads to the area of the postcentral gyrus of the cerebral cortex, sensitivity disorders join, the restoration of impaired motor functions slows down, and decreases. muscle hypertonia, imitation synkinesis appear.
With the defeat of the upper part of the precentral gyrus, leg monoplegia occurs, with the defeat of its middle section, the arm monoplegia (on the side opposite to the lesion focus). Hemiplegia, which is observed when the pyramidal pathway is damaged in the area of the internal capsule, is usually combined with hemianesthesia, central paresis of the facial and hypoglossal nerves. With the localization of the lesion in the brain stem, central paralysis of the extremities opposite to the focus is combined with dysfunction cranial nerves on the affected side and with conduction disorder of sensitivity in the paralyzed limbs (see the complete body of knowledge: Alternating syndromes, gaze paralysis, convulsion).
In the presence of a lesion in the pons of the brain or in the medulla oblongata, the alternating syndrome can be combined with respiratory distress, impaired activity of the heart and vascular tone, vomiting (see the complete body of knowledge: Bulbar palsy, Pseudobulbar paralysis). The defeat of the pyramidal tract in the spinal cord is accompanied by central paralysis or paresis, which develops below the level of the lesion on the side of the pathological focus. The defeat of half the diameter of the spinal cord is manifested by the Brown-Séquard syndrome (see the complete body of knowledge: Brown-Séquard syndrome).
Peripheral paralysis or paresis by the nature of changes 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 the complete 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 complete body of knowledge: Muscular atrophy), their hypotension (see the complete body of knowledge: Tonus, pathology of muscle tone), areflexia (see the full body of knowledge). Peripheral paralysis and paresis are characterized by changes in the electrical excitability of the muscles (the so-called rebirth reaction). Depending on the localization of the lesion along the neuron, peripheral paralysis has other features. So, with damage to the cells of the anterior horn of the spinal cord, fibrillar twitching is observed; damage to the anterior roots of the spinal nerves causes movement disorders of the radicular type; movement disorders arising from damage to a peripheral nerve are combined with sensory disorders in the innervation zone of the affected nerve, as well as vasomotor and trophic disorders, especially in connection with damage to nerves containing a large number of autonomic fibers (eg, 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 with damage to the pallidonigral system of the brain. It is caused by a change in the influence of this system on the reticular formation (see the complete body of knowledge) and a violation of the cortical-subcortical stem neural connections. Extra pyramidal paralysis and paresis, in contrast to central (pyramidal), is characterized mainly by the absence or decrease in motor activity or initiative (see the complete body of knowledge: Hypokinesia, Movement), a decrease in the pace of movements (see the complete body of knowledge: Bradykinesia), loss of friendly and automatic movements ... As a result, there is a poverty of movement (oligokinesia), slow speech, gait with small steps with the absence of accompanying hand movements (acheirokinesis). Muscle tone in extrapyramidal paralysis and paresis is increased in a plastic type and is not springy (as in pyramidal paralysis), but a waxy character (muscle resistance, determined by studying their tone, remains uniformly increased in all phases of movement due to its simultaneous increase in the flexors and extensors , pronators and instep supports). Often, the phenomenon of "cogwheel" (jerky rhythmic resistance to passive flexion and extension of the limbs) can be noted, and the limb freezes in the given position (see the complete body of knowledge: Catalepsy). In contrast to the pyramidal, with extrapyramidal 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 the complete body of knowledge).
An outward resemblance to peripheral paralysis, as well as hemiplegia, paraplegia, or monoplegia of organic origin, may have hysterical paralysis. But unlike them, in hysterical paralysis, the absence of movement and a 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 trauma to the central or peripheral nervous system and can be central or peripheral, respectively. The most common cause of central traumatic paralysis or paresis is contusion or compression of the brain and spinal cord. Due to diaskhiz (see complete body of knowledge) - a special type of shock that develops in nerve centers, in the acute period of trauma - this paralysis can be in the nature of diaschisal paralysis.
Peripheral traumatic paralysis is observed with injuries of the spinal cord, spinal nerve roots, plexuses, peripheral nerves. In cases associated with birth trauma, it is called obstetric paralysis. Obstetric paralysis occurs as a result of trauma, most often of the brachial plexus and the roots forming it, in the fetus, when, when providing manual assistance in childbirth, traction is made by the hand. Obstetric hand paralysis can be one or bilateral; at the same time, there are upper Duchenne-Erb paralysis (see the complete body of knowledge: Duchenne-Erb paralysis), the lower paralysis of Dejerine-Klumpke (see the complete body of knowledge: Dejerine-Klumpke paralysis) and total paralysis. Obstetric hand paralysis is often accompanied by Bernard-Horner syndrome (see complete body of knowledge: Bernard-Horner syndrome).
Peripheral traumatic paralysis or paresis can occur in women in the postpartum period (postpartum paralysis or paresis). It occurs, as a rule, after prolonged 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 asymmetric. It manifests itself as weakness in the legs, gait disorder, impaired sensitivity in the innervation zone of the affected branches of the plexus and is characterized by a tendency to rapid recovery of impaired functions.
Eclamptic paralysis or paresis can be central or peripheral and develop late in pregnancy or during childbirth. Central eclamptic paralysis is caused by an acute disturbance of blood circulation in the brain, more often of the type of hemorrhagic stroke, less often paralysis is a consequence of thrombosis of the vessels of the brain 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 impact of products of impaired metabolism on the peripheral nervous system. More often, these paralysis are observed in the late stages of pregnancy, proceed as polyneuritis and are characterized by a predominant lesion of the distal muscles of the extremities, accompanied by impaired sensitivity and trophic disorders in the zone of innervation of peripheral nerves.
Diagnosis. Determining the nature of paralysis or paresis and identifying their causes is closely related to the diagnosis of the underlying disease that caused the development of paralysis or paresis. In diagnostics, various methods of clinical, laboratory, X-ray, electrophysiological and other types of special studies are used.
Treatment of paralysis and paresis is part of the comprehensive treatment of the underlying disease. It includes the use of drugs that improve metabolism in the nervous tissue, increase the speed of nerve impulse conduction, increase synaptic conduction, and normalize muscle tone. Physiological balneotherapy, exercise therapy, massage, orthopedic treatment are widely used.
Physiobalneotherapy helps to restore the motor function of the 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 to normalize muscle tone.
In case of peripheral paralysis and paresis in the first days of treatment, UHF therapy (see the complete body of knowledge) and microwave therapy (see the complete body of knowledge), pulse currents (see the full body of knowledge), ultrasound (see the full body of knowledge), electrophoresis are used (see full body of knowledge) drugs that have analgesic effects - calcium, novocaine, etc. (see full body of knowledge: Electrophoresis), UV irradiation in erythemal doses (see full body of knowledge: Ultraviolet radiation). In the future, in order to improve the conductivity and excitability of the affected neuromuscular system, electrophoresis of anticholinesterase substances (proserin, galantamine), an alternating magnetic field of high frequency, paraffin and ozokerite therapy in combination with electrical stimulation of the affected muscles and the corresponding segments of the spinal cord are used. Electrical stimulation (see the complete body of knowledge), causing muscle contraction, improves their blood supply and trophism, prevents muscle atrophy, enhances afferent impulses, which helps to restore the impaired motor function of the muscles. For electrical stimulation, various impulse currents are used, the parameters of which are selected depending on the severity of the lesion and the state of excitability of the neuromuscular apparatus.
In the late recovery and residual periods apply mud therapy (see the complete body of knowledge) and mineral baths (sulfide, radon, sodium chloride, nitrogen-siliceous thermal and others), which have a stimulating effect on the regeneration processes.
With central paralysis and paresis, physiotherapy is administered in complex treatment in the early recovery period: with brain and spinal cord injuries - for 2-3 weeks, inflammatory lesions of the central nervous system - for 3 weeks, cerebral circulation disorders - for 3-5 weeks It is aimed at improving blood circulation in the zone defeat, 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 carotid sinus zones according to the method of general exposure or according to 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. In inflammatory lesions, the central nervous system is also prescribed UHF and microwave therapy.
Physiotherapy is used to restore impaired motor function, reduce spasticity, eliminate pain and contractures that impede movement. Electrostimulation is used with pulses of low and high frequencies generated by single and multichannel devices. Antagonists of spastic muscles are predominantly stimulated. 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. With mild spasticity, it is recommended to conduct 1-2 courses, with moderate and severe spasticity - 2-3 courses of electrical stimulation at intervals of 3-6 weeks. 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 with heat (mud, paraffin, ozocerite applications) or cold in combination with treatment with the position of a paralyzed limb is carried out. Cryotherapy (see the complete body of knowledge) is especially indicated for pronounced spasticity with contractures in patients not older than 60-65 years.
To relieve pain, sinusoidal modulated or diadynamic currents, electrophoresis with novocaine are used locally. In case of joint and muscle contractures, thermal procedures are prescribed (paraffin, ozokerite, mud applications, local warm baths), electrophoresis medicinal substances, ultrasound, pulse currents.
Sanatorium 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. With peripheral paralysis and paresis, spa treatment is indicated 2-6 months after the end of the acute period; with central paralysis and paresis - after 4-6 months (see the complete body of knowledge: Sanatorium selection).
Physiotherapy exercises 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 a special arrangement of paralyzed limbs. With hemiplegia and hemiparesis resulting from ischemic stroke, treatment with the position begins from the 2nd-4th day of the disease; in case of cerebral hemorrhage - on the 6-8th day (if the patient's condition allows this treatment). Laying on the back is carried out in a posture opposite to the Wernicke-Mann posture: the shoulder is taken to the side at an angle of 90 °, the elbow and fingers are extended, the hand is supinated and held on the palmar side by a splint; the entire limb is fixed in a given position with sandbags. The paralyzed leg is bent at the knee joint at an angle of 15-20 °, a roller of cotton wool and gauze is placed under the knee. The foot is given a 90 ° dorsiflexion position and held in this position with a wooden support. Laying on the back is periodically alternated with laying on a healthy side; while 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 on the healthy side is changed every l½ - 2 hours. Simultaneously with the treatment by the position, massage is prescribed. Of the massage techniques (see the complete 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. With peripheral paralysis, the entire limb is first stroked, then the paralyzed muscles are massaged, and their antagonists only stroke. The massage starts from the proximal extremities and is carried out daily for 10-15 days, and its duration gradually increases from 10 to 20 minutes; the course of treatment is 30-40 sessions (if necessary, it can be repeated after 2 weeks). Also shown are point and reflex-segmental massage. Simultaneously with massage, passive movements are used. They are carried out in isolation for each joint (5-10 movements in full and at a slow pace), starting from the proximal parts of the extremities 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.
For the restoration of motor function, active gymnastics is of primary importance. With central paralysis and paresis, it is started on the 7-10th day from the onset of the disease with ischemic stroke, with cerebral hemorrhage - on the 15-20th day. It is advisable to start it with exercises in holding the limb in the position given to it. 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 with the use of special devices for fastening and unfastening buttons, tying and undoing ribbons, and others.
Patients begin to learn to sit in case of ischemic stroke after 10 days from the onset of the disease, and in case of cerebral hemorrhage - after 3-4 weeks. Preparation of the patient for walking begins in the supine position, and then sitting, and exercises that imitate walking are practiced. When the patient's condition allows getting out of bed, they begin to learn to stand on both legs, alternately on a healthy and diseased leg, walking on the spot, with an instructor, then in a special wheelchair, using a tricycle crutch, along the track, stairs. During the entire course of exercise therapy with central paralysis, a set of exercises is also carried out aimed at eliminating pathological synkinesis. Gymnastic exercises with peripheral paralysis are advisable to be carried out in a bath or pool with warm water. The duration of the course of exercise therapy 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 of the pathological process that caused the onset of paralysis or paresis.
Orthopedic treatment can be conservative and operative. Conservative treatment as an independent one is usually indicated in the absence of data on a break or compression of the nerve trunk and is carried out with the use of prosthetic and orthopedic devices, shoes, plaster, plastic and other removable splints, special beds and other means. Its purpose is to partially compensate for the lost motor function. Surgical treatment of paralysis is carried out mainly with anatomical breaks of the nerve (partial or complete), compression or crushing of the nerve trunk and with the ineffectiveness of conservative treatment. Surgical interventions are performed directly on the nerves with the imposition of a primary or secondary nerve suture (see full body of knowledge), neurolysis (see full body of knowledge); on tendons and muscles - transplantation, muscle plastic surgery, transosseous tenodesis (see the complete body of knowledge); on joints - operations to fix the joint in a permanent fixed position (see the complete body of knowledge: Arthrodesis) and the formation of an artificial bone brake in order to limit mobility in the joint (see the complete body of knowledge: Arthrodesis).
In case of persistent pronounced loss of nerve functions in terms of more than 2 years after injury and the impossibility or ineffectiveness of surgical intervention on the nerves, orthopedic operations are indicated. So, for example, in order to replace the function of the paralyzed deltoid muscle in children over 6 years old, an operation of myolavsanoplasty of the trapezius muscle is performed. The operation consists in cutting off the trapezius muscle from the clavicle and scapular spine together with the periosteum, suturing a lavsan 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. With peripheral paralysis of the limb, tenodesis of the wrist joint is sometimes performed.
With high defeat sciatic nerve the function of the muscles innervated by the tibial and common peroneal nerves falls out. At the same time, the ligamentous apparatus of the foot is weakened, there is a pronounced atrophy of the bones and excessive mobility in the ankle and small joints of the foot. To restore the support ability of a limb, arthrodesis, arthrorisis, tenodesis of the joints of the foot are used. For example, with pronounced valgus or varus placement of the foot, arthrodesis of the ankle joint is used, in some cases combined with subtalar arthrodesis.
Bridge arthrodesis according to Vreden consists in the simultaneous closure of the ankle joint and the transverse joint of the tarsus (Shopar's joint) while maintaining mobility in the tarsometatarsal joints (Lisfrank joint) using a sliding bone graft from the tibial crest. Arthrodesis of Oppel - Dzhanelidze - Lortiuar consists in the closure of the ankle, subtalar and talocalcaneal-navicular joints. To limit excessive mobility with a dangling equine foot, Campbell's posterior arthrosis is recommended; with the heel foot - anterior arthroresis according to Mitbraith.
Damage to the superficial peroneal nerve leads to a loss of function of the peroneal muscle group. In these cases, transplantation of the tendon of the tibialis anterior muscle to the outer edge of the foot is indicated. The defeat of the deep peroneal nerve leads to a loss of function of the muscles that extend and supine the foot. To compensate for them, transplantation of the tendon of the peroneal longus muscle to the inner edge of the foot is indicated. The defeat of the common peroneal nerve entails a loss of function of the muscles that extend, supinate and penetrate the foot. In this case, tenodesis is most often resorted to with the help of the tendons of the same paralyzed muscles, which are fixed in the lower third of the tibia. Split transplant operation calf muscle on the back of the foot consists in isolating the soleus tendon, cutting it off at the point of attachment to the tubercle of the calcaneus and fixing it to the rear of the second or third metatarsal bones... The tendon of this muscle is lengthened with a lavsan tape.
For radial nerve palsy, the flexor carpal ulnar tendon can be transplanted to the extensor tendon of the fingers, and the radial wrist flexor tendons can be transplanted separately to the extensor and abductor muscles of the thumb. This operation was first carried out in 1898 by F. Frank. One of its modifications is the Osten-Saken-Dzhanelidze operation: cross-transplantation of the ulnar flexor tendon of the wrist onto the long extensor of the thumb and the long muscle, abductor thumb hand, and the tendons of the radial flexor of the hand - on the extensor of the fingers.
In the postoperative period, the limb is immobilized with the help of splints, splints, functional orthopedic devices (see the complete body of knowledge), and in some cases - distraction-compression devices (see the complete body of knowledge). A feature of immobilization is the fixation of the limb in a position that provides minimal tension on the operated nerves, muscles or tendons. Its duration is determined by the timing of the fusion of these formations or the timing of the formation of ankylosis or callus (in operations on bones).
The prognosis depends on the nature of the pathological process, the depth and prevalence of damage to the motor analyzer and the compensatory capabilities of the organism. With central paralysis and paresis that have developed as a result of circulatory disorders, the range of motion increases with the restoration of blood flow. With central paralysis and paresis caused by the cortical focus of the lesion, movements are restored faster and more completely in comparison with paralysis caused by the defeat of the inner capsule. With peripheral paralysis and paresis that developed as a result of trauma to the brachial plexus during childbirth, movements in the affected limbs are restored within 1 - 2 years.
With peripheral paralysis and paresis caused by damage to peripheral nerves, with the ineffectiveness of conservative treatment, they resort to reconstructive surgery. After operations on the nerves, the restoration of their conduction occurs no earlier than 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 .; G.S. Fedorova; Fitsenko P.Ya.
Psychogenic (hysterical) paralysis that occurs under the influence of traumatic influences (see.Neuroses) may outwardly resemble both central and peripheral P. However, there are no changes in muscle tone, tendon-periosteal and skin reflexes, there are 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 sluggish P., along with clinical data, an essential role is played by the study of electroexcitability of nerves and muscles, as well as the bioelectric activity of muscles (see. Electromyography). Hysterical P. are differentiated from similar states of organic genesis. An essential role in this 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.
Comparison of muscle strength on both sides is of great importance for the diagnosis of hemiparesis. This is achieved by comparing scores for symmetric movements, as well as using various additional techniques. The essence of the latter is the performance of voluntary movements in a physiologically uncomfortable position. In this case, the following techniques and functional tests can be used.
Venderovich's motor ulnar defect is a technique that reveals the strength of the adductor muscles of the IV-V fingers of the hand. Method of determination: with the unbent position of the hands, the examined with maximum strength presses the fingers together, the doctor removes the little finger, taking it by the first interphalangeal joint. If the function of the ulnar nerve is impaired or the pyramidal tract is slightly affected, less effort is required to abduct the little finger.
Rusetsky's symptom. Make the maximum extension of the brushes, which are at the same level; on P.'s side, extension is limited.
Symptom of automatic pronation Babinsky. The patient stretches his arms forward in a state of supination; there is a tendency towards pronation on the affected side.
A symptom of Mingazzini is the lowering of an outstretched hand on the side of P.
Reception of Panchenko (Buddha phenomenon). The subject raises his arms up and over his head brings his hands together, turned palms up, almost to the touch of the fingers. On P.'s side, the pronation of the hand is observed, and the hand goes down.
Test Mingazzini - Barre. In the prone position, the patient bends his legs in knee joints at an angle of 90 ° and holds them for 1-2 minutes. In the presence of slight weakness in one of the lower extremities, it begins to descend. The test is more demonstrative if the lower leg is bent at an angle of 30-45 ° (leg drop test). You can offer the patient in the prone position to bend the shins as much as possible: on the side of P., the flexion is less pronounced (Vitek's symptom).
Early signs of P. of mild degree: muscle weakness, violation of the pace of movements. If there is even a slight weakness of the hand, it is difficult for the patient to perform delicate movements, the hand gets tired (tired) while writing, and the handwriting may change. Weakness of the hand is also determined by examining the force of dilation or pinching of the fingers, opposing the first finger to the rest. Very early sign weakness of the hand - the inability to touch the tip of the first finger to the V from the palmar surface of the hand. To study the tempo of movement, it is recommended to quickly perform maximum flexion - extension of the feet, contrasting the first finger of the hand with 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 hands by the wrists with one hand and slowly pulls towards himself. In healthy children, uniform resistance to extension is determined.
Withdrawal reflex. The alternating tingling sensation of the soles causes an even bending of the thighs, legs and feet.
Cross reflex of extensors. The child's leg is extended and fixed, then several injections are applied to the sole of the fixed limb. In response, extension and easy adduction of the other leg occur.
Lower limb abduction test. With a quick movement, the bent legs of the child are taken to the sides, while they feel moderate resistance to abduction.
P. must be differentiated from movement disorders arising from damage to muscles, the osteoarticular system, the ligamentous apparatus, as well as from restriction of movement in ataxia, apraxia, sensitivity disorders (including severe pain syndrome).
P.'s treatment depends on the localization and the nature of the lesion of the nervous system. Prescribe medications, physiotherapeutic agents, exercise therapy, massage. Orthopedic measures are carried out and, if necessary, neurosurgical operations (see.Obstetric paralysis, children's cerebral paralysis, stroke, neuritis, polyneuritis).
Hysterical neurosis (hysteria) can manifest itself in a variety of functional mental, neurological and somatic disorders against the background of a person's increased suggestibility.
Hysteria got its name from the Greek word "hystera", which means the uterus. The fact is that the symptoms of hysterical neurosis often occur in women, so the ancient Greek doctors thought that the manifestations of hysteria were associated with dysfunction of the uterus.
Causes of the disorder
Some people are prone to developing hysteria. Among them are people who are suffering. However, this is not the only personality disorder against which hysterical reactions can appear. They can form in people with, with, among narcissistic personalities.
People with an immature psyche are prone to hysterical reactions - they are characterized by increased suggestibility, lack of independence of judgments, impressionability, slight excitability, emotional changes, egocentrism.
Freud believed that the development of hysteria is based on two factors - mental trauma of early childhood and sexual complexes. From the point of view of the well-known Freud, the embryos of our adult problems are laid 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.
The clinical picture of the disease
Hysteria is also called “the great simulant”, because it can manifest itself in a variety of symptoms, and there are no serious deviations from the work of internal organs, which could be confirmed with the help of laboratory or instrumental examinations.
There are 3 groups of symptoms of hysterical neurosis: motor (motor), sensory (sensory) disorders and disorders of autonomic functions that mimic somatic or neurological diseases. Vegetative symptoms observed in hysteria -.
Movement disorders in hysteria
Hysteria can be manifested by motor disorders in the form of partial or complete paralysis of the limbs, impaired coordination, inability to move independently while maintaining all movements within the bed. In hysteria, the voice may disappear, its sonority may be lost while the whispered speech is preserved, the speech may become slurred, incomprehensible. Stuttering, difficulty in pronouncing individual words, stuttering in speech may appear.
Also, various involuntary muscle twitching (tics), rough rhythmic tremors of the head and limbs may occur, which intensifies with fixation of attention. Some patients complain that their legs are braided, or there is heaviness in them, staggering when walking. With anxiety, instead of paralysis, weakness in the arms and legs may appear.
The area of paralysis that occurs in neurological diseases always depends on the location of the brain damage. Also, over time, with neurological paralysis, signs of circulatory disorders appear in the paralyzed parts of the body. In hysterical paralysis, there is no relationship between the affected area of the limb and the location of a particular focus in the central nervous system.
If hysterical neurosis is accompanied by the onset of paralysis, then clinical picture will be somewhat different. With this pathology, most often, movement disorders will spread either to the entire limb, or strictly limited to the articular line (for example, a leg to the knee, an arm to the elbow), and there will be no signs of trophic disturbance.
The severity of involuntary movements (hyperkinesis) is closely related to the emotional state of a person. During stressful situations, they can be pronounced, and in a calm state they can pass. They can also weaken or completely disappear when the patient's attention is switched. The nature of hyperkinesis can change against the background of new information received (by the type of imitation).
Hysterical fit
Hysteria can manifest itself in seizures. In response to psychological stress in hysterical neurosis, widespread convulsive phenomena resembling an epileptic seizure can develop.
Unlike epileptic seizures, seizures in hysterical neurosis always occur in the presence of "spectators", a person falls on 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 at all understand what is happening to him, where he is, and what happened during a seizure, as is the case with epileptic seizures, never happens.
Unlike epileptic seizures, during hysterical seizures, there is never an involuntary urination, biting of the tongue, severe injuries, the pupillary reaction to light is preserved.
Sensitive disorders
Hysteria can be accompanied by sensory disturbances. The following sensitivity disorders are most often observed:
- complete loss of sensitivity (anesthesia);
- decreased sensitivity (hypesthesia);
- strengthening (hyperesthesia);
- painful sensations in various parts of the body and organs.
Hysterical neurosis is most often manifested by anesthesia (lack of sensitivity) or hypesthesia (decreased sensitivity) in the form of socks (the affected area is the area of the leg on which socks are usually worn), gloves, vest, belt, half of the face.
Hysteria in women is often manifested by hysterical pains that can appear in any part of the body - joint pain, back pain, headaches, heart pains, abdominal pains, etc.
Hysterical neurosis, in addition to loss of sensitivity or pain, can be manifested by a loss of function of the sense organs - deafness or blindness. Quite often, with hysteria, there is a narrowing of the visual fields, a perversion of color perception. 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 autonomic disorders: there are multiple complaints of a somatic nature. Most often, vegetative signs of hysteria are disorders of the gastrointestinal tract (nausea, vomiting, pain, belching, a feeling of transfusion in the abdomen) and skin sensations (burning, itching, numbness). Autonomic disorders can manifest as dizziness, fainting, palpitations.
Distinctive features and course of the disorder
The appearance and further development of the symptoms of the disease is always closely associated with unpleasant life events, conflicts, but the patients themselves deny such a connection. The inability to convince doctors and relatives of the seriousness of their illness, of the need for further examination and treatment, provokes the emergence of demonstrative behavior aimed at attracting the attention of others to their personality. Hence the appearance of fainting, seizures, dizziness attacks.
Such disorders are characterized by variability under the influence of new information, the sudden appearance and disappearance of symptoms. For the patients themselves, the symptoms of hysterical neurosis are a means of manipulating others. They can disappear completely once the goal is achieved.
Hysteria is not a mental disorder for which a group of disabilities is indicated. However, many patients still hope for social support, and therefore very clearly describe the severity of their mental and somatic state, although no objective signs of this are determined.
Hysterical reactions caused by psychogenic influence can be short-lived and disappear spontaneously, without concomitant treatment... In some patients, the symptoms of hysterical neurosis can persist for several years.
Treatment and prevention
Medical 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 neuroleptics that have a corrective effect on human behavior (neuleptil, eglonil, chlorprothixene).
Frankly speaking, hysteria is very difficult to treat, because the whole problem lies not so much in the presence of some serious pathology as in personal characteristics, in the person's need to be in the center of attention.
Psychotherapy should be central to the treatment and prevention of hysteria. During the sessions, the doctor will try to gently find out exactly what events triggered the onset of symptoms of hysterical neurosis, exacerbation of the existing personality disorder, and will help the patient to understand the existing problems in his social environment. However, therapy should be long-term, one cannot count on quick results.
Interesting article
Case 4. Hysterical paralysis
The psychiatrist made a phone call and asked for a consultation. He wanted to simultaneously undergo marital therapy and receive supervision over his case. The therapist replied that in three weeks he would have a long-distance business trip, 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 made.
When the couple arrived for the first session, the young man was holding a book, Strategies for 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, dark-haired husband. He said that he and his wife had a serious problem that other therapists were unable to cope with. 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 bellow and make strange sounds. The symptom disappeared when the wife took Valium, resting after that for about an hour. Over the past six months, a strange illness has overtaken her quite often, but now the young woman has to work with patients, she will have to publicly present cases, and the young woman fears a sudden onset of paralysis: she will not be able to speak, and then everyone will know about her illness. The therapist remarked that the symptom is very interesting, even exotic: it may coincide with the latest case of hysterical paralysis, which took place in Western Europe and described by Freud. The husband and wife smiled without much pride in agreeing with the therapist.
The husband then reported that psychoanalytic therapy and psychoanalysis were unsuccessful. He read Haley's book and is now convinced that it is strategic marital therapy, through the use of paradox, that will help solve the problem. He knew that the symptom was undoubtedly related to marriage.
The therapist inquired about what had happened during the previous therapy and learned that the wife's last therapist was her husband's co-worker who was his supervisor. The nature of the symptom aroused great interest in him, and he studied the patient during therapy. The wife added that according to the psychiatrist, the symptom is caused by feelings of guilt, which was born of her fantasies about oral sex. She stopped therapy after he tried to seduce her. The young woman almost yielded to his proposals when she suddenly realized that despite all his assurances of love, he was cheating and deceiving her. She ran away from the psychotherapy room and never returned there. This episode became a source of colossal difficulties and troubles for my husband, as he continues to work in a team, where the psychiatrist is still the supervisor.
The therapist asked when the symptom first appeared. Both husband and wife clearly remembered that day. 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 an hour later she was flying with her daughter to another country. She would like to say goodbye to her son and his fiancée, 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 the 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 pill of Valium to calm her down. After about an hour, the speech returned.
The therapist commented that the situation experienced was indeed quite painful for both of them, especially for the husband. The wife turned out to be extremely 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 seems that the wife's symptom was an important aspect of the husband's career. He gave a reason to involve teachers in the discussion, in 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 the recovery of his wife. He already felt like an expert on her problem when he discussed with the therapist what approach to take in this case. And although until now he has not been able to help his wife, the reason for the failure was not a cowardly escape from difficulties, but the originality of the problem. So, in order to succeed in dealing with this case, the first thing that is required is to deprive 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. When the therapist is upset or anxious about something, she has abdominal pain, which is the result of gastric constriction or spasm. The stomach becomes stiff, tight, 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 seen as a result of a muscle spasm, like a stomach spasm? The husband recognized the legitimacy of this line of thought. And then the therapist noticed that the symptom seemed to her not as hysterical paralysis, but as a phenomenon of psychosomatic spasm of one of the parts digestive system- language. As for the causes of the spasm, then, most likely, they lie in the patient's anxiety. The husband and wife were forced to agree with this argument as well.
A psychosomatic spasm is, of course, not nearly as interesting and unusual as hysterical paralysis. The therapist redefined the symptom and prevented possible confrontation by teaming up with a wife, whose ailment was likened to that of the therapist, and enlisting the support of her husband as a medical professional.
The therapist then said that she must evaluate the symptom in light of all the terrible things that a person of her profession has to face in her therapy 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 recall. The husband and wife accepted this argument as well.
The symptom has now been defined not only as a psychosomatic disorder instead of an exotic hysterical paralysis, but also as one of the various organic phenomena that are found in abundance in the practice of any therapist.
Then, during the conversation, questions arose about the patient's professional career. The young woman complained about her insecurity, the situation of involuntary rivalry with her husband, the uncertainty about whether she could become a good therapist if she herself had such serious emotional problems.
The therapist then asked the spouses to describe them. life together and the difficulties they faced in their marriage. It turned out that the husband, in comparison with his wife, is not only more passionate about his profession, but also surpasses it in sociability: he usually spends weekends in a club where he plays tennis and goes in for other sports. At this time, the wife sits at home, not finding a place for herself out of anger and resentment. At nights, anxiety often finds her, 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 language refuses to obey her, becoming wooden. She usually falls asleep after taking Valium, but neither of them likes that way. The couple fear that addiction may arise. In a word, both of them think that they are not doing well with communication, and would like their mutual understanding to improve.
Finally, the therapist commented that she should consider whether it would be possible to 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 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 language, in her opinion, is associated with the difficulty of keeping secrets. The wife was probably always open and sincere, the therapist continued her thought, and therefore it is difficult for her to keep secrets. This feature of hers culminated when her husband's mother asked the young girl to keep a daring plan in secret. The girl's language seemed to be 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 is not reduced to a lack of communication, but to its redundancy. Those nights when anxiety attacks prevented the girl from sleeping, long nights filled with conversations and emotional outpourings, are convincing evidence of the validity of this conclusion. The therapist was sure that the wife never had even one of the little secret... The young woman confirmed that this is indeed the case. Therefore, the therapist concluded, it is very important to increase the distance between husband and wife by limiting the saturation of communication between them. The symptom is a purely individual problem that affects only the wife and has nothing to do with the husband. Therefore, everything that happens in therapy must remain a secret of the patient and the therapist. The latter thought that through such a decisive and short intervention it would be possible to bring relief to his wife. Immediately following her conclusion, the therapist got up from her chair and, escorting 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. Against the background of his wife, the husband looked both more competent in professional matters, and more adequate, helping her to overcome the symptom, but ... unsuccessfully: the symptom not only did not disappear after the conclusion of their marriage, but even intensified, demanding more and more attention and energy from both. By associating the symptom with the episode when it first made itself felt, and defining its meaning as the difficulty in keeping secrets, the therapist was able to change the metaphor that he served as an expression: the marital problem was now seen not in the lack of communication between husband and wife, but in their excessiveness. Earlier, the metaphor, finding expression in the system of conjugal 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 helplessness and the power of a wife who begs her husband to help her, but deep down in her soul realizes 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 incongruence in a marriage in which both husband and wife were simultaneously in positions of subordination and superiority to each other. Inconsistency was a misguided way of achieving greater equality in relationships with a husband and an equally misguided attempt to neutralize his superiority in social life. Having defined the patient's problem as a result of excessive communication and excluding her husband from the therapy process, moreover, having surrounded her with an aura of the strictest secrets, access to which is forbidden 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 the husband was blocked, and, finally, left alone, the woman received the advantage of participating in this so-called "strategic paradoxical psychotherapy." The husband lost much 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 spoke of Frankl's paradoxical intention 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 becomes clumsy and inactive. The patient tried her best, but to no avail. Well, nothing, the therapist had mercy, but over the next week, the girl should evoke the symptom three times a day, lasting no less than fifteen minutes in each case. The therapist then started a conversation with the young woman about her business career and which area she was most attracted to. She replied that she needed supervision and a deeper study of the practice.
Arriving at the next meeting, the woman stated that she had followed the directive exactly and that she no longer had the symptom. She kept the therapist's prescription secret from her husband. Then the therapist noticed: something must be done with her nocturnal attacks of anxiety, and offered one more instruction. The patient should have placed a desk near the bedroom where she could hold paper, pencils, therapy session notes, and therapy textbooks and books in which she found something useful. In cases where the state of anxiety reaches such a level that it does not allow her to fall asleep, or makes her awake from sleep, when her tongue becomes rigid again, it is not necessary to wake her husband. Moreover, he should not talk about anything. Instead, you should quietly get up, walk over to your desk, and spend an hour at it taking notes on a therapy meeting she had with a patient in the past week or this week. It is necessary to write down everything that the patient said. If the patient is a child with whom she conducted play therapy, record everything that he performed during their play. You should describe in detail your therapeutic intervention, reveal its meaning, and give reasons for its use. You can use books to explain what has been done or to justify your understanding of the case. When the hour is up, the woman should return to the bedroom and lie down. If she is unable to fall asleep after fifteen minutes, she can go back to her desk and resume the task. You must 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 will compose thanks to insomnia. The therapist will review and discuss the notes to help her professional growth. If an anxiety attack catches the patient not at night, but during the day, she can set the hands of her alarm clock at three in the morning, get up on the call and record the results of the session for an hour. All this must be kept in strict secrecy from her husband and in no case should he be told that her actions are related to therapy. The young woman, with apparent reluctance, yielded to the therapist's demands, expressing doubt about what it would be like for her the next day if she did not get enough sleep, and whether it was possible to do business when she was in the grip of anxiety.
The tongue stiffness phenomenon was blocked by a paradoxical symptom-prescribing intervention. The anxiety attacks also ceased as a result of the prescription of grievous nocturnal ordeals, through which the patient would have to go if the symptom suddenly recalled itself. The trial was planned in such a way that whatever 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 cases and subsequent supervision. Previously, her anxiety served as a test for her husband, now anxiety has become a test for herself.
At the next meeting, the young woman said that nothing special was happening to her tongue. As for anxiety, there was one attack after all. She brought back several pages of text describing the case. After working for an hour, the woman went to bed. The tapes brought in contained a series of hateful remarks about the therapist, interspersed with sketchy comments about the child's play. The client admitted that she was filled with anger and hatred as she filled out these pages, as she had to go through the test instead of sleeping. The therapist replied that this was understandable and began to discuss the notes, explaining what should be done to make the author's thoughts clearer, the description more accurate, etc. The previous instructions were retained for the coming week.
For the next week, the patient had no symptoms. This was the last interview since the therapist was leaving the country. In parting, she said that the patient needed to follow the previous guidelines for anxiety attacks. If they resume, 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 payment for each hour of supervisory work.
At a follow-up meeting two years later, the young woman reported that tongue spasm had never recurred. She had several meetings with the supervisor, then the need for them disappeared. Although a woman experiences anxiety from time to time, there has never been a case of anxiety attacks overtaking her at night. The husband and wife are still together, both actively working as therapists, but each in his own field. They can't decide if they should have a baby. Although their relationship has improved markedly, it seems to them that the limit is far from being reached: there is something to change and improve.
The therapeutic intervention consisted of the following stages:
1. The therapist rebuilt the symptom-based marital interaction system, 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 redundant communication between husband and wife.
2. The husband was excluded from the therapy process, and the wife received instructions to keep the content of the therapeutic process secret from the spouse, which made it impossible for him to use the symptom as a source of strength and weakness.
3. A paradoxical instruction was successfully used, which instructed the wife to voluntarily induce a spasm of the tongue in order to achieve its complete immobility.
4. In dealing with the anxiety symptom, the therapist prescribed an ordeal that the patient had to go through every time she had an outbreak, and which was calculated to make the young woman either less helpless or as a result of a new experience given test - more competent.
5. Therapist, forced ahead of time to complete the work with the patient, refer the case to another therapist, whose functions included supervision, which made it possible to make sure that the patient adhered to the instructions blocking outbreaks of anxiety for some time.
In this case, the incongruent hierarchy in marriage manifested itself at the moment when the wife's dependence and insecurity became fertile ground for her "hysterical" symptom. The so-called "hysterical paralysis" was for her a source of power over her husband, while remaining a position of weakness in relation to him. The husband's "wife's hysteria" allowed him to establish himself in a position of superiority, at the same time putting him in a position of dependence, since all attempts to help ended in failure, although the symptom was within the sphere of his professional competence. The therapist organized the pair in such a way that strength and weakness were no longer centered on symptomatic behavior; he also used paradoxical instruction and the prescription of a difficult trial to overcome the symptom.
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Hysterical paralysis, contractures and hyperkinesis
Paralysis and contractures cover a group of muscles involved in the performance of some purposeful motor act, for example, chewing, sucking, closing our eyes, etc., regardless of whether this group is innervated by one or more nerves. Paralysis of the muscles of the face and especially the tongue are rare.
Hysterical blepharospasm manifested by a spasm of the circular muscle of the eyes. Usually occurs after significant neuropsychic stress. The orbital and zygomatic reflexes remain unchanged. When reflexes are evoked, deliberate shuddering of the whole body or a demonstrative increase in the reflex are often observed. It can also be observed when, after several evocations of the reflex, only a stroke gesture is made (the hammer is held back), without touching the patient. During sleep and in a state of passion, the spasm of the circular muscle of the eye 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 the immobility of one of the halves of the face. It arises if it is "conditionally pleasant or desirable" for the patient. In its development, either hysterical fixation or self-hypnosis or suggestion matters.
Hysterical hyperkinesis. Among functional hyperkinesis, tics occupy an important place. These are short-term, monotonous, stereotypical violent clonic twitchings of a certain muscle group, often having the appearance of deliberate: various grimaces, protruding the tip of the tongue, involuntary blinking of both eyes or winking at the same time, frowning of eyebrows, wrinkling of the forehead, repeated head movements to the sides and stretching of the neck, reminiscent of gestures , as if the patient seeks to free himself from a tight collar, sucking a finger, the tip of the tongue, lips, convulsive pulling of the lips with the trunk, biting nails (onychophagia), puffing out the cheeks, moving the tongue to remove a food lump from the gums, chewing, tic spitting, sniffing, snorting, sniffing, snoring, forced coughing, etc.
They arise in connection with negative emotion, mental trauma, and also as imitation.
The disease is chronic, periodically intensifying, in rare cases it proceeds as an episodic manifestation.
Hysterical glossoplegia arises under the influence of negative emotions, manifested by a violation of active movements of the tongue. In patients, speech and movement of food in the oral cavity are upset. However, voluntary movements of the tongue are more often possible. The patient moves his tongue in his mouth very slowly, but stick it out oral cavity can not. Hypesthesia of the tongue, pharynx and skin in the tracheal region is noted, which does not correspond to the zone of innervation of the nerves or nerve roots, i.e., hysterical hypesthesia. The cough in patients is sonorous. Patients prefer to explain in writing.
The prognosis is usually favorable, movements can recover 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 the aphonia caused by organic lesions of the nervous system, the cough in patients remains sonorous.
On examination, hysterical hypesthesia of the tongue and pharynx may be noted, the glottis remains open with significant tension of the vocal cords. Hysterical aphonia is very difficult to treat and can turn into hysterical stuttering.
Emergency and specialized care. Usually, hysterical symptom complexes arise acutely, and in cases where curative care render out of time, can be fixed for many years. The main method of treatment in this case is psychotherapy in combination with medication... In very severe cases, hypnosis with explanation is used. The method of self-hypnosis and autogenic training are important.
Against the background of 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. They also use valerian root, bromine preparations, barbital sodium (medinal) and motherwort tincture in combination with small doses of caffeine.
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 barbamil: 1 ml of 20% caffeine solution is injected subcutaneously and then, 5-10 minutes later, very slowly - 3-5 ml of 5% barbamil solution. The patient is taught that his existing violations will gradually be smoothed out. The course of treatment is 6-10 sessions.
Patients with mild and moderate forms of the disease are recommended daily morning exercises. Shown physiotherapy followed by warm baths, preferably in a sanatorium (change of scenery).
