Functional Weakness and Sensory Loss

Douglas J. Lanska

doi:10.1055/s-2006-945516

Seminars in Neurology, Table of Contents

Semin Neurol 2006; 26(3): 297-309
DOI: 10.1055/s-2006-945516

Functional Weakness and Sensory Loss

Douglas J. Lanska¹

¹Staff Neurologist, VA Medical Center, Tomah, Wisconsin; Professor of Neurology, Department of Neurology, University of Wisconsin, Madison, Wisconsin

Abstract

ABSTRACT

Functional weakness and sensory loss are common clinical problems with variable presentations. Functional weakness commonly presents as weakness of an entire limb, paraparesis, or hemiparesis, with observable or demonstrable inconsistencies and nonanatomic accompaniments. Documentation of limb movements during sleep, the arm drop test, the Babinski thigh-trunk test, Hoover tests, the Sonoo abductor test, and various dynamometer tests can provide useful bedside diagnostic information on functional weakness. Functional sensory loss typically affects all sensory modalities, either in a hemisensory distribution or affecting an entire limb. Although often inconsistent over serial examinations with nonanatomic features, many clinical findings reported to be helpful in diagnosing functional sensory loss are neither sensitive nor specific for functional sensory loss. The yes-no test, Bowlus-Currier test, and forced-choice tests can provide useful bedside diagnostic information on functional sensory loss. Clinicians must be prepared to make more than one diagnosis in some cases, including an organic neurological diagnosis and a diagnosis of functional overlay. Recent studies have reported relatively low rates (< 5%) of misdiagnosis of functional weakness or sensory loss as indicated by subsequent diagnosis of neurological or psychiatric conditions that explained the presenting symptoms. Most neurologists find such patients more difficult to help than patients with organic disease. Management focuses on supportive psychotherapy and behavioral management, exploration of social and psychological issues, treatment of comorbid depression or anxiety, and facilitation of development of more appropriate and constructive coping methods. Many patients with functional weakness, and to a somewhat lesser extent functional sensory loss, have persisting or relapsing-remitting somatic symptoms and persistently impaired social/interpersonal, occupational, and psychological functioning.

KEYWORDS

Conversion - psychogenic - paralysis - sensory loss

Full Text

References

REFERENCES

1 Ovsiew F. What is wrong in conversion disorder? A disorder of many names. J Neurol Neurosurg Psychiatry. 2003; 74 557
2 Reuber M, Mitchell A J, Howlett S J, Crimlisk H L, Grünewald R A. Functional symptoms in neurology: questions and answers. J Neurol Neurosurg Psychiatry. 2005; 76 307-314
3 Stone J, Carson A, Sharpe M. Functional symptoms and signs in neurology: assessment and diagnosis. J Neurol Neurosurg Psychiatry. 2005; 76(suppl 1) i2-i12
4 Stone J, Carson A, Sharpe M. Functional symptoms in neurology: management. J Neurol Neurosurg Psychiatry. 2005; 76(suppl 1) i13-i21
5 Stone J, Wojcik W, Durrance D et al.. What should we say to patients with symptoms unexplained by disease? The “number needed to offend”. BMJ. 2002; 325 1449-1450
6 Carter A B. The functional overlay. Lancet. 1967; 2 1196-1200
7 Gatfield P D, Guze S B. Prognosis and differential diagnosis of conversion reactions (a follow-up study). Dis Nerv Syst. 1962; 23 623-631
8 Whitlock F A. The aetiology of hysteria. Acta Psychiatr Scand. 1967; 43 144-162
9 Merskey H, Buhrich N A. Hysteria and organic brain disease. Br J Med Psychol. 1975; 48 359-366
10 Stefánsson J G, Messina J A, Meyerowitz S. Hysterical neurosis, conversion type: clinical and epidemiological considerations. Acta Psychiatr Scand. 1976; 53 119-138
11 Roy A. Hysteria. J Psychosom Res. 1980; 24 53-56
12 Tissenbaum M J, Harter H M, Friedman A P. Organic neurological syndromes diagnosed as functional disorders. JAMA. 1951; 147 1519-1521
13 Ziegler D K, Paul N. On the natural history of hysteria in women (a follow-up study twenty years after hospitalization). Dis Nerv Syst. 1954; 15 301-306
14 Slater E TO, Glithero E. A follow-up of patients diagnosed as suffering from “hysteria”. J Psychosom Res. 1965; 9 9-13
15 Blustein J, Seeman M V. Brain tumors presenting as functional psychiatric disturbances. CMAJ. 1972; 17(suppl 2) SS59-SS63
16 Miller B L, Benson D F, Goldberg M A, Gould R. Misdiagnosis of hysteria. Am Fam Physician. 1986; 34 157-160
17 Fishbain D A, Goldberg M. The misdiagnosis of conversion disorder in a psychiatric emergency service. Gen Hosp Psychiatry. 1991; 13 177-181
18 Carson A J, Ringbauer B, Stone J et al.. Do medically unexplained symptoms matter? A prospective cohort study of 300 new referrals to neurology outpatient clinics. J Neurol Neurosurg Psychiatry. 2000; 68 207-210
19 Chodoff P. A re-examination of some aspects of conversion hysteria. Psychiatry. 1954; 17 75-81
20 Stephens J H, Kamp M. On some aspects of hysteria: a clinical study. J Nerv Ment Dis. 1962; 134 305-315
21 Raskin M, Talbott J A, Meyerson A. Diagnosis of conversion reactions: predictive value of psychiatric criteria. JAMA. 1966; 197 530-534
22 Lazare A. Conversion symptoms. N Engl J Med. 1981; 305 745-748
23 Gould R, Miller B L, Goldberg M A, Benson D F. The validity of hysterical signs and symptoms. J Nerv Ment Dis. 1986; 174 593-597
24 Rolak L A. Psychogenic sensory loss. J Nerv Ment Dis. 1988; 176 686-687
25 Chabrol H, Peresson G, Clanet M. Lack of specificity of the traditional criteria for conversion disorders. Eur Psychiatry. 1995; 10 317-319
26 Todd R B. Clinical Lectures on Paralysis, Certain Diseases of the Brain, and Other Affections of the Nervous System. London; John Churchill 1856
27 Freud S. Some points for a comparative study of organic and hysterical motor paralyses. In: Freud S The Standard Edition of the Complete Psychological Works of Sigmund Freud. Vol. I (1866-1899). Strachey J London; Hogarth Press 1966: 160-172
28 DeJong R N. Examination in cases of suspected hysteria and malingering. In: DeJong RN The Neurologic Examination: Incorporating the Fundamentals of Neuroanatomy and Neurophysiology. New York; Paul B. Hoeber 1950: 931-958
29 Maurice-Williams R S, Marsh H. Simulated paraplegia: an occasional problem for the neurosurgeon. J Neurol Neurosurg Psychiatry. 1985; 48 826-831
30 Baker J HE, Silver J R. Hysterical paraplegia. J Neurol Neurosurg Psychiatry. 1987; 50 375-382
31 Crimlisk H L, Bhatia K, Cope H, David A, Marsden C D, Ron M A. Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms. BMJ. 1998; 316 582-586
32 Stone J, Sharpe M, Carson A et al.. Are functional motor and sensory symptoms really more frequent on the left? A systematic review. J Neurol Neurosurg Psychiatry. 2002; 73 578-581
33 Stone J, Warlow C A. 1908 systematic review of the laterality of hysterical hemiplegia. J Neurol Neurosurg Psychiatry. 2003; 74 1163-1164
34 Binzer M, Andersen P M, Kullgren G. Clinical characteristics of patients with motor disability due to conversion disorder: a prospective control group study. J Neurol Neurosurg Psychiatry. 1997; 63 83-88
35 Weiser H I. Motor sensory dysfunction of upper limb due to conversion syndrome. Arch Phys Med Rehabil. 1976; 57 17-19
36 Hemphill III J C, Chung S S. Factitious stroke presenting for acute treatment. J Stroke Cerebrovasc Dis. 1999; 8 88-90
37 Lazar R B. Munchausen syndrome presenting as acute spinal cord injury. Arch Phys Med Rehabil. 1986; 67 568-569
38 Keane J R. Hysterical hemianopia: the “missing half” field defect. Arch Ophthalmol. 1979; 97 865-866
39 Keane J R. Patterns of hysterical hemianopia. Neurology. 1998; 51 1230-1231
40 Keane J R. Hysterical hemiparesis accompanying Bell's palsy. Neurology. 1993; 43 1619
41 Duikova G M, Stolajrova A V, Vein A M. Sternocleidomastoid (SCM) muscle test in patients with hysterical and organic paresis [abstract]. J Neurol Sci. 2001; 187(suppl 1) S108
42 Keane J R. Wrong-way deviation of the tongue in hysterical paralysis. Neurology. 1986; 36 1406-1407
43 Lauerma H. Nocturnal limb movements in conversion paralysis. J Nerv Ment Dis. 1993; 181 707-708
44 Worley G. Diagnosis of psychogenic paralysis by observation of patient movement in sleep [letter]. J Neurol. 2002; 249 1322
45 Okun M S, Koehler P J. Babinski's clinical differentiation of organic paralysis from hysterical paralysis: effect on US neurology. Arch Neurol. 2004; 61 778-783
46 Koehler P J, Okun M S. Important observations prior to the description of the Hoover sign. Neurology. 2004; 63 1693-1697
47 Hoover C F. A new sign for the detection of malingering and functional paresis of the lower extremities. JAMA. 1908; 51 746-747
48 Arieff A J, Tigay E L, Kurtz J F, Larmon W A. The Hoover sign: an objective sign of pain and weakness in the back or lower extremities. Arch Neurol. 1961; 5 673-678
49 Archibald K C, Wiechec F. A reappraisal of Hoover's test. Arch Phys Med Rehabil. 1970; 51 234-238
50 Ziv I, Djaldetti R, Zoldan Y, Avraham M, Melamed E. Diagnosis of “non-organic” limb paresis by a novel objective motor assessment: the quantitative Hoover's test. J Neurol. 1998; 245 797-802
51 Sonoo M. Abductor sign: a reliable new sign to detect unilateral non-organic paresis of the lower limb. J Neurol Neurosurg Psychiatry. 2004; 75 121-125
52 Knutsson E, Mårtensson A. Isokinetic measurements of muscle strength in hysterical paresis. Electroencephalogr Clin Neurophysiol. 1985; 61 370-374
53 van der Ploeg R JO, Oosterhuis H JGH. The “make/break test” as a diagnostic tool in functional weakness. J Neurol Neurosurg Psychiatry. 1991; 54 248-251
54 Ashford R F, Nagelburg S, Adkins R. Sensitivity of the Jamar dynamometer in detecting submaximal grip effort. J Hand Surg [Am]. 1996; 21 402-405
55 Gilbert J C, Knowlton R G. Simple method to determine sincerity of effort during a maximal isometric test of grip strength. Am J Phys Med. 1983; 62 135-144
56 van der Ploeg R JO, Oosterhuis H JGH, Reuvekamp J. Measuring muscle strength. J Neurol. 1984; 231 200-203
57 Carlsöö S. With what degree of precision can voluntary static muscle force be repeated?. Scand J Rehabil Med. 1986; 18 1-3
58 Bohannon R W. Make tests and break tests of elbow flexor strength. Phys Ther. 1988; 68 193-194
59 Solzi P, Lotem M. Malingering detected by electromyography (EMG)[abstract]. Electroencephalogr Clin Neurophysiol. 1990; 75 S 142
60 McComas A J, Kereshi S, Quinlan J. A method for detecting functional weakness. J Neurol Neurosurg Psychiatry. 1983; 46 280-282
61 Pillai J J, Markind S, Streletz L J, Field H L, Herbison G. Motor evoked potentials in psychogenic paralysis. Neurology. 1992; 42 935-936
62 Meyer B-U, Britton T C, Benecke R, Bischoff C, Machetanz J, Conrad B. Motor responses evoked by magnetic brain stimulation in psychogenic limb weakness: diagnostic value and limitations. J Neurol. 1992; 239 251-255
63 Marshall J C, Halligan P W, Fink G R, Wade D T, Frackowiak R SJ. The functional anatomy of a hysterical paralysis. Cognition. 1997; 64 B1-B8
64 Halligan P W, Athwal B S, Oakley D A, Frackowiak R SJ. Imaging hypnotic paralysis: implications for conversion hysteria. Lancet. 2000; 355 986-987
65 Spence S A, Crimlisk H L, Cope H, Ron M A, Grasby P M. Discrete neurophysiological correlates in prefrontal cortex during hysterical and feigned disorder of movement. Lancet. 2000; 355 1243-1244
66 Vuilleumier P, Chicherio C, Assal F, Schwartz S, Slosman D, Landis T. Functional neuroanatomical correlates of hysterical sensorimotor loss. Brain. 2001; 124 1077-1090
67 Stone J, Zeman A, Sharpe M. Functional weakness and sensory disturbance. J Neurol Neurosurg Psychiatry. 2002; 73 241-245
68 Chodoff P. A re-examination of some aspects of conversion hysteria. Psychiatry. 1954; 17 75-81
69 Stephens J H, Kamp M. On some aspects of hysteria: a clinical study. J Nerv Ment Dis. 1962; 134 305-315
70 Raskin M, Talbott J A, Meyerson A T. Diagnosis of conversion reactions: predictive value of psychiatric criteria. JAMA. 1966; 197 530-534
71 Lazare A. Conversion symptoms. N Engl J Med. 1981; 305 745-748
72 Gould R, Miller B L, Goldberg M A, Benson D F. The validity of hysterical signs and symptoms. J Nerv Ment Dis. 1986; 174 593-597
73 Rolak L A. Psychogenic sensory loss. J Nerv Ment Dis. 1988; 176 686-687
74 Bowlus W E, Currier R D. A test for hysterical hemianalgesia. N Engl J Med. 1963; 269 1253-1254
75 Brady J P, Lind D L. Experimental analysis of hysterical blindness. Arch Gen Psychiatry. 1961; 4 331-339
76 Pankratz L. Symptom validity testing and symptom retraining: procedures for the assessment and treatment of functional sensory deficits. J Consult Clin Psychol. 1979; 47 409-410
77 Miller E. Detecting hysterical sensory symptoms: an elaboration of the forced choice technique. Br J Clin Psychol. 1986; 25 231-232
78 Hernández-Peón R, Chávez-Ibarra G, Aguilar-Figueroa E. Somatic evoked potentials in one case of hysterical anaesthesia. Electroencephalogr Clin Neurophysiol. 1963; 15 889-892
79 Levy R, Behrman J. Cortical evoked responses in hysterical hemianaesthesia. Electroencephalogr Clin Neurophysiol. 1970; 29 400-402
80 Levy R, Mushin J. The somatosensory evoked response in patients with hysterical anaesthesia. J Psychosom Res. 1973; 17 81-84
81 Kaplan B J, Friedman W A, Gravenstein D. Somatosensory evoked potentials in hysterical paraplegia. Surg Neurol. 1985; 23 502-506
82 Howard J E, Dorfman L J. Evoked potentials in hysteria and malingering. J Clin Neurophysiol. 1986; 3 39-49
83 Redlich F C. Organic and hysterical anesthesia: a method of differential diagnosis with the aid of the galvanic skin response. Am J Psychiatry. 1945; 102 318-324
84 Tegner R. A technique to detect psychogenic sensory loss. J Neurol Neurosurg Psychiatry. 1988; 51 1455-1456
85 Tiihonen J, Kuikka J, Viinamäki H, Lehtonen J, Partanen J. Altered cerebral blood flow during hysterical paresthesia. Biol Psychiatry. 1995; 37 134-135
86 Solyom C, Solyom L. A treatment program for functional paraplegia/Munchausen syndrome. J Behav Ther Exp Psychiatry. 1990; 21 225-230
87 Shen W, Bowman E S, Markand O N. Presenting the diagnosis of pseudoseizure. Neurology. 1990; 40 756-759
88 Delargy M A, Peatfield R C, Burt A A. Successful rehabilitation in conversion paralysis. BMJ. 1986; 292 1730-1731
89 Carson A J, Stone J, Warlow C, Sharpe M. Patients whom neurologists find difficult to help. J Neurol Neurosurg Psychiatry. 2004; 75 1776-1778
90 O'Malley P G, Jackson J L, Saantoro J, Tomkins G, Balden E, Kroenke K. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract. 1999; 48 980-990
91 Mace C J, Trimble M R. Ten-year prognosis of conversion disorder. Br J Psychiatry. 1996; 169 282-288
92 Baron D A, Nagy R. The amobarbital interview in a general hospital setting, friend or foe: a case report. Gen Hosp Psychiatry. 1988; 10 220-222
93 Menza M A. A suicide attempt following removal of a conversion paralysis with amobarbital. Gen Hosp Psychiatry. 1989; 11 137-138
94 Bok S. The ethics of giving placebos. Sci Am. 1974; 231(5) 17-23
95 Brody H. The lie that heals: the ethics of giving placebos. Ann Intern Med. 1982; 97 112-118
96 Devinsky O, Fisher R. Ethical use of placebos and provocative testing in diagnosing nonepileptic seizures. Neurology. 1996; 47 866-870
97 Hopkins A, Clarke C. Pretended paralysis requiring artificial ventilation. BMJ. 1987; 294 961-962
98 Lipsitt D R. The factitious patient who sues. Am J Psychiatry. 1986; 143 1482
99 Feldman M D, Duval N J. Factitious quadriplegia: a rare new case and literature review. Psychosomatics. 1997; 38 76-80
100 Slater E. Diagnosis of hysteria. BMJ. 1965; 5447 1395-1399
101 Slater E TO, Glithero E. A follow-up of patients diagnosed as suffering from “hysteria”. J Psychosom Res. 1965; 9 9-13
102 Couprie W, Wijdicks E F, Rooijmans H G, van Gijn J. Outcome in conversion disorder: a follow up study. J Neurol Neurosurg Psychiatry. 1995; 58 750-752
103 Stone J, Sharpe M, Rothwell P M, Warlow C P. The 12 year prognosis of unilateral functional weakness and sensory disturbance. J Neurol Neurosurg Psychiatry. 2003; 74 591-596
104 Carson A J, Best S, Postma K, Stone J, Warlow C, Sharpe M. The outcome of neurology outpatients with medically unexplained symptoms: a prospective cohort study. J Neurol Neurosurg Psychiatry. 2003; 74 897-900
105 Binzer M, Kullgren G. Motor conversion disorder: a prospective 2- to 5-year follow-up study. Psychosomatics. 1998; 39 519-527
106 Ljungberg L. Hysteria: a clinical, prognostic and genetic study. Acta Psychiatr Neurol Scand Suppl. 1957; 112 1-162
107 Toth C. Hemisensory syndrome is associated with a low diagnostic yield and a nearly uniform benign prognosis. J Neurol Neurosurg Psychiatry. 2003; 74 1113-1116

Douglas LanskaM.D.

VA Medical Center, 500 E. Veterans Street, Tomah, WI 54660