Als And Regional Cerebral Blood Flow Changes In Conversion-Books Pdf

als and Regional Cerebral Blood Flow Changes in Conversion
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left parietal region Spence and colleagues 2000 have In this report the changes in regional blood flow and. documented decreased activity in the left dorsolateral evoked potentials found in a patient with conversion. prefrontal cortex in patients with conversion disorders symptoms is presented Informed consent was obtained. presenting as hemiparesis in functional brain imag prior to pursuing work up. ing studies In another study involving conversion pa Case A 21 year old female single unemployed. tients with sensory motor functional impairment the patient She lives in Artvin with her family The initial. thalamus putamen and caudate regions contralateral symptoms reported are tremor and loss of balance while. to the symptomatic body half had decreased regional ascending stairs that started five years ago These symp. blood flow Investigators have reported improvement in toms have recurred several times at one to two month. blood flow accompanying improvement in sypmtoms intervals Thereafter they were more persistent Initially. Vuilleumier et al 2001 In another case report infarct no difficulties in ambulation were reported however. of the right parietal lobe has been reported to accompany over time walking became difficult She reports fre. the clinical picture in a patient with conversion disorder quent falls or the need to support herself by grabbing. Ramasubbu 2002 onto furniture while walking When faced with another. In patients with conversion disorders studies on person approaching her from the opposite direction. electrophysiological measurements have largely had her imbalance increased and she experienced tremors. negative findings The few reports in the literature are of the whole body She had difficulties turning over in. conflicting and are not based on recent large scale stud bed while sleeping She could not get up from her bed. ies with adequate sample size Hernandez et al 1963 without support in the morning When she had to go. have reported a case of absence of SEP waves in a conver up the stairs she had leg trembling and could not keep. sion patient with loss of sensation in the arm In another her balance Therefore she was home bound for most of. study it is reported that when a patient with findings of the time and also had difficulties with daily household. hysterical hemiparesis was given a subliminal stimulus chores Her complaints increased when she was tired. Sometimes hand tremors were also superimposed on dif. in the symptomatic body half a decrease in amplitude. ficulties in walking and balance, of SEP waves occurred while SEP waves remained sym. metrical with supraliminal stimulus Levy and Mushin The patient was evaluated by neurologists in the. 1973 Flor Henry et al 1981 have performed neuro area she lived in Brain magnetic resonance imag. physiological testing on patients with symptoms of con ing was reported to be within normal limits Since no. version disorder and have reported impairment in both improvements in her complaints were seen over time. the dominant and non dominant hemispheres that were she presented to Hacettepe University Medical School. more pronounced in the dominant side In addition to Neurology Outpatient Clinic. these Yazici et al 2004 have reported inability to detect On initial evaluation in the outpatient clinic of our. normal somatosensorial potentials in disease activation center she was found to have no other significant neu. with restoration of normal SEP responses after the reso rological abnormalities other than difficulty in walking. lution of symptoms in two conversion patients Yaz c et The reported symptoms were not compatible with any. al 2004 In another study conducted in our country known neurological disorder therefore she was referred. event related auditory evoked potentials were studied in to the psychiatry clinic with a working diagnosis of con. a group of patients with conversion disorder manifested version disorder Her initial evaluation in the psychiatry. by various neurological symptoms According to these clinic concurred with the same assessment and she was. results N1 and P2 latency times were prolonged com hospitalized in the psychiatry clinic for further treat. pared to the control group with decreased amplitude of ment. P 3 K se et al 1998, On admission to the psychiatry ward the patient. Despite the presence of these scarce positive find had significant difficulty in walking She experienced. ings in the literature negative conclusions predominate frequent falls and had to grab for support Despite the. Kaplan et al 1985 Foong et al 1997 Haghighi et al fact that ambulation problems interfered with her daily. 2001 Ramassubu 2002 The studies that belong to this life she was noted to be in a state of partial emotional. latter group support the notion of absence of pathologi detachment about the difficulties she was going through. cal evoked potential findings as a diagnostic parameter Physical examination findings were within normal lim. in conversion disorder its On neurological examination cranial nerves were. her age and socioeconomic status Her speech was at a. normal rate and tone Even though she was unhappy, there were no signs of depression There were no per. ception problems Thought process was normal She did. have concerns about her disease Physical examination. was within normal limits A complete blood count rou. tine chemistries thyroid function tests serum vitamin B. 12 levels folic acid levels urinalysis did not reveal any. abnormalities EEG was within normal limits With nor. mal findings on brain imaging studies MR conversion. disorder was diagnosed The first evoked potential SEP. MEP measurements and regional blood flow assess, A ments SPECT were performed concurrently. While an inpatient in the psychiatry ward the patient. underwent supportive psychotherapy that focused on. conflict areas and also was started on sertraline 50mg. day She also received physical therapy in order to help. her acquire physical abilities to cope with ambulation. problems During her stay in the hospital she was noted. to have more episodes of loss of balance and falls around. health care personnel Further interview revealed that. she was sexually abused by a relative two years older than. herself when she was seven years old Patient reported. feelings of guilt and concerns about the future related. B to this incident Furthermore it was learned that when. patient was 8 years old her father suffered an accidental. gunshot wound and the patient felt sorrow about this. While the frequency of the balance problems and, falls waxed and waned throughout the day in general.
the frequency decreased During her initial stay her legs. trembled when walking and she had to grab for support. and sometimes collapsed These episodes recurred 3 4. times a day However after several weeks she was noted. to have less tremors and better balance The number of. falls decreased to a couple of events per week In addi. tion though she could not keep her balance upon turn. ing while walking initially later on she was able to han. Figure 1 A B C Pre and post treatment SEP findings In the first SEP dle turns better In her initial days in the ward she had. evaluation 1 A N20 and P25 wave latencies were within normal lim a wide based gait and walked with support over time. its however peak amplitude of P25 N33 was observed to be very high she was noted to have a quicker pace with normalized. giant SEP It was observed that amplitude gradually ascended higher. in the assessment made in the 3rd 1 B and 6th months 1 C follow. gait She initially could not climb stairs or could only. ing discharge from hospital do so with assistance during her stay she could climb. stairs slowly on her own and could perform the physical. intact motor and sensory examinations were within therapy exercises better After eight weeks of hospitaliza. normal limits All reflexes were normal There were no tion and improvement in imbalance and fall complaints. pathological reflexes the patient was discharged to continue outpatient fol. On psychiatric examination she was alert and co, operative Her general appearance was compatible with At discharge the patient was given a daily exercise. Image 1 A B 2 A B Images of pre and post treatment regional blood flow of brain A decrease in perfusion is observed in the left parietal 1. A and left temporal 1 B regions in the pre treatment period It was found that treatment resulted in recovery of decrease of perfusion in the. parietal region 2 A though decrease of perfusion in the temporal region continued 2 B. regimen by the physical therapist The patient and her lessness and frequent crying had decreased However. family were educated about the disease and behavioral she still experienced ambulation problems She reported. recommendations were given On a follow up visit 10 being unable to do housework dropping plates when. days after hospital discharge she reported no episodes she attempted to wash the dishes and tripping on the. of falling she could help her mother with housework carpet and falling Her hands trembled when she ate and. could get in cars without support She performed her she spilled food on her clothes She could go to the bath. daily exercise regimen regularly The family could only room only with her mother s assistance and could not. come for follow up every two months for transporta leave the house alone She was advised to stick to the. tion problems In a follow up visit two months after she daily exercise regimen and to continue to attempt doing. reported increased episodes of falling however she had house chores The patient is still being followed at two. days when she was free of any symptoms On her good month intervals. days she could help her mother with housework and, Since publication of this article in The Turkish. could walk out to the fields with her mother s assistance. Journal of Psychiatry March 2007 the patient was seen. In further visits she had increased complaints such as. for another follow up appointment She reported marked. reluctance and joylessness and appeared depressed dur. improvement in ambulation problems Depressive symp. ing the interview She expressed pessimism for failure of. toms had almost completely resolved, complete resolution of her walking problems The sertra. line dose that was started during her hospitalization was Electrophysiological Studies and Findings. increased to 100 mg day During follow up the family. lost their home to a fire with an undetermined cause Somatosensorial evoked potentials SEP With. and she had to stay with her relatives and her depressive complaints of difficulty in ambulation and imbalance. symptoms increased Thereafter the patient s falls started in order to rule out a posterior cord involvement soma. increasing She became homebound and was not able to tosensorial evoked potentials were obtained SEP For. perform any chores around the house Sertraline was this the right median nerve was stimulated continuously. stopped and venlafaxine was started at 150 mg day In with surface electrode simulators with stimulations of 0 2. a follow up visit one month later lithium was added for msec at a frequency of 2 Hertz at the level of the wrist. failure of improvement in symptoms The most recent SEPs were recorded from the opposite parietal sensory. visit was two months ago Complaints of reluctance joy cortex C3 The average of two hundred stimulations. was taken and this process was repeated two times The With double stimulation and interstiulus interval 1 5. average of the two results was reported ms there was decrease in response amplitude compared. to the control inhibition and increased amplitude over. The first SEP assessment was performed during hos, 7 ms facilitation These findings were deemed to be. pitalization In this test while the latency of N20 P25. within normal limits, waves and the amplitude of N20 were within normal.
limits the peak amplitude of P25 N33 was very high. Regional Brain Blood Flow SPECT Finding, giant SEP Two more SEP studies were performed in. the following 6 month period when her symptoms had In the evaluation of regional blood flow per. partially abated In these tests the amplitude of P25 fusion SPECT Single Photon Emission Computed. N33 was found to increase as 87 V 103 9 V and Tomography was performed The patient underwent. 113 5 V respectively Figure 1 A B C SPECT study twice once before treatment and once. three months after treatment, Based on these results the following electrophysi. ological procedures used to study motor control and For brain SPECT study the patient was kept in a. movement disorders were performed dark and quiet room for five minutes then the bran. perfusion agent named Tc 99m ECD ethyl cystein, Event related potentials Standard oddball para. ate dimer Neurolite Bristol Myers Squibb Belgium, digms were used Frequent tones were given at regular. was injected intravenously at a dose of 555 MBq Fifteen. intervals rare tones were randomly given recording were. minutes after injection brain perfusion SPECT imag. made from Cz and Pz electrodes The recording was re. ing was performed with a double headed SPECT gamma. peated twice In both recordings the latency of the P300. camera Siemens E CAM Erlangen Germany high, wave was within normal limits 330 ms.
resolution parallel hole colimator 360 degree rotation. Movement related potentials The patient was 128 x 128 matrix 128 x 40 sec. evoked potentials of a patient with conversion symptoms are presented Somatosensory evoked potentials SEP of this patient with conversion disorder who had signs of movement disorder revealed that the latency to N20 P 25 waves were in normal limits while the amplitudes of the P25 and N33 components were extremely high giant SEP Regional

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