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Background Psychogenic nonepileptic seizures (PNES) represent one of the most sizable treatment challenges in neuropsychiatry. Although the underlying mechanism is far from being understood, several interventions have been suggested. However, patients with comorbid psychiatric diagnoses and epilepsy are excluded from most intervention studies. Objective To To present a within-group posttreatment vs pretreatment study representing the retrospective clinical results of an integrative psychotherapy model. Methods: We present the clinical results of 22 patients with PNES diagnosed in an epilepsy center and treated in our neuropsychiatry clinic using an integrative rehabilitative psychotherapy. Therapy included presenting the diagnosis, psychoeducation, seizure reduction behavioral techniques, and coping with past and present stressors. Insomuch as integrative biopsychosocial psychotherapy is based on an individualized treatment protocol for each patient, treatment was individualized and case specific. Results By the end of treatment, 36% of patients had become seizure free and a further 54% achieved a major seizure reduction (reduction of more than 70%). Seventy-two percent of patients kept at least 70% seizure reduction at follow-up. Global Assessment of Functioning scores improved from a mean of 43.09 to a mean of 72.81 at the end of treatment and 69.72 at follow-up. In addition, we present 3 case descriptions that emphasize the individualized nature of psychotherapeutic decisions. Conclusions Our results support the feasibility and effectiveness of biopsychosocial based integrative psychotherapy for PNES and set principles for future treatment and prospective clinical trials in the field of individualized psychotherapy.

Background Psychiatric illness can mimic a comatose state. The most common is a conversion reaction resulting in a functional coma, which poses a unique diagnostic challenge to the clinician. Little is known about this condition, and the literature is limited by inconsistent terminology and by a lack of high-quality evidence. Objective To provide a conceptual definition of functional coma, describe case examples, summarize management, and increase recognition of this often underacknowledged entity. Methods We present two cases and provide a comprehensive review of the literature on the differential diagnosis, pathophysiology, workup, and management. Results Functional coma is defined as an involuntary coma-like state that occurs in the absence of structural or metabolic damage to the brain and that is distinct from catatonia. This term should supplant the previous phrase of “psychogenic coma.” Psychiatric disorders are frequently present premorbidly, but are not required for the diagnosis. About half of the cases occur in the perioperative setting. Physical exam can provide helpful clues, including passive resistance to eye opening or avoidance of the face with arm drop. Additional work-up, including laboratory studies, brain imaging, and electroencephalography, should be obtained but are unremarkable in functional coma. Case studies suggest that the episodes last for several hours, with a range of 45 minutes to 4 days. Treatment includes supportive management and careful psychoeducation. Conclusions Functional coma should be conceptualized as a distinct condition from catatonia and psychogenic non-epileptic seizures. Additional clinical and translation research is needed to further explore the etiology of this condition.

BACKGROUND Psychogenic non-epileptic seizures (PNES) may involve hypoactivity in the right temporoparietal junction (TPJ), suggesting a promising target for therapeutic neuromodulation. In this proof-of-concept case series, we aimed to investigate the tolerability and potential efficacy of high frequency repetitive Transcranial Magnetic Stimulation (rTMS) over the right TPJ to decrease non-epileptic seizure rates. METHODS Seven subjects with video-EEG documented PNES without comorbid epileptic seizures were recruited. The rTMS protocol involved thirty stimulation sessions administered twice per day over three weeks. Each session consisted of three thousand pulses of high frequency (10 Hz) rTMS applied over the right TPJ. Tolerability was monitored throughout treatment. Weekly PNES counts were recorded at baseline, during treatment, and at post treatment intervals as the primary outcome measure. Additional psychometric scales assessing dissociation and functional neurological symptoms were collected at baseline and within 1-week post treatment as secondary outcome measures. RESULTS Treatment with rTMS was well tolerated by all participants. Participants reported a decrease in weekly seizure rates post vs. pre-treatment, which was sustained at 3-month follow-up. Improvement was also reported on the Dissociative Experiences Scale and the Conversion Disorder Subscale of the Screening for Somatoform Symptoms-7 Scale. CONCLUSION High-frequency rTMS over the right TPJ represents a promising treatment for PNES that warrants additional research.

Background Few publications deal with non-neurogenic language disorders (NNLDs), distinct from psychogenic speech disorders such as psychogenic dysphonia or stuttering. NNLDs are alterations in language owing to psychosomatic preoccupations, conversion disorder, psychiatric disorders, or other psychological reasons. Objective To identify and classify the range of NNLDs and their characteristics. Methods This review summarizes the literature on disturbances in language, broadly defined as the use of symbols for communication, which may have a psychogenic or psychiatric etiology. Results The literature suggests a classification for NNLDs that includes psychogenic aphasia with dysgrammatism; psychogenic “lalias” including oxylalia and agitolalia, palilalia and echolalia, xenolalia, glossolalia, and coprolalia; psychologically-mediated word usage; psychotic language; and psychogenic forms of the foreign accent syndrome. Conclusions Clinicians and researchers have insufficiently emphasized the presence of NNLDs, their characteristics, and their identification. Yet, these disorders may be the first or predominant manifestation of a psychologically-mediated illness. There are 2 steps to recognition. The first is to know how to distinguish NNLDs from the manifestations of neurogenic language impairments after a neurological evaluation. The second step is awareness of specific associated and examination features that suggest the presence of a NNLD.

Background The relationships between baseline neuropsychiatric factors and clinical outcome in patients with functional neurological disorder (FND)/conversion disorder remain poorly understood. Objective This prospective, naturalistic pilot study investigated links between predisposing vulnerabilities (risk factors) and clinical outcome in patients with motor FND engaged in usual care within a subspecialty FND clinic. Methods Thirty-four patients with motor FND were enrolled and completed baseline and 6-month follow-up psychometric questionnaires. Univariate screening tests followed by multivariate linear regression analyses were used to investigate neuropsychiatric predictors of 6-month clinical outcome in patients with motor FND. Results In univariate analyses, baseline secure attachment traits and depression as measured by the Relationship Scales Questionnaire and Beck Depression Inventory-II positively correlated with improved Patient Health Questionnaire-15 scores. In a multivariate linear regression analysis adjusting for the interval time between baseline and follow-up data collection, baseline secure attachment and depression scores independently predicted improvements in Patient Health Questionnaire-15 scores. In additional analyses, patients with a diagnosis of psychogenic nonepileptic seizures compared to individuals with other motor FND subtypes showed a trend toward worse 6-month physical health outcomes as measured by the Short Form Health Survey-36. Conclusion Future large-scale, multi-site longitudinal studies are needed to comprehensively investigate neuropsychiatric predictors of clinical outcome in patients with motor FND, including functional weakness, functional movement disorders, and psychogenic nonepileptic seizures.

Background Motor functional neurologic disorders (FND)—previously termed “hysteria” and later “conversion disorder”—are exceedingly common and frequently encountered in the acute hospital setting. Despite their high prevalence, patients with motor FND can be challenging to diagnose accurately and manage effectively. To date, there is limited guidance on the inpatient approach to the neuropsychiatric evaluation of patients with functional (psychogenic) neurologic symptoms. Objective The authors outline an inpatient multidisciplinary approach, involving neurology, psychiatry, and physical therapy, for the assessment and acute inpatient management of motor FND. Methods A vignette of a patient with motor FND is presented followed by a discussion of general assessment principles. Thereafter, a detailed description of the neurologic and psychiatric assessments is outlined. Delivery of a “rule-in” diagnosis is emphasized and specific guidance for what can be accomplished postdiagnosis in the hospital is suggested. Discussion We encourage an interdisciplinary approach beginning at the early stages of the diagnostic assessment once an individual is suspected of having motor FND. Conclusions Practical suggestions for the inpatient assessment of motor FND are presented. It is also important to individualize the diagnostic assessment. Future research should be conducted to test best practices for motor FND management in the acute inpatient hospital setting.

Background Psychogenic nonepileptic seizures (PNESs) clinically resemble epileptic seizures (ESs) without concomitant electroencephalograph (EEG) changes. Although most studies focus on the differences between ESs and PNESs in different groups of patients, few studies have focused on patients with a comorbidity of PNESs and ESs. Objectives The aim of this study, was to establish the pattern of relationships between PNESs and ESs in patients who had both types of events during long-term video EEG monitoring, expecting to find that PNESs would be longer, more frequent, and more dramatic than ESs. Methods This retrospective study included only patients who had both ESs and PNESs during long-term video EEG monitoring. Results 12 patients with both types of seizures during long-term video EEG monitoring were recruited. Taking into account the hypothesized differentiating pattern (number of PNESs ≥ ESs, duration of PNESs ≥ ESs, and semiology of PNESs ≥ ESs), in 8 patients, all 3 conditions were fulfilled; in 3, 2 conditions were fulfilled; and in only 1, none of the conditions were fulfilled. Conclusion Although there are semiological similarities between PNESs and ESs in the PNES + ES group of patients, there is still a recognizable pattern of differences between these 2 states, with characteristics of PNESs resembling those of PNESs in patients with PNESs alone—dramatic and prolonged seizures. Provoking PNESs during long-term video EEG monitoring can cause diversion from the pattern, raising the suspicion of provoking pseudo-PNESs. Although this finding needs to be further investigated provocation should be used cautiously.

Nonepileptic events (pseudoseizures, nonepileptic seizures, psychogenic nonepileptic seizures) are a common manifestation of conversion disorder. The treatment of nonepileptic events (NEEs) is complex and the literature on the etiology and treatment of this disorder is quite divergent. One therapy that has shown initial effectiveness in conversion disorder, but has not yet been applied to the treatment of NEEs, is paradoxical intention (PI) therapy. In PI therapy, the most common intervention is symptom prescription (i.e., patients are instructed to deliberately continue or increase symptomatic behavior) combined with a rationale for the use of this therapy. This case report is the first to give a detailed description of PI therapy and to show sustained clinical improvement in a patient with refractory NEEs.

Itch (or pruritus) is defined as an unpleasant sensation inducing the desire of scratch. Chronic pruritus ( 6weeks duration) is a major and distressing symptom of many dermatological, systemic, neurological, or psychogenic diseases. A recent study assessed that patients with chronic pruritus carry a significant burden of disease with a substantial impact on quality of life that may be comparable to that of chronic pain. According to the neurophysiologic classification, pruritus can be classified into four major types: pruritoceptive, when itch fibers are activated by pruritogens that stimulate their sensory ending; neuropathic, due to primary lesion or dysfunction along the afferent fibers; neurogenic, generated by central mediators without neuronal damage; and psychogenic, when resulting from a pure central psychic processing in the absence of skin pathology or underlying medical disease. Hence, psychogenic pruritus (PP) is often a diagnosis of exclusion after other possible causes of pruritus have been ruled out. In particular, both PP and neuropathic itch present with no evidence of primary cutaneous lesions (pruritus sine materia), therefore clinical presentation and strategies of treatment can partially overlap. Psychiatric disturbances are common in patients who suffer from chronic itch, revealing a high psychiatric comorbidity in this population. PP can occur along with a known psychological abnormality or concurrently in patients suffering from other types of itch. While PP incidence in the general population is unknown, its incidence in patients seen in dermatology clinics is about 2%. Moreover, there is a female predominance with an average age of onset between 30 and 45 years of age. The typical clinical findings associated with psychogenic pruritus can vary considerably from superficial excoriations, erosions, or even ulcers to thickened hyperpigmented nodules and atrophic scars. Lesions are commonly found on body areas that are most accessible to the hand

Psychogenic neurologic disorders are common in clinical practice, but their underlying mechanisms are largely unknown. These disorders represent “functional” neurologic deficits, such as amnesia, paralysis, or somatosensory losses that are not explained by organic lesions in the nervous system but arise in the context of “psychogenic” stress or emotional conflicts. Therefore, even though the pathophysiology of the spectrum of these disorders is unclear, the patients fall in different psychiatric categories with possible psychological and psychodynamic etiologies. Recently, this topic has received increasing attention. Indeed, several studies have used functional brain imaging techniques in an attempt to identify specific neurologic hallmarks associated with conversion disorder and its multiple clinical manifestations. 1–3 For psychogenic dystonia, the clinical distinction between an organic and psychogenic origin is even more difficult because they frequently overlap. 4 Published studies remain inconclusive so far, but promising theories have been proposed. These theories are based on active inhibition of motor areas by limbic brain areas, 5–7 and on the concept of impaired movement conceptualization, 8 such as in psychogenic paralysis. Interestingly, hypnosis-induced paresis—a model of “functional” paresis— of the left leg showed enhanced cerebral blood flow in the right orbitofrontal and right anterior cingulate cortices (limbic system). This is accompanied by decreased activation of the right primary motor cortex in a positron emission tomography (PET) study. Both observations support the concept of modulation of sensorimotor representations by affective and stressful events via increased limbic input. 9 Following up on this concept, we present a clinical long-term follow up of Mrs. B, a 47 year-old female, who progressively developed psychogenic tetraparesis and bilateral upper limb dystonia. Both completely returned to normal under two specific conditions: initially under a short propofol-induced sedation, and later at an advanced stage of hepatic encephalopathy. We hypothesize that these two conditions interfered with the abnormal limbic input, allowing for the alleviation of the symptoms.

Catatonia may be monosymptomatic at presentation, with stupor or coma as the cardinal and only manifestation. A case of catatonic coma with profound bradycardia is presented to help clinicians recognize this entity and include catatonia in the differential diagnosis of coma as a rare etiology after other more common causes of coma have been excluded. Cases of catatonic coma are nevertheless important to identify because treatment with intravenous benzodiazepines is simple and highly effective. The authors argue that the descriptive term "catatonic coma" is preferable over terms implying psychogenesis, such as "psychogenic" or "hysterical" coma; for catatonia, the authors have a specific treatment, in the form of benzodiazepines; for "psychogenesis," there is none.

Background Psychogenic non-epileptic seizures are the most common paroxysmal event misdiagnosed as epilepsy. They significantly affect quality of life, functional status, and use of medical resources. Objective The goal of this review is to provide guidance to psychiatrists and other mental health professionals in the understanding and practical management of this condition. Results An abundance of new reports on the pathogenesis and effective treatments have become available over the last decade, yet specific barriers impede the fluid transition to treatment and remain an important challenge in the management of patients with psychogenic non-epileptic seizures. In the context of these difficulties, we initially present background information on psychogenic non-epileptic seizures covering their historic context, epidemiology, etiologic factors (including psychiatric, neuromedical, and neuropsychological factors), and current neurobiological models. Updated evidence-based treatments are discussed along with data on long-term outcomes. We also provide practical tools to help clinicians navigate differential diagnoses, establish their interdisciplinary roles, communicate the diagnosis, deliver treatment, and sort out commonly encountered challenges in the management of this condition.

Nonorganic chronic headache is a common, challenging presentation in clinical practice. The aim of this study was to investigate the frequency of associated psychiatric psychopathology, personality disorders, or traits. In addition, the study attempted to investigate possible relationships of nonorganic chronic headache with alexithymia, locus of control, and pain perception. Psychiatric pathology, personality traits, and pain profiles were examined in 100 randomized patients with chronic headache lacking an obvious organic basis, and they were compared with 100 subjects, 50 with headache of a known organic cause and 50 seemingly healthy persons, by using structured clinical interviews. Somatoform pain disorder was diagnosed in 43% of the nonorganic and 20% of the organic headache group. Nine percent of the former group had major depression, 16% had dysthymia, and 8% had both. In the organic group, 56% had no psychiatric disorder and 20% had somatoform pain disorder. Seventy-seven percent of the patients in the nonorganic pain group had personality disorders, mostly of the mixed and multiple types, compared with 24% of the organic headache patients. The study sample was more alexithymic than the other groups (in 65% of subjects) and had a culturally influenced locus of control and a pain profile characterized by dramatization, vagueness, lower pain threshold, and lower pain tolerance. The nonorganic chronic headache patients showed a high prevalence of somatoform, depressive, and other forms of psychiatric disorders. The high frequency of personality disorders, mostly the mixed and multiple types, the high alexithymic pattern, and low pain threshold and tolerance in the study group should be taken into consideration in the evaluation and management of nonorganic headache patients.

Received May 7, 2013; revised June 14, 2013; accepted June 17, 2013. From Department of Psychiatry (CH) and Department of Medicine (CH, KR), Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI; Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA (JG). Send correspondence and reprint requests to Colin J Harrington, M.D., Department of Psychiatry, Alpert School of Medicine of Brown University, APC 9, 593 Eddy Street, Providence, RI 02903; e-mail: colin_harrington@brown.edu & 2014TheAcademy of PsychosomaticMedicine. Published by Elsevier Inc. All rights reserved. Introduction

Seizure surgery for medically intractable partial epilepsy in selected patients usually results in dramatically improved seizure control. However, the authors present six patients who, after surgery for refractory complex partial seizures, postoperatively experienced pseudoseizures (also known as nonepileptic seizures), confirmed with EEG monitoring. Three of these patients also had nonepileptic seizures preoperatively that coexisted with their partial epilepsy. Psychiatric assessment revealed that this patient group had several characteristics in common, which suggests that preoperative psychiatric consultation may help identify those patients at risk for developing nonepileptic seizures. Treatment strategies with anticonvulsant medications and behavioral therapy are reviewed.

A literature review of reported cases of intractable sneezing reveals that intractable sneezing typically occurs in children or adolescents and is a manifestation of conversion disorder. Analysis of these cases demonstrates a number of features that are helpful in differentiating psychogenic from organic sneezing. Also discussed are aspects of patient management once a diagnosis of conversion disorder is established.

Background Psychogenic non-epileptic seizures (PNES) pose a substantial burden to patients and the health care system, due to long diagnostic and treatment delays. Methods This study used medical chart notes from 103 patients to shed light on the diagnostic process. Electronic medical records and cost data from a US health system were also used to investigate costs and utilization for the 12-months before and after PNES diagnosis. Results The results show that accurate diagnosis was typically achieved via the use of multiple medical tests, including vEEG, magnetic resonance imaging (MRI), and computed tomography (CT) scans, as well as historical diagnostic and clinical information. In the year following PNES diagnosis, a decline in average visits (−1.45) and costs (−$1784) were observed. The largest cost savings were seen in neurology care and inpatient stays. Conclusions This study has implications for timely and accurate diagnosis of PNES, which may decrease the overall health care burden for individuals and the health care system.

Background Video electroencephalography (vEEG) has proven to be a valuable tool in the differentiation of pseudoseizures or psychogenic non-epileptic seizures (PNES) from epileptic seizures. Clinicians should, however, be aware of a number of conditions that may be misdiagnosed as pseudoseizures. Objective To review a number of somatic conditions that can present with disturbances of consciousness and unusual motor activity without epileptiform findings on vEEG. Method We report a case of a young woman who presented with a number of neuropsychiatric symptoms, including episodic posturing and rhythmic movements. The absence of epileptiform findings on vEEG resulted in a diagnosis of conversion disorder with pseudoseizures. She was ultimately diagnosed with N-methyl-D-aspartate (NMDA) receptor autoimmune encephalitis (AIE) secondary to an ovarian tumor. AIE and other potential mimics of pseudoseizures are discussed. Results A number of somatic conditions can present with symptoms that may be misinterpreted as pseudoseizure.

Two subgroups of patients with psychogenic pseudoseizures were identified among 20 neurology patients referred for consultation to rule out pseudoseizures. Patients with pseudo complex partial seizures were found to have primarily dissociative symptoms with guilt-laden bereavement as an important precursor. Patients with pseudo grand mal type seizures appeared to have developed their illness in the context of longstanding personality traits. Diagnostic and prognostic implications of these findings are discussed.

Psychogenic non-epileptic seizures (PNES) and psychogenic movement disorders (PMDs) are common in neurology practice, yet it is not established whether clinically relevant differences between these two groups exist.In this retrospective chart review 172 patients were identified (PNES n = 116, PMD n = 56).The whole group was characterized by female gender (82%), abuse history (45%), chronic pain (70%), depression (42%), subjective fatigue (47%), subjective cognitive complaints (55%), and referral for psychiatric evaluation (54%). Statistically significant differences (P. 01) were found for age, education, frequency of symptoms, altered consciousness, developmental abuse, and coexisting anxiety. Clinical practice also differed for the two groups in history-taking and referrals for neuropsychological testing and/or psychiatric evaluation.This retrospective study revealed more similarities than differences suggesting these are manifestations of the same psychopathology, with age and co-morbid anxiety potentially being important factors in predicting the symptomatic presentation. Prospective studies are needed to confirm our results. Future studies focusing more globally on somatoform disorders, rather than each phenotypic presentation, are likely needed to improve clinical care and outcomes.

Received August 11, 1999; revised November 29, 1999; accepted December 9, 1999. From the Department of Psychiatry and Department of Internal Medicine, Division of Hematology, Istanbul Medical School, Istanbul Turkey. Address reprint requests to Dr. Yucel, Istanbul Medical School, Department of Psychiatry, Capa 34390 Istanbul, Turkey. Copyright 2000 The Academy of Psychosomatic Medicine. Pychogenic purpura was first described in four women by Gardner and Diamond in 1955 as the occurrence and spontaneous recurrence of painful ecchymoses after minor trauma. This phenomenon was initially thought to result from sensitization of patients against their own extravasated erythrocytes and thus was called “autoerythrocyte sensitization purpura” (Gardner-Diamond syndrome). This syndrome was renamed “psychogenic purpura” by Ratnoff and Agle, who postulated a psychogenic basis for the etiopathogenesis of the disorder; however, the exact mechanism of this syndrome is still unknown. The primary clinical feature reported in the literature is recurring ecchymoses. Apart from skin lesions, different systemic symptoms have been mentioned, including episodic abdominal pain, nausea, vomiting, arthralgia, headache, and other hemorrhages such as epistaxis, gastrointestinal bleeding, and bleeding from ear canals. Although bleeding from the eyes is very rare, especially in Western literature, seven cases have been reported in Turkey. Some of the patients with psychogenic purpura also had dissociative reactions, conversion symptoms, and hysterical traits along with their hemorrhagic symptoms. In this case report we describe a patient diagnosed with dissociative identity disorder (DSM-IV) who presented with psychogenic purpura in the form of bleeding from the eyes and various body surfaces.

The only consistent finding in studies of psychogenic seizures is the approximately threefold higher incidence in women. Therefore, why women? Charcot and Freud emphasized the sexual aspects of the seizure as has the current interest in childhood sexual abuse. From case studies and review of the literature the author believes that psychogenic seizures in women express rage, fear, and helplessness against the dominant and abusive male rather than sexual conflicts. Emphasizing the aggressive component of seizures does not minimize the traumatic effects of sexual abuse but rather includes it as leading to rage and helplessness.

Received Nov. 18, 2002; accepted Dec. 13, 2002. From the Temple University School of Medicine, Philadelphia. Address reprint requests to Dr. Lamdan, Temple University Health Sciences Center and Department of Psychiatry, 1316 West Ontario St., Jones Hall, 7th Floor, Philadelphia, PA 19140. Copyright 2003 The Academy of Psychosomatic Medicine. In 1898, German psychiatrist Siegbert Ganser first recognized the syndrome that would bear his name as a presentation of Vorbeireden, or “approximate answers.” Central features of Ganser’s syndrome include 1) approximate answers, 2) somatic conversion symptoms, 3) clouding of consciousness, and 4) hallucinations. Although it has been regarded as a psychotic disorder, it is currently classified among disorders of dissociation. The syndrome is uncommon, and rates of incidence and prevalence remain unclear. There appears to be a higher incidence of the condition in male subjects who belong to an ethnic minority. According to a review of 41 cases of Ganser’s syndrome, symptoms may span a wide range and include conversion features such as paralysis, anesthesias, paresthesias, and hysterical seizures (seen in 33% of the cases); psychogenic fugue (seen in 33%); disorientation to time and place (seen in 56%); perceptual disturbances such as auditory hallucinations, visual hallucinations, and olfactory hallucinations (seen in 51%); and amnesia, including localized, selective, and continuous types (seen in 93% of the cases). Approximate answers and amnesia were highly correlated at 93%, suggesting a dissociative mechanism. Onset of the syndrome is frequently associated with a stressful life event, which is most often of a domestic, sexual, or financial nature. Most cases are transient and resolve suddenly with an inability to recall the event. Ganser’s syndrome has been reported in a variety of patients, including those who have suffered trauma (per Ganser), organic brain disease, alcoholism with Korsakov’s psychosis, schizophrenia, depression, and neurosyphillis, although it has been most commonly reported in forensic settings. The condition is thought to unconsciously occur in response to a psychologically intolerable event. Further, it has been suggested that individuals presenting with Ganser’s syndrome frequently have underlying axis II psychopathology. Presented here is a description of an HIV-positive male patient who came into an outpatient psychiatry clinic exhibiting Ganser’s syndrome.

Research on psychogenic nonepileptic seizures (PNES) has focused on childhood abuse, but less is known about other stressors and psychosocial risk factors. The authors compared 25 patients with PNES with 33 control subjects with epilepsy on stressful life events and other risk factors for somatoform disorders. Compared with control subjects, patients with PNES reported significantly more prevalent and stressful negative life events (including adulthood abuse) and more current rumination, stress-related diseases, somatic symptoms, bodily awareness, and marginally more anxiety and depression. However, the relationship of many of these variables to PNES was accounted for by life stress. Groups did not differ on illness worry, alexithymia, or psychotic symptoms. The results suggest that PNES are part of a larger pattern of somatic symptoms responses to a wide range of negative events, including stress in adulthood.

About 100 years ago, psychogenic parasitosis was first described in the literature. This peculiar symptom may complicate medical and psychiatric conditions or indicate the presence of a delusional disorder (somatic type). By using the authors' case series of 12 patients, which are reported in the article, and a review of the literature, an historical perspective and the authors' clinical orientation to evaluation and treatment of psychogenic parasitosis are presented.

Medical records were reviewed for 94 consecutive inpatients diagnosed with nonepileptic seizures. A 122-item follow-up questionnaire was returned by 71 patients (76%). The majority of the subjects reported fewer seizures (73%), their general health as "very good" (20%) or "good" (37), and "improved" quality of life (55%). Many patients had either discontinued (50%) or reduced (17%) use of anticonvulsant medications. The patients most often sought care from primary care providers (46%), followed by psychiatrists/psychologists (41%) and neurologists (31%). Of the 57 patients (80%) advised to seek psychiatric care, 27 individuals (47%) followed this recommendation.

Patients with environmental somatization syndrome (ESS) believe that their symptoms are caused by exposure to tangible components of the external environment or by ergonomic stress at work. ESS is distinguishable by mental contagiousness and by the patients' focus on the external environment as cause of the illness. The presentation is often polysymptomatic, and epidemic outbreaks may appear. The patients usually refuse alternative explanations of their symptoms and discredit and reject any suggestion of a psychogenic etiology. It is important to distinguish between hygienic problems and ESS problems, particularly when poor and inadequate hygienic factors are present simultaneously with an ESS epidemic.

A study of 260 patients was conducted in 1990 using a questionnaire that was designed to measure and assess their recall of symptom patterns, symptom distress levels, symptom interpretation, and physician-recommended treatment plans. The questionnaire was mailed 6-18 months after they had undergone a gastrointestinal workup for unexplained chest or abdominal pain. The authors found comparably high rates of both younger patients (age65) and older patients (ageor = 65) reporting symptom patterns sufficient to meet DSM-III criteria for panic, generalized anxiety, and depressive disorders. For younger but not older patients, the number of symptom complaints was related to their recall of a stress-related diagnosis made by the physician, which was less frequent for older patients. The older patients less often identified their symptoms as tension-related. Further research is needed concerning symptom reporting, illness attribution, and physician recognition of emotional etiology among elderly and younger patients with somatizing disorders.

Timolol was compared with placebo in a double-blind randomized crossover study in 54 women affected by menopausal symptoms. The results were assessed with Blatt's Menopausal Index, modified so that it could be subdivided into vasomotor, psychogenic, and sexual symptoms. There was significant relief of vasomotor symptoms with both timolol and placebo by week 4, but no further significant differences during the next four weeks. Other symptoms were relieved to a lesser or insignificant extent. This study demonstrates the existence of noticeable, if time limited, placebo effect on selected menopausal symptoms.

Few reports have been published of patients explaining their symptoms as “psychogenic” in order to defend against the recognition of potentially threatening physical illness. With increasing public sophistication and awareness that emotional problems can cause somatic symptoms, such cases may become more common. The author reports on four physically ill patients who considered their symptoms psychogenic. They used denial, rationalization, and displacement to avoid recognizing the physical nature of their disorders. Family members’ reactions rein-forced their distorted perceptions. Careful psychiatric interviewing with supportive confrontation facilitated a therapeutic alliance, and the patients all achieved or approached acceptance of their correct diagnoses.

Neurasthenic neurosis may be physical —with weakness and fatigue stemming from chronic overwork brought on by attempts to compensate for low self-esteem and the lack of primary coping techniques; or symbolic —with the somatic symptoms serving as expressions of and excuses for functional helplessness rather than resulting from actual physical exertion. Since functional helplessness results from the lack of effective coping patterns and inhibitions motivated by low self-esteem, the underlying dynamics in both types of neurasthenic neurosis are similar. In either type, helping the patient come to better terms with himself and acquire more adaptive coping patterns provides a practical approach to treatment.

Management of the patient with somatizing behavior frequently is a frustrating endeavor for the physician who has been trained in a bioscientific model. However, rather than merely looking at these patients as “functional,” “crocks,” or “turkeys,” if we recognize that somatization is not randomly determined and that there are specific therapeutic interventions that can be employed to reduce the intensity of the somatizing behavior, then treatment of these patients can become more satisfactory to the physician.

Physical, social, and vocational changes characteristic of middle age often activate emotional distress in normal individuals and precipitate overt neurotic illness in predisposed individuals. Since the emotional distress tends to be focused on physical well being and since the neuroses tend to be expressed in somatic symptoms, knowledge of the interactions peculiar to this period can help the physician not only better understand and deal with emotional and neurotic reactions but also better distinguish between organic and psychogenic etiology, thus lessening the possibility of iatrogenic harm.

Review of the literature on delusions of halitosis confirms their fundamentally psychogenic basis. However, assessment of six recent cases reveals some new findings, especially that all six patients complained of sensations of bad taste. In such patients, with histories of medical problems such as rhinorrhea and rhinitis, distortions in taste physiology may contribute to the delusions of bad breath.

The authors describe traditional and modern approaches to the management of patients with chronic pain. They recommend a reintegration of psychiatry into pain-management programs net only for patients with nonorganic pain but also for those with mixed (psychogenic and organic) pain problems. Case histories are included.

Recent findings challenge the belief that most cases of impotence are psychogenic. Research indicates that nocturnal penile tumescence (NPT) can be viewed as a biologic marker for physiologic erectile capacity. Thus, the test can help to distinguish between physicogenic and psychogenic impotence. To determine proximal causes of erectile failure, other evaluations are easily performed during NPT monitoring.

Psychogenic amenorrhea results from the interaction of intrapsychic vulnerability, external stress, and neuroendocrine disturbances. It may result from exposure to a known stress or may be associated with a major psychiatric disorder. Psychogenic amenorrhea frequently remits spontaneously, particularly when patients eliminate or adapt to external stresses. Various types of psychotherapeutic intervention are effective for more persistent amenorrhea.

Twenty-four patients who had been diagnosed by a gastroenterologist as psychogenic vomiters were evaluated. Eighteen underwent a comprehensive psychological evaluation consisting of an interview, administration of the MMPI and the Beck Depression Inventory, and follow-up contacts. The majority of the patients did not have serious psychiatric disturbances and were not incapacitated by their illness. The vomiting seemed to be chronic and nondebilitating, with exacerbations in times of stress. The authors conclude that most psychogenic vomiters can be treated effectively by an empathetic primary care physician.

Persistent abdominal pain can be a diagnostic challenge. This study compared the presence of 13 factors, which have been considered positive indicators of psychological etiology, in three patient populations: psychogenic abdominal pain (PAP), inflammatory bowel disease, and general medical-surgical. Four factors in the patient history that are particularly useful in differentiating PAP patients are: (1) past evidence of somatization; (2) the presence of a symptom model; (3) prominent guilt; and (4) a history of physical abuse by either a parent or spouse.