Nice article in the guardian about stress-related physical symptoms...long piece written by a neurologist for their book (seems quite Dr Sachs-esque!....)
A small part posted below:
When we met in the outpatient department one month later, her arm was in a sling and all four fingers were curled inwards, the index and middle ones completely folded, their nails hidden from view. When I tried to straighten them, there was resistance. It was painful but possible to draw the fingers outwards, so that the palm of the hand was bared. Four red welts were visible where the nails had burrowed into the skin. When I released the fingers, they sprang back into their coiled position.
“Have you ever seen anything like that? Do you know what it is?” her mother asked.
“It looks as if Shahina has developed focal dystonia,” I said. “It’s a condition in which people’s muscles go into spasm. It can be triggered by trauma, but we need to look for other causes.”
When Shahina and I met again, she had been admitted as an inpatient on the ward. Her hand was just as it had been when I saw her last. Blood tests, genetic tests and brain scans designed to look for an underlying neurological disease were all normal. But Shahina’s dominant hand was useless to her now, and she needed her mother to do up her buttons and cut her food.
A specialist neurologist recommended that she be given a therapeutic trial of botulinum toxin. Botox isn’t just for cosmetic use: it has long been used as a treatment for neurological disorders. In people whose muscles go into painful spasm, for whatever reason, it can paralyse the muscles so they relax. The paralysed muscle may then prove useless, but if it results in an improvement in pain and deformity, it can be worth it anyway.
I accompanied Shahina to have the procedure. A small needle electrode was placed in the muscles of her forearm. The electrode recorded the excess electrical activity that was produced by the furiously over-contracting muscles leading to her fingers. The computer converted the electrical activity to a noise, so that when the needle was inserted into Shahina’s arm, the room filled with a wild crackling sound. The doctor running the test leaned over and turned down the volume.
“Is that my arm making that noise?” Shahina asked.
“Yes.”
“Is that what it is supposed to sound like?”
“Not if you are trying to relax. If the muscles going to your fingers were able to relax, there would be silence.”
The doctor took a small syringe filled with botulinum toxin, attached it to the needle, and slowly injected. Shahina watched the computer screen. We were all listening. The static crackling that had been present since the electrode had been inserted was dying down. Shahina’s gaze moved from the screen to her hand. Her eyes were transfixed as her fingers slowly unfurled.
Do you really think my daughter could hold her hand like this for weeks? She's in pain. I know my own child
“It worked!” she cried.
The doctor who had given the injection looked at me with raised eyebrows.
That afternoon I went to the ward to see if Shahina’s improvement was sustained. I found her tapping away at the keyboard of her computer.
“It hurts and my hand feels a bit weak, but look how good it is.” She opened and closed her fist. “I’m cured, can I go home now?”
What I did next I would regret many times.
“I need to explain something to you, Shahina.” I sat beside her on the bed as I spoke. “Botulinum toxin poisons the nerve ending and the result is that it relaxes the muscles. But it doesn’t usually work instantaneously. It takes a day or two.”
Shahina looked at me, puzzled. She had not understood the full implications of what I’d said.
“But it worked straight away for me. That’s a good sign, right?”
“Yes, which is all that really matters.”
“OK, so I can go home.”
Shahina had offered me an opportunity to retreat and I ignored it.
A week later, a letter of complaint arrived. It was printed on the headed stationery of the law office where Shahina’s mother worked. It ended by saying that Shahina had met another doctor, who had assured her that there was no possibility that the problem could be psychosomatic.
More than a year later, I received a letter from another neurologist at a different hospital, who informed me that Shahina’s dystonia had recurred and that she had responded well to a further administration of Botox, but that later the dystonic contraction had moved to her left arm and spread to her trunk. “I am beginning to wonder whether some, if not all, of her problem may be psychological in origin,” it said.
Even when a diagnosis of psychosomatic illness is delivered carefully, anger is a common response and it can prevent a patient getting the help they need. I have often wondered if the outcome for Shahina could have been different had I managed to communicate my suspicions in a better way.
http://www.theguardian.com/society/...-im-mad-the-truth-about-psychosomatic-illness
A small part posted below:
When we met in the outpatient department one month later, her arm was in a sling and all four fingers were curled inwards, the index and middle ones completely folded, their nails hidden from view. When I tried to straighten them, there was resistance. It was painful but possible to draw the fingers outwards, so that the palm of the hand was bared. Four red welts were visible where the nails had burrowed into the skin. When I released the fingers, they sprang back into their coiled position.
“Have you ever seen anything like that? Do you know what it is?” her mother asked.
“It looks as if Shahina has developed focal dystonia,” I said. “It’s a condition in which people’s muscles go into spasm. It can be triggered by trauma, but we need to look for other causes.”
When Shahina and I met again, she had been admitted as an inpatient on the ward. Her hand was just as it had been when I saw her last. Blood tests, genetic tests and brain scans designed to look for an underlying neurological disease were all normal. But Shahina’s dominant hand was useless to her now, and she needed her mother to do up her buttons and cut her food.
A specialist neurologist recommended that she be given a therapeutic trial of botulinum toxin. Botox isn’t just for cosmetic use: it has long been used as a treatment for neurological disorders. In people whose muscles go into painful spasm, for whatever reason, it can paralyse the muscles so they relax. The paralysed muscle may then prove useless, but if it results in an improvement in pain and deformity, it can be worth it anyway.
I accompanied Shahina to have the procedure. A small needle electrode was placed in the muscles of her forearm. The electrode recorded the excess electrical activity that was produced by the furiously over-contracting muscles leading to her fingers. The computer converted the electrical activity to a noise, so that when the needle was inserted into Shahina’s arm, the room filled with a wild crackling sound. The doctor running the test leaned over and turned down the volume.
“Is that my arm making that noise?” Shahina asked.
“Yes.”
“Is that what it is supposed to sound like?”
“Not if you are trying to relax. If the muscles going to your fingers were able to relax, there would be silence.”
The doctor took a small syringe filled with botulinum toxin, attached it to the needle, and slowly injected. Shahina watched the computer screen. We were all listening. The static crackling that had been present since the electrode had been inserted was dying down. Shahina’s gaze moved from the screen to her hand. Her eyes were transfixed as her fingers slowly unfurled.
Do you really think my daughter could hold her hand like this for weeks? She's in pain. I know my own child
“It worked!” she cried.
The doctor who had given the injection looked at me with raised eyebrows.
That afternoon I went to the ward to see if Shahina’s improvement was sustained. I found her tapping away at the keyboard of her computer.
“It hurts and my hand feels a bit weak, but look how good it is.” She opened and closed her fist. “I’m cured, can I go home now?”
What I did next I would regret many times.
“I need to explain something to you, Shahina.” I sat beside her on the bed as I spoke. “Botulinum toxin poisons the nerve ending and the result is that it relaxes the muscles. But it doesn’t usually work instantaneously. It takes a day or two.”
Shahina looked at me, puzzled. She had not understood the full implications of what I’d said.
“But it worked straight away for me. That’s a good sign, right?”
“Yes, which is all that really matters.”
“OK, so I can go home.”
Shahina had offered me an opportunity to retreat and I ignored it.
A week later, a letter of complaint arrived. It was printed on the headed stationery of the law office where Shahina’s mother worked. It ended by saying that Shahina had met another doctor, who had assured her that there was no possibility that the problem could be psychosomatic.
More than a year later, I received a letter from another neurologist at a different hospital, who informed me that Shahina’s dystonia had recurred and that she had responded well to a further administration of Botox, but that later the dystonic contraction had moved to her left arm and spread to her trunk. “I am beginning to wonder whether some, if not all, of her problem may be psychological in origin,” it said.
Even when a diagnosis of psychosomatic illness is delivered carefully, anger is a common response and it can prevent a patient getting the help they need. I have often wondered if the outcome for Shahina could have been different had I managed to communicate my suspicions in a better way.
http://www.theguardian.com/society/...-im-mad-the-truth-about-psychosomatic-illness
