Psychotherapy

Treatment.—The treatment of these conditions consists first in bringing the patient's health up to its normal condition as far as that is possible. Many of the sufferers from tremors are under weight. Whenever they are, a definite, determined effort must be made to bring them up to it. This must be done even though they insist that they have never been heavier and that to be rather underweight is a family trait. In many cases it will be found that this family trait, instead of being due to some inevitable hereditary tendency, is only the result of family habits in the matter of eating. Many of these people do not eat substantial breakfasts. Their tremor, too, is likely to be worse in the early morning than at any other time during the day, unless, of course, they have become overtired during the day, when the tremor will reassert itself with vigor. Most of them are much less disturbed in the afternoon than before. The drug treatment of the affection consists mainly in the use of nux vomica, but, not in the small doses of five or ten drops so often employed, but, according to the size of the individual, beginning with fifteen or twenty minims, thirty or forty drops, and gradually increased to physiological tolerance, when the dose should be set somewhat below that.

Mental Control .—The main treatment must consist, however, in enabling the patient to secure psychic control over himself and his muscles. This is not an easy matter. Most of them are quite discouraged, but their attitude of mind must be changed and the real significance of their affection made clear to them. As a rule, they have either heard or read or been told by a physician that their intentional tremor is significant of a serious pathological lesion of the central nervous system. Some of them have heard of multiple sclerosis and are much disturbed. They must be reassured and it must be made clear to them that their disease is really due to over-consciousness and consequent lack of control. A good deal of reassurance can be given by telling them of patients who suffer from ailments not unlike theirs, showing how multiform the affection is. A man who has trouble with his signature may be told about the man who finds it difficult to drink when under observation, then, as a rule, he will better realize the neurotic character of his affection. With hysterical women this method must be used with care or the story of another patient will act as a suggestion and the physician will subsequently be treated to an exhibition of the symptoms which he has described.

Self-Discipline .—Persistent quiet discipline is the one thing that eventually does any good. When patients are first told of this and are persuaded to attempt it, they make such a determined effort to overcome the affection that they make themselves more conscious of it than before with the result that their tremor and spasmodic movements are emphasized. It is the old story of the man trying to stand so straight that he falls backwards. It must be made clear to them that discipline, to be of any value, must be carried out as much as possible without consciousness of it and with all available artificial aids. The man who has trouble with his signature may be shown that he can overcome much of the tendency to tremor and spasm of the forearm muscles that are at the root of his difficulty by sitting at a higher chair, so that his arm swings free of the table and so that, in Gowers' phrase, if a pen were attached to his elbow it would write the same thing as the pen in his hand. The man who trembles as he drinks may be taught for a time to raise a cup to his lips while resting his elbow on the table and bringing his head well down. Nearly always methods of performing particular actions that require less effort can be found, until the habit of over-consciousness and loss of control is overcome.

Hypnotism and Waking Suggestion .—Occasionally hypnotism is effective in these cases, but there is likely to be a relapse unless there is some discipline before and after its use. Suggestion in the waking state is often very effective. Patients need to be talked to and even though intelligent they need to be reminded at regular intervals for some time that their ailment is merely functional and not organic. Nearly always it will be found that they trace its beginning to some pathological event: occasionally there has been a severe accident, but sometimes only a slight accident seems to them a sufficient explanation. Sometimes it follows an attack of pneumonia, oftener still typhoid fever. In these cases the patients become convinced that this is one of the marks left after the accident or disease and so it is rather hard to persuade them that they can be cured. All such impressions, which act as auto-suggestions for the continuance of their tremor and lack of control, must be combated, otherwise there is very little hope of improvement. The preceding disease is not the direct cause, though the weakness consequent upon it may predispose to the tremor. Overhaste in attempting to resume their occupations before their strength has returned is often the real cause. It is the patient's mind more than his body that needs to be set in order, but this will not be possible unless the physical condition is normal and thorough reassurance can be given.

DISORDERS OF THE PSYCHE

SECTION XVII

PSYCHO-NEUROSES

CHAPTER I

PSYCHO-NEUROSES (HYSTERIA)

As the derivation of the name indicates, psycho-neuroses are functional nervous affections dependent on states of mind. They are not necessarily originated by the mind, though they may be. Their spontaneous occurrence as pure psychic phenomena, however, is rather rare. There is practically always some slight physical cause. This may be severe, for all diseases have neurotic accompaniments that disturb the nerves involved and exaggerate the original symptoms. In most cases the patient has no serious interest to divert his or her mind from this occupation with self, and as a consequence the particular feeling fills up the whole of consciousness, and as it is painful to begin with, the pain, following Cajal's law of avalanche, may become almost intolerable.

It is of primary importance to remember, however, that there is practically always a physical basis for these curiously interesting affections which are so difficult to treat and which have so often proved the despair of physicians. While the attitude of mind must be changed, the physical state itself must be corrected. These two things must be secured at the same time, however, for attention to the physical state without correction of mental attitude will usually only emphasize the condition by calling further attention to the symptoms. This is especially true of local treatment. The mind must, above all, be treated and diversion of attention secured. Psycho-neuroses may occur in connection with sensory or motor nerves. The patient may either complain of intense pain in some part of the body for which there is but a very slight basis, or may be unable to move certain muscles, or there may be a combination of sensory and motor symptoms with complaint of pain on movement. The painful conditions are most important because they prove a source of worry and anxiety to the patient's friends, as well as often of such annoyance at unsuitable hours as deprives those near them of rest to a degree that may undermine health.

FORMS OF NEUROTIC SIMULATION

Every possible painful condition is simulated by these psycho-neurotic conditions. They occur probably with more frequency in the abdomen than elsewhere; they may be thought to be colicky in nature and, as a rule, some accumulation of gas will be found. This gas is sometimes swallowed air and sometimes gaseous products that have been diffused apparently from the blood in the intestinal walls. This always produces discomfort but nothing like the discomfort that the patient complains of. The condition if treated by carminatives will nearly always be emphasized rather than relieved. Local treatment by heat will help oftener, but may exacerbate it. When chronic constipation is present, calomel in divided doses is suggestive as well as medicinal.

There may be gastric crises that recall those of tabes, and there may be vesical and rectal crises of a similar nature. I have seen a patient complain of every symptom of stone in the kidney. At the beginning the pains were vague, but after she had been to several physicians and had been asked certain questions intended to elicit pathognomonic signs of stone these questions were answered in the affirmative. Her attacks became strikingly like renal colic. After a consultation, at which two physicians and a surgeon were present, she was operated upon for stone in the left kidney. No trace of it was found. But after this she was well nearly a year. Then she had another crisis of pain in the early morning hours, a time when her painful condition always came on, apparently because it attracted more attention and caused more disturbance at this time, and now all the symptoms pointed to the right kidney. She was treated on the principle that it was a neurosis, was made to gain some fifteen pounds in weight, has since then had no attacks, has not passed any stones, and there seems no doubt but that the whole case was merely neurotic. During her attacks instead of having suppression of urine, she had a free flow of urine and no blood. It is not unlikely that the physical basis of the attacks was that condition of the kidney which allows urine to flow through very freely during neurotic conditions and which somehow got into the sphere of her consciousness and being over-attended to became extremely painful.

Secretory Neuroses.—Lying between the pain and motor neuroses and dependent on psychic elements to some extent at least, there is a series of neuroses that have as their principal symptoms an increase or decrease of secretion. Occasionally, of course, they are complicated by motor neuroses, especially in connection with the viscera. There are various stomach affections, represented by an increase or decrease in stomach secretion, and accompanied by pain, discomfort, and decrease or increase of peristalsis. There are biliary neuroses accompanied by increase or inhibition of biliary secretions. There are gastric neuroses associated with vomiting, often very intractable, in which there seems to be sometimes a hypersecretion of gastric juice and sometimes a lessened secretion. All of these occur, as is said, spontaneously, but there will usually be found a history of some exhaustive work or worry during the weeks or months just before. Apparently nervous control is lost and then the secretory neurosis manifests itself sometimes in conjunction with painful or motor affections.

Neurotic Vomiting.—Persistent vomiting occurs in these cases but is not so serious as it seems and patients do not lose weight, as might be expected. There is sometimes even a probability that some of the food ingested finds its way through the pylorus and is used for nutrition, though the vomiting may come on not long after ingestion. Practically always nature asserts herself and stops the vomiting when serious conditions seem about to develop. The solicitude of relatives may be calmed by this assurance, and just as soon, as a rule, as they show less anxiety about the patient, the first symptoms of improvement will be noted. The fasting girls exploited in the newspapers, in connection with these neurotic conditions are often frauds and investigation has shown on a number of occasions that they were obtaining food surreptitiously. It must not be forgotten, however, that, even though these cases have been discredited, we have a number of cases on record of men and women who have taken absolutely nothing nutritious and only water for from ten to forty or even fifty days. Until at least ten days have passed in one of these gastric neuroses, then, there is no need for urgent solicitude, and this of itself, when properly explained, makes an excellent favorable suggestion for these patients, and, above all, for their friends.

Simulant Appendicitis.—Some of these abdominal psycho-neuroses may simulate serious pathological conditions that, in recent years, have come to be looked upon as surgical. I have seen a number of cases, especially in women who have been constipated for some time, in which there was considerable discomfort in the right lower abdominal segment and occasionally surgeons thought that an operation should be performed. Usually in these cases there is no localized tenderness and no mass of any kind to be felt in this region. Sometimes tenderness is complained of, though when the patient's attention is diverted even deep pressure may be made without their wincing. Whenever there is no history of an acute attack, no temperature and no increase in pulse rate, unless there are very definitely localized symptoms, the question of operation is always to be answered in the negative. Disturbances of the pulse may mean little. The history must guide. I have seen these cases operated on, improved for a while, but relapse afterwards just as soon as there was a resumption of their constipation. As a rule, when the appendix has been removed, either because its function has something to do with the inhibition of putrefactive processes in the lower bowel, or because as the result of the operation and consequent adhesions, the colon was not so active in its peristalsis, the constipation seemed to be worse than before, unless special care was exercised. If there is relapse after an operation the patients' attacks are almost sure to be more frequent than before and their discomfort likely to be more pronounced.

Lest it be thought that such cases are mainly confined to women or that the most striking cases occur only in women, I may say that the most interesting case of this kind I ever saw was in a young, vigorous German soldier. He was admitted to Koenig's clinic in Berlin with a story of abdominal tenderness and pain, the tenderness being located in the right iliac region. There seemed even to be some distention of the abdomen after a time and the development of greatly increased diffuse tenderness. The pulse was considerably disturbed, but there was only a slight rise in temperature, and for a time it was thought that this might be a case of appendicitis without fever. A surprising feature of the case was the presence in the right iliac region of a scar which, on careful investigation, proved to be double. Apparently the patient had been opened twice before in this region. His history was carefully investigated. He had had a fall from a horse about two years before and afterwards had considerable abdominal discomfort. He was quite sure that something serious had happened within his abdominal cavity as the result of the fall and his attention was concentrated on his right iliac region. At the time of the accident his symptoms were considered to be a psycho-neurosis or perhaps an exaggeration of symptoms with malingering tendencies.

Shortly after his term of service expired, however, some acute symptoms developed and there was swelling, or at least tympanitic distention of the abdomen with disturbance of the pulse, and he was operated on in the hospital and his appendix removed. There proved to be nothing the matter with it and no pathological condition was found within his abdomen. He seemed to recover completely. After six months he was admitted to another hospital with the same symptoms. He seemed to have the habit of swallowing air which found its way beyond his pylorus, or else gas leaked from the blood vessels in the walls of his intestines, producing a symptom-complex not unlike the tympanitic distention consequent upon general peritonitis. Once more this was taken to mean very probably a ruptured appendix and another operation was done. This operator went through the old scar, but to his surprise found no appendix and found everything within the abdomen normal. The third time the patient came to Koenig's clinic and, owing to his military record, his hospital experience was available and a third operation was not done. Instead, according to the story current at the time, the patient was tattooed with the legend "no appendix here." The case is interesting as an example of the extent to which an abdominal psycho-neurosis may simulate a ruptured appendix.

Pseudo Biliary Colic.—A similar state of affairs to that with regard to the appendix has developed in all that concerns the gall bladder and the biliary tract generally. Any complaint of discomfort in the right upper quadrant of the abdomen, if persisted in, is almost sure sooner or later to be diagnosed as due to a calculus. Now that operations for gallstones are more common than they used to be, it is probable that almost as many gall bladders are found without pathological conditions as appendices without justifiably operative lesions. In treating individuals who have a history of recurrent symptoms of intestinal reaction to various foods complicated by urticaria, it is important to remember that there may probably be lesions corresponding to those in the skin in portions of the intestinal tract which may functionally involve either the appendix or the biliary passages. Some of these cases are extremely difficult to handle because often there is pain, definite tenderness and some fever with the attacks, and very localized symptoms. The history, however, will be helpful. Operation will not relieve the patient from liability to recurrence. There are, however, other cases where the discomfort is much more vague, where there is no tenderness, no disturbance after jolting rides and where there has never been any severe pain. These should not be set down as biliary calculi without further developments. The possibility of a stone being present should not be hinted to the patient until some definite pathognomonic sign is discovered.

Other Simulated Conditions.—There are many painful conditions of the head that are psycho-neurotic. Many forms of headache are due to sensations of pressure or tension or constriction, usually in the external integuments of the skull, which are dwelt on and then become painful achy conditions. This is particularly true of so-called headaches in the back of the head. As we emphasize in the chapter on Headache, probably most of the headaches of patients who have not much to occupy themselves with, are due rather to queer feelings in the head emphasized by the concentration of attention on them than to real pains. Earache may occur in the same way. Nearly always when one has been out in the wind, there is likely to be an uncomfortable sensation in the ear. By attention to it this may readily be exaggerated into an earache. Occasionally the physical basis of an ache in the region of the ear seems to be an unconscious performance of Valsalva's experiment while blowing the nose when catarrhal conditions are present.

All sorts of painful conditions of the arms and legs may develop in the same way. Unusual tiredness, or some special exertion of the muscles, may produce a sense of fatigue readily exaggerated by attention to it, into severe pain. This condition is not a voluntary simulation, but is due to lack of diversion and a certain inborn tendency in these people to pay attention to anything that is the matter with them. Very seldom does the physical condition need much treatment, though nearly always something can be done for it with advantage, but the mental state needs alteration and, above all, the patient needs to be diverted from over-concentration of mind.

Motor Neuroses.—As has been said, beside painful conditions, various forms of motor trouble may develop. These usually consist of inability to move certain groups of muscles. They have sometimes been spoken of as hysterical palsies or paralyses. The word hysterical, by its derivation connected with the Greek word for womb, apparently indicates that these conditions are limited to women. It is well known now that they are extremely common among men and especially among young men and have absolutely nothing to do with the genital system. As with painful psycho-neurotic conditions, there is practically always a physical basis. This sometimes requires careful questioning to locate exactly. There is some injury of the muscles of a particular region, or some over-use of them, or some employment of them under bad mechanical conditions with over-fatigue, and then attention to this leads to incapacity to use the muscles or inability to co-ordinate them properly.

Neurotic palsies, to use a term that carries much less unfavorable suggestion with it than the word paralysis or the word hysterical, may occur in any limb or group of muscles. They may occur in the legs with the production of complete paraplegia. One well-known form, astasia-abasia, inability to stand or to walk, affects the muscles of the trunk as well as of the lower limbs. These conditions often remain for long periods in spite of treatment, frequently recur, are often called by all sorts of names and continue to be a source of annoyance to the patient, until a definite successful effort is made to change the patient's mental state to one of less attention to the particular part.

There is, it seems to me, an unfortunate tendency to think that our observations upon these cases are comparatively recent. Sir Benjamin Brodie, nearly a century ago, insisted that at least four-fifths of the female patients among the higher classes of society supposed to suffer from diseased joints were really sufferers from neurotic conditions, or, as they called them then, hysteria. Sir James Paget, in his Clinical Lectures and Essays, thinks that Brodie has exaggerated the proportion, for in his own practice, though, of course, he includes his hospital cases and the poor as well as the rich, he found less than one-fifth suffering from neurotic joints. The hip and the knee, which are the most frequent seats of genuine pathological conditions, are also most frequently the subject of neuroses. Next in order, but much more rarely, the metatarsal and metacarpal joints are affected and then the elbow and shoulder. In Sir James Paget's chapter on Nervous Mimicry or Neuro-Mimesis, he cites a number of cases which show how clearly psycho-neurotic affections were recognized in his time. He tells the story of a young man who had been overworking for examinations and who "after a three-hours' mathematical cram, fainted and when he rallied set up a very close mimicry of paraplegia which lasted many weeks." He insists that "such mimicry is found not only or chiefly in the silly selfish girls among whom it is commonly supposed that hysteria is rife, but even among the wise and accomplished, both men and women."

DIFFERENTIAL DIAGNOSIS

For the differential diagnosis of psycho-neuroses from definite organic conditions, the most important element is the patient's previous history and a knowledge of the condition of the nervous system. Where this is known the diagnosis is comparatively easy, but when the patient is seen for the first time it may often be extremely difficult. It is, above all, important not to jump to conclusions, for every nervous specialist knows of cases in which the diagnosis was considered to be surely a neurosis, yet a fatal termination showed that a serious organic condition was at work. It must not be forgotten either that neurotic patients may develop serious organic disease in the midst of their neurotic symptoms and care must be taken not to miss the significance of special symptoms. When the patient is not well known, the presence of certain stigmata, as they have been called, enable the physician to recognize the probability that a neurotic condition is present. Patients who are subject to neuroses are likely to have certain areas of the skin surface and of the palpable mucous membranes more or less sensitive than normal. There are likely to be spots of hyperesthesia or hypesthesia or even complete anesthesia somewhere on the skin. These should be carefully looked for and in serious cases an examination of the whole skin surface should be made. Not infrequently anesthesia or a decided lack of sensitiveness to irritation will be found in the throat or in the nose. Occasionally the conjunctiva is much less sensitive than usual.

These used to be called hysterical stigmata. The word hysteria carries an innuendo of imaginativeness or occasionally of affection of the sexual organs that is unfortunate. It would be better, therefore, not to use the term in any way. The presence of these areas of hyperesthesia, hypesthesia and anesthesia indicates that association fibers are abnormally connected in the brain for the moment at least, and that as a consequence there is over-attention to certain portions of the body with lack of ordinary attention to others. This will account very readily for the occurrence of painful conditions in certain cases and palsies in others. When over-attention is paid, there may be a hyperesthesia corresponding to that seen in the skin in any organ of the body. When, for any reason, there is a disturbance in a particular part, there may be a lack of motility due to nervous influences, just as there is a lack of sensation. In all of these cases the one essential element is to correct the nervous state through the mind as far as possible. Experience has shown that this can be done in nearly all cases. It must be the principal effort of the physician.