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Am Fam Physician. 1998;58(9):1970-1972

to the editor: The recent article by Drs. Shaibani and Sabbagh1 focuses on “nonorganic” neurologic symptoms. The article describes individuals with symptoms such as paresthesias/hypesthesias, pseudoseizures, dizziness/vertigo, weakness, tremors, ataxia, bowel/bladder dysfunction, cognitive dysfunction and chronic pain syndromes. On the basis of normal findings on neurologic examination, laboratory testing, imaging and other standard testing, the symptoms ultimately are seen as pseudoneurologic or psychogenic in etiology.

The implication is that neurophysiologic dysfunction is not present in these individuals—that is, the problem is in their minds. It is interesting to note that the authors did not mention post-traumatic stress disorder when they discussed mental health concerns or psychiatric diagnoses in the individuals described in the article. We believe that the literature on post-traumatic stress disorder offers some relevant and useful information when considering the possibility of “pseudoneurologic syndromes.”

Post-traumatic stress disorder is a complex psychobiologic syndrome that results from profound psychoemotional trauma. Manifestations include disturbances in the psychologic, emotional, psychosocial and physiologic functioning of affected individuals.2 Physical symptomatology, including neurologic symptoms, is frequently seen in individuals with post-traumatic stress disorder.3 Individuals with pseudoseizures have a prevalence of post-traumatic stress disorder of 49 percent,4 and 84 percent have a history of psychoemotional trauma.5

Associations have been noted between a history of sexual abuse and chronic pelvic pain, as well as between a history of physical abuse and headaches.6 Histories of trauma are so common among individuals with medically unexplained symptoms that a proposal has been made to consider such symptoms as diagnostic of “atypical post-traumatic stress disorder” (i.e., post-traumatic stress disorder manifested by physical symptoms only).7

In certain cases involving “pseudoneurologic” symptomatology, particularly in patients with a history of psychoemotional trauma, the discrimination between what is neurologic and what is “nonorganic” may be more complex than the article by Drs. Shaibani and Sabbagh implies. For the clinician, the distinction may be less significant and relevant than is our capacity to approach our patients in a circumspect and integrated fashion. Physicians are encouraged to appreciate the inextricably linked phenomena of behavior and physiology, environment and organism, mind and body.

in reply: I would like to thank Drs. Hunt and Richardson for their very interesting letter regarding the psychobiology and prevalence of post-traumatic stress disorder. They are correct that we did not mention post-traumatic stress disorder in our article, and this is regrettable. Unfortunately, we were constrained by space and editorial parameters established by A merican Family Physician. Therefore, much of the discussion regarding the psychologic issues in the somatoform disorders was beyond the scope of our review.

Our review focused on enlightening the primary care physician about the use of bedside techniques to differentiate between the structural/organic causes of disease and the nonstructural/psychologic causes of disease. It was, therefore, impossible to include a discussion about post-traumatic stress disorder.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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