Chromosomal Deletion in 7q31.2-31.32 Involving Ca2⁺-Dependent Activator Protein for Secretion Gene in a Patient with Cerebellar Ataxia: a Case Report

We present a 33-year-old male patient with cerebellar ataxia. He was first considered to have a psychiatric conversion disorder but finally found to have chromosomal deletion in 7q31.2-31.32 involving Ca2⁺-dependent activator protein for secretion (CADPS) gene. When a targeted gene sequencing using next-generation sequencing panel and chromosomal microarray analysis were performed, an 8.6 Mb deletion within chromosome 7q31.2-31.32 was discovered. Deletion of CADPS gene in the 7q31.2-31.32 was suggested as the causative factor of cerebellar ataxia. Functional levels evaluated by Berg balance scale and modified Barthel index were improved via comprehensive rehabilitation including balance training and a dopamine agonist medication. To the best of our knowledge, this is the first report of chromosomal deletion in 7q31.2-31.32 including CADPS gene detected in patients with cerebellar ataxia.

Del trastorno conversivo a los trastornos neurológicos funcionales. ¿Superando el diagnóstico por descarte? / From Conversion Disorders to Functional Neurological Disorders. Overcoming the Rule-out Diagnosis?

RESUMEN Los trastornos neurológicos funcionales, antes llamados trastornos conversivos, son un problema clínico frecuente en los servicios de neurología y psiquiatría y en atención primaria. En las nuevas categorías diagnósticas se hace énfasis en las características positivas necesarias para el diagnóstico de este trastorno. Se realizó una revisión narrativa de la literatura médica para determinar las diferencias y las ventajas clínicas que la actual clasificación aporta al diagnóstico y el tratamiento de los trastornos neurológicos funcionales. Se identifican las diferencias conceptuales entre los trastornos conversivos y los trastornos neurológicos funcionales y las implicaciones de estos cambios en el abordaje clínico. La nueva propuesta diagnóstica para los trastornos neurológicos funcionales brinda la oportunidad de transformar un diagnóstico realizado a partir del descarte de otras afecciones en otro en el que se verifica la presencia de signos neurológicos que apuntan al trastorno y se pueden ensenar al paciente, y a partir de ellos, plantear estrategias de tratamiento.

ABSTRACT Functional neurological disorders, formerly referred to as conversion disorders, are a frequent clinical problem in neurology, psychiatry and primary care departments. In the new diagnostic categories, emphasis is placed on the positive characteristics necessary to diagnose this disorder. A narrative review of the scientific medical literature related to the subject was performed in order to determine the differences and advantages that the new classification of functional neurological disorders gives to doctors and patients. Historical, diagnostic, clinical and treatment concepts related to functional neurological disorders are reviewed. The conceptual differences between conversion disorders and functional neurological disorders and the implications of these changes in the clinical approach are identified. The new proposed diagnosis for functional neurological disorders provides the opportunity to transform a diagnosis made by ruling out other pathologies to a diagnosis where the presence of neurological signs suggestive of the disorder are verified and can be taught to the patient, and based on them, treatment strategies posed. © 2017 Asociacion Colombiana de Psiquiatria. Published by Elsevier España, S.L.U. All rights reserved.

Síndrome de persona rígida confundido por trastorno conversivo: un error común. caso clínico / Stiff-person syndrome mistaken for conversive disorder: a common error

Stiff-person syndrome is characterized by persistent muscle spasms, involving agonist and antagonist muscles simultaneously, starting in the lower limbs and trunk. It tends to occur in the fourth to sixth decade of life, presenting with intermittent spasms that later become continuous and usually painful. Minor sensory stimuli, such as noise or light touch, precipitate severe spasms. Spasms do not occur during sleep and only rarely involve cranial muscles. We present a case that for two years was diagnosed and treated as a conversion disorder associated with depression. After two years she was admitted to another hospital with an unmistakable picture of stiff-person syndrome with hypertrophy and rigidity of lower limb muscles, compatible electrophysiology and positive anti-GAD antibodies. She had autoimmune hypothyroidism, that should have raised the suspicion of stiff-person syndrome earlier. She responded to intravenous immunoglobulin and mycophenolate mofetil and and to tranquilizers that have muscle relaxant properties.

Terapias de conversão: histórico da (des)patologização das homossexualidades e embates jurídicos contemporâneos / Conversion therapies: a history of the (de)pathologization of homosexuality and contemporary legal conflicts / Terapias de conversión: histórico de la (des)patologización de las homosexualidades y los enfrentamientos legales contemporáneos

O presente artigo analisa alguns elementos concernentes ao embate atual no campo legal brasileiro em relação às "terapias de conversão". É apresentado inicialmente um breve panorama da patologização das sexualidades dissidentes para, em seguida, descrever tal processo em relação às homossexualidades em específico. Na sequência, é feita uma descrição e análise histórica das terapias de reversão da orientação sexual, em especial nos EUA e no Brasil, seguida da discussão sobre as "terapias de conversão", de base religiosa, e do enfrentamento de seus proponentes com os conselhos profissionais nestes mesmos países. Ao final, são analisados aspectos concernentes aos discursos presentes em Ação Popular recente contra a Resolução no 001/1999, do CFP, apontando-se alguns elementos para se pensar estratégias de enfrentamento da disseminação destas terapias. Dentre eles, destacam-se: a necessidade de desconstrução do argumento da liberdade individual, utilizado pelos defensores destas terapias; a problematização do uso da "ciência" como argumento central pelos conselhos de classe nesse embate jurídico, uma vez que tais práticas foram sustentadas historicamente por argumentos "científicos" de sua época; e a necessidade do debate se centralizar nas questões éticas que envolvem tais práticas a partir do conceito de laicidade, tendo em vista que os discursos jurídicos e científicos se mostraram em muitos momentos históricos inseparáveis das concepções de base religiosa.(AU)

The present article analyzes some elements concerning the current clash in the Brazilian legal field in relation to "conversion therapies". A brief overview of the pathologization of dissident sexualities is presented initially and then this process is described especially in relation to homosexuality. After this, the paper presents a description and historical analysis of sexual orientation reversion therapies, especially in the USA and Brazil, followed by the discussion of religiously based "conversion therapies" and the confrontation of their proponents with professional counseling in these countries. Finally, aspects related to the discourses present in the recent Popular Action against Resolution 001/1999 of the CFP are analyzed, pointing out some elements for the analysis of the coping strategies of the dissemination of these therapies. Among them, the following stand out: the need to deconstruct the arguments of individual freedom used by proponents of these therapies; the problematization of the use of "science" as central argument by the class councils in this juridical attack, since such practices were supported historically by "scientific" arguments of its time; and the need to focus on the ethical issues surrounding such practices, based on the concept of secularity, given that legal and scientific discourses have been shown in many historical moments inseparable from conceptions of religious basis.(AU)

El presente artículo analiza algunos elementos relacionados con el choque actual en el campo legal brasileño con respecto a las "terapias de conversión". Se presenta una breve descripción de la patologización de las sexualidades disidentes, y luego se describe en relación con homosexualidades específicas. A continuación, se presenta una descripción histórica y un análisis de las terapias de inversión de la orientación sexual, particularmente en EE. UU. y en Brasil, seguida de una discusión sobre las "terapias de conversión" basadas en la religión y la confrontación de sus defensores con los consejos profesionales en estos mismos países. Al final, se analizan aspectos relacionados con los discursos presentes en la reciente Acción Popular contra la Resolución 001/1999, del CFP señalando algunos elementos para pensar en estrategias para hacer frente a la difusión de estas terapias. Entre ellos, destacan los siguientes: la necesidad de desconstrucción del argumento de la libertad individual, utilizado por los defensores de estas terapias; la problematización del uso de la "ciencia" como argumento central por parte de los consejos de clase en este choque legal, ya que tales prácticas fueron históricamente apoyadas por argumentos "científicos" de su tiempo; y la necesidad del debate para centrarse en los problemas éticos que rodean a tales prácticas desde el concepto de secularismo, dado que los discursos legales y científicos se han mostrado en muchos momentos históricos inseparables de concepciones basadas en la religión.(AU)

Fósseis do campo psi: sobre conversão de orientação sexual e gênero / Psy fossils: on sexual orientation conversion and gender / Fósiles del campo psi: sobre conversión de la orientación sexual y del género

Neste escrito analisamos a atualidade das discussões sociais e políticas em torno das práticas de conversão de orientação sexual e de gênero. Propomos pensar os riscos que teorias e técnicas estruturantes do campo psi - Psicanálise, Psicologia e Psiquiatria - têm de serem capturadas por grupos sociais, políticos e religiosos que podem utilizá-las para legitimar e ampliar o poder e o alcance de suas proposições no tocante ao exercício da sexualidade e à identidade de gênero. Construímos a hipótese de que certos fósseis morais, religiosos e conceituais, que pertencem aos registros lógicos e históricos das teorias e discursividades constituintes do campo psi, acabam sendo registros privilegiados para tal captura de práticas e de sentido conceitual. Dentre estes fósseis, citamos as discussões sobre a natureza psicopatológica da homossexualidade e mesmo sobre a formação de psicanalistas homossexuais, o que provocou debates intensos até tempos bastante recentes.(AU)

In this paper we analyze the current social and political discussions around the practices of conversion of sexual orientation and gender. We propose to think about the risks that the theories and structuring techniques of the field of psychoanalysis, psychology and psychiatry involve if captured by social, political and religious groups that can use them to legitimize and broaden the power and scope of their propositions regarding exercise of sexuality and gender identity. We construct the hypothesis that certain moral, religious, and conceptual fossils, which belong to the logical and historical records of the constituent theories and discursivities of the psy field, end up being privileged records for such capture of practices and conceptual sense. Among these fossils, we cite the discussions about the psychopathological nature of homosexuality and even about the formation of homosexual psychoanalysts, which provoked intense debates until quite recent times.(AU)

En este artículo analizamos las discusiones sociales y políticas actuales sobre las prácticas de conversión de orientación sexual y de género. Proponemos pensar en los riesgos que tienen que capturar las teorías y técnicas de estructuración en el campo psi - psicoanálisis, psicología y psiquiatría por parte de grupos sociales, políticos y religiosos que pueden usarlas para legitimar y extender el poder y el alcance de sus proposiciones con respecto al ejercicio de sexualidad e identidad de género. Presumimos que ciertos fósiles morales, religiosos y conceptuales, que pertenecen a los registros lógicos e históricos de las teorías y discursividades que constituyen el campo psi, terminan siendo registros privilegiados para tal captura de prácticas y de significado conceptual. Entre estos fósiles, citamos discusiones sobre la naturaleza psicopatológica de la homosexualidad e incluso sobre la formación de psicoanalistas homosexuales, lo que ha provocado un intenso debate hasta tiempos muy recientes.(AU)

Uma análise histórica da resolução n° 01/1999 do conselho federal de psicologia: 20 anos de resistência à patologização da homossexualidade / A historical analysis of the resolution n° 01/1999 of the federal council of psychology: 20 years of resistance to the pathologization of homosexuality / Un análisis histórico de la resolución n° 01/1999 del consejo federal de psicología: 20 años de resistencia a la patologización de la homosexualidad

A Resolução no 01/1999 do Conselho Federal de Psicologia (CFP) - que proíbe a patologização da homossexualidade - completou, em 2019, 20 anos de existência em uma trajetória marcada por conflitos, ataques e resistências. Trata-se da Resolução mais atacada da história do CFP, assim como a Resolução que mais mobilizou grupos e movimentos em sua defesa. Os ataques foram realizados por grupos, contrários às políticas de diversidade sexual e de gênero, vinculados a um conservadorismo cristão que vêm se rearticulando em importantes espaços político-institucionais no Brasil. Desse modo, este artigo tem como objetivo analisar a história da Resolução no 01/99, desde sua proposição aos dias atuais, abarcando fundamentalmente o período de 1998 a 2019. A partir de um levantamento documental e de uma perspectiva analítico-discursiva, buscamos descrever os eventos, os conflitos e os sentidos produzidos em seu entorno, traçando também alguns pontos de análise sobre as suas reverberações sociais e político-institucionais. O artigo foi dividido em duas partes, a primeira trata sobre a história da presença da Resolução no 01/99 no âmbito das políticas de diversidade sexual e de gênero no Sistema de Conselhos de Psicologia; e a segunda trabalha sobre os conflitos que perpassaram a Resolução nos últimos 20 anos.(AU)

The Resolution n. 01/99 of the Federal Council of Psychology (CFP) - which prohibits the pathologization of homosexuality - completed twenty years of existence in 2019, through a trajectory marked by conflicts, attacks and resistances. It is the most attacked resolution in the history of the CFP, as well as the resolution that most mobilizes groups and movements in its defense. The attacks were carried out by groups that are contrary to the policies of sexual and gender diversity and linked to a Christian conservatism that re-articulates itself in important political-institutional spaces in Brazil. Thus, this article aims to analyze the history of Resolution n. 01/99 from its proposition to the present day, basically covering the period from 1998 to 2019. Based on a documentary survey and an analytical-discursive perspective, we seek to describe the events, conflicts and meanings produced in its surroundings, also drawing some points of analysis on its social and political-institutional reverberations. The article was divided in two parts; the first one deals with the history of the Resolution n. 01/99 in the scope of the policies of sexual and gender diversity in the System of Councils of Psychology; and the second works on the conflicts that have permeated the resolution in the last 20 years.(AU)

La Resolución no 01/99 del Consejo Federal de Psicología - que prohíbe la patologización de la homosexualidad - completó en 2019 20 años de existencia en una trayectoria marcada por conflictos, ataques y resistencias. Se trata de la resolución más atacada de la historia del CFP, así como la resolución que más movilizó grupos y movimientos en su defensa. Los ataques fueron realizados por grupos, contrarios a las políticas de diversidad sexual y de género, vinculados a un conservadurismo cristiano que se rearticula en importantes espacios político-institucionales en Brasil. De este modo, este artículo tiene como objetivo analizar la historia de la Resolución no 01/99, desde su proposición hasta los días actuales, abarcando fundamentalmente el período de 1998 a 2019. A partir de un levantamiento documental y de una perspectiva analítico-discursiva, buscamos describir los eventos, los conflictos y los sentidos producidos en su entorno, trazando también algunos puntos de análisis sobre sus reverberaciones sociales y político-institucionales. El artículo se dividió en dos partes, la primera trata sobre la historia de la presencia de la Resolución no 01/99 en el ámbito de las políticas de diversidad sexual y de género en el Sistema de Consejos de Psicología; y la segunda trabaja sobre los conflictos que han transpuesto la resolución en los últimos 20 años.(AU)

A psychotic experience during adolescence: reasoning about differential diagnosis. case report

ABSTRACT CONTEXT: The aim of the present clinical review was to illustrate the diagnostic difficulty associated with psychotic experiences during adolescence, in the light of the multiplicity of circumstances interplaying during this period. It was also intended to illustrate the observation that not all hallucinations occur in the context of a declared psychotic disorder. Case Report: The patient was a 16-year-old adolescent girl who came to the Emergency Department of Coimbra Pediatric Hospital. On admission, she displayed mood and sensory perception disorders, with a bizarre gait abnormality. A diagnosis of conversion disorder was finally suggested, in accordance with the International Classification of Diseases, 10th edition. CONCLUSIONS: Conversive hallucinations are rare in the psychiatric literature. This diagnostic hypothesis only gained consistency over a long period of follow-up within a child and adolescent psychiatry outpatient service, which was fundamental for appropriate diagnostic clarification. The authors discuss psychotic experiences that can arise from a neurotic setting and share the reasoning that was constructed in relation to the differential diagnosis. The psychogenesis and phenomenology of this young patient's conversive hallucinations and the therapeutic strategies adopted over the course of the follow-up are also discussed.

Lo visible y lo menos visible en el padecimiento de un trastorno conversivo en niños y adolescentes. Un estudio cualitativo sobre los modelos explicativos de la enfermedad que ofrecen los cuidadores de niños y adolescentes con trastorno conversivo / The Visible and Less Visible in the Suffering of a Conversion Disorder in Children and Adolescents. A Qualitative Study of Illness Explanatory Models Presented to Caregivers of Children and Adolescents with Conversion Disorder

RESUMEN Antecedentes: El trastorno conversivo es un reto para los clínicos por los vacíos conceptuales en lo que respecta a la patogenia y cómo confluyen otras entidades psiquiátricas y la falta de aproximaciones a las vivencias tanto de pacientes como de familiares con la enfermedad. Objetivo: Describir los modelos explicativos (ME) que utilizan los cuidadores de niños y adolescentes con trastorno conversivo que consultan al Hospital Pediátrico de La Misericordia. Métodos: Se realizó un estudio cualitativo con una muestra por conveniencia de 10 casos atendidos entre mayo de 2014 y abril de 2015. La herramienta usada fue una entrevista en profundidad con padres y/o cuidadores. Resultados: Los cuidadores tienen diversas creencias en torno al origen de los síntomas, y consideran principalmente enfermedad, factores mágicos místicos y factores psicosociales. Se explican los síntomas en cada caso de varias maneras, y no se encontró una relación directa entre estas creencias, el patrón de síntomas y los comportamientos de búsqueda de ayuda. La presentación sintomática es polimorfa y genera interferencia principalmente en la actividad escolar de los pacientes. La atención médica se percibe como pertinente y la atención psiquiátrica, como insuficiente. Entre los itinerarios terapéuticos, se describen consultas con diversos agentes, además de la atención médica, incluidas medicinas alternativas y enfoques mágico-religiosos. Conclusiones: Los ME en trastorno conversivo son variados, pero incluyen con frecuencia elementos mágico-religiosos y factores psicosociales. Las creencias subyacentes no se relacionan directamente con la búsqueda de ayuda u otras variables.

ABSTRACT Background: Conversion disorder is a challenge for clinicians due to the conceptual gaps as regards its pathogenesis, the way in which it converges with other psychiatric disorders, and the lack of approaches to the experiences of both patients and family members with the disease. Objective: To describe Explanatory Models (EM) offered to caregivers of paediatric patients with conversion disorder who attended the Hospital de la Misericordia. Methods: A qualitative study was conducted with a convenience sample of 10 patients who attended the Hospital de La Misericordia, ¿Bogotá? between May 2014 and April 2015. The tool used was an in-depth interview applied to parents and/or caregivers. Results: Caregivers have different beliefs about the origin of the symptoms, especially considering sickness, magical-mystical factors, and psychosocial factors. The symptoms are explained in each case in various ways and there is no direct relationship between these beliefs, the pattern of symptoms, and help-seeking behaviours. Symptomatic presentation is polymorphous and mainly interferes in the patient's school activities. The medical care is perceived as relevant, and psychiatric care as insufficient. Among the therapeutic routes, consultations with various agents are described, including medical care, alternative medicine, and magical-religious approaches. Conclusions: EMs in conversion disorder are varied, but often include magical-religious elements and psychosocial factors. The underlying beliefs are not directly related to help-seeking behaviours or other variables.

La histeria moderna: Parte III trastornos disociativos y conversión / The modern hysteria: Part III dissociative disorders and conversion

La conciencia: característica esencial de esta dimensión de autorepresentación es la interpretación de ciertos estados internos del propio cuerpo como identidad mental y somática. La neurociencia de la conciencia sugiere fuertemente que un nivel de sincronización y unión entre varias partes del cerebro hasta cierto punto refleja la accesibilidad de varios contenidos mentales. Janet (1889) propuso el término désagrégation para referirse a los fenómenos de «no integración¼ y lo situó en el terreno de la anormalidad. Trastornos disociativos: en estos trastornos hay pérdida parcial o completa de la integración normal entre ciertos recuerdos del pasado, la conciencia de la propia identidad, ciertas sensaciones inmediatas y el control de los movimientos corporales (conversión)

The conscience: essential feature of this dimension of self-representation is the interpretation of certain internal states of the body itself as mental and somatic identity. The neuroscience of consciousness strongly suggests that a level of synchronization and union between various parts of the brain to some extent reflects the accessibility of various mental contents. Janet (1889) proposed the term désagrégation to refer to the phenomena of "non integration" and placed it in the terrain of abnormality. Dissociative disorders: in these disorders there is partial or complete loss of normal integration between certain memories of the past, awareness of one's own identity, certain immediate sensations and control of bodily movements (conversion)

La histeria moderna: Parte IV: evolución de criterios diagnósticos del trastorno por somatización / The modern hysteria: Part III dissociative disorders and conversion

La conciencia: característica esencial de esta dimensión de autorepresentación es la interpretación de ciertos estados internos del propio cuerpo como identidad mental y somática. La neurociencia de la conciencia sugiere fuertemente que un nivel de sincronización y unión entre varias partes del cerebro hasta cierto punto refleja la accesibilidad de varios contenidos mentales. Janet (1889) propuso el término désagrégation para referirse a los fenómenos de «no integración¼ y lo situó en el terreno de la anormalidad. Trastornos disociativos: en estos trastornos hay pérdida parcial o completa de la integración normal entre ciertos recuerdos del pasado, la conciencia de la propia identidad, ciertas sensaciones inmediatas y el control de los movimientos corporales (conversión)

The conscience: essential feature of this dimension of self-representation is the interpretation of certain internal states of the body itself as mental and somatic identity. The neuroscience of consciousness strongly suggests that a level of synchronization and union between various parts of the brain to some extent reflects the accessibility of various mental contents. Janet (1889) proposed the term désagrégation to refer to the phenomena of "non integration" and placed it in the terrain of abnormality. Dissociative disorders: in these disorders there is partial or complete loss of normal integration between certain memories of the past, awareness of one's own identity, certain immediate sensations and control of bodily movements (conversion)

Postoperative visual loss due to conversion disorder after spine surgery: a case report / Perda visual conversiva em pós-operatório de cirurgia de coluna: relato de caso

Abstract Background and objective Patients undergoing spinal surgeries may develop postoperative visual loss. We present a case of total bilateral visual loss in a patient who, despite having clinical and surgical risk factors for organic lesion, evolved with visual disturbance due to conversion disorder. Case report A male patient, 39 years old, 71 kg, 1.72 m, ASA I, admitted to undergo fusion and discectomy at L4-L5 and L5-S1. Venoclysis, cardioscopy, oximetry, NIBP; induction with remifentanil, propofol and rocuronium; intubation with ETT (8.0 mm) followed by capnography and urinary catheterization for diuresis. Maintenance with full target-controlled intravenous anesthesia. During fixation and laminectomy, the patient developed severe bleeding and hypovolemic shock. After 30 min, hemostasis and hemodynamic stability was achieved with infusion of norepinephrine, volume expansion, and blood products. In the ICU, the patient developed mental confusion, weakness in the limbs, and bilateral visual loss. It was not possible to identify clinical, laboratory or image findings of organic lesion. He evolved with episodes of anxiety, emotional lability, and language impairment; the hypothesis of conversion syndrome with visual component was raised after psychiatric evaluation. The patient had complete resolution of symptoms after visual education and introduction of low doses of antipsychotic, antidepressant, and benzodiazepine. Other symptoms also regressed, and the patient was discharged 12 days after surgery. After 60 days, the patient had no more symptoms. Conclusions Conversion disorders may have different signs and symptoms of non-organic origin,including visual component. It is noteworthy that the occurrence of this type of visual dysfunc-tion in the postoperative period of spinal surgery is a rare event and should be remembered asa differential diagnosis.

Resumo Justificativa e objetivo Pacientes submetidos a procedimentos cirúrgicos espinhais podem evoluir com perda visual pós-operatória. Apresentamos quadro de perda visual bilateral total em paciente que, apesar de apresentar fatores de risco clínicos e cirúrgicos para lesão orgânica, evoluiu com distúrbio visual conversivo. Relato de caso Masculino, 39 anos; 71 kg; 1,72 m; ASA I, admitido para realização de artrodese e discectomia em L4-L5 e L5-S1. Venóclise, cardioscopia, oximetria, PANI; indução com remifentanil, propofol e rocurônio; intubação com TOT 8,0 mm seguida por capnografia e diurese por sondagem vesical. Manutenção em anestesia venosa total alvo-controlada. Durante fixação e laminectomia, evoluiu com importante sangramento e choque hipovolêmico. Após 30 minutos obteve-se hemostasia e estabilidade hemodinâmica com infusão de noradrenalina, expansão volêmica e hemoderivados. Na UTI, evoluiu com confusão mental, fraqueza em membros e perda visual bilateral. Não foi possível identificar achados clínicos, laboratoriais ou de imagem para lesão orgânica. Evoluiu com episódios de ansiedade, labilidade emocional e distúrbio de linguagem; foi aventada hipótese de síndrome conversiva com componente visual após avaliação psiquiátrica. Apresentou melhoria total de sintomas visuais após educação e introdução de baixas doses de antipsicótico, antidepressivo e benzodiazepínico. Houve regressão dos demais sintomas com alta no décimo segundo dia pós-operatório. Encontrava-se assintomático após 60 dias. Conclusões Distúrbios conversivos podem apresentar diversos sinais e sintomas de origem nãoorgânica, incluindo componente visual. Destaca-se que a ocorrência desse tipo de disfunçãovisual no pós-operatório de cirurgias espinhais é evento raro e deve ser lembrado como diag-nóstico diferencial.

Chasing the Chameleon: Psychogenic Paraparesis Responding to Non-Invasive Brain Stimulation

Neurologic symptoms that develop unconsciously and are incompatible with known pathophysiologic mechanisms or anatomic pathways belong to Conversion Disorder (CD). CD diagnosis is based on the clinical history and the exclusion of physical disorders causing significant distress or social and occupational impairment. In a subgroup of CD, called functional weakness (FW), symptoms affecting limbs may be persistent, thus causing a permanent or transient loss of limb function. Physiotherapy, pharmacotherapy, hypnotherapy and repetitive transcranial magnetic stimulation (rTMS) have been proposed as treatment strategies for FW-CD. Herein, we report a 30 year-old male, presenting with lower limb functional paraparesis, having obtained positive, objectively, and stable effects from a prolonged r-TMS protocol associated to a multidisciplinary approach, including psychological and sexuological counseling, and monitored by gait analysis. We postulate that our rTMS protocol, combined with a multidisciplinary approach may be the proper treatment strategy to improve FW-CD.

La histeria clásica y moderna: una visión sinóptica Parte II Diagnóstico / Classic and modern hysteria: a synoptic view. Part II Diagnosis

Todo diagnóstico de un problema descubierto lleva implícito un proceso de análisis y síntesis. Todavía no se ha logrado encontrar una clara definición de la histeria, precisamente por su "psicoplasticidad", es decir, por la infinidad de expresiones clínicas en que se puede presentar. Además su eliminación de los códigos diagnósticos la fragmentó en diversos síndromes o conjuntos sintomáticos. El psicoanálisis, asociado al concepto, fue desperfilado por la psiquiatría americana con el advenimiento de la investigación biológica sobre trastornos mentales y nuevos descubrimientos como los sistemas de neurotransmisores. Quedaron atrás los criterios de Feighner, que abarcaban los diagnósticos de neurosis de ansiedad, neurosis obsesivo-compulsiva, neurosis fóbica, histeria. Se analiza clasificaciones CIE y DSM, en las que se puede rastrear la histeria. Palabras claves: histeria, neurosis, diagnóstico, CIE-10.

Every diagnosis of a discovered problem implies a process of analysis and synthesis. A clear definition of hysteria has not yet been found, precisely because of its "psychoplasticity", that is, by the infinity of clinical expressions in which it can be presented. In addition its elimination of the diagnostic codes fragmented it in diverse syndromes or symptomatic sets. Psychoanalysis, associated with the concept, was unburied by American psychiatry with the advent of biological research on mental disorders and new discoveries such as neurotransmitter systems. Feighner's criteria, which included diagnoses of anxiety neurosis, obsessive-compulsive neurosis, phobic neurosis and hysteria, were left behind. We analyze CIE and DSM classifications, in which hysteria can be traced.

Síndrome do sotaque estrangeiro psicogênico: relato de caso / Psychogenic foreign accent syndrome: a case report

Introdução: A Síndrome do Sotaque Estrangeiro (SSE) é uma alteração da parte central do sistema nervoso, cuja manifestação principal é uma afasia que mimetiza foneticamente o sotaque de determinado idioma. Objetivos: Abordar a manifestação dessa síndrome secundária à causa psicogênica. Casuística e Métodos:Este estudo tratará do relato de caso de Síndrome do Sotaque Estrangeiro psicogênica e irá discutir os contrastes com a Síndrome do Sotaque Estrangeiro clássica. Resultados:A paciente deste relato procurou atendimento de saúde em virtude de cefaleia e se apresentou durante o atendimento com sotaque caracteristicamente hispânico, negando qualquer contato prévio com o idioma. Conclusão: Após inúmeros exames e investigação clínica detalhada, a paciente teve como diagnóstico final SSE psicogênica, secundária a Transtorno Dissociativo Misto, entidade pouco descrita e relatada em arquivos e estudos médicos.

Introduction: The Foreign Accent Syndrome (FAS) is a disturbance at thecentral nervous systemexpressed as an aphasia that imitate phonetically the accent of a determined language. Objective:Approach the secondary manifestation of a psychiatry disorder. Patients and Methods: This study will report a case of a Psychogenicand will discuss the contrasts between the classic Foreign Accent Syndrome. Results:the patient of this study sought medicalattentiondue to a headache. During consultation, the patient started speaking with a Hispanic accent. She denied any previous contact with this idiom. Conclusion: After countlesslab exams and a thorough clinic investigation, the patient was diagnosed with psychogenicForeign Accent Syndromesecondary to Dissociative Mixed Disorder, a little known disease andrarely reported in medical studies.

When a patient falls (asleep) and can't get up: conversion disorder - paraplegia following general anesthesia / Quando um paciente cai (no sono) e não consegue acordar: transtorno conversivo - paraplegia após anestesia geral

Abstract Background and objectives This case report describes the rare occurrence of paraplegia caused by conversion disorder in a woman who received general anesthesia for breast surgery. Case report A 46-year-old healthy woman received general anesthesia for excision of a left breast fibroepithelial lesion. In the post-anesthesia care unit, she reported bilateral loss of both sensation and motor function below the knees. Physical signs and symptoms did not correlate with any anatomical or neurological patterns; imaging revealed no abnormalities. Psychiatric consultation was performed wherein familial stressor circumstances were identified, leading to diagnosis and management of conversion disorder. Conclusion Conversion disorder is characterized by alteration of physical function due to expression of an underlying psychological ailment. Its diagnosis requires thorough evaluation including appropriate workup to exclude organic causes. The meshing together of anesthesiology and psychiatry - as demonstrated by this case report - offers an opportunity to highlight important information pertaining to the definition, diagnosis, and management of conversion disorder as it may be encountered in the postanesthesia recovery period.

Resumo Justificativa e objetivos Descrever a rara ocorrência de paraplegia causada por distúrbio conversivo em uma mulher que recebeu anestesia geral para a cirurgia de mama. Relato de caso Mulher saudável de 46 anos recebeu anestesia geral para excisão de uma lesão fibroepitelial na mama esquerda. Na sala de recuperação pós-anestesia, a paciente relatou perda bilateral de sensibilidade e motricidade abaixo dos joelhos. Os sinais físicos e sintomas não se correlacionavam com qualquer padrão anatômico ou neurológico; exame de imagem não revelou anormalidades. Uma consulta psiquiátrica foi feita e constatou circunstâncias familiares estressantes, o que levou ao diagnóstico e ao tratamento de transtorno conversivo. Conclusão O transtorno conversivo é caracterizado por alteração da função física devido à expressão de uma doença psicológica subjacente. Seu diagnóstico requer uma avaliação minuciosa, incluindo tratamento adequado para excluir causas orgânicas. O entrosamento de anestesiologia e psiquiatria, como demonstrado neste relato de caso, oferece uma oportunidade para destacar as informações importantes relativas à definição, ao diagnóstico e ao manejo do transtorno conversivo, pois esse transtorno pode ser encontrado no período de recuperação pós-anestesia.

Estridor y dificultad respiratoria: aproximación neurológica: caso clínico / Stridor and dyspnea caused by a conversion disorder: a case report

Paradoxical vocal cord motion or vocal cord dysfunction is a descriptive term for an inappropriate adduction of the vocal cords during respiration, which can cause respiratory obstruction and stridor. It is associated with psychiatric conditions in the great majority of cases. We report a 23 year-old high performance female athlete, referred for a recurrent bilateral paralysis of the vocal cords, with a history of four intensive care unit admissions for severe dyspnea and stridor, which were treated several times with intubation and with tracheostomy on two occasions. Myasthenia gravis was suspected and she was treated with pyridostigmine and prednisone. She was discharged but despite the treatment, she presented new episodes of stridor and was readmitted six months later. This time the pharmacological treatment was suspended. The neurological study disclosed a normal brain magnetic resonance, normal cerebrospinal fluid analysis and a normal electromyography. A conversion disorder was suspected and the patient was successfully treated with psychotherapy.

La somatización y conversión en la adolescencia: Un desafío diagnóstico y terapéutico en la consulta / Somatization and conversion in adolescence: A diagnostic and therapeutic challenge in the consultation

El término somatización está muy extendido en el campo de la clínica psicológica y psiquiátrica. Desde el punto de vista nosográfico la somatización y la conversión se encuentran conceptualizadas en el Manual Diagnóstico y Estadístico de las Enfermedades mentales (DSM-IV-TR) dentro de los Trastornos Somatomorfos. Los trastornos Somatomorfos (TS) agrupan diversos cuadros con una característica en común: la presencia de síntomas somáticos vinculados a un malestar psíquico y deterioro significativo, presentándose frecuentemente en niños y adolescentes. Los síntomas se corresponden con dolencias simples hasta cuadros funcionales invalidantes no explicados por una condición médica general, consumo de sustancias, simulación u otra patología mental. La prevalencia de los TS en la adolescencia ha aumentado en las últimas décadas, representando un desafío clínico y terapéutico para el médico por su dificultad clínica y general desconocimiento (AU)

The term somatization is a broad concept in the field of clinical psychology and psychiatry. From the nosographic point of view, somatization and conversion are conceptualized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IVTR) within the somatoform disorders (SD) characterized by the presence of somatic symptoms associated with psychic pain and significant deterioration, often seen in children and adolescents. The symptoms range from simple discomfort to invalidating functional impairment unexplained by the general medical condition, substance abuse, and simulation or any other mental disorder. Prevalence of SD in adolescence has increased over the past decades, becoming a therapeutic and clinical challenge due to clinical difficulties and lack of unawareness of the disorde (AU)

O corpo petrificado: um caso de conversão histérica e mutismo seletivo / The body petrified: a case of hysterical conversion and selective mutism

Um olhar sobre a evolução da psicanálise revela que o corpo sempre foi central para o funcionamento e para o desenvolvimento da mente. A histeria e sua característica definidora, a conversão, são sensíveis às correntes culturais e, em lugares como o Irã, a gama limitada de opções sociais e interpessoais para as mulheres torna tal solução autoplástica ainda possível. Este artigo foca o tratamento psicanalítico de uma jovem mulher iraniana que apresenta conversão histérica e mutismo seletivo. A paciente apresenta-se em uma cadeira de rodas e muda, após um coma prolongado que se sucedeu a uma dramática rejeição por parte um parceiro amoroso. A sua apresentação trouxe à mente ideias de depressão essencial e de narcisismo negativo. O tratamento foi adaptado a partir da Escola Psicossomática de Paris, sendo conduzido por uma psicoterapeuta treinada em psicodinâmica no Irã, supervisionada nos Estados Unidos por uma psicanalista de origens iranianas. No decurso das primeiras dez sessões, a paciente voltou a falar e a se movimentar. O processamento mental da transferência foi encorajado e, até a vigésima terceira sessão, a paciente caminhava. Abordamos a paciente como uma feminista não declarada, cujos sintomas imitavam modos culturalmente aceitáveis de expressar a sua angústia. O nosso objetivo foi recuperar a linguagem perdida que pudesse conectar-lhe a mente ao corpo(AU)

A glance at the evolution of psychoanalysis reveals body to have always been central to the function and development of the mind. Hysteria, and its defining characteristic conversion are responsive to cultural currents and in places like Iran, the limited range of social and interpersonal options for women make such an autoplastic solution still likely. This article details psychoanalytic treatment of a young woman presenting with hysterical conversion and selective mutism in Iran. The patient, who was wheelchair-bound and mute presented after an extended coma following a dramatic rejection by a romantic partner. Her presentation brought to mind notions of essential depression and negative narcissism. Treatment was adapted from the Paris Psychosomatic School and was carried out by a psychodynamically trained female psychotherapist in Iran, supervised by an Iranian- born female psychoanalyst in the United States. Within the first 10 sessions, the patient regained speech and movement. Mentally processing the transference was encouraged and by session-23, the patient walked. We approached the patient as a closet feminist, one whose symptoms mimicked culturally acceptable ways of expressing her distress. Our aim was to recover the lost language that could connect her mind and body(AU)

El cuerpo petrificado: un caso de conversión histérica y mutismo selectivo Una revisión de la evolución del psicoanálisis revela que, para esta teoría, el cuerpo siempre fue central para el funcionamiento y para el desarrollo de la mente. La histeria y su conversión característica y definidora son sensibles a las corrientes culturales y, en lugares como Irán, la gama limitada de opciones sociales e interpersonales para las mujeres hace que aún sea posible dicha solución autoplástica. Este artículo se centra en el tratamiento psicoanalítico de una joven mujer iraní que presentaba conversión histérica y mutismo selectivo. La paciente, en una silla de ruedas y muda, se presentó tras un coma prolongado que sobrevino después del rechazo dramático dirigido a la joven por una pareja amorosa. Su presentación puso sobre el tapete nociones de depresión esencial y de narcisismo negativo. El tratamiento se adaptó de acuerdo a los preceptos de la Escuela Psicosomática de París y lo condujo una psicoterapeuta en psicodinámica en Irán, supervisionada en Estados Unidos por una psicoanalista de origen iraní. En el transcurso de las primeras diez sesiones, la paciente volvió a hablar y a moverse. Se estimuló el procesamiento mental de la transferencia y en la vigésimo tercera sesión la paciente caminaba. Abordamos a la paciente como una feminista no declarada cuyos síntomas imitaban modos culturalmente aceptables de expresar su angustia. Nuestro objetivo fue recuperar el lenguaje perdido que pudiera conectar su mente al cuerpo(AU)

Psychodynamic Psychotherapy for Functional (Psychogenic) Movement Disorders

OBJECTIVE: As the literature for the treatment of functional (psychogenic) movement disorders (FMD) is sparse, we assessed clinical outcomes in patients with FMD who underwent treatment with psychodynamic psychotherapy (PDP). METHODS: A retrospective analysis of the data of patients with FMD who were referred for PDP from 2008−2014 at Emory University Medical Center was performed. RESULTS: Thirty patients were included, mean age at presentation was 50 years (SD 13.9) and majority were female (27/30). Most common movement disorder was involuntary shaking/jerky movements (50%) and tremor (43%). Mean duration of symptoms was 3.2 years and mean number of PDP visits was 4.9. PDP lead to good outcomes in 10, modest in 8, and poor in 9. Three patients lost to follow up. Mean duration of symptoms between two groups (good vs. poor) was not statistically significant (p = 0.11), mean number of PDP visits showed a trend towards significance (p = 0.053). In all cases of good outcomes precipitants of the movement disorder were identified and a majority (60%) was receptive of the diagnosis and had good insight. CONCLUSION: PDP lead to improvement in 60% of the patients which is encouraging as the treatment is challenging. This study supports heterogeneous causes of FMD including varied roles of past/recent events and demonstrates importance of psychological approaches such as PDP. Treatment with PDP should be considered in some patients with FMD but predicting who will respond remains a challenge. Further long term prospective studies with large sample size and placebo control are needed.

Estado actual de los trastornos somatomorfos y conversivos en niños y adolescentes / Current state of somatoform and conversion disorders in children and adolescents

Introducción: Los trastornos somatomorfos (TS) y conversivos (TC) han aumentado su incidencia durante las dos últimas décadas en niños y adolescentes, aunque ambos son habitualmente subdiagnosticados. Objetivo: Efectuar una puesta al día de la evidencia sobre TS y TC en niños y adolescentes. Método: Se realizó una búsqueda bibliográfica mediante las bases de datos Medline/PubMed, SciELO y textos especializados. Resultados: Existe una alta intercurrencia con trastornos afectivos y ansiosos y se han identificado algunos factores de riesgo, especialmente mayor vulnerabilidad al estrés, disfunción familiar, sobreprotección parental y limitada mentalización de los síntomas físicos (alexitimia), que también perpetuan la sintomatología. Desde la perspectiva etiopatogénica se han invocado hipótesis psicodinámicas, psicosomáticas, traumático-ambientales y biológicas. Los pacientes con TS y TC frecuentemente son mujeres, presentan rasgos más introvertidos de personalidad, más eventos vitales estresantes y défictis ejecutivos. Las convulsiones psicógenas no epilépticas se relacionan con más comorbilidades psiquiátricas y peor pronóstico. Las psicoterapias cognitivo-conductual y la hipnoterapia-psicodinámica combinadas con fármacos inhibidores de la recaptura de serotonina han demostrado ser eficaces en el tratamiento. Conclusiones: Los TS y TC en poblaciones infanto juveniles se observan en contextos médicos y psiquiátricos. Su reconocimiento es difícil debido a su etiología multifactorial, la falta de consenso diagnóstico yla escasa experiencia clínica, implicando un verdadero desafío terapéutico, por lo que es indispensable realizar futuras investigaciones en este tópico. Su manejo en la atención primaria parece apropiado, pero en casos más complejos es necesaria su derivación al especialista.

Background: Somatoform (SD) and conversion (CD) disorders have increased their incidence during the last two decades in children and adolescents, although both are currently underdiagnosed. Objective: To review the evidence on SD and CD in children and adolescents. Method: A review ofspecialised textbooks and the available literature in Medline/PubMed and SciELO was made. Results: There is a high intercurrence with affective and anxiety disorders and some riskfactors have been identified, especially higher vulnerability to stress, family disfunction, parental overprotection, and limited mentalization of physical symptoms (alexithymia), which at the same time, perpetuate the symptomatology. From an ethiopathogenicperspective, psychodynamic, psychosomatic, traumatic-environmental and biological hypothesis have been invoked. Patients with SD and CD are frequently females, show more introversive personality features, more stressful life events and executive deficits. Psychogenic non-epileptic seizures are related with more psychiatric co-morbidities and worse outcome. Cognitive-behavioural psychotherapy and psychodynamic-hypnotherapy combined with selective serotonin reuptake inhibitors have been effective. Conclusions: SD and CD in child and adolescent populations have been observed in medical and psychiatric contexts. Their recognition is difficult due to their multifactorial ethiology, the lack of diagnosis consensus and the scarce clinical experience, involving a true therapeutic challenge; therefore, it is imperative to carry out future researches on this issue. Their management in primary care seems suitable, but in more complex cases the referral to the specialist is necessary.