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Camptocormia in a case of manic-depressive disorder
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Camptocormia in a case of manic-depressive disorder E. A. GOMEZ, M.D. • A. S. DROOBY, M.D.
Camptocormia, camptocormy, or camptospasm is a rare disorder that is seldom discussed in the commonly used textbooks of psychiatry, orthopedics, and neurology. It was originally described by Brodie' in 1837 and received its present name from two French neurologists, Souques and Rosanoff-Saloff.' The diagnosis is based on a characteristic bent (kamptos, in Greek) of the trunk (kormos) at an angle of 30 to 70 degrees, such that the head and the trunk are almost parallel to the ground with the arms swinging by the side in a simian fashion. The back is habitually flexed forward although the spine remains flexible with an almost always noticeable compensatory extension of the neck. Military neurologists, psychiatrists, and orthopedic physicians have described the majority of cases during the Balkan Wars' and World Wars I and 11". among French, Italian, English, and American soldiers. Because it was common in military camps, the question subsequently arose as to whether the symptom was psychologically contagious. An article by Rockwood and Eilert' reviewed camptocormia for orthopedists. Only a few civilian cases have been reported. The condition is rare in women, with only four cases in the literature as of 1983.· No prevalence by race seems to be characteristic, and the ages of the patients range between 17 and 35 years. A consistent finding is the occurrence of this condition in soldiers who are not in combat but who anticipate it. Camptocormia is considered a special form of hysteria, seen most often in neurotic soldiers and less frequently in persons with schizophrenia or borderline personality disorders and in compensation cases. Typically this awkward anthropoid posture has its onset after trivial trauma. The differential diagnosis should include malingering, unusual spinal cord neoplasms, vertebral infections, intradural or extradural hematomas, ankyOr. Gomez is professor ofclinical psychiatryand Or. orooby is clinicalassociate professor ofpsychiatry, both at the Baylor College ofMedicine. Reprint requests to Or. Gomez, Department of Psychiatry, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030.
losing spondylitis, spinal stenosis. and. occasionally, herniated disks. The examination of the patient should be thorough, but prolonged test procedures are neither beneficial nor desirable as these may tend to reinforce the patient's belief that the condition is irreversible. Almost invariably the diagnosis is confirmed by the characteristic posture, normal findings on orthopedic and neurologic examinations, and disappearance of the deformity in the recumbent position. We present a case of camptocormia in a patient with manicdepressive disorder.
I Case report This 36-year-old, unmarried, unemployed, and homeless male veteran had a six-year history of psychiatric problems. He is the third of nine children, with a father reportedly prone to cyclic depressions with one or two periods of excitement. The father was described by the patient as a strict disciplinarian, irascible, and ever ready to give a whipping to his son when he misbehaved. The father's early retirement was allegedly the reason for the patient's premature cessation of school at the age of 13, when he had to go out to work. He described his mother as a sickly woman with no time to care properly for the children. The patient had suffered many disappointments and losses in his life, including jobs and a seven-yearlong relationship with a woman who left him for another man. He stated that the only stable period of his life was during military service from age 18 to 21 . The patient had received the diagnosis of paranoid schizophrenia at each of the previous psychiatric hospitalizations. Prior to the last admission, he presented himself to the hospital emergency room with an exaggerated stooped posture and complaining of low back pain, both of which had begun suddenly two weeks earlier after pushing a stalled pickup truck. Lumbosacral spine x-ray films showed no fractures, spondylolisthesis, or narrowing of intervertebral spaces. The patient's overtly psychotic behavior, delusional thinking, irascible manners, and loudness promptly led the admitting officer to refer him to the psychiatric service (continued)
592
PSYCHOSOMATICS
XAN.uelllblets
IMpruolam. fa,
INDICATIONS AND USAGE
Anxiety disorders. short-tenn relief of the symptoms of anxiety. and anxiety associated with depression. Anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic. Effectiveness for more than four months has not been established: periodically reassess the usefulness of the drug for the individual patient
CAS E
REP 0 R T S
CONTRAlNDICATIONS
Patients with sensitivity to this drug or other benzodiazepines and in acute narrow angle glaucoma. WARNINGS
Not of value in psychotic patients. caution patients against hazardous occupations requiring complete mental alertness and about the simultaneous ingestion of alcohol and other CNS depressant drugs. Benzodiazepines can cause fetal hann in pregnant women. Wam patients of the potential hazard to the fetus. Avoid dUring the first trimester PRECAUTIONS
GftmI/: The dosage of XANN< Thblets should be reduced or withdrawn gradually. since witl1drawal seizures have been reported upon abrupt withdrawa!'lf XANA>< is combined with 0ther psychotropics or anticonvulsant drugs. consider drug potentiation lsee Drug Interaction section~ Exercise the usual precautions regarding size of the prescription for depressed or suicidal patients. In elderly and debilitated patients. use the lowest possible dosage (see Dosage and Administrationr Observe the usual precautions in treating patients with impaired renal or hepatic function. l"fotwl4liD" for PGtIftlts: Alert patients about la) consumption of alcohol and drugs. fbI possible fetal abnormalities.IC) operating machinery or driving. ld) not increasing dose of the drug due to risk of dependence. leI not stopping the drug abruptly. LAboralDl1j Tests: Not ordinarily required in otherwise healthy patients. [)ug Inltractions: Additive CNS depressant effects with other psychotropics. anticonvulsants. antihistamines. ethanol and other CNS depressants. Phannacokinetic interactions with other drugs have been reported. Cimetidine can delay clearance of benzodiazepines. [)ug/LAboralDl1j Test Inltractions: No consistent pattem for a drug or test Cartin09tntsis. MUlIIgtntsis.lmpainnent of Fel/i1ity: No carcinogenic potential or impainnent of fertility in rats. Pllgnancy: See Wamings. NonltralDgenic Effects: The child bom of a mother on benzodiazepines may be at some risk. for withdrawal symptoms and neonatal flaccidity LAborand ~illrl1j: No established use. Nursing Mothers: Benzodiazepines are excreted in human milk. Women on XANN< should not nurse Pediatric Use: Safety and effectiveness in children below the age of 18 have not been established. ADVERSE REACTIONS
Side effects are generally observed at the beginning of therapy and usually disappear with continued medication. In the usual patient the most frequent side effects are likely to be an extension of the pharmacologic actiVity ofXANA><. e.g.. drowsiness or lightheadedness. Central nelllOUS sysltm: Drowsiness.lightheadedness. depression. headache. confusion. insomnia. nervousness. syncope. diuiness. akathisia. and tiredness! sleepiness. ~strointtstinal: Dry mouth. constipation. diarrhea. nausea/vomiting. and increased salivation. Cardiovascular. Thchycardia/palpitations. and hypotension. Stnsol1j: Blurred vision. Musculosiftlelll/: Rigidity and tremor CulIIntous: Dermatitis/allergy. Other side effects: Nasal congestion. weilZht gain. and weight loss. Withdrawal seizures have been reported upon rapiadecrease or abrupt discontinuation of XANN<.ISee Precautions.) In addition. the following adverse events have been reported with the use of benzodiazepines: dystonia. irritability. concentration difficulties. anorexia. transient amnesia or memory impainnent loss ofcoordination. fatigue. sedation. slurred speech. jaundice. musculoskeletal weakness. pruritus. diplopia. dysarthria. changes in libido. menstrual irregularities. incontinence and urinary retention. Paradoxical reactions such as stimulation. agitation. increased muscle • spasticity. sleep disturbances. and hallucinations may occur Should these occur discontinue the drug. During prolonged treatment periodic blood counts. urinalysis. and blood chemistry analysis are advisable. Minor EEG changes. of unknown significance. have been observed. DRUG ABUSE AND DEPENDENCE Physical and Psychological DependenCt: Withdrawal symptoms have occurred follow-
ing abrupt discontinuance of benzodiazepines. Withdrawal seizures have occurred upon rapid decrease or abrupt discontinuation of therapy. In all patients. dosage should be gradually tapered under close supervision. Patients with a history of seizures or epilepsy should not be abruptly withdrawn from XANA><. Addiction-prone individlJals should be under careful surveillance. Controlled SubslIInCt Class: XANA>< is a controlled substance and has been assigned to schedule IV OVERDOSAGE
Manifestations include somnolence. confusion. impaired coordination. diminished reflexes and coma. No delayed reactions have been reported. DOSAGE AND ADMINISTRATION
Dosage should be individualized. The usual starting dose is 0.25 to 0.5 mg. ti.d. Maximum total daily dose is 4 mg.ln the elderly or debilitated. the usual starting dose is 0.25 mg. two or three times daily. Reduce dO!'age gradually when tenninating therapy. by no more than 0.5 milligram every three days. HOW SUPPLIED
XANA>< Thblets are available as 0.25 mg. 0.5 mg. and I mg tablets. CAUTION: FEDERAL LAW PROHIBITS DISPENSING WITHOUT PRESCRIPTION. . . . . . . . THE UPIOHN COMPANY . . . . . Kalamazoo. Michigan 49001 USA
B-6-S
1-7751 September 1987
On admission his mental state was characterized by adequate orientation and alertness, overtalkativeness. flight of ideas, and grandiose delusions. (He believed that he had a special relationship with God and the president of the United States.) There were, however, no discordant affect and no loosening of associations, tangentiality or neologisms. Hallucinations were denied. He said that he had been repeatedly diagnosed as "schizophrenic paranoid" and had been placed on various neuroleptics, the last being haloperidol. This was allegedly used with an antiparkinsonian agent for several months. He resented such treatments, which, he knew, were given to mental cases, people unlike himself. He adamantly denied any mental problems and argued that he had a spine injury with swelling of the back. That, according to him, explained his inability to stand upright since the accident. He also complained of overdosage from "government-issued drugs" given in previous hospitalizations. He acknowledged that such treatment caused no back pain or deformity as experienced currently. He said that he had no choice but to take the prescribed drugs lest he receive whippings, like those from his father, for refusal to be treated. Pending the completion of orthopedic and neurologic consultations and the prelithium workup, the patient was given haloperidol. 2 mg po qid, and benztropine, 2 mg po bid. As expected, the consultants reported normal findings in the musculoskeletal and neurologic states, including disappearance of the positional dorsal deformity in the recumbent position. Although some improvement of the irritability, argumentativeness, and loudness was noticed after the administration of haloperidol, the absence of severe extrapyramidal side effects and apparent aggravation of the posture suggested that the patient was probably noncompliant with the prescribed treatment, a fact that was confirmed by the negative urine screen for neuroleptics. The haloperidol was discontinued, as was the benztropine three days later. The diagnosis of schizophrenia was thenceforth deemed inappropriate, and the patient's mental status was considered to reflect clearly a major affective disorder, bipolar type. When the EEG, ECG, and laboratory tests generated normal results, the patient was started on lithium carbonate, 600 mg bid. By the sixth day there was only a trace of flight of ideas and no grandiose thinking, and it became possible to have a conversation without interruptions and contentiousness. Ten days later, an improvement was noticeable in the stooped posture with a decrease in the compensatory neck extension. The patient also conceded partial relief of pain in the back. No analgesics were prescribed. His emotional responses became fully appropriate and exhibited a wider range of expressed feelings, including friendliness. gratefulness, and pertinent sociable smiling.
594
PSYCHOSOMATICS
c
A
s
E
R
During individual counseling sessions, occasional references were made to the significance of his bizarre posture and how it seemed to convey a message of pain, helplessness, and a call for assistance and protection. This was done in conjunction with identification of the role played by psychosocial stressors in his case. Repeated attempts were made to lead the patient to understand the connection between the conversion symptoms, ie, the bizarre posture, and the secondary gains, namely shelter, clothing, food, and medications in a medical ward free of charge. He admitted to having a strong aversion to neuroleptics and great resentment to being seen as a mental patient. Whereas initially he had insistently spoken of his organically injured spine and demanded analgesics and a plaster cast to straighten his back, he eventually conceded that his stooped appearance was significantly related to desires to justify his chronic unemployment and his request for compensation benefits. His father had to retire prematurely after a painfully deforming illness of the back. For two weeks prior to discharge, the patient's posture and gait resumed a normally erect and painless state. This was maintained together with a stable mood during the follow-up visits at monthly intervals for 12 months.
I Discussion Knowledge of this rare presentation appears important because it allows early diagnosis, effective treatment, and disposition. Early detection without recourse to complicated and costly procedures diminishes the possibility that the
E
p
o
R
T
s
symptom may become fixed. In patients with conversion symptoms, satisfactory results have been reported" with the use of suggestion. While still symptomatic, patients are usually unwilling to abandon somatization and the use of body language. Success of treatment may reside in suggestions based on the defensive aspects of the conversion symptom. Later on, if the patient appears amenable to psychotherapy, the psychological conflict can be clarified, confirmed, or interpreted.'· Lazare and Klerman," in particular, suggested a reciprocal relationship between the intensity of depressive affect and the presence of conversion symptoms. Another important aspect of treatment success is recognition of secondary gain and its resolution. In our patient, reassurance was frequently given that he would not be discharged to the streets but to a halfway house of his liking and that we ourselves would continue his follow-up as an outpatient at this facility. The relative diagnostic validity of the criteria for conversion symptoms can be found in Lazare's article." Patients with severe ego defects experience difficulties working through the meaning of conversion by means of insight therapy alone. We believe that patients such as ours need a combination of the therapist-patient relationship with a supportive and sometimes active directive approach that may even incorporate confrontational psychotherapy in tandem with pharmacotherapy. Environmental manipulation may have to be resorted to in order to achieve, if not a resolution of, at least a compromise with the patient's secondary gains. 0
REFERENCES 1. Crainz F: Manuale dl Chirurgia. Rome. Pozzi. 1983. vol 3 2 Souques A. RosanoH-Saloff A: La camptocormie. Rev Neuro128:937 -939. 1915 3. Divry P: Camptocormie post-traumatique. Uege Med 22:585-590. 1929 4. Weiss II: Study of camptocormia with presentation of three post-spinal cases Millt Surg97462-474. 1945 5. Belgrano V. Giordano GB: Sur la camptocormie. Rev Neurol 79:25-35. 1947 6 HurSI AF: The bent backo! soldiers. Br MedJ2:621-623. 1918 7. Rockwood CA. Eilert RE: Camptocormia. J Bone Joint Surg 51 A(3):553-
NOVEMBER 1987· VOL 28· NO II
556.1969 8. Rosen JC. Frymoyer JW: A review of camptocormia and an unusual case in the female Spine 10:325-327. 1983 9. Babinski J. Fromen J: Hysterie-Pithiatisme et Troubles Nerveux d'Ordre Rellexe en Neurologie de Guerre. Paris, Masson & Cie. 1917. 10. Ballenger JC: A case of camptocormia occurring in psychotherapy. J Nerv Ment Dis 162:291-294, 1976. 11. Lazare A. Klerman G: Camptocormia in a female: A five-year study. Br J Med PsychoI43:265-270, 1970. 12. Lazare A: Conversion symptoms. N EnglJ Med305745-748. 1981.
595
A
s
E
R
E
p
o
R
T
s
Camptocormia in a case of manic-depressive disorder E. A. GOMEZ, M.D. • A. S. DROOBY, M.D.
Camptocormia, camptocormy, or camptospasm is a rare disorder that is seldom discussed in the commonly used textbooks of psychiatry, orthopedics, and neurology. It was originally described by Brodie' in 1837 and received its present name from two French neurologists, Souques and Rosanoff-Saloff.' The diagnosis is based on a characteristic bent (kamptos, in Greek) of the trunk (kormos) at an angle of 30 to 70 degrees, such that the head and the trunk are almost parallel to the ground with the arms swinging by the side in a simian fashion. The back is habitually flexed forward although the spine remains flexible with an almost always noticeable compensatory extension of the neck. Military neurologists, psychiatrists, and orthopedic physicians have described the majority of cases during the Balkan Wars' and World Wars I and 11". among French, Italian, English, and American soldiers. Because it was common in military camps, the question subsequently arose as to whether the symptom was psychologically contagious. An article by Rockwood and Eilert' reviewed camptocormia for orthopedists. Only a few civilian cases have been reported. The condition is rare in women, with only four cases in the literature as of 1983.· No prevalence by race seems to be characteristic, and the ages of the patients range between 17 and 35 years. A consistent finding is the occurrence of this condition in soldiers who are not in combat but who anticipate it. Camptocormia is considered a special form of hysteria, seen most often in neurotic soldiers and less frequently in persons with schizophrenia or borderline personality disorders and in compensation cases. Typically this awkward anthropoid posture has its onset after trivial trauma. The differential diagnosis should include malingering, unusual spinal cord neoplasms, vertebral infections, intradural or extradural hematomas, ankyOr. Gomez is professor ofclinical psychiatryand Or. orooby is clinicalassociate professor ofpsychiatry, both at the Baylor College ofMedicine. Reprint requests to Or. Gomez, Department of Psychiatry, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030.
losing spondylitis, spinal stenosis. and. occasionally, herniated disks. The examination of the patient should be thorough, but prolonged test procedures are neither beneficial nor desirable as these may tend to reinforce the patient's belief that the condition is irreversible. Almost invariably the diagnosis is confirmed by the characteristic posture, normal findings on orthopedic and neurologic examinations, and disappearance of the deformity in the recumbent position. We present a case of camptocormia in a patient with manicdepressive disorder.
I Case report This 36-year-old, unmarried, unemployed, and homeless male veteran had a six-year history of psychiatric problems. He is the third of nine children, with a father reportedly prone to cyclic depressions with one or two periods of excitement. The father was described by the patient as a strict disciplinarian, irascible, and ever ready to give a whipping to his son when he misbehaved. The father's early retirement was allegedly the reason for the patient's premature cessation of school at the age of 13, when he had to go out to work. He described his mother as a sickly woman with no time to care properly for the children. The patient had suffered many disappointments and losses in his life, including jobs and a seven-yearlong relationship with a woman who left him for another man. He stated that the only stable period of his life was during military service from age 18 to 21 . The patient had received the diagnosis of paranoid schizophrenia at each of the previous psychiatric hospitalizations. Prior to the last admission, he presented himself to the hospital emergency room with an exaggerated stooped posture and complaining of low back pain, both of which had begun suddenly two weeks earlier after pushing a stalled pickup truck. Lumbosacral spine x-ray films showed no fractures, spondylolisthesis, or narrowing of intervertebral spaces. The patient's overtly psychotic behavior, delusional thinking, irascible manners, and loudness promptly led the admitting officer to refer him to the psychiatric service (continued)
592
PSYCHOSOMATICS
XAN.uelllblets
IMpruolam. fa,
INDICATIONS AND USAGE
Anxiety disorders. short-tenn relief of the symptoms of anxiety. and anxiety associated with depression. Anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic. Effectiveness for more than four months has not been established: periodically reassess the usefulness of the drug for the individual patient
CAS E
REP 0 R T S
CONTRAlNDICATIONS
Patients with sensitivity to this drug or other benzodiazepines and in acute narrow angle glaucoma. WARNINGS
Not of value in psychotic patients. caution patients against hazardous occupations requiring complete mental alertness and about the simultaneous ingestion of alcohol and other CNS depressant drugs. Benzodiazepines can cause fetal hann in pregnant women. Wam patients of the potential hazard to the fetus. Avoid dUring the first trimester PRECAUTIONS
GftmI/: The dosage of XANN< Thblets should be reduced or withdrawn gradually. since witl1drawal seizures have been reported upon abrupt withdrawa!'lf XANA>< is combined with 0ther psychotropics or anticonvulsant drugs. consider drug potentiation lsee Drug Interaction section~ Exercise the usual precautions regarding size of the prescription for depressed or suicidal patients. In elderly and debilitated patients. use the lowest possible dosage (see Dosage and Administrationr Observe the usual precautions in treating patients with impaired renal or hepatic function. l"fotwl4liD" for PGtIftlts: Alert patients about la) consumption of alcohol and drugs. fbI possible fetal abnormalities.IC) operating machinery or driving. ld) not increasing dose of the drug due to risk of dependence. leI not stopping the drug abruptly. LAboralDl1j Tests: Not ordinarily required in otherwise healthy patients. [)ug Inltractions: Additive CNS depressant effects with other psychotropics. anticonvulsants. antihistamines. ethanol and other CNS depressants. Phannacokinetic interactions with other drugs have been reported. Cimetidine can delay clearance of benzodiazepines. [)ug/LAboralDl1j Test Inltractions: No consistent pattem for a drug or test Cartin09tntsis. MUlIIgtntsis.lmpainnent of Fel/i1ity: No carcinogenic potential or impainnent of fertility in rats. Pllgnancy: See Wamings. NonltralDgenic Effects: The child bom of a mother on benzodiazepines may be at some risk. for withdrawal symptoms and neonatal flaccidity LAborand ~illrl1j: No established use. Nursing Mothers: Benzodiazepines are excreted in human milk. Women on XANN< should not nurse Pediatric Use: Safety and effectiveness in children below the age of 18 have not been established. ADVERSE REACTIONS
Side effects are generally observed at the beginning of therapy and usually disappear with continued medication. In the usual patient the most frequent side effects are likely to be an extension of the pharmacologic actiVity ofXANA><. e.g.. drowsiness or lightheadedness. Central nelllOUS sysltm: Drowsiness.lightheadedness. depression. headache. confusion. insomnia. nervousness. syncope. diuiness. akathisia. and tiredness! sleepiness. ~strointtstinal: Dry mouth. constipation. diarrhea. nausea/vomiting. and increased salivation. Cardiovascular. Thchycardia/palpitations. and hypotension. Stnsol1j: Blurred vision. Musculosiftlelll/: Rigidity and tremor CulIIntous: Dermatitis/allergy. Other side effects: Nasal congestion. weilZht gain. and weight loss. Withdrawal seizures have been reported upon rapiadecrease or abrupt discontinuation of XANN<.ISee Precautions.) In addition. the following adverse events have been reported with the use of benzodiazepines: dystonia. irritability. concentration difficulties. anorexia. transient amnesia or memory impainnent loss ofcoordination. fatigue. sedation. slurred speech. jaundice. musculoskeletal weakness. pruritus. diplopia. dysarthria. changes in libido. menstrual irregularities. incontinence and urinary retention. Paradoxical reactions such as stimulation. agitation. increased muscle • spasticity. sleep disturbances. and hallucinations may occur Should these occur discontinue the drug. During prolonged treatment periodic blood counts. urinalysis. and blood chemistry analysis are advisable. Minor EEG changes. of unknown significance. have been observed. DRUG ABUSE AND DEPENDENCE Physical and Psychological DependenCt: Withdrawal symptoms have occurred follow-
ing abrupt discontinuance of benzodiazepines. Withdrawal seizures have occurred upon rapid decrease or abrupt discontinuation of therapy. In all patients. dosage should be gradually tapered under close supervision. Patients with a history of seizures or epilepsy should not be abruptly withdrawn from XANA><. Addiction-prone individlJals should be under careful surveillance. Controlled SubslIInCt Class: XANA>< is a controlled substance and has been assigned to schedule IV OVERDOSAGE
Manifestations include somnolence. confusion. impaired coordination. diminished reflexes and coma. No delayed reactions have been reported. DOSAGE AND ADMINISTRATION
Dosage should be individualized. The usual starting dose is 0.25 to 0.5 mg. ti.d. Maximum total daily dose is 4 mg.ln the elderly or debilitated. the usual starting dose is 0.25 mg. two or three times daily. Reduce dO!'age gradually when tenninating therapy. by no more than 0.5 milligram every three days. HOW SUPPLIED
XANA>< Thblets are available as 0.25 mg. 0.5 mg. and I mg tablets. CAUTION: FEDERAL LAW PROHIBITS DISPENSING WITHOUT PRESCRIPTION. . . . . . . . THE UPIOHN COMPANY . . . . . Kalamazoo. Michigan 49001 USA
B-6-S
1-7751 September 1987
On admission his mental state was characterized by adequate orientation and alertness, overtalkativeness. flight of ideas, and grandiose delusions. (He believed that he had a special relationship with God and the president of the United States.) There were, however, no discordant affect and no loosening of associations, tangentiality or neologisms. Hallucinations were denied. He said that he had been repeatedly diagnosed as "schizophrenic paranoid" and had been placed on various neuroleptics, the last being haloperidol. This was allegedly used with an antiparkinsonian agent for several months. He resented such treatments, which, he knew, were given to mental cases, people unlike himself. He adamantly denied any mental problems and argued that he had a spine injury with swelling of the back. That, according to him, explained his inability to stand upright since the accident. He also complained of overdosage from "government-issued drugs" given in previous hospitalizations. He acknowledged that such treatment caused no back pain or deformity as experienced currently. He said that he had no choice but to take the prescribed drugs lest he receive whippings, like those from his father, for refusal to be treated. Pending the completion of orthopedic and neurologic consultations and the prelithium workup, the patient was given haloperidol. 2 mg po qid, and benztropine, 2 mg po bid. As expected, the consultants reported normal findings in the musculoskeletal and neurologic states, including disappearance of the positional dorsal deformity in the recumbent position. Although some improvement of the irritability, argumentativeness, and loudness was noticed after the administration of haloperidol, the absence of severe extrapyramidal side effects and apparent aggravation of the posture suggested that the patient was probably noncompliant with the prescribed treatment, a fact that was confirmed by the negative urine screen for neuroleptics. The haloperidol was discontinued, as was the benztropine three days later. The diagnosis of schizophrenia was thenceforth deemed inappropriate, and the patient's mental status was considered to reflect clearly a major affective disorder, bipolar type. When the EEG, ECG, and laboratory tests generated normal results, the patient was started on lithium carbonate, 600 mg bid. By the sixth day there was only a trace of flight of ideas and no grandiose thinking, and it became possible to have a conversation without interruptions and contentiousness. Ten days later, an improvement was noticeable in the stooped posture with a decrease in the compensatory neck extension. The patient also conceded partial relief of pain in the back. No analgesics were prescribed. His emotional responses became fully appropriate and exhibited a wider range of expressed feelings, including friendliness. gratefulness, and pertinent sociable smiling.
594
PSYCHOSOMATICS
c
A
s
E
R
During individual counseling sessions, occasional references were made to the significance of his bizarre posture and how it seemed to convey a message of pain, helplessness, and a call for assistance and protection. This was done in conjunction with identification of the role played by psychosocial stressors in his case. Repeated attempts were made to lead the patient to understand the connection between the conversion symptoms, ie, the bizarre posture, and the secondary gains, namely shelter, clothing, food, and medications in a medical ward free of charge. He admitted to having a strong aversion to neuroleptics and great resentment to being seen as a mental patient. Whereas initially he had insistently spoken of his organically injured spine and demanded analgesics and a plaster cast to straighten his back, he eventually conceded that his stooped appearance was significantly related to desires to justify his chronic unemployment and his request for compensation benefits. His father had to retire prematurely after a painfully deforming illness of the back. For two weeks prior to discharge, the patient's posture and gait resumed a normally erect and painless state. This was maintained together with a stable mood during the follow-up visits at monthly intervals for 12 months.
I Discussion Knowledge of this rare presentation appears important because it allows early diagnosis, effective treatment, and disposition. Early detection without recourse to complicated and costly procedures diminishes the possibility that the
E
p
o
R
T
s
symptom may become fixed. In patients with conversion symptoms, satisfactory results have been reported" with the use of suggestion. While still symptomatic, patients are usually unwilling to abandon somatization and the use of body language. Success of treatment may reside in suggestions based on the defensive aspects of the conversion symptom. Later on, if the patient appears amenable to psychotherapy, the psychological conflict can be clarified, confirmed, or interpreted.'· Lazare and Klerman," in particular, suggested a reciprocal relationship between the intensity of depressive affect and the presence of conversion symptoms. Another important aspect of treatment success is recognition of secondary gain and its resolution. In our patient, reassurance was frequently given that he would not be discharged to the streets but to a halfway house of his liking and that we ourselves would continue his follow-up as an outpatient at this facility. The relative diagnostic validity of the criteria for conversion symptoms can be found in Lazare's article." Patients with severe ego defects experience difficulties working through the meaning of conversion by means of insight therapy alone. We believe that patients such as ours need a combination of the therapist-patient relationship with a supportive and sometimes active directive approach that may even incorporate confrontational psychotherapy in tandem with pharmacotherapy. Environmental manipulation may have to be resorted to in order to achieve, if not a resolution of, at least a compromise with the patient's secondary gains. 0
REFERENCES 1. Crainz F: Manuale dl Chirurgia. Rome. Pozzi. 1983. vol 3 2 Souques A. RosanoH-Saloff A: La camptocormie. Rev Neuro128:937 -939. 1915 3. Divry P: Camptocormie post-traumatique. Uege Med 22:585-590. 1929 4. Weiss II: Study of camptocormia with presentation of three post-spinal cases Millt Surg97462-474. 1945 5. Belgrano V. Giordano GB: Sur la camptocormie. Rev Neurol 79:25-35. 1947 6 HurSI AF: The bent backo! soldiers. Br MedJ2:621-623. 1918 7. Rockwood CA. Eilert RE: Camptocormia. J Bone Joint Surg 51 A(3):553-
NOVEMBER 1987· VOL 28· NO II
556.1969 8. Rosen JC. Frymoyer JW: A review of camptocormia and an unusual case in the female Spine 10:325-327. 1983 9. Babinski J. Fromen J: Hysterie-Pithiatisme et Troubles Nerveux d'Ordre Rellexe en Neurologie de Guerre. Paris, Masson & Cie. 1917. 10. Ballenger JC: A case of camptocormia occurring in psychotherapy. J Nerv Ment Dis 162:291-294, 1976. 11. Lazare A. Klerman G: Camptocormia in a female: A five-year study. Br J Med PsychoI43:265-270, 1970. 12. Lazare A: Conversion symptoms. N EnglJ Med305745-748. 1981.
595