SOMATOFORMA SYNDROM SÄRSKILT PSYKOGENA RÖRELSERUBBNINGAR Sven Wiklund Barnneurolog SUS

Flicka 16 år ■Plötslig synnedsättning vid 8 års ålder ■Sjukgymnast kontakt vid 10 års ålder pga avvikande motorik ■Samma år ramlat av sin häst – därefter ville högerbenet inte ” följa ” med. ■Vid 11 års ålder enures + sökt pga andnöd/ hyperventilation ■BUP kontakt vid 13 års ålder Utredning pga markant trötthet, bl.a. Uteslöts narkolepsi Somatoformt syndrom misstänks. Allvarlig mobbing i skolan uppdagas. Psykolog bedömning visar på normal begåvning. NP utredning ua. ■Får krampanfall på barnakut ■14 års ålder så springer hon 400 meter och efter loppet får hon svårt att gå, behöver gåbord och snart rullstol. ■Utvecklar senare fokal dystoni i vänster hand och senare även dystoni i vänster fot ■17,5 års ålder fixerad dystonin i hand och fot. Ärfortsatt rullstols bunden.

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Somatoform disorders ICD 10 F 45 ■The main feature is repeated presentation of physical symptoms together with persistent requests for medical investigations, in spite of repeated negative findings and reassurances by doctors that the symptoms have no physical basis. ■Somatization disorder The main features are multiple, recurrent and frequently changing physical symptoms of at least two years duration. F45.0 ■Undifferentiated somatoform disorder F45.1 ■Hypochondriacal disorder F45.2 ■Somatoform autonomic dysfunction F45.3 ■Persistent somatoform pain disorder F45.4 ■Other somatoform disorders F45.5 Any other disorders of sensation, function and behaviour, not due to physical disorders, which are not mediated through the autonomic nervous system, which are limited to specific systems or parts of the body, and which are closely associated in time with stressful events or problems. ■Somatoform disorder, unspecified F45.9

Somatic Symptom Disorder DSM5 ■Somatic symptom disorder (SSD) is characterized by: ■Somatic symptoms that are either very distressing or result in significant disruption of functioning ■as well as excessive and disproportionate thoughts, feelings and behaviors regarding those symptoms. ■To be diagnosed with SSD, the individual must be persistently symptomatic (typically at least for 6 months). ■SSD diagnosis does not require that the somatic symptoms are medically unexplained.

Fahn och Williams kriterier 1988 ■Documented: persistent relief by psychotherapy, suggestion or placebo has been demonstrated, which may be helped by physiotherapy, or the patient was seen without the movement disorder when believing him- or herself unobserved ■Clinically established: the movement disorder is incongruent with a classical movement disorder or there are inconsistencies in the examination, plus at least one of the following three: other psychogenic signs, multiple somatisations, or an obvious psychiatric disturbance ■Probable: the movement disorder is incongruent or inconsistent with typical movement disorder, or there are psychogenic signs or multiple somatisations ■Possible: evidence of an emotional disturbance.

■Abrupt ■Utlösande faktor – t.ex kroppslig skada ■Når snabbt sitt maxium. ■Stämmer inte med kända sjukdomar ■Distraherbar.La belle indifference. ■Har ofta flera olika typer av rörelse rubbningar. Ofta bisarra. Ofta variationer i amplitud och frekvens.

■När fokus läggs på den affekterade kroppsdelen ökar symtomen ■Ofta påtagliga långsamma rörelser ■Entrainment ■Positivt Hoovers tecken ■Ofta associerad svaghet, känsel bortfall och smärta ■Läkemedel hjälper ej

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■Behandling: sjukgymnastik; psykiatrisk behandling ■Dålig prognos

Diffusion Tensor Imaging – structural connectivity

fMRI – functional connectivity

Effective connectivity

Human Connectome Project A multi-modal parcellation of human cerebral cortex Nature 11 augusti 2016

■The functional brain connectome of the child and autism spectrum disorders Katell Mevel Peter Fransson Acta Pædiatrica. Published by John Wiley & Sons Ltd , pp. 1024–1035 ■Emotional stimuli and motor conversion disorder Valerie Voon et al Brain 2010: 133; 1526–1536