Politics Covid U. News World Opinion Business. Share this —. Follow NBC News. By Meghan Holohan. Due to the various medical complications the course of his illness ended fatally after 1. Three weeks after admission a peculiar phenomenon of strongly clenched fists appeared. As there was no plausible organic cause for this, a psychiatric disorder, clenched fist syndrome CFS , was suggested. In the literature, the nosological status of CFS is unclear.
Clinical medicine very often entails an inherent uncertainty regarding diagnosis, treatment, and prognosis. Although we strive for certainty, we often have to settle for temporary and tentative diagnoses. Thus we feel this report is illustrative of medicine in practice.
Our patient had been a heavy tobacco smoker for several decades and 5 years earlier was diagnosed as having diabetes mellitus type 2. In hindsight, the brain autopsy findings might have contributed to his dysarthric speech, dysphagia, and dizziness, maybe justifying a retrospective diagnosis of pseudobulbar palsy. The intermittent slight lead pipe rigidity of his upper left extremity might be explained either by the vascular changes or by his antipsychotic medication.
It is relevant to ask whether the cerebral lesions could have caused the clenched fists. In considering this question we first have to take into account the various relevant differential diagnoses. The slight increase in muscle tone, described in our case as being lead pipe rigidity, was — as already mentioned — possibly caused by the antipsychotic medication.
However, the clenching of his fists is not a typical extrapyramidal side effect. Our patient had no known physical disease of his hands prior to the clenching of his fists. The onset was abrupt and symmetrical.
The clenching onto the bed rails was most probably motivated by his anxiety. There were no known acute cerebrovascular occurrences prior to the hands clenching. In addition, spasticity following a stroke affecting the upper motor neuron usually takes some days or weeks to develop. Initially, upper motor neuron lesions cause flaccid paresis or paralysis. It is hard to conceive of any of the abovementioned diseases numbers 1—12 , other than the cerebrovascular category number 8 , to start acutely and symmetrically.
Besides, the abovementioned diseases that is, numbers 1—7 and numbers 9—12 , each have their distinctive clinical features that were not present.
In sum, we find it reasonable to consider a psychopathological mechanism the most likely cause. However, the diagnostic work-up of the clenched fists could have been more systematic from the start and throughout the course. This syndrome seems not to have been described in medical or psychiatric literature before E. In Simmons and Vasile published a case series of five patients [ 9 ].
The features were very similar, and it appeared obvious that it was essentially the same entity. Today, CFS seems to be the favored term. There is a variety of psychopathologies affecting the upper extremity. These can be difficult to detect and diagnose correctly. In order to alleviate some of the confusion that can arise, researchers have proposed classifications for these disorders [ 7 , 12 , 13 ].
In , Grunert et al. They put CFS in the third factitious category, that is, finger and hand deformities, although the original publication on the syndrome [ 9 ] emphasized it being a conversion disorder. The two categories — factitious and conversion — are mutually exclusive.
A conversion disorder cannot be a subgroup of the factitious disorders. The third category, finger and hand deformities, was wisely relabeled as psychopathological dystonias, which comprised conversion disorders, factitious disorders, and malingering. In other words, the authors acknowledged conversion as a designation for at least some hand disorders.
As Eldridge and co-authors note, this disorder is unconsciously motivated and unconsciously produced, while factitious disorders are unconsciously motivated, but consciously produced [ 13 ] see Table 1.
This makes good sense in theory. Alas, in clinical practice, the distinction is not always that clear. A factitious disorder cannot be diagnosed with certainty unless the patient admits to having produced the physical sign s , or, alternatively, health personnel have observed this production. Also, it can be hard to find a clear distinction between unconscious and conscious production of symptoms or signs. Apart from the muscular contraction of flexor muscles in CFS, other major features are [ 9 , 10 ]:.
The diagnosis of CFS is — at the time being — typological, that is, based on its similarity to those cases that have been described in the medical literature so far. Although not very experienced with conversion disorders affecting the hand, we concluded that our patient most likely had CFS. He had the characteristic clenched hands compatible with the description of CFS. He had had a physical trauma although not directly to his hands a few weeks earlier when he fell on the floor.
EMG and nerve conduction studies in his upper extremities were normal. All fingers were affected although his thumbs to a lesser degree. The swelling on his left hand was probably caused by repeated blood tests and intravenous infusions administered to several places on his arm. There was no indication that it was self-inflicted. In teenagers there is usually a family conflict [ 3 , 9 ].
Grunert et al. Our patient had for several months been apprehensive about walking up and down staircases. This was understandable as he was dizzy and walked unsteadily. After the fall on the floor a series of events occurred that might have caused his anxiety to increase: the hospitalization, the medical work-up including the noisy and claustrophobic MRI, the hip surgery, the postoperative complications including a short delirious episode, and well-meaning health personnel trying to mobilize him against his will.
From the perspective of an anxious and psychotic person with delusions, hallucinations, and speech problems, it is not hard to imagine that the hospitalization with all its alienating elements could have been a very stressful experience. This might have activated an acute stress reaction, and an equivalent to the flight, fight, or freeze-response. He could not flee. Furthermore, maybe his hands clutching onto the side rails was part of a freeze-response.
As he deteriorated and let go of the side rails, his hands were still clenched. The once adaptive response was no longer adaptive. Why his hands would not open, we cannot easily explain. If this rather short and simple psychodynamic hypothesis has some validity, we might not have to invoke a more complex psychoanalytic explanation assuming a subconscious intrapsychic conflict resulting in the physical symptom, that is, clenched fists, as a symbolic representation of this conflict [ 16 ].
Anyhow, to get a better understanding of the psychological underpinnings, we would have had to wait until he was able to communicate better. Unfortunately, he died before we reached that point.
In Batra et al. Wolfe and associates, does in fact include this disorder in its chapter on factitious disorders, published in [ 19 ]. Interestingly, neither of the two major textbooks in psychiatry mentions CFS in their most up-to-date editions [ 20 , 21 ].
Ours was a complex case, and there was clinical uncertainty. There is still insufficient clinical data on CFS. Further research should strive to gain more knowledge on etiology, pathogenesis, clinical manifestations, and treatment.
Also, the nosological status should be clarified. Should it be labelled a syndrome, a disorder, a reaction, a conversion reaction, a phenomenon, or an entity? In itself, that is an indication of the unresolved nosological status. The medical community will hopefully design studies that can broaden our understanding. We also urge the psychiatric community to disseminate the current knowledge, report on further observations, and collaborate with colleagues from other medical specialties that encounter this or similar disorders.
Koranyi EK. Morbidity and rate of physical illnesses in a psychiatric clinic population. A previous study from UCLA demonstrated that stimulating key areas of the brain can improve memory. Results showed that the volunteers who clenched their right fist when memorizing the list and then clenched their left when recalling the words performed better than all of the other hand-clenching groups. Future research will examine whether hand clenching can also improve other forms of cognition, for example verbal or spatial abilities.
More research is necessary to determine whether their results with word lists extend to memories of visual stimuli, such as remembering faces, or spatial tasks, such as remembering where your keys are. A recent study published earlier this month in the journal Neuron showed that listening to certain types of sounds while a person is sleeping can improve his or her memory.
Blackfishing is a type of interpersonal racism that depicts Black people as stereotypes and portrays Black culture as a product. It ignores the…. So, if you have been experiencing a prolonged period of clenching your fists, you might need to look to see if you are under a high amount of stress. Either way physical exertion, tension, and pain can all express itself directly or indirectly in your hands.
Look to see if there are any recent changes in your lifestyle that could be a contributing factor. If you have increased your physical exertion, make sure you are staying hydrated, as dehydration can cause muscle cramping. Cholesterol medications are known for causing muscle pain and cramping, known as statin-induced muscle pain. This condition is caused by an increase in creatine kinase in the bloodstream and more commonly affects women. Antidepressant medications are also known to cause joint pain and muscle aches.
Epilepsy, rheumatoid arthritis, and schizophrenia have all been linked with causing clenched fists, however these conditions present during the daytime as well as at night. And although bruxism has been tied to sleep apnea, no link has yet been made between sleep apnea and fist clenching. While more studies continue to come forward, there are some steps you can take to try to alleviate your symptoms.
As with any changes in your health, a little detective work can always go a long way.
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