Occupation Neurosis

During the 19th century there was increasing awareness that upper limb pain syndromes could result from a variety of occupations involving repetitive use of the upper limb (Fry, 1986; Quintner, 1991). Some patients presented a clinical picture similar to those whose pain syndrome had persisted after acute traumatic episodes (Schuster, 1908). As will be discussed in the following section, conditions previously known as "cramps" or "palsies" of various occupations (Reynolds, 1872) were subsumed by the "neurosis" construct. As with the constructs of "traumatic neurosis" and "shell shock", the recognition of psychosocial factors in the pathogenesis of "occupation neurosis" lead to the abandonment from consideration of any organic contribution at all. The occupation neuroses Definition The English neurologist William Gowers (1892) used the term "Occupation Neuroses" as a "convenient designation for a group of maladies in which certain symptoms are excited by the attempt to perform some often-repeated muscular action, commonly one that is involved in the occupation of the sufferer". He adopted this classification from the German "Beschdftigungs-neurosen" which implied a neurogenic basis for symptoms despite the absence of a demonstrable organic lesion within the nervous system (Cassirer, 1908). Clinical features and "differential diagnosis" The commonest symptom was painless muscle spasm which prevented the performance of the particular activity. Less common was tremor or weakness, especially related to activity. Sensory symptoms (pain in the muscles, bones and joints, or neuralgia) could accompany the spasm or be the sole cause of occupational difficulties. Eventually these symptoms could appear whenever the sufferer attempted to perform tasks outside of his or her occupation. Tremor alone however was rarely the sole cause of writing difficulty. These clinical features of the Occupation Neuroses, as outlined by Gowers, did not differ appreciably from the account of these disorders given by his contemporary neurologists in Germany (Oppenheim, 1901; Cassirer, 1906), or America (Walton, 1907; Paul, 1911; Dana, 1912). By 1912, the Occupation Neuroses proper had been classified into spastic, paralytic, tremor-like, neuralgic and mixed forms (Patrick and Bassoe, 1913). Some authors had difficulty distinguishing "hysteric" from "neurasthenic" tremor, especially as hysteria and neurasthenia frequently could be found in conjunction with writers' cramp. The "differential diagnosis" included organic neurological diseases of the brain and spinal cord, hereditary tremors as well as tremors due to alcohol and tobacco, tics and chorea, the occupational neuritides, vasomotor neuroses (possibly carpal tunnel syndrome) and localised musculo-skeletal conditions (Patrick and Bassoe, 1912). In this situation, the tautology of the construct threatened its failure. Evolution of proposed pathogenesis of occupation neurosis Two concurrent themes remained intertwined throughout this period: central neurological disturbance and psychological abnormality. Writers' and telegraphists' cramp - the "prototype" occupation neuroses - will be discussed to illustrate these themes. Although the possible importance of peripheral neuro-muscular dysfunction was largely neglected by neurologists and psychiatrists (Paul, 1911), this theme was taken up in the rheumatology literature.

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