Writers' cramp

By the end of the 19th century theories of central nervous dysfunction to explain all forms of Occupation Neuroses held sway over peripheral (neuromuscular) theories (Paul, 1911). Writers' cramp exemplified the model of an "occupation neurosis" favoured by Gowers (1892) and Oppenheim (1901) who theorised that the disorder is "primarily and essentially central, the result of a deranged action in the centres concerned in the act of writing". They did not assume a separate centre for writing or for any other movement but "only that there are variable lines of resistance in the innumerable connections of the motor cells". The onset of the disorder was caused by a "morbid lowering of resistance" between nerve cells, either through impaired nutrition (for example, due to anxiety, or to fatigue of motor cortical cells induced by excessive writing) or from local disease or injury of the limb thus "deranging the centre". Gowers was often able to trace an "hereditary tendency to nervous affections" in his patients. Those are, again, the concepts of "predisposition" and "commotion". Cramp or spasm (spasmodic form) was attributed by Gowers to the "release of excessive and irregular energy" when the sufferer attempted to write; weakness was due to a deficiency in the total amount of "nerve force" available to the upper limb musculature. This formulation was no different from the constructs of hysteria or neurasthenia, respectively. Specifically, the neuralgic pain (sic) and nerve trunk tenderness (neuralgic form) were explained by assuming a state of sensitisation of sensory centres induced by fatigue. Their persistence reflected a "morbid independence" of these centres. The structural changes in sensory and motor nerves sometimes found in the "occupation neuroses" were explained by Gowers as being reflexly induced: "Such changes, once set up, may develop in relative independence, especially under the reflex influence of pain, and may even induce secondary changes in the irritability and nutrition of the muscles." Oppenheim's concept ran in parallel: "Anatomic alterations have not been found ... a purely functional disorder, an exhaustion neurosis, which has its seat in the centres for co-ordination, in the central apparatus which governs the associative acts of the muscles which are necessary in writing. The centrifugal and sensory excitation which accompany writing, and which are not perceived normally, now become apparent, and evoke a disinclination for writing, and the more attention is directed towards these occurrences, the more severe the spasm becomes." However, in tandem with the substitution of reflex neural activity by dissociation of different neural functions over the 1890 to 1920 period, this concept of response to external stimuli was challenged by concepts of psychogenesis. Williams (1913), an American neurologist, described an occupation neurosis as "ideational in origin" and as a "motor obsession contingent upon the idea of certain situations within or without the body." Successful treatment required that the patient accept this theory and also "abandon any previous belief that the disability is of physical origin whether of muscle, nerve or brain". Dana (1920) defined writers' cramp as "a chronic psychoneurosis characterised by spasmodic, tremulous, inco-ordinate or paralytic disturbance when the act of writing is attempted, associated with feelings of fatigue and pain". Dana also invoked a "neuropathic constitution" and a "hereditary tendency". Meanwhile, in France, Janet (1925) conceptualised the spasmodic form of writers' cramp as "psychasthenic habit-spasm" which, although still somatic, emphasised the importance of deep-seated psychological factors. Taken together with the resolution of the debate over the aetiology of "shell shock" in favour of psychogenic theories, these teachings of Janet had a profound influence upon both neurologists and psychiatrists in the early part of the twentieth century. Physicians in both specialties came to espouse an exclusively psychogenic basis for the Occupation Neuroses (Williams, 1913; Devine, 1929; Culpin, 1931). Between 1920 and 1980 most of the discussion on Occupation Neuroses in the neurology literature was concerned with spasmodic symptomatology, virtually ignoring, or dismissing as of minor importance, complaints of upper limb pain and other sensory phenomena (Wilson, 1955; Gilroy and Meyer, 1975; Brain, 1977). An exception was Walshe (1945), who identified dystonia as the predominant symptom of writers' cramp but also stated: "in some patients pain is prominent from the outset and may remain the predominant symptom throughout, cramp being minimal" and that "in violin and piano players neuralgic or painful forms of occupation neurosis are more common than muscular spasm". Crisp and Moldofsky (1965) studied 7 patients with writers' cramp. Although they could not support a diagnosis of hysteria or neurosis in any of their patients, they found them all to possess "excessive obsessional and dependency characteristics" and to have developed anger, which they found difficult to express, associated with the onset of their writing difficulties. Their anger was attributed to each of the patients having had to write under "frustrating but unavoidable circumstances". These researchers reported a favourable response to psychotherapy. By contrast, Bindman and Tibbetts (1977) also found their patients to be obsessional and in a conflict situation at work over writing but that their symptoms were unresponsive to psychotherapy. By the late 1980s, neurological opinion on the Occupation Neuroses was less dogmatic. According to Adams and Victor (1989):"The nature of these disorders is quite obscure. They have been classed traditionally as 'occupational neuroses' and a psychiatric causation has been suggested repeatedly but careful clinical analysis does not bear this out".

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