Camptocormia - another disease blamed on conversion disorder

[Art Vandelay]

Recently, I randomly came across yet another poorly understood disease that was once blamed on psychogenic factors:

Camptocormia

Camptocormia, also known as bent spine syndrome (BSS), is a symptom of a multitude of diseases that is most commonly seen in the elderly. It is identified by an abnormal thoracolumbar spinal flexion, which is a forward bending of the lower joints of the spine, occurring in a standing position.

When the disorder was first clinically studied around the time of First World War, it was believed to be a psychogenic conversion disorder that resulted from the severe trauma of war. Souques and others treated patients with psychological therapy and early versions of electrotherapy. Samuel A. Sandler used a similar approach to treat soldiers during the Second World War. The view of BSS as a conversion disorder led to a lack of awareness about the conditions and few diagnoses by physicians.

As time progressed and advances were made in knowledge of neuroscience and physiology, biological mechanisms behind the irregular bending were identified. The current medically preferred term for the condition is bent spine syndrome, because of the psychological origin associated with camptocormia.

I wonder which branch of pseudo-scientific nonsense peddled by charlatans just after WWI brought this about...

 

[Hubris]

Do we have a comprehensive list of these somewhere? Should probably add it there.

How nice would it be to have a mega class action lawsuit against doctors for the harm they've caused patients through psychologizing illness? Don't know how realistic it is though.

 

[Jonathan Edwards]

I have written a paper on Camptocormia in the past, having studied a case in an elderly woman.

I don't think the article is very accurate and I don't think we should dismiss the very likely explanation that during WWI camptocormia was a manifestation of post-traumatic stress disorder. If you had been to the trenches and had all your friends blown to bits around you , you might well end up with a psychiatric disorder that included this, just as soldiers developed tremors or inability to speak.

Camptocormia as seen nowadays is in fact due to failure to contract the hip extensors - the gluteal muscles. The lumbar spine does not flex a huge amount anyway. In camptocormia the person is more or less bent at right angles at the hips so that the whole body is horizontal. It occurs in the elderly with gluteal muscle wasting although I could not find evidence about whether that was primary or secondary. It is not due to generalised muscle weakness and does not occur in polymyositis or genetic myopathies as far as I know. Apparently significant numbers of servicemen in WWI developed a grossly bent posture. It is virtually never seen in young men now. I am not sure that their posture was the same as seen nowadays and from photographs looks to have included spinal rather than just hip flexion. It may well have been a quite different condition. I think PTSD or something similar is a very likely basis.

 

[Hubris]

I have written a paper on Camptocormia in the past, having studied a case in an elderly woman.

I don't think the article is very accurate and I don't think we should dismiss the very likely explanation that during WWI camptocormia was a manifestation of post-traumatic stress disorder. If you had been to the trenches and had all your friends blown to bits around you , you might well end up with a psychiatric disorder that included this, just as soldiers developed tremors or inability to speak.

Camptocormia as seen nowadays is in fact due to failure to contract the hip extensors - the gluteal muscles. The lumbar spine does not flex a huge amount anyway. In camptocormia the person is more or less bent at right angles at the hips so that the whole body is horizontal. It occurs in the elderly with gluteal muscle wasting although I could not find evidence about whether that was primary or secondary. It is not due to generalised muscle weakness and does not occur in polymyositis or genetic myopathies as far as I know. Apparently significant numbers of servicemen in WWI developed a grossly bent posture. It is virtually never seen in young men now. I am not sure that their posture was the same as seen nowadays and from photographs looks to have included spinal rather than just hip flexion. It may well have been a quite different condition. I think PTSD or something similar is a very likely basis.

How does PTSD relate to posture? I don't get it. Plenty of people have PTSD nowadays and none of them have this posture problem as far as I can tell? Is it because soldiers were often ducking in the trenches?

 

[Hutan]

(I don't know what article is being discussed here.)

I've read some of my grandfather's diaries, including one covering time in the Somme in WW1. He didn't write about anything that sounds like conversion disorder, but he did comment a few times about how shells would cause outcomes that sound like concussion (as well as death and obvious injuries, of course). The thing is, people were ok to start with despite the awful conditions and stressful events not involving an explosion very near them, then after a particular shelling, they wouldn't be. I suspect more of the incidents of lasting confusion and inability to speak were related to brain damage than emotional trauma. There's a lot of evidence now that explosions that cause people to be knocked off their feet can easily cause traumatic brain injury.

As far as the camptocormia goes, I'm pretty sceptical about that too. I think it's a whole lot more likely to have mostly been a fad that seemed to be successful in getting soldiers who had had more than enough out of the hell of the frontline. Perhaps that is why the phenomenon was eventually treated with repeated electric shocks until the soldiers gave up their symptoms and went back to the battlefield.

Camptocormia in an Adolescent: A Case Report and Review of the Literature 2018

Souques treated these patients with persuasive electroshock therapy or “torpillage.” This was not the ECT of today; it consisted of administering painful faradic and galvanic shocks repeatedly until the soldiers gave up their symptoms and returned to the battlefield. Some regarded this as simple torture. In the relative peace following WWI, camptocormia was rarely seen but reemerged during WWII [4].

In the twenty-five years following World War II, the condition was rarely discussed in the medical literature. Beginning in the 1960s, scattered reports appeared, initially describing camptocormia as a psychogenic illness. In 1965 an influential paper by Eric Slater disparaged the concept of psychosomatic illness. It was his view that many patients had underlying organic disorders which were not yet diagnosed (“the diagnosis of ‘hysteria' is a disguise for ignorance and a fertile source of clinical error”) [5].

Since 2005, only two cases of psychological camptocormia have been reported in PubMed. Bayazit et al. and Skidmore et al. described it in patients with schizophrenia and bipolar disease, respectively. [10, 11]. It is important to note, however, that the diagnosis in these cases may be confounded as both patients were also on classes of psychoactive drugs known to cause camptocormia.

Psychogenic camptocormia was most often described in male soldiers involved in stressful conflict. Depression has also been suggested as a possible etiologic factor. [12]. Massa described camptocormia in a patient with underlying depression whose symptoms resolved with psychotherapy and amitriptyline. The first reports of women with the disease were not until 1961. Domestic abuse may have contributed to the disorder in some patients. Children and adolescents have rarely been affected. In 2000 Pfeiffer and von Moers reported the first case in an individual under 17 years of age, occurring in a 13-year-old boy. The authors felt this was due to his traumatic immigration away from his birthplace and hinted at severe parental violence and conflict [13]. Several years later, Rajmohan 2004 described the ailment in a 15-year-old girl with oppositional defiant disorder and borderline mental retardation. They noted the patient was receiving secondary benefits, that is, constant reassuring parental attention and care [14].

That article then goes on to talk about FNDs, saying all of the usual things...

Psychogenic camptocormia may also be regarded as a member of the Functional Movement Disorder group or a Conversion Disorder. Utilizing this concept, while our patient's particular manifestation of “camptocormia'” is unusual, FMD and conversion reactions are far more common. The American Psychiatric Association estimates that “Somatic Symptom Disorder” affects 5-7% of the population, including children. Females are more often affected than males. Physical and sexual violence may be an important factor in women who manifest somatic symptoms and illness [17].

Another paper: Camptocormia 2018

We reviewed medical records of all adult patients evaluated at Mayo Clinic Rochester with a diagnosis of camptocormia from 2000 to 2014.

48.2% were put down to neuromuscular and musculoskeletal disorders; 41.3% were CNS and neurodegenerative disease; 6.2% were miscellaneous/rare; 2.5% were immune mediated; 1.8% were drug induced. Of the 276 people, only two were regarded as having the symptoms as a result of conversion disorder. It doesn't seem to be very common, even if the diagnosis of the two is right.

Of course 'humans are odd', and perhaps it's true that people do walk around bent over simply because they have suffered some sort of trauma.
But I think, in the case of those two Mayo Clinic patients out of the 276, it's more likely that 'humans are fallible', and the doctors have missed some physical cause, perhaps something that they don't yet have the capability to identify.

In any case, given that the harm of telling someone effectively that it's all in their heads when it isn't, and the poor performance of treatments for FND, isn't it kinder to say 'we don't know what is causing your disability, perhaps it will come right with time'? And, if the doctor has identified some past trauma that they think might be causing problems for the person in the present, suggesting counselling, but without linking the two or suggesting that counselling will fix the physical problem?

 

[JemPD]

They noted the patient was receiving secondary benefits, that is, constant reassuring parental attention and care [14].my god what criminals these parents are, reassuring their child, caring for them.... how utterly terrible! Lock em up i say!

 

[Jonathan Edwards]

As far as the camptocormia goes, I'm pretty sceptical about that too. I think it's a whole lot more likely to have mostly been a fad that seemed to be successful in getting soldiers who had had more than enough out of the hell of the frontline. Perhaps that is why the phenomenon was eventually treated with repeated electric shocks until the soldiers gave up their symptoms and went back to the battlefield.

That is certainly another way of analysing it. But if you were as terrified as people had a right to be I think it may become hard to draw a line between a 'fad' and something that people found taking over them. You could call it malingering but if you are being expected to return to a likely horrible death malingering starts to be a doubtful concept.

Head injuries are common enough nowadays and they do not produce camptocormia as far as I know.

It is probably better to forget the term altogether since there is unlikely to be much in common with recent cases and the syndrome that led to the name.

 

[Hutan]

Head injuries are common enough nowadays and they do not produce camptocormia as far as I know.

My comment about shell shock was just in relation to the mention of physical manifestations of PTSD. I suspect a lot of what was termed 'neurasthenia' after World War 1 had a fair bit to do with brain damage.

That is certainly another way of analysing it. But if you were as terrified as people had a right to be I think it may become hard to draw a line between a 'fad' and something that people found taking over them. You could call it malingering but if you are being expected to return to a likely horrible death malingering starts to be a doubtful concept.

I agree that 'faking it to avoid being sent back to near certain death' could possibly morph into something less voluntary. I personally wouldn't call it malingering, either way.

 

[CRG]

It is probably better to forget the term altogether since there is unlikely to be much in common with recent cases and the syndrome that led to the name.

There are just too many variables affecting WW1 populations. One element that can't be discounted in any postural condition in 1914-18 is dietary insufficiency so that even in young adults osteomalacia & osteoporosis become relevant as does osteoarthritis where spinal damage sets in from prolonged mechanical stresses which ordinary soldiers were regularly subject to.

 

[Jonathan Edwards]

There are just too many variables affecting WW1 populations. One element that can't be discounted in any postural condition in 1914-18 is dietary insufficiency so that even in young adults osteomalacia & osteoporosis become relevant as does osteoarthritis where spinal damage sets in from prolonged mechanical stresses which ordinary soldiers were regularly subject to.

I don't really buy that. These are soldiers considered fit to fight in the first place. Certainly in those days people were stunted and had chest disease but they probably got better nutrition in the army than they had before. Osteoarthritis doesn't really exist as a disease. Spinal disc disease, which could well have been a problem, is often lumped in with it but doesn't produce camptocormia. I have assessed thousands of people with spinal disc disease and none had camptocormia. The only case I did see was an eighty year old woman and, as I said, the problem was actually in the glutei. The spine was not painful. You could not maintain the posture of camptocormia with dic pain.

 

[Hubris]

I don't really buy that. These are soldiers considered fit to fight in the first place. Certainly in those days people were stunted and had chest disease but they probably got better nutrition in the army than they had before. Osteoarthritis doesn't really exist as a disease. Spinal disc disease, which could well have been a problem, is often lumped in with it but doesn't produce camptocormia. I have assessed thousands of people with spinal disc disease and none had camptocormia. The only case I did see was an eighty year old woman and, as I said, the problem was actually in the glutei. The spine was not painful. You could not maintain the posture of camptocormia with dic pain.

Off topic but out of curiosity, roughly how many people did you see during your practice that most definitely had ME?

 

[Jonathan Edwards]

Off topic but out of curiosity, roughly how many people did you see during your practice that most definitely had ME?

I can think of one, or maybe two, over thirty odd years.

It is an interesting question. I have to assume that in general PWME are not referred to rheumatologists. On the other hand my paediatric and adolescent service colleagues saw a lot - but they were part of the regional Great Ormond Street service.

The other thing is that one of my colleagues had an interest in disorders thought to have a psychological component so he may have had all the referrals. Later on in my practice I saw a relatively high proportion of people with rheumatoid arthritis although I still saw general problems like frozen shoulder and back pain.

 

[SNT Gatchaman]

I couldn't find references to this as being a common finding in subsequent wars. Vietnam, Iraq, Afghanistan have all lasted longer than WW1 and WW2. That suggests something different about the environments. Perhaps as Hutan said it was the frequent artillery bombardment, more than the IEDs and small arms fire that were more common in the later conflicts.

Also, I wonder whether it was more common for the soldiers to be flexed while moving in the trench warfare of muddy fields, rather than fully prone or semi-hunkered, but then moving more upright in jungle/urban/desert environments.



There were conflicting views in 1990.

Camptocormia (1990, Br J Psych) said —

Camptocormia is a rare conversion syndrome found mainly in soldiers from World War I and II. No case has been reported since, but this paper reports the syndrome in a former soldier of the Nicaraguan army. It is characterised by severe frontal flexion of the spinal cord and knees, with passive dropping of both arms, and sometimes behavioural abnormalities.

Camptocormia (1990, Military Med) said —

Camptocormia is a disabling psychiatric condition characterized by a fixed flexion of the spine usually occurring dining[sic] the stress or anticipation of battle. We present an illustrative case study and a summary of six cases. In this clinical sample the camptocormia was associated with a high likelihood of a history of significant back trauma; this lends to difficulty in assigning a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). Camptocormic patients retained in the military have a poor prognosis; rapid diagnosis and medical separation is recommended.

 

[Hutan]

There were also a range of poison gases used in WW1, often in different combinations, along with poor nutrition and other factors. The poisons, which were typically delivered in glass vials in the shells, probably also contributed to temporary and longer term psychiatric symptoms caused by physiological damage. Given that drugs are known to cause non-psychogenic camptocormia, it doesn't seem impossible that there was an environmental contribution to the phenomenon, at least for some of the soldiers affected and at least temporarily.

I've just found a letter written in response to a journal article about camptocormia in war - 2003

"
The article by Umapathi et al1 in this journal referred to the original use of the term camp-tocormia by Souques in 1915,2 though functional bent back was first described by Brodie in 1837. Mlle Rosanoff-Saloff supported Souques’ case study with a photographic record of this soldier’s bent back and his recovery. According to the English translation abstract in Southard’s fine collection of shell shock cases3 this soldier was wounded five months previously by a bullet that entered along the auxiliary border of the scapula and emerged near the spine. “He spat blood for several days ... and when he got up his trunk and thighs were found to be in a state of moderate flex- ion upon the pelvis, the trunk being bent almost at a right angle.” He was able to bend his trunk still further forward than ‘its habitual contractured position’ and it was evident that there was contraction of the muscles of the abdominal wall and of the iliopsoas. “No motor, sensory, reflex, trophic, vasomotor, electrical, visceral or X-ray disorders could be found.” The application of plaster corsets ‘cured’ this man’s deformity within six weeks.

The poilus spoke of this condition as cintrage (arching), suggesting that it was not an uncommon affliction of the French soldier. Seemingly only recorded by French neurologists, Roussy and Lhermitte reported two subsequent cases.3 An infantryman was thrown into the air by the bursting of a shell, rendered unconscious and recovered experiencing violent pains in the back. He remained stooped to the right. His bent back was corrected by the application of plaster corsets.

The other reported case was that of a chasseur who was buried in an explosion, knocked unconscious, and experienced acute respiratory distress, and subsequent mutism and camptocormia. One séance of electrical treatment corrected the improper attitude of the trunk, though he did continue to experience “a few persistent lumbar pains”.

It would be difficult to doubt the probability that psychological factors influenced these men’s recuperation. To describe these soldiers as hysterical,1 though this was the terminology used during this period, or indeed that they suffered functional bent back, is probably unfair. They may well have suffered acute traumatic spinal injury and reactive muscle spasm (and contractures). Persistent stooping in shallow trenches, in appalling conditions of deprivation and danger, may have been contributing factors weakening the tone of paraspinal muscles. However, these case reports suggest that the
traumatic injury alone may be sufficient explanation for the bent spines. The management of camptocormia in the first world war was to provide biomechanical supports, such as corsets, apparently with good results. The psychological therapies of “persuasive re-education” were additive rather than pivotal, and faradisation (and other tortures) used only “if necessary”.

The Sandler triad of low self esteem with confusion of identity, sadomasochistic behaviour toward military authorities, and impotence4 were, in 1947, proposed as being an essential part of camptocormia. Umapathi’s1 recognised causes of campto-cormia and the contributing factors however implicate organicity, as indeed do the original case reports.
A D Macleod, Psychiatric Consultation Service, Christchurch Hospital, New Zealand
"

That letter makes me think that psychosomatic camptocormia is just another in the long line of so-called functional diseases, where the incidence is way over-stated, and where facts have not been allowed to get in the way of a belief-confirming story.

 

[CRG]

I don't really buy that. These are soldiers considered fit to fight in the first place. Certainly in those days people were stunted and had chest disease but they probably got better nutrition in the army than they had before. Osteoarthritis doesn't really exist as a disease. Spinal disc disease, which could well have been a problem, is often lumped in with it but doesn't produce camptocormia. I have assessed thousands of people with spinal disc disease and none had camptocormia. The only case I did see was an eighty year old woman and, as I said, the problem was actually in the glutei. The spine was not painful. You could not maintain the posture of camptocormia with dic pain.

I wasn't clear, I didn't mean I was supporting what we now understand as camptocormia as being the condition that affected WW1 soldiers, just that there are so many confounders that it's difficult to make any certain finding of what might have been behind any given postural pathology.

It's true that by the early 20thC the British Army had a reasonably sound grasp of basic nutritional need, although of course the more detailed understanding of the role of individual vitamins and minerals was to follow WW1. The notional allocation of food per soldier certainly met calorific need however what was available in barracks could be very different to what was available on the front lines and there's good reason to think that many soldiers regularly failed to have the 3,000+ calories a day it was estimated they required. Also the overall quality of food delivered from kitchens way behind the front lines to those men in the trenches was often reported as poor. So while some soldiers from less wealthy backgrounds could have been 'built up' under the army regime, equally there will have been periods when many front line soldiers were exposed to chronic poor nutrition. Add in the many afflictions of digestion, including stress induced anorexia (difficult to build an appetite when surrounded by corpses) as well as the rife Trench Fever, then a portion of soldiers may have been effectively malnourished. And for those on the Western Front many lived a subterranean existence that actually kept them out of the sun raising the possibility of Vitamin D deficiency. And of course a week at time spent in a dug out, relieved only by hours hunched on a firing step might well induce an occupational stoop.

Selection processes should have kept less fit men out the ranks altogether or streamed the less physically capable to non front lines duties however at various points in the war recruitment was chaotic and/or desperate and the quality of soldiers engaged in fighting certainly didn't match the regulations over all the four years of war - witness the number of 'boy soldiers' including 14 - 16 year olds, who made it through selection to end up in combat roles when they should never have left UK territory. The scale of what we now call PTSD certainly was never recognised, and no doubt many postural symptoms could have been psychological responses but with individual soldiers exposed to everything from combat fatigue, to blast injury, to gas (4 varieties), to typhus, to syphilis, to influenza I'm not sure how it is possible to parse any one causation or contributor from any other.

I thought this paragraph from an essay on Souques was interesting:

"In 1915, Souques coined the term ‘camptocormia’, with Mrs. Rosanoff-Saloff, to describe the stooped posture of the trunk, disappearing on lying down, in soldiers injured during trench warfare [10]. They assumed the disorder could be caused by organic injury, but also by neurosis. Indeed, some soldiers had camptocormia from mental stress in anticipation of the battle, while others were afraid to suffer again from a previous spinal injury."

The key point seemed to be that the ‘camptocormia’ was not the primary reason for hospitalisation but were under medical care because they had been injured, including spinal injury.