Catch-22: Paradox=Resolution

“Catch-22”: a situation in which there are only 2 possibilities and you cannot do either because each depends on having done the other first; a problematic situation for which the only solution is denied by a circumstance inherent in the problem or by a rule. As physicians, we are all accustomed to dealing with difficulties with patient diagnosis and treatment secondary to a Catch-22—an unaccountable reason that makes no sense, but nevertheless prevents us from doing what we need to do.

The patient in question was seen in the 1980s: a 35-year-old, right handed Caucasian woman with a history of neurologic abnormalities occurring for 2 months. She had been diagnosed with transient ischemic attacks (TIAs). At issue, there was no diagnosis as to the cause, or even if the attacks were real. On reviewing her old records, I read that several physicians had written in their charts that the patient was “faking.” The patient was sent to see me secondary to complaints of a constant headache. I took a history, during which the patient and her husband described about a dozen instances of transient neurological episodes over the prior 2 months, including, by patient description, aphasia, hemiplegia, paraplegia, unilateral blindness, and more, the duration of the typical episode ranging from hours to 2 days. The patient’s husband of 6 months was solicitous of his wife, perhaps too exceptionally solicitous. Questions of secondary gain were on my mind. After her history was obtained, the patient was taken by my nurse to the examination room, along with her husband, and asked to change into an exam gown. I started the neurological examination: she had normal cranial nerves, and gait and station were intact. I began the muscle testing examination and AS I WAS EXAMINING her upper extremity strength, her left upper extremity became weak as I was testing the biceps/triceps. She appeared to develop a paresis, not a total hemiplegia. I did what I could to see if the patient was faking, but I could not determine that she was. Both she and her husband were, of course, aware of the paresis. At the end of the examination, after they were back in my consultation room, I retested her left upper extremity strength, and it remained weaker than the right.

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