Lumbar Puncture Reactions: Relative Importance of Physiological and Psychological Factors

The relative significance of purely physiological and emotional factors in the pathogenesis of the post lumbar puncture syndrome was subjected to investigation. One hundred hospitalized psychiatric patients were punctured routinely. From this random group were excluded all persons with gross deterioration, extreme psychotic states and contra-indications to spinal puncture. Alternate patients were punctured with number 16 and number 22 gauge needles. Preliminary observations, preparations and the procedure itself, as well as after-care, were carried out under standard conditions. In the two groups punctured with different needles, patients were found to be well matched with respect to diagnoses, age, sex, and ratings as to intelligence, mood, emotional stability, chronic anxiety, and hypochondriacal trends. The patients' knowledge of the procedure and its underlying principles was evaluated. This proved as low as their anticipatory anxiety was high. Before the puncture about half of the patients had heard of someone who had undergone the test and 23 per cent knew of ill effects in others. Fifty-four per cent of the total showed some lumbar puncture symptoms; in the 16 needle group, 74 per cent reacted unfavorably as compared to 52 per cent in the 22 needle group. Five times as many severe reactions occurred with the large needle, and the duration of symptoms was markedly longer. These differences are statistically significant. Other symptoms, such as backache, nausea and vomiting, and stiff neck, are too rare to permit valid comparisons between the two groups, but they tended to occur with the severe reactions more characteristic of the group punctured with a 16 gauge needle. The occurrence of symptoms had no significant relationship to the intelligence and emotional stability of the patients. Persons with normal mood seemed to suffer more severe headaches than those who were depressed or elated. The presence of chronic anxiety or hypochondriasis—mild or marked—evidently predisposed to a slight increase in incidence of complications, but there was no increase in the number of severe reactions. Some increase in mild reaction was associated with anxiety with regard to the procedure. Unlike the intrinsic personality traits of the patients, which did not significantly affect reactions, knowledge of ill-effects in others does increase post lumbar puncture sequelae to a statistically significant degree. Hence, suggestion appears to be the primary psychological factor of importance in the production of symptoms. Knowledge of ill-effects in others does enhance anticipatory anxiety, and exerts a suggestive influence with consequent rise in number of sequelae. The conclusion was reached that drainage is the most significant factor in the production of symptoms following lumbar puncture, outweighing by far the small contribution of anxiety, hypochondriasis and other emotional elements.