Why is my fist always clenched

The patient had already consulted 19 hand surgeons without a diagnosis. She suffered from depression and obsessive-compulsive disorder, classified as mysophobia, but had not been receiving any medications. She reported diffuse pain in the hand without being able to recall any previous injury and intermittent numbness in the first three fingers of your hand.

On physical examination all digits of the right hand, including the thumb, were held in a flexed position at the level of the proximal and distal interphalangeal joint Fig. Active extension was not possible. No signs of joint tenderness, joint or tendon sheath swelling were observed. Peripheral sensibility and blood perfusion was normal.

Hand x-rays excluded bone injuries or degenerative changes, such as arthritic conditions. Electromyography of the brachial plexus and the peripheral nerves of the upper extremity did not show any pathologic conditions. Based on these findings, the diagnosis of CFS was made. Although initially being susceptible to receiving treatment, Despite initially being susceptible in receiving treatment, the patient was treated with splint and intensive physiotherapy.

She was already consulting a psychiatrist for the mysophobia and continued with biofeedback training and cognitive behavioral therapy CBT. The hand was brought back to the neutral position after 1 month. CFS is a very rare clinical entity, with less than 40 cases reported. It is a psychiatric syndrome without clear and well-established etiology that can be assigned to the group of conversion disorders.

Therefore, it is to be differentiated from factitious disorders or malingering [ 1 , 2 ]. Patients suffering from CFS develop flexion contractures of the hand and fingers with potentially devastating outcomes if left untreated. The term clenched fist syndrome was first introduced in by Simmons et al. Particular affected fingers were the ulnar three digits. In , Frykman et al. In this case series, though, the dominant hand was involved. The patients were all middle-aged and none of them had the entire hand clenched.

While there are differences between both reported patient groups, it is possibly the same entity that varies in symptoms. In the past, many authors described CFS as a subgroup of SHAFT-syndrome, which is a factitious disorder, leading affected patients to seek polysurgery and manipulate medical staff in order to satisfy their psychological needs.

These patients tend to be sad, hostile, anxious, frustrating and tenacious, so the acronym SHAFT was built [ 6 ]. Many recent reports indicate that CFS is a conversion disorder that is unconsciously motivated and unconsciously produced [ 1 , 4 , 7 , 8 ]. Therefore, it should not be grouped with the factitious disorders, which are unconsciously motivated and consciously produced, or with malingering which is consciously motivated and consciously produced [ 1 , 2 , 10 ].

In the literature these types of disorders are also often recognized as psychogenic movement disorders. This term emphasizes the psychogenic etiology [ 12 ]. Even though the terminology is not uniformly, the diagnostic criteria are very similar. Patients with CFS present with a variety of symptoms ranging from simple flexion deformities to contraction in the entire hand.

Even minor trauma seems to trigger the disease in most cases. Bilateral involvement is also possible, but not the rule. Most often the disorder involves both interphalangeal joints. Additional psychiatric comorbidities are almost always present in patients with CFS and a thoroughly psychiatric assessment should be performed in the first consultation [ 3 , 7 — 9 , 13 , 14 ].

Our patient showed an unexplainable flexion contracture of all digits at the level of the proximal and distal interphalangeal PIP and DIP joints of the right hand resembling previously described cases with no prior trauma.

In addition, the patient had a positive psychiatric history, as she was suffering from obsessive compulsion disorder and depression. Both disorders have been closely linked to the clenched fist syndrome in the literature [ 1 , 5 , 14 ]. Mysophobia has not been increasingly represented in the published cases though [ 2 , 12 , 14 ].

In the physical examination, the majority of patients show flexion contractures in the interphalangeal and metacarpophalangeal MCP joint, resulting in clenching the hand into a fist. The ulnar-sided fingers are most commonly affected. Active extension is not possible and trying to passively extend the fingers without anesthesia is too painful to accomplish. In advanced cases, the contractures become permanent due to changes in the soft tissue, joints and tendons.

Macerations and infections due to palm hygiene problems also occur in these cases [ 3 , 7 , 8 , 13 ]. In our patient, all fingers including the thumb were affected at the level of metacarpal and interphalangeal joints.

There was no joint tenderness, joint or tendon sheath swelling. Passive digital extension was painlessly possible in all fingers. Radiography, laboratory tests, MRI and electromyography are in most cases normal, but comprise the standard diagnostic tools used to rule out any organic etiology before CFS diagnosis can be made.

All of these tests were carried out in our patient and showed no pathological results. Differential diagnosis includes rheumatologic diseases, Dupuytren contracture, camptodactyly, complex regional pain syndrome, central neurological and peripheral nerve diseases. Consult your doctor for the proper dose and to ensure it can be taken with your other medications. Since being dehydrated can cause muscle cramps, be sure you are staying hydrated and getting electrolytes.

Some sleepers have found temporary relief in holding onto an object when they sleep, such as a squeeze ball or a pillow. There is some good news to be aware of. There are signs that a clenched fist while sleeping is actually good for you. Studies have shown clenching our fists helps us better handle physical or emotional discomfort, and even give us a sense of control and empowerment.

If clenching your fists is keeping you from sleeping, it may be time to see a specialist. At Jacksonville Sleep Center, we understand that no two patients are the same, which is why we personalize each visit and plan to each patient. We want to help you improve your quality of life through sleep. Contact us today to request your appointment. Request An Appointment Previous Next. Things You Can Do While more studies continue to come forward, there are some steps you can take to try to alleviate your symptoms.

Jacksonville Sleep Center If clenching your fists is keeping you from sleeping, it may be time to see a specialist. This was understandable as he was dizzy and walked unsteadily.

After the fall on the floor a series of events occurred that might have caused his anxiety to increase: the hospitalization, the medical work-up including the noisy and claustrophobic MRI, the hip surgery, the postoperative complications including a short delirious episode, and well-meaning health personnel trying to mobilize him against his will.

From the perspective of an anxious and psychotic person with delusions, hallucinations, and speech problems, it is not hard to imagine that the hospitalization with all its alienating elements could have been a very stressful experience.

This might have activated an acute stress reaction, and an equivalent to the flight, fight, or freeze-response. He could not flee. Furthermore, maybe his hands clutching onto the side rails was part of a freeze-response. As he deteriorated and let go of the side rails, his hands were still clenched.

The once adaptive response was no longer adaptive. Why his hands would not open, we cannot easily explain. If this rather short and simple psychodynamic hypothesis has some validity, we might not have to invoke a more complex psychoanalytic explanation assuming a subconscious intrapsychic conflict resulting in the physical symptom, that is, clenched fists, as a symbolic representation of this conflict [ 16 ].

Anyhow, to get a better understanding of the psychological underpinnings, we would have had to wait until he was able to communicate better. Unfortunately, he died before we reached that point. In Batra et al. Wolfe and associates, does in fact include this disorder in its chapter on factitious disorders, published in [ 19 ].

Interestingly, neither of the two major textbooks in psychiatry mentions CFS in their most up-to-date editions [ 20 , 21 ]. Ours was a complex case, and there was clinical uncertainty. There is still insufficient clinical data on CFS. Further research should strive to gain more knowledge on etiology, pathogenesis, clinical manifestations, and treatment.

Also, the nosological status should be clarified. Should it be labelled a syndrome, a disorder, a reaction, a conversion reaction, a phenomenon, or an entity? In itself, that is an indication of the unresolved nosological status. The medical community will hopefully design studies that can broaden our understanding. We also urge the psychiatric community to disseminate the current knowledge, report on further observations, and collaborate with colleagues from other medical specialties that encounter this or similar disorders.

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Oxford: Oxford University Press; Philadelphia: Wolters Kluver; Download references. We appreciate medical student Frida Igland Nissen for critical reading of the first draft of the manuscript and for adding relevant literature.

You can also search for this author in PubMed Google Scholar. TN supported the management of the patient. Both authors contributed to the production and finalizing of the manuscript.

Both authors read and approved the final version. Correspondence to Rolf Wynn. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Download PDF. Case presentation We present a case we encountered in an intensive care unit. Background Medical disorders mimic psychiatric ones, and vice versa. Case presentation A year-old white unmarried man with chronic schizophrenia fell to the floor and was unable to get up or walk. Past history From his relatives we learned that he had grown up in a village on the Norwegian coastline as the fourth of five siblings.

Present illness This was the first time he had been hospitalized. The abnormal hand postures The focus of this case presentation, however, is on the unusual observation of his clenched hands. Full size image. Discussion Our patient was hospitalized after a fall that caused a left hip fracture that was operated on. Table 1 Differences between conversion disorders, factitious disorders, and malingering Full size table.

Conclusions Ours was a complex case, and there was clinical uncertainty. MRI: Magnetic resonance imaging. References 1. Article PubMed Google Scholar 3.