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Case Study: Ms. James Ms. James, a 26-year-old single woman employed as an office manager, is brought to an emergency room in a suburban area by her boyfriend and several other friends. She complains of “numbness” in the left side of her face, left arm. and shoulder subsequent to an incident at a picnic. The “numbness” consists of having no sensation as well as “weakness” in her left arm and shoulder. Apparently, the left side of her head accidentally struck the ground while she was being carried by several friends. Her friends report that immediately following the incident she seemed dazed, out-of-sorts, and was inconsistently unresponsive. Within minutes, she was fully conscious but reported the numbness and so was brought to the emergency room. Upon examination, Ms. James is somewhat perplexed but rather nonchalant about her symptoms. She is fully cooperative with all examination procedures. There are no pupillary abnormalities, and her blink response is normal. There are no signs of facial weakness. On sensory examination, she acknowledges no sensation in any modality on the entire left side of her face, left shoulder, and left arm, with a sharp boundary running down the middle of her forehead and neck, then angling to her axilla. She is seen to move her left arm in conjunction with undressing, but she supports this arm in her right hand and shows weak force in all movements involving her left arm and shoulder. Deep tendon reflexes are symmetrical and have normal strength. Ms. James reports being in good health and denies any past or present abuse of alcohol or drugs. She describes herself as a “shy and sensitive” person who “never feels self-confident like I should” but always has a few good friends nonetheless. She is a high school graduate from an outlying rural area who maintained “OK” grades (Bs and Cs) in the “easiest classes I could take.” She especially disliked science and mathematics. Her father worked as a clerk in a feed store and her mother as a waitress in a truck stop. She moved to the city 2 years after graduation when her parents divorced, a breach that upset her greatly. Shortly after relocating, she was hospitalized for a “spell” after she was found walking in a park not knowing who she was and how, when, or why she had gotten there. Although she regained memory function soon after admission, her recollection of the “spell” was vague. She clearly recalled her hospitalization, reporting that after a “thorough evaluation” (which included several types of “brain wave tests”), no explanation for the spell was given other than that she must have been “very upset.” No further evaluation or care was recommended, but she did not return to work for several weeks “in order to recuperate.” Ms. James had no recurrence of this or any other neurological symptoms until the present episode. She has stayed with the same job and reports that “I enjoy the people there now that I know all of them so well.” She has had two previous serious romantic relationships, but “they just did not work out.” Her current relationship has lasted eight months, but her boyfriend recently told her that “maybe we should date other people.” She was distressed by this, especially because it reminded her of her previous break-ups. After admission to the hospital, she continues to manifest the same symptoms; however, all objective evaluations are negative. She is advised that there does not appear to be any neurological damage and that her symptoms should progressively improve and disappear. By the next morning, all symptoms have disappeared except for a feeling of “awkwardness” in her left hand for which no objective cause can be found. She is discharged with a referral for outpatient psychiatric care. Risk factors

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