A 16-year-old girl presents with multiple unconsciousness. These started about six months ago and have become progressively worse. During the episodes, there is the jerky movement of the body but no urinary or faecal incontinence. These symptoms last for a few minutes and are followed by drowsiness. Neurological examination is normal.
What differential diagnoses would you consider in this case?
What other information would you enquire from the family about the episodes?
Which specific investigations would you like to order?
Conversion disorder (F44.5 Dissociative convulsions) suggested by the episodes of unconsciousness and lack of findings on neurological examination and absence of incontinence.
Epilepsy suggested by the recurrent brief episodes of unconsciousness, accompanied by jerky movements and followed by drowsiness
Vasovagal syncope suggested by the brief episodes of unconsciousness, jerky movements (may occur) and normal physical examination
Paroxysmal arrhythmia, which also can cause episodic unconsciousness
History of the Fits
A detailed account of (what happens during) the episodes
Examining a videotape if they have recorded it.
The duration of the fits
Whether there is a clonic phase
Whether they experience an aura.
The occurrence of headache after the episode
Whether the patient remembers the events during the episode
Whether the fits are stereotypic in presentation
Whether the patient shouts or moans during the episodes ,
Whether the eyes remain open or closed during the episode
Whether they observe cyanosis
Tongue bite and location of the injury
The pattern of occurrence
The Frequency of the episodes
The weather there is a special time of occurrence
Fits/jerky movements during sleep
A 17-year-old girl is admitted in a psychiatry ward. She was brought unconscious with a reported history of 5-6 episodes of unconsciousness daily, each episode lasting more than an hour but not associated with body movements, tongue bite or urinary incontinence. These episodes started after her engagement to a middle-aged entrepreneur who is already married. Family members and neighbours believe she is under the influence of black magic. Radiological and lab investigations are unremarkable.
What is your provisional diagnosis?
What psychosocial explanations could you use to help the patient and her family?
How will you manage this patient?
Conversion disorder (F44.5 Dissociative convulsions)
Functional neurological symptom disorder (DSM-5)
Useful Psychosocial Explanations
Experiencing a queasy stomach when talking in front of a vast audience.
Stress can worsen or cause hypertension.
Stress may worsen or cause even stress ulcers
Inform the patient about the results of the assessment and the lack of evidence of an underlying physical condition.
Emphasise that the symptoms are real, well recognised and familiar to the clinician and strictly avoid giving the impression that there is 'nothing wrong' with them.
Explain the role of psychosocial factors in all medical conditions. Provide socially acceptable examples of diseases that often are deemed stress-related (e.g., peptic ulcer disease, hypertension).
Provide common examples of emotions producing symptoms (e.g., queasy stomach when talking in front of an audience) and examples of how the subconscious influences behaviour (e.g., nail-biting, pacing, foot tapping). Then offer and discuss a psychosocial explanation of the patient's symptoms.
Reassure the patient that the condition is temporary and, with motor disorders, because of a problem in converting willed intention into action.
Provide positive reinforcement/suggestion that the symptoms can improve and encourage the patient to overcome them.
Provide a graceful way for the patient to improve and allow time for a gradual recovery.
Avoid reinforcing symptoms or disability, including the provision of wheelchairs and stretchers. If the condition is long term, help remove the identified reinforcements.
Treat any associated psychiatric disorder (commonly anxiety or depression) and provide possible help with any related social issues.
Allow adequate time for the patient and their partner/family to ask questions.
Sorry for your loss, sorry to hear about your loss in vision/ sensation etc
(If vision – ask 1 or both eyes, red? Painful? Fluctuating vision loss?)
What do you think has caused this?
Do you think it might link with recent stresses in your life?
Do you know anyone with this, anyone in the family with this, or have you read about it?
Reassured by the Drs?
Do you think you have a particular illness?
Apart from this, do you have any other physical symptoms? How often do you see the GP?
What now? Treatment or believe you need investigations?
How have other people reacted?
Any court case pending?
Drugs and Alcohol? Impact – i.e. social situation- off sick? – stresses Risk – to self, to others, from others, neglect
Anxiety – PTSD, GAD, OCD
PMHx- thyroid, HI, epilepsy
Forensic – any court case pending?
For Dissociative seizures: include – any tongue biting, physical injuries sustained during seizures? Any incontinence? When to they occur, ABC?
Non-epileptic seizures are common in people who have epilepsy.
Tests for conversion disorder
disturbed somatosensory perception;
diminished or absent on side of defect.
Mild cognitive impairment
Objective: Minnesota Multiphasic Personality Inventory-2 (MMPI-2)
increased instinctual drives,
Hysterical aphonia TX?
E.g. intravenous amobarbital (Amytal) (100 to 500 mg) in slow infusion
Test for dissociative stupor?
Lorazepam challenge test
Patient has an a taxi gait. Does not fit any pattern. Patient does not fall to ground. Organic causes ruled out. What is this?
Patient has transient blindness for few hours. Tracking movements and pupil ary response is absent. Patient recovers two hours later. What is it
Pupillary response and tracking movements are not absent in conversion disorder.
Patient says she is deaf. You think she is not. Conversion suspected. How will you prove your point?
Bring two metal plates, Bang heavily near her bed while she is asleep. If it awakens her, congratulate her that her hearing is normal. Okay, that was a joke, but the loud noise test during sleep is true.
Patient is having gtc fits. You are not sure whether they are conversion or epileptic. She is seizing right in front of you. Test?
Babinski is absent in seizures and in postictal state
Psychotherapy of choice?
Pathological jealousy. What ethical principles are related?
mental health professionals have a duty to protect individuals who are being threatened with bodily harm by a patient.
Motor Symptoms of Conversion Disorder. The International Classification of Diseases 10th edition has enlisted the following motor symptoms of conversion disorder.
Abnormal gait, Atasia-abasia
>> Dissociative Motor Disorders