Conversion Disorder

Conversion Disorder J.P. Leleszi, D.O. FAACAP, FAPA, FACN, FAAHPM Director of Pediatric Consultation/Liaison and Palliative/Hospice Psychiatry Children’s Hospital of Michigan Associate Professor - Psychiatry Wayne State University Medical School

Antigone bySophocles “No one loves the messenger who brings bad news”

Conversion Disorder • Unexplained symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. • Psychological factors are judged to be associated with the symptoms or deficits.

Essential Features • Voluntary motor or sensory function symptoms or deficits suggesting a neurological or medical problem. • Symptom or deficit associated with psychological factors. • No medical condition, direct effects of a substance or as a culturally sanctioned behavior can fully explain the symptoms. • Symptom or deficit causes significant clinic distress in important areas of functioning. • Not intentionally produce or feigned. • Symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder. Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision American Psychiatric Association

Conversion Specific Types with • Motor Symptom or Deficit • Sensory Symptom or Deficit • Seizure or Convulsions • Mixed Presentations

Motor Symptom • Astasia-abasia • “Intermittent” weakness or paralysis • Weakness not anatomical • “Lump in throat” • Urinary retention

Sensory Symptom • “Unilateral” blindness • Tunnel vision • “Glove” anesthesia • Circum-oral anesthesia • “Band like” constriction of chest • Vertex projectile needle-like pain

Seizure Episodes • Tonic-clonic muscular contractions • Pelvic thrusting • Able to communicate during episode • Avoidance of harmful circumstances during episode

Assessment • Appropriate medical investigation. • Cardiac assessment of syncope. • Some rarer medical conditions such as Multiple Sclerosis, Crohn’s, TB, etc can be the nidus of the symptoms which can appear much later in life.

EEG • EEG is not 100% “test” for seizures. • EEG changes during an episode documents if it is a “true” seizure, reason for 24 hour monitoring

“Conversion” The hypothesis that the individual’s somatic symptom represents a symbolic resolution of an unconscious psychological conflict, reducing anxiety and serving to keep the conflict out of the person’s awareness.

“Primary Gain” The emotional conflict is kept from the person’s awareness by the use of a somatic symptom.

“Secondary Gain” External benefits are obtained or dangerous or undesired responsibilities are avoided.

Physicians, Surgeons and Nurses Frequently Do Not Recognize The Various Forms of AFFECT

“la belle indifference” “the beautiful indifference” • Lack of concern about the ‘illness’ • Dramatic or histrionic display • Not seen in organically ill patients

Sick Children DO NOT WANT TO BE IN A HOSPITAL

What is the Difference • Major Surgery ? • Minor Surgery ?

According to Bill Cosby • Major surgery is the surgery done ON the surgeon. • Minor surgery is the surgery done BYthe surgeon.

“When I first saw you at Children’s, you told me to “get out of bed”. I knew right then and there If I didn’t I would be dead! At first I didn’t like you I thought you were being mean. I knew at this point in time I had to grow up and be a teen. Once I was in the process, the family got involved, And soon I could slowly see my problems begin to dissolve.”

Vignettes A.B., “Passing out in school” C.D. “Can’t Walk” E.F. “Can’t walk due to ankle pain” G.H. “Left leg atrophic, needs crutches”

Vignette: A.B., “Passing out in school” 17 year old male, three younger siblings; single mother, father in and out of his life last 12 years. GPA: 9th 3.5; 10th 3.25; 11th 2.20; 12th not in school Post high school hopes – Central Michigan for chemical engineering Worked 9 months successfully earning $100 a week in fast food industry, promoted to head cashier “I work hard and am honest. I pay for all my school stuff helping out my Mom” “Change in management in 11th grade, new manager brought in his family members; “I was the last one left. He said I stole, so we argued and I was let go”

Vignette: A.B., “Passing out in school”, continued “Two weeks later I fell out in school” “My doctor said it was nerves, but the guidance center said I didn’t have a problem so they let me go” ”The emergency doctor said I have seizures and now on Trileptial” Four hospitalizations in past 6 months, multiple ambulance brought emergency department visits “I still fall out and all the tests are normal” said with la belle indifference

Vignette: A.B., “Passing out in school”, continued • “Weird pain around my belly button” • “Something is stuck in my throat” • “My lips are numb” • “Some sharp pin is sticking me down on top of my head” • “It’s like a tight rope around my chest and I can’t get air in unless I open a window” • “My fingers get hot then cold and numb all of a sudden” • “Every time I’m in school I pass out, the principal says I can’t come back until I’m well enough. I want to go to school but I just fall out, no one knows why”

Vignette: A.B., “Passing out in school”, continued Taught his body is talking for him not his words Not faking anything – relieved, “So I’m not going crazy?” Primary gain: Do not physically attack your accuser so you don’t go to jail. Secondary gain: Not attending school, not needing school expense money, no money stress for his mother. Not successful as defense mechanism: a. Can not get into Central Michigan b. Not helping his family c. Issues of emancipation, individuation, and separation d. Prior medical interventions not successful

C.D. • 12 year old female suddenly can not open her left eye; has numbness of the dorsum of her feet; ‘wobbles’ when standing and must touch the walls with her finger tips when she walks. • Seen on her third hospital day • States she feels secure in the hospital with a la belle indifference

C.D. • “This happened when my Dad ran over my Mom when she got out of the car on Friday”. • ‘My Mom got a broken leg and all of a sudden my eye won’t open, I can’t feel the tops of my feet and I can’t stand or walk like I did before” said in a robust tone • “If I don’t get better, I’ll just stay here for ever” said with broad smile la belle indifference.

C.D. • Her mother was staying in her room • Smiled broadly that she felt safer that her doctors and nurses could watch after her mother while she is in hospital • Broad smile vanished, head flexed, low tone, answering ‘What would happened if Mom went to an adult floor?’ – “I’d be sad”

C.D. • Interpreted to both of them that she closed her eye as not to ‘see’ the accident. • She opened and kept open her eye when directed to do so. • Her mother at first could not ‘see’ her daughter’s eye was open until her daughter said her eye stayed open

C.D. • She at first ‘struggled’ to walk to her mother. • Her mother in a cast tried at first to walk to her daughter. • In a loud voice, smiling, “I did” when asked about her walking to her mother

C.D. • Both were tearful and talked about that this was an accident and Dad would never try to hurt them. • This was a traumatic event for all the family members and C.D. was ‘talking’ with her body, not her words and feelings

E.F. “Can’t walk due to ankle pain” • 16 year old female complained of right ankle pain a week after mother beginning thyroid cancer treatment • Bright 3.90 GPA active in high schools athletics • Father owns successful business, mother active home maker, 19 year old sister freshman at U of M • Complained of sudden no trauma related, severe bilateral shooting pains up her leg as well as an inability to flex as well as rotate her right ankle with inability to walk without crutches • After two weeks of intense outpatient care – worsening of symptoms -‘frozen ankle’ • Diagnosed with Reflex Sympathetic Dystrophy

E.F. “Can’t walk due to ankle pain”, continued • Very active in physical rehabilitation therapy • Does all the therapies with enthusiasm and never complains about the duration and intensity of the therapies • Does not want to take prescribed pain medications • Ankle still ‘frozen’ except observed by hospital staff, RNs and parents freely movable during sleep time • Multiple inpatient hospitalizations – parents described statement by orthopedic surgeon as “the most stoic hard working teenager, who never complains about the work out. Always smiling during the therapies. Ankle remains ‘frozen’ with loss of bone since she is not using that joint. No other bone wasting in the body. Still will not take pain medications. Will have to fuse the joint with screws, she does not use the ankle anyways.”

E.F. “Can’t walk due to ankle pain”, continued • Second Hospital System opinion sought PM & R consult who recommended psychiatric consult • Parents outraged - complained to hospital administration and PM&R physician about the psychiatrist diagnosis of “Conversion Disorder” • Third Hospital System consulted, again fuse the ankle but they can not explain why she moves the ankle freely during sleep. This hospital staff encouraged them to fuse the ankle soon due to continued rapid joint wasting visible on all studies. Amputation is considered. • Returned to original PM&R referred psychiatrist for ‘clarification’ • Same material told to parents-they then agreed that all other interventions not useful and they were concerned that she is ‘wasting away’

E.F. “Can’t walk due to ankle pain”, continued • Primary Gain:Unable to leave mother, thus mother can not ‘leave’ by dying. She had previously described she was not worried about the cancer, all other family members were worried. • Secondary Gain:She was brought to treatments by her mother. With la belle indifference affect, ‘When I am working out, if the cancer hurts my Mom she is in the hospital anyways so the doctors can help my Mom” • Parents then accepted the diagnosis that their older daughter already had during the first psychiatric consult.

E.F. “Can’t walk due to ankle pain”, continued • Enraged with parents and psychiatrist at first. • Family therapy dealt with issues of the fear of loss: a. Close to sister who left her for college b. Soon after sister left, mother diagnosed with cancer, fear of her mother dying c. Everyone at school telling her how mature and bright she is and how happy she’ll be away at college, when she never told anyone she is terrified to leave home at this time • During family therapy her father was diagnosed with an virulent cancer and he died before she graduated from high school. • Now at U of M, had some difficulty eating before starting college and understood she needed to ‘talk’ since her father had nausea before his death. She is now doing well. Still sees psychiatrist for continued support with her family. Both ankles have equal functional use and now no bone loss.

G.H. “Left leg atrophic, needs crutches” • 17 year old, youngest of three girls. • Father a high school coach in a rural school district • She was the only daughter active in athletics • Father said, “Two years ago in last track meet of the year all she had to do was walk from the starting block to the finish line last to get that gold medal” • Mother said, “She then could not move her left leg. We went to different hospitals and doctors, they can not find anything wrong. The last orthopedic doctor said it was psychiatric. I said let’s try, my husband is angry.”

G.H. “Left leg atrophic, needs crutches” continued • Entire left leg ¼ of the diameter of the right leg, covered with long, dark hair; right leg however has been neatly shaven • She used crutches to ambulate, stating with a la belle indifferent affect, “I’m used to these. It doesn’t stop me from going to all of the school dances and watching my friends.” Mother weeping silently, father glaring angrily. • The various reports reviewed state no medical, physical or neurological explanation can give reason for the loss of function and girth of the left leg other than disuse by “functional causes”.

G.H. “Left leg atrophic, needs crutches” continued • She and parents agreed to use hypnosis • She discarded her crutches and began to walk. • She laughed and said, "Now I can dance like my sisters” • Her mother laughed, stood up clapping saying “We don’t have to do that surgery!”

G.H. “Left leg atrophic, needs crutches” continued • Her father lit a cigarette quietly saying, “This doctor doesn’t have a leg to stand on” • She gently eased herself to the floor, her mother handing her daughter the crutches, smiles abruptly leaving their faces • Father said, “This was a waste of my time, what do we owe you for this?”

G.H. “Left leg atrophic, needs crutches” continued • Attempts to review what had happened were met by the father holding up his hand saying, “Thanks, but my daughter is no psycho” • They were told to review what they had heard and seen and that there would be no financial charge since their daughter has been dealing with a heavy burden. • None of the family members said anything else as they left the office.

G.H. “Left leg atrophic, needs crutches” continued • The original referring orthopedic surgeon reported one month later the following: • Family returned to the original medical center to have exploratory back surgery.

G.H. “Left leg atrophic, needs crutches” continued • The spinal chord was accidently severed causing her to be permanently confined to a wheelchair. • No law suit was ever filed. • Primary Gain: • She tried to identify with father’s sports interest – not being as father described his family “I have no sons and the other two are girls” • Secondary Gain: Prevent parental conflict. Sacrifice herself for the family unity.

Factitious Disorder • Intentional production or feigning of physical or psychological signs or symptoms • The motivation for the behavior is to assume the sick role • External incentives for the behavior (such as economic gain, avoiding legal responsibility, or improving physical well-being, as in Malingering) are absent

Conversion Disorder