Psychiatric Annals

CME Article 

A 38-Year-Old Woman with Depression, Stomach Pain

Seema Hashmi, MD; Laura Lamontanaro, PsyD; Adeel Zubair; Monica Pal, MA; Mohammad Asim Nisar, MD

Abstract

The patient is a 38-year-old woman of low socioeconomic class, who resides in a suburban neighborhood. The patient was born and raised in the Dominican Republic by her biological parents, along with her 15 siblings. She was married and had her first daughter at 14 years, and then she had two more children with her first husband shortly thereafter.

Abstract

The patient is a 38-year-old woman of low socioeconomic class, who resides in a suburban neighborhood. The patient was born and raised in the Dominican Republic by her biological parents, along with her 15 siblings. She was married and had her first daughter at 14 years, and then she had two more children with her first husband shortly thereafter.

Seema Hashmi, MD, is Senior Attending, Nassau University Medical Center, East Meadow, NY. Laura Lamontanaro, PsyD; Adeel Zubair; Monica Pal, MA; and Mohammad Asim Nisar, MD are with the Department of Psychiatry, Nassau University Medical Center.

Dr. Hashmi; Dr. Lamontontanaro; Mr. Zubair; Dr. Pal; and Dr. Nisar have disclosed no relevant financial relationships.

Address correspondence to: Seema Hashmi, MD, Department of Psychiatry, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554; fax: 516-572-4725; or e-mail: shashmi@numc.edu.

The patient is a 38-year-old woman of low socioeconomic class, who resides in a suburban neighborhood. The patient was born and raised in the Dominican Republic by her biological parents, along with her 15 siblings. She was married and had her first daughter at 14 years, and then she had two more children with her first husband shortly thereafter.

When the patient was 18 years, her mother died. The patient said her mother’s dying wish was for her to divorce her husband, despite her conservative father’s discontent. The patient and her husband subsequently divorced. The patient met another man 1 year later. They married, and she had two pregnancies; one was a miscarriage, and the second was her son, who is now 15 years. The patient’s second marriage then also dissolved.

Currently, the patient lives with her 30-year-old boyfriend and her 15-year-old son. The patient said she came to the United States 8 years ago, and three of her children are in her native country, having been raised by her sister.

The patient was taken to the emergency room after falling in her bathroom. Her chief complaint was, “I am dizzy.” A few hours later, while still in the emergency room, she was given normal saline. Then, when she was having a computerized tomography (CT) scan, she said, “I can’t feel anything on my left side.” The patient was admitted to the inpatient medical unit with left side hemiparesis to rule out multiple etiologies for her presenting symptoms. After weeks of hospitalization and intensive medical and neurological evaluation, the patient was discharged and seen for a follow-up in the neurology clinic, where the neurologist noticed that the neurological exam was inconsistent with her symptoms. At her initial evaluation in the psychiatry outpatient clinic, she denied any stressors and was not sure whether she needed to be given a psychiatric evaluation, but she was cooperative.

On the initial evaluation during her physical exam, the patient displayed 5/5 motor strength on the right side and 1/5 on the left side, including decreased sensation on the left side. The patient’s deep tendon reflexes were 2+. Beyond these findings, the physical exam was unremarkable. Her chest X-ray showed no focal consolidation, and CT spine showed no fracture or subluxation. CT of the head showed punctate hyperdense focus in the right parietal lobe, which suggests a vessel on end. Repeat CT of the head the next day showed the same thing, with no apparent pathologies. An echocardiogram showed normal left ventricle size and systolic function with a mild dilated right atrium. Anti-cardiolipin workup was negative. Complement 3 and 4 levels were normal. Magnetic resonance imaging (MRI) showed a normal study. Anti-smooth muscle antibody was negative. The patient was admitted to the hospital and was immediately worked up for a stroke, for which all tests were negative. Tests were then ordered to rule out other metabolic causes of hemiparesis; those tests were negative. The patient was then discharged with the follow-up for neurology clinic, from where she was then sent to the psychiatry clinic.

On her initial evaluation, the patient was cooperative, although she did not understand the reasons that she was recommended for a psychiatric evaluation. She had no past psychiatric history, no history of somatization with pain, or any physical complaints before the incident. Initially, she had denied any stressors before the incident and said that she was working in a deli with her brother, where she had worked off and on for the past 3 years. Collateral information was obtained from the boyfriend and the brother, who also denied stressors before the incident. The patient denied any active-passive suicidal ideation intent or plan. She denied any signs and symptoms of mania or psychosis.

She admitted having a depressed mood due to current physical limitations. She said, “My son has to bathe me, I can’t walk anymore” but denied feelings of anhedonia, worthlessness, or hopelessness. The patient was calm, controlled, and cooperative. She said she would not be interested in pharmacotherapy but would be interested in individual therapy. It was noted on the evaluation of her medical records that she had been trying to schedule her reversal of a tubal ligation and had missed several appointments in the past year and the past 3 months before the incident. When asked about it, she said that her boyfriend wanted to have children and that she did not go for the procedure because they did not have enough money, which was revealed on her subsequent visit.

Diagnosis

Culturally Influenced Conversion Disorder

Discussion

As Freud stated in regards to symptoms formation, “We find a struggle between two trends, of which one is unconscious and ordinarily repressed and strives towards satisfaction — that is, wish-fulfillment — while the other, belonging probably to the conscious ego, is disapproving and repressive. The outcome of this conflict is a compromise formation, in which both trends have found an incomplete expression.”1

Unable to escape her cultural values, the patient faced a conflict because she was scheduled to have a surgery for the reversal of a tubal ligation and yet did not want to have the surgery because she did not want to have children with her boyfriend. The patient comes from a big family and already has four children. She said she does not consider the man she is currently with a man with whom she wants to have children because he has a problem with alcohol abuse.

She has, therefore, developed a compromise formation because she is dependent on him financially, physically, and emotionally and yet she is afraid to be assertive and state what she wants, which is to be separate from him and have no more children. Her unconscious desires to be a single woman with no additional children are against her cultural values; this conflict led to the conversion disorder.

As a result, she physically created a way in which she could escape the dilemma she faced: Her left-sided paresis gave her the excuse to not have the surgery and avoid having more children. She said she hoped this would cause the man to end the relationship with her.

The patient said she suffered stress due to immigration, acculturation, language barrier, her divorces, and her separation from her children and her family. According to Garcia and Zea, somatization is prevalent in Spanish-speaking women who “communicate distress symbolically through their bodies, rather than assertively.”2 In this case, the patient was feeling pressure from her boyfriend who wanted to have children, but she was conflicted. On one hand, she wanted to be with him because he was supportive in some ways — financially and emotionally — but she was not in love with him and did not want to have children with him. Her inability to express this verbally to him, in addition to the anticipatory anxiety about the upcoming surgery, led to a physical expression of this conflict when she fell and experienced left-sided hemiparesis.

Additionally, there are gender-specific roles regarding the expression of anger. The “marianista” concept discourages women from asserting themselves in oppressive situations, such as the patient staying in a relationship with a man whom she did not love or want to be with.2 This complements “machismo,” which is a concept that encourages men to be overassertive, controlling, and show exaggerated strength and power in relationships.3,4

Conclusion

The case illustrates the development of conversion disorder by a Hispanic woman after severe psychosocial stressor. One of the problems in diagnosing conversion disorder is the assessment of psychological factors and whether they should be associated with the conversion symptom. Earlier studies leave no doubt about the female preponderance in conversion syndromes.5

In less psychologically sophisticated patients, the available means of coping with precipitating life events may be more limited. In these patients, sickness might become the most feasible way of gaining relief from emotional strain, the symptom thus taking on an effective protective function.5 According to the Psychodynamic Diagnostic Manual (PDM Task Force 2006), “forbidden sexual or aggressive impulse might take the form of a physical paralysis.”6 Patients with conversion symptoms are classically “known for an accompanying blasé attitude toward their symptoms (la belle indifference),” which involves minimizing the seriousness of the paralysis. This can also be tied to past traumas, which in the patient’s case include pregnancy at an early age, the loss of her mother, and the miscarriage of a child.

It is important to consider secondary gains from the paralysis. In this case, she will no longer work, will not have the tubal ligation or get pregnant, and can test her boyfriend, with whom she is not completely secure. She also receives desired attention from her family members and friends.

Despite recent advances in our understanding of the epidemiology, etiology, and treatment of common psychiatric disorders, our understanding of conversion disorder remains limited. The literature reveals that there is a limited knowledge regarding the incidence and prevalence of this condition, especially involving complex cultural implications. It continues to be a diagnosis of exclusion. Although for decades, the battle between neurology and psychiatry has continued with the debate over whether the patient has neurological disorder or has a diagnosis of “hysteria.” Slater addressed this issue. He said that there is no diagnosis of hysteria as per this cohort study, but more recent studies have proven that conversion disorder is diagnosable and also treatable.7

The neuroimaging findings of altered prefrontal functioning suggest that this condition may be sensitive to drug treatments, which can modify neural activation in these areas. A combination of treatment with antidepressant medication and appropriate psychotherapy and multidisciplinary rehabilitation should focus on improving the patient’s level of functioning and reducing subjective distress. There is a clear need for further systematic research in this area.8

References

  1. Freud S. Two encyclopaedia articles: psychoanalysis and the libido theory. 1923;18:233–259.
  2. Garcia J, Zea M, eds. Psychological Interventions and Research with Latino Populations. Boston, MA: Allyn & Bacon; 1997.
  3. Drozdek B, Wilson JP, eds. Voices of Trauma: Treating Survivors Across Cultures. Netherlands: Springer; 2007.
  4. Albert R. Latin/Anglo-American differences in attributions to situations involving touch and silence. International Journal of Intercultural Reactions. 2004;28:253–280. doi:10.1016/j.ijintrel.2004.06.003 [CrossRef]
  5. Binzer M. Clinical characteristics in motor conversion disorder. J Neurol Neurosurg Psychiatry. 1997;63(1):83–88. doi:10.1136/jnnp.63.1.83 [CrossRef]
  6. PDM Task Force. Psychodynamic Diagnostic Manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations; 2006.
  7. Slater E. The Diagnosis of ‘Hysteria.’ Taken from: John Stone et al (BMJ). Eliot Slater’s myth of the non-existence of hysteria. J R Soc Med. 2005;98:547–548. doi:10.1258/jrsm.98.12.547 [CrossRef]
  8. Allin M, Steeruwitz A, Curtis V. Progress in understanding conversion disorder. Neuropsychiatr Dis Treatment. 2005;1(3):205–209.

CME Educational Objectives

  1. Review how cultural backgrounds can influence a patient’s psychological status.

  2. Describe the differential diagnosis for conversion disorder.

  3. Discuss futuristic methods of diagnosing and treating conversion disorder.

Authors

Seema Hashmi, MD, is Senior Attending, Nassau University Medical Center, East Meadow, NY. Laura Lamontanaro, PsyD; Adeel Zubair; Monica Pal, MA; and Mohammad Asim Nisar, MD are with the Department of Psychiatry, Nassau University Medical Center.

Dr. Hashmi; Dr. Lamontontanaro; Mr. Zubair; Dr. Pal; and Dr. Nisar have disclosed no relevant financial relationships.

Address correspondence to: Seema Hashmi, MD, Department of Psychiatry, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554; fax: 516-572-4725; or e-mail: .shashmi@numc.edu

10.3928/00485713-20100902-06

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