Psychiatric Annals

CME Article 

A 14-Year-Old Girl with Seizures, Gait Problems, Paralysis

Nadeem Hanif Bhatti, MD; Mohammad Amjad Ullah Khan, MD; Edna Reyes Wilson, PhD; Elizabeth Ledger, MT, ASCP, MS

Abstract

A 14-year-old girl of Hispanic descent presented with symptoms of seizure, gait problems, and paralysis of the lower extremities. She said she had been experiencing these symptoms for the past 5 days. The episodes were described as eyes rolling upward, jaw locking, body aching, and numbness and tingling in the whole body. These seizures lasted 5 to 10 minutes. These episodes were not accompanied by incontinence, tongue biting, or loss of consciousness.

Abstract

A 14-year-old girl of Hispanic descent presented with symptoms of seizure, gait problems, and paralysis of the lower extremities. She said she had been experiencing these symptoms for the past 5 days. The episodes were described as eyes rolling upward, jaw locking, body aching, and numbness and tingling in the whole body. These seizures lasted 5 to 10 minutes. These episodes were not accompanied by incontinence, tongue biting, or loss of consciousness.

Nadeem Hanif Bhatti, MD, is Psychiatry Resident, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX. Mohammad Amjad Ullah Khan, MD, is Fellow, Child and Adolescent Psychiatry, University of Michigan, Ann Arbor. Edna Reyes Wilson, PhD, is Assistant Clinical Professor, Paul L. Foster School of Medicine. Elizabeth Ledger, MT, ASCP, MS, CCRP, is a Research Associate, Paul L. Foster School of Medicine.

Dr. Bhatti; Dr. Khan; Dr. Wilson; and Ms. Ledger have disclosed no relevant financial relationships.

A 14-year-old girl of Hispanic descent presented with symptoms of seizure, gait problems, and paralysis of the lower extremities. She said she had been experiencing these symptoms for the past 5 days. The episodes were described as eyes rolling upward, jaw locking, body aching, and numbness and tingling in the whole body. These seizures lasted 5 to 10 minutes. These episodes were not accompanied by incontinence, tongue biting, or loss of consciousness.

A psychiatry consult was requested after thorough medical and neurological investigations, which also included EEG video monitoring. During video EEG monitoring, the patient had seizure-like symptoms, but the episode did not coincide with EEG tracings, which were within normal limits. She also gave a history of panic attacks, which included chest pain, shortness of breath, and loss of consciousness 1 year ago. She said she had these panic attacks because of problems with her math teacher, and that the attacks resolved when she changed classes. She was treated with clonazepam and sertraline for her possible anxiety.

During the earlier interview, the patient disclosed problems with boys and her band class teacher because she was the only female percussionist at school. She said the male band members were undermining her position at band competitions and that the band teacher always sided with the male students. During the sixth session, the patient revealed that she was sexually molested by a male friend when she was 11 years.

The patient also disclosed seeing the perpetrator in band nearly every day for 3 months. There was no direct contact between the patient and the perpetrator during these classes. She said she also saw the boy at a party a few months before. At that point, she said she would then experience nonepileptic fits, gait problems, and paralysis of lower extremities.

The patient was also followed by a neurologist during this period, who had prescribed oxcarbazepine and baclofen. The patient also had another EEG, and she experienced an episode during EEG monitoring, even though the EEG showed no abnormalities. The neurologist discontinued oxcarbazepine because it did not exhibit any benefit.

About 6 months after medication was initiated, and after intensive supportive-expressive and cognitive behavioral therapy (CBT) therapy sessions nearly every week, the patient showed relief of symptoms.

Diagnosis

Conversion Disorder

Discussion

Conversion disorder is part of the somatoform disorders. In the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), it is defined as one or more symptoms or deficits that affect voluntary motor or sensory function suggestive of a neurologic or other general medical condition.1 The symptoms in DSM-IV are categorized as motor, sensory, seizures, and mixed. In the past, conversion disorder was known as “hysteria.” By the end of the 19th century, Briquet and Charcot related it closely to traumatic events. Freud’s work with Anna O associated it with unconscious conflicts, which were converted into symptoms.2

Conversion disorder usually has a temporal relationship with conflicts and stressors in the patient’s life. The International Classification of Diseases, 10th edition (ICD-10), classifies conversion disorder as dissociative convulsions.3

The prevalence in children and adolescents is considered to be 1% to 3%, according to an estimate by some psychiatrists in the West.4,5 In children, it occurs usually among the 10- to 15-year age group and is experienced by girls more than boys, probably because of physical and sexual abuse factors.6 Conversion disorders are notably observed more in developing countries compared with more industrialized countries.7–9

Traumatic experiences10 and mood disorders, such as anxiety and depression, contribute significantly toward the development of conversion disorders.11–16 In developing countries, many people with mood disorders present with physical complaints.11 Personality disorders, such as histrionic, passive-aggressive, dependent, and antisocial disorders, also relate to conversion disorder. Many studies have shown significant personality traits associated with conversion disorders.11 Psychosocial stressors in children with conversion disorder are often related to school, friendships, parents, death or disease of loved ones, and personal health-related issues.6,11,17 Some studies have shown that the youngest child in the family can be affected.11–19 In our case, the child is the youngest in the family.

Neurologically, the available evidence suggests a broad hypothesis that frontal cortical and limbic activation associated with emotional stress may act via inhibitory basal ganglia-thalamocortical circuits to produce a deficit of conscious sensory or motor processing.20 Psychodynamically, unconscious intrapsychic conflicts are repressed and converted into physical symptoms. It could also be considered as behaviors learned earlier help to deal with unconscious psychological stressors and also used as coping mechanisms.

Conversion disorder can cause motor, sensory, and/or seizure symptoms.1 The symptoms include paralysis or weakness of the extremities, gait disturbances, and other abnormal movements, such as chorea, tics, jerks, tremors, and pseudoseizures. Anesthesia and paresthesia can also be present. Involvement of the senses, such as vision, hearing, and speech, can cause blindness, mutism, and deafness. Neurological evaluations of these patients are usually normal, unless a true neurological disorder is present.

We diagnosed our patient with conversion disorder on the basis of clinical history, direct observation, clinical examination, EEG, neuroimaging, and confirmatory video EEG. The patient did not exhibit urinary or fecal incontinence or tongue biting. There were very clearly stressors related to her illness, such as coming into contact with the perpetrator and sexual harassment in band classes, as well as stressors related to different teachers. In malingering in or factitious disorders, the histories are usually inconsistent and contradictory, but the patient’s history was very consistent and correlated with collateral information from teachers and family. The neurologist was consistently following up with the patient to rule out any occult neurological problems.

While diagnosing conversion disorder, patients should also be screened for depressive, anxiety, personality, and other psychiatric disorders.

The focus of treatment for these children should be a very empathic and supportive approach, and should also involve their families.8 It is also very important to explain to the family and to the patient that symptoms could also be caused by nonorganic etiologies. For example, our patient was consistently followed by a neurologist. A confirmatory video EEG video did not correlate with her symptoms and helped us to reassure the family. Family education is also very important, and it can help the patient reduce stressors in the current environment, reduce everyday problems, and return to daily function.

Prognosis

During treatment of conversion disorder, factors such as education, culture, stressors, environment, and personality structure should be taken into consideration. They can affect the course and outcome of the illness or condition, as the physician’s understanding of these issues can improve the physician–patient relationship and result in resolution of the symptoms. Symptom resolution also helps families to accept the nonorganic diagnosis.8,11

With early recognition of the nature of the condition and prompt intervention, some patients recover within a few weeks or even days.21,22

References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Publishing; 2000.
  2. Breuer J, Freud S. Studies in Hysteria. 1895.
  3. International Classification of Diseases. 10th ed. Geneva, Switzerland: World Health Organization; 1994.
  4. Goodyer I. Hysterical conversion reactions in childhood. J Child Psychol Psychiatry. 1981;22(2):179–188. doi:10.1111/j.1469-7610.1981.tb00541.x [CrossRef]
  5. Gelder M, Gath D, Mayou R, Cowen P, eds. Oxford Textbook of Psychiatry. Oxford: Oxford University Press, 1996:353.
  6. Roelofs K, Keijsers GP, Hoogduin KA, Naring GW, Moene FC. Childhood abuse in patients with conversion disorder. Am J Psychiatry. 2002;159(11):1908–1913. doi:10.1176/appi.ajp.159.11.1908 [CrossRef]
  7. Tomasson K, Kent D, Geryell W. Somatization and conversion disorder: comorbidity and demographics at presentation. Acta Psychiatr Scand. 1991;84(3):288–293. doi:10.1111/j.1600-0447.1991.tb03146.x [CrossRef]
  8. Manchanda M, Manchanda R. Neuroses in children: epidemiologic aspects. Indian J Psychiatry. 1978;20:161–164.
  9. Srinath S, Bharat S, Girimaji S, Seshadri S. Characteristics of a child inpatient population with hysteria in India. Am J Child Adolesc Psychiatry. 1993;32(4):822–851. doi:10.1097/00004583-199307000-00017 [CrossRef]
  10. Harden CL. Pseudoseizures and dissociative disorders: a common mechanism involving traumatic experiences. Seizures. 1997;6(2):151–155. doi:10.1016/S1059-1311(97)80070-2 [CrossRef]
  11. Binzer M, Andersen PM, Kullgren G. Clinical characteristics of patients with motor disability due to conversion disorder: a proscpective control group study. J Neurol Neurosurg Psychiatry. 1997;63(1):83–88. doi:10.1136/jnnp.63.1.83 [CrossRef]
  12. Minhas FA, Nizami AT. Somatoform disorders: perspectives from Pakistan. Int Rev Psychiatry. 2006;18(1):55–60. doi:10.1080/09540260500466949 [CrossRef]
  13. Pehlivanturk B, Unal F. Conversion disorder in children and adolescents: clinical features and comorbidity. Turk J Ped. 2000;42(2):132–137.
  14. Folks DG, Feldman MD, Ford CV. Somatoform disorders, factitious disorders, and malingering. In: Stoudemire A, Fogel BS, Greenberg DB. Psychiatric Care of the Medical Patient. 2nd ed. New York, NY: Oxford University Press; 2000:459–475.
  15. Lesser RP. Psychogenic seizures. Neurology. 1996;46(6):1499–1507.
  16. Cybulska EM. Globus hystericus or depressivus?Hosp Med. 1998;59(8):640–641.
  17. Crimlisk HL, Bhatia K, Cope H, David A, Marsden CD, Ron MA. Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms. BMJ. 1998;316(7131):582–586.
  18. Ziegler FJ, Imboden JB, Meyer E. Contemporary conversion reactions: a clinical study. Am J Psychiatry. 1960;116:901–910.
  19. Stephens JH, Kamp M. On some aspects of hysteria: a clinical study. J Nerv Ment Dis. 1962;134:305–315. doi:10.1097/00005053-196204000-00002 [CrossRef]
  20. Harvey SB, Stanton BR, David AS. Neuropsychiatr Dis Treat. 2006;2(1):13–20.
  21. Turgay A. Treatment outcome for children and adolescents with conversion disorder. Can J Psychiatry. 1990;35(7):585–589.
  22. Hafeiz HB. Hysterical conversion: a prognostic study. Br J Psychiatry. 1980;136:548–551. doi:10.1192/bjp.136.6.548 [CrossRef]

CME Educational Objectives

  1. Identify the clinical features and longitudinal course of conversion disorder.

  2. Explain the diagnostic clarification of conversion disorder and how this can improve patient outcome.

  3. Describe the complexity of the clinical presentation of conversion disorder.

Authors

Nadeem Hanif Bhatti, MD, is Psychiatry Resident, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX. Mohammad Amjad Ullah Khan, MD, is Fellow, Child and Adolescent Psychiatry, University of Michigan, Ann Arbor. Edna Reyes Wilson, PhD, is Assistant Clinical Professor, Paul L. Foster School of Medicine. Elizabeth Ledger, MT, ASCP, MS, CCRP, is a Research Associate, Paul L. Foster School of Medicine.

Dr. Bhatti; Dr. Khan; Dr. Wilson; and Ms. Ledger have disclosed no relevant financial relationships.

10.3928/00485713-20100902-05

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