MJP Online Early MJP-01-07-09

CASE REPORT

CONVERSION SYMPTOMS IN : A CASE REPORT

Ting JH*, Nor Zuraida Z*, Sharmilla K*, Salina M* * Department of Psychological Medicine, Faculty of Medicine, University Malaya, 50603 Kuala Lumpur.

Abstract

We report a 35 year-old Iranian female who presented with a sudden onset of left sided hemiparesis associated with temporary loss of consciousness of about 3 minutes. Neurological examination revealed a power of 0/5 over the left upper/lower limbs but reflexes were normal and plantar reflex was downgoing and equivocal. A computed tomography scan was done and it revealed mild bilateral frontal atrophy and a temporal arachnoid cyst which was decidedly an incidental finding and it did not have any relation to the clinical presentation. Electroencephalogram and other laboratory findings were all normal. When the psychiatric team interviewed her, it was revealed that the patient had recently experienced a major stressful event just prior to the hemiparesis. On further interview, the patient had complained of of persecution, delusions of reference and also auditory hallucinations for approximately a year prior to admission. There have been only a spatter of reports of conversion symptoms seen in patients with schizophrenia and this is such a case.

Keywords: Schizophrenia, conversion disorder

Case Report was downgoing and equivocal. The first clinical impression was that the patient A 35-year-old Iranian female was was a young patient. brought to the emergency department with a sudden onset of left sided A computed tomography scan was done hemiparesis associated with temporary and it revealed mild bilateral frontal loss of consciousness of about 3 atrophy and a temporal arachnoid cyst. minutes. The patient also complained of The team decided that the decrease in sensation and paraesthesia radiological findings were incidental and over the left upper limb (UL) and lower it did not have any relation to the clinical limb (LL). A neurological examination presentation. Electroencephalogram and revealed 0/5 power in the left UL/LL. other laboratory findings were all Reflexes were normal and plantar reflex normal. The patient was referred to the

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consultation-liaison team for across a curious illness. They named it an opinion as the neurology team felt ‘’, which is derived from the that her symptoms were not consistent. belief that unexplainable losses of motor When the psychiatric team interviewed and special sensory function in women her, it was revealed that the patient had were caused by the wanderings of recently experienced a major stressful unanchored uteri to distant body parts, event just prior to the hemiparesis. She where they interfered with normal was in a relationship and recently, her physiology1. boyfriend of 7 months had asked to break up with her. Hysteria eventually became recognized and coined as ‘conversion disorder’, On further interview, the patient had which has its origin in the underpinnings complained of delusions of persecution, of Freud’s assumption that patients delusions of reference and also auditory converted their psychological symptoms hallucinations for approximately a year into physical or somatic ones. The prior to admission. The patient had been interest in conversion disorder peaked at in Malaysia for 7 months to further her the turn of the 20th century, after which a study. However, her symptoms of steady decline of interest was observed, persecutory delusions had been there up to a point where the disease itself was since she was in Iran. She had been thought to have waned2. However, over telling her family members that people the past 10 years there has been a were following her and she appeared resurgence in research into conversion fearful. She was diagnosed to have disorder. Conversion disorder has been Schizophrenia. established that it remains common, and disabling3. When she finally managed to arrange and persuade to meet her boyfriend, the Interestingly, conversion disorder is a patient’s hemiparesis resolved psychiatric diagnosis which rarely immediately and was discharged the presents to psychiatrists first. next day with no clinical sequelae. Neurologists are invariably the first line However, the auditory hallucinations of physicians to see these patients as the and the persecutory delusions persisted. presenting complaint is typically a The patient was treated with Quetiapine neurological symptom. The full 100mg daily increased daily to 400mg diagnosis, however, requires an per day after 4 days. The psychotic ‘associated psychological factor’4 which symptoms improved after starting the is where the expertise of the psychiatrists patient on treatment. The patient is sought. As conversion disorder has subsequently went back to Tehran and frequently been associated with a co- she was advised to continue treatment morbid psychiatric or neurological there. diagnosis, care should be taken to explore other co-morbidities. Most Discussion literature finds that conversion disorder is associated with an or Approximately 2,500 years ago, sage as well as mood disorders, and Greek philosophers and physicians of occasionally schizophrenia5. This report the great ancient Greek civilization came highlights the complexity of diagnosis

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and the uncommon occurrence of a disorder and 34% among clinical presentation where conversion patients with conversion disorder. Slater symptoms are seen in the background of and Glithero13 studied 85 patients with schizophrenia. hysteria and followed up with them for 9 years. 39% of the patients had no The full diagnosis of conversion disorder significant organic disease while others usually requires both a psychiatrist and a received diagnoses such as neurologist, and therefore needs good schizophrenia and depression. collaboration between them in the multiple-step process: careful history Conversion symptoms has been reported taking and physical examination by the in patients with schizophrenia although neurologist, referral to the psychiatrist, infrequently. Some authors have and finally, optimally, a clear joint described it as a possible prodromal explanation to the patient6. The presentation of schizophrenia5. diagnosis of conversion disorder relies Cernovsky studied 112 patients with on clues and signs such as inconsistency schizophrenia and hysterical symptoms of symptoms, give-way , ‘la were recorded in 37.5% of the patients14. belle indifference’ and the Hoover’s Noble15 also observed 6 of his patients sign. However, these signs may not who presented with a mixture of reliably exclude neurological disease7. hysterical and schizophrenic symptoms. Joubert reported that anxiety and A question that lingers amongst the hysterical symptoms have been therapists is how are the symptoms and described in schizophrenic populations signs produced, if they are not feigned? and wondered if such symptoms Electrophysiological, single-photon represent discrete clinical entities or are emission computed tomography and intrinsic to the schizophrenic process16. positron emission tomography studies suggested a central corticofugal In fact, hysteria seems to have a rather inhibition of afferent stimuli as closely interrelated past with responsible for hysterical sensory loss, schizophrenia. Historically, ‘hysterical since evoked potentials showed ’ was used to describe a vast abnormalities that disappeared when amount of posttraumatic tested again after resolution of the . In the 19th century, it symptoms8-10. In 2001, Vuilleumier and was especially well-studied, particularly colleagues11 shed further light on central in French psychiatry. In the early 20th inhibitor mechanisms, involving not century the diagnosis of hysteria and only cortical areas but also hysterical psychosis fell into disuse. corticosubcortical circuits. These Patients formerly diagnosed as hysterical findings explain the possible biological psychosis were later diagnosed as etiology of conversion disorders. schizophrenics or malingerers17. If hallucinations occur in conversion Conversion disorders have been disorder, it differs from those of frequently associated with other mental psychotic disorders in the way that they illnesses, mostly depression and anxiety generally occur with intact insight, disorders. Sar et al12 reported 50% involvement of more than one sensory anxiety, 42% phobia, 71% affective

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modality, psychologically meaningful 6. Aybek S, Kanaan RA, David AS. and described as an interesting story 4. The neuropsychiatry of conversion disorder. Curr Opn in Psychiatry 2008; In conclusion, conversion symptoms in 21(3):275-280. patients with schizophrenia are not common but comorbidity has been 7. Ziv I, Djaldetti R, Zoldan Y, et documented. After all, psychiatry is a al. Diagnosis of ‘nonorganic’ limb discipline where comorbidities are the paresis by a novel objective motor general rule rather than exception. assessment: the quantitative Hoover's Therefore it is essential to tease out the test. J Neurol 1998; 245:797–802. comorbidities so as to best manage the patient and possible achieve the best 8. Levy R, Mushin J. The outcome. somatosensory evoked response in patients with hysterical anaesthesia. J References Psychosom Res 1973; 17:81–84.

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3. Stone J, Sharpe M, Rothwell PM, 11. Vuilleumier P, Chicherio C, Warlow CP. The 12 year prognosis of Assal F, et al. Functional unilateral functional weakness and neuroanatomical correlates of hysterical sensory disturbance. J Neurol Neurosurg sensorimotor loss. Brain 2001; Psychiatry 2003; 74:591–596. 124:1077–1090.

4. First MB, Williams JBW, 12. Sar V, Akyuz G, Kundakci T, et Gibbon M et al: The structured clinical al. Childhood trauma, dissociation, and interview for DSM-IV axis I disorders- psychiatric comorbidity in patients with clinical version. American Psychiatric conversion disorder. Am J Psychiatry Association, American Psychiatric Press, 2004; 161:2271–2276. Washington. 1997; 452-7. 13. Slater ET, Glithero E. A follow 5. Kaplan HI, Sadock BJ. Synopsis up of patients diagnosed as suffering of psychiatry:behavioral sciences & from ‘hysteria’. J Psychosom Res. 1965; clinical psychiatry, 10th ed. Lippincott 9:9-13. Williams and Wilkins. 2007; 638-642.

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14. Cernovsky Z, Landmark J. 16. Joubert PM. Anxiety and Correlates of hysterical symptoms in hysterical symptoms in schizophrenia. S schizophrenic patients. Psychological African Psychiatry Rev. 2002; 5(4): 9- Reports. 1994; 75 (1): 251-5. 14.

15. Noble D. Hysterical symptoms 17. van der Hart O, Witzum E, manifest in schizophrenic illness. Friedman B. From hysterical psyhosis to Psychiatry XIV. 1951; 153-160. reactive dissociative psychosis. J of Traumatic . 1993; 6(1): 1-13.

Corresponding author: Ting Joe Hang, Department of Psychological Medicine, Faculty of Medicine, University Malaya, 50603 Kuala Lumpur.………………………..

Email: [email protected]

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