Cases That Test Your Skills

A teen who is wasting away John Leipsic, MD

How would you Cassandra, age 17, presents with and muscle wasting, but handle this case? medical workup is negative for any illness. Her father wants you to Visit CurrentPsychiatry.com to input your answers order more tests. How would you address his demands? and see how your colleagues responded

CASE Weak and passive Cassandra’s father is unemployed and Cassandra, age 17, recently was discharged has no social contacts or supports. He as- from a medical rehabilitation facility with a serts that “the medical system” is against him, diagnosis of conversion disorder. Her school and he believes medical interventions are performance and attendance had been harming his daughter. He keeps Cassandra steadily declining for the last 6 months as she isolated from friends and other family lost strength and motivation to take care of members. herself. Cassandra lives with her father, who is her primary caretaker. Her parents are sepa- How would you proceed? rated and her mother has fibromyalgia and a) separate Cassandra from her father dur- chronic fatigue syndrome, which leaves her ing the interview unable to care for her daughter or participate b) contact Cassandra’s mother for collateral in appointments. information Now lethargic and wasting away physically, c) assure Cassandra that there is no medical Cassandra is pushed in a wheelchair by her cause for her physical condition weary father into a child psychiatrist’s office. d) order the testing her father requests She does not look up or make eye contact. Her father says “the doctors didn’t know what they were doing. That needle test, a nerve conduc- EVALUATION Demoralized, hopeless tion study they did, is what made her worse.” Cassandra is uncooperative with the interview Although Cassandra moves her arms to adjust and answers questions with one-word an- herself in the wheelchair, she does not move swers. Her affect is irritable and her demeanor her legs or try to move the wheelchair. is frustrated. She does not seem concerned Cassandra’s father states that she has “con- that she needs assistance with eating and genital neuromyopathy. Her mother gave it to toileting. her in utero. But nobody listens to me or orders When outpatient treatment with her pri- the tests that will prove I am right.” He insists on mary care physician did not stop her physical obscure and specialized blood tests and immune deterioration, she was referred to a tertiary function panels to prove that a congenital condi- care academic medical center for a complete tion is causing his daughter’s deterioration and physical debility. He is unwilling to accept that Dr. Leipsic is Assistant Professor of Child and Adolescent Current Psychiatry, University of Arizona College of Medicine, 40 June 2013 there is any other cause of her condition. Tucson, AZ. Cases That Test Your Skills

medical and neurologic workup. The workup, Table 1 including an MRI, electroencephalogram, nerve conduction studies, and full immunologic pan- Differential diagnosis els, was negative for any physical illness, includ- of somatoform disorders ing neuromuscular degenerative disease. A muscle biopsy was considered, but not ordered Conversion disorder because Cassandra and her father resisted. During this hospitalization, she was diag- nosed with conversion disorder by the psy- chiatry consultation service, and transferred to a physical rehabilitation facility for further syndrome by proxy. An underlying de- care. At the rehab facility, Cassandra’s father pressive or also should be interfered with her care, arguing constantly considered and treated appropriately. Clinical Point with the medical team. Cassandra demon- Conversion disorder has a challeng- strated no effort to work with physical or ing and often complex presentation in An overbearing and was discharged children and adolescents. Conversion and conflict- after 2 weeks because of noncompliance disorders in children commonly are as- prone parenting with treatment. Cassandra and her father are sociated with stressful family situations style is associated resentful that no physical cause was found including divorce, marital conflict, or loss with childhood and feel that the medical workup and time at of a close family member.1 An overbear- conversion disorders the rehabilitation facility made her condition ing and conflict-prone parenting style also worse. The rehabilitation hospital referred is associated with childhood conversion Cassandra to an outpatient child psychiatrist disorders.2 Common physical symptoms for follow-up. in conversion disorder are functional ab- During the intake evaluation and follow- dominal pain, partial , numbness, up appointments with the child psychiatrist, or seizures. Individuals such as Cassandra her affect is negativistic and restrictive. She who are unable to express or verbalize is resistant to talking about her condition their emotional distress are vulnerable to and accepting psychotherapeutic interven- expressing their distress in somatic symp- tions. She is quick to blame others for her lack toms. Cassandra demonstrates La belle in- of progress and unable to take responsibility difference, the characteristic attitude of not for working on her treatment plan. Cassandra being overly concerned about what others feels demoralized, depressed, and hopeless would consider an alarming functional about her situation and prospects for recov- impairment. ery. She feels that no one is listening to her father and if “they did just the tests he wants, . A diagnosis of de- we will know what is wrong with me and that lusional disorder, somatic type with fa- he is right.” milial features was considered because Cassandra and her father shared persecu- tory and paranoid beliefs that her condition The author’s observations was brought on by some hidden, unrec- Discuss this article at Table 1 lists conditions to consider in the ognized medical condition. A delusional www.facebook.com/ differential diagnosis of conversion dis- disorder with shared or “familial” features CurrentPsychiatry order. Although Cassandra’s conversion develops when a parent has strongly held disorder diagnosis appears to be appropri- delusional beliefs that are transferred to ate, it is important to consider 2 other pos- the child. Typically, it develops within the sibilities: delusional disorder, somatic type context of a close relationship with the Current Psychiatry with familial features, and Munchausen parent, is similar in content to the parent’s Vol. 12, No. 6 41 Cases That Test Your Skills

Table 2 b) hospitalize Cassandra for intensive treat- ment of conversion disorder Enhancing acceptance c) start Cassandra on an atypical of and recovery from conversion antipsychotic disorder d) begin cognitive-behavioral therapy (CBT) Validate and acknowledge that the patient’s and an distress is real to him or her Reassure the patient and family that no physical cause of illness has been found Treatment approach Explain that conversion disorder is a mind- body condition Treating a patient with a conversion dis- Emphasize that the condition is not under the order, somatic type starts with validating patient’s voluntary control and is not his or her that the patient’s and parent’s distress is fault Clinical Point real to them (Table 2).5 The clinician ac- Explain that the condition is physically knowledges that no physical evidence of Munchausen by disabling and that careful, appropriate, and intensive treatment is necessary physiological dysfunction has been found, proxy is a condition Shift the focus from finding what is wrong which can be reassuring to the patient and whereby illness- to engaging the patient in recovery and family. The clinician then states that the pa- rehabilitation to return to normal functioning producing behavior tient’s condition and the physical manifes- Source: Reference 5 is exaggerated, tation of the symptoms are real. A patient’s or parent’s resistance to this reassurance fabricated, or may indicate that they have a large invest- induced by a parent belief, and is not preceded by or ment in the symptoms and perpetuating prodromal to .3 the dysfunction. Because Cassandra’s father transferred Taking a mind-body approach— his delusional system to his daughter, she explaining that the child’s condition is cre- clung to the belief that her physical symp- ated and perpetuated by a mind-body con- toms and immobility were caused by med- nection and is not under their voluntary ical misdiagnosis and failure to recognize control—often is well received by patients her illness. Cassandra’s father strongly re- and parents. The treating clinician empha- sisted and defended against accepting his sizes that the condition is physically dis- role in her medical condition. abling and that careful, appropriate, and intensive treatment is necessary. Munchausen by proxy. Because Cassandra A rehabilitation model has power for and her father share a delusional system that patients with conversion disorder because prevented her from accepting and follow- it acknowledges the patient’s discomfort ing treatment recommendations, it is pos- and loss of function while shifting the fo- sible that her father created her condition. cus away from finding what is wrong. The Munchausen syndrome by proxy is a con- goal is to actively engage patients in their dition whereby illness-producing behavior own care to help them return to normal in a child is exaggerated, fabricated, or in- functioning.6 duced by a parent or guardian.4 Separating Cassandra was encouraged to par- Cassandra from her father and initiating ticipate in , go to school, antipsychotic treatment for him are critical and take care of herself. Actively par- considerations for her recovery. ticipating in her care and recovery meant that Cassandra had to leave the sick role How would you treat Cassandra? behind, which was impossible for her fa- a) call Child Protective Services (CPS) to ther, who saw her as passive, helpless, and Current Psychiatry 42 June 2013 remove Cassandra from her father’s custody fragile. Cases That Test Your Skills

TREATMENT Pharmacotherapy, CBT Table 3 During psychiatric evaluation, it becomes clear that in addition to her physical debil- Family risk factors for pediatric ity, Cassandra has major depressive disorder, somatoform disorders moderate without psychotic features. Her Somatization draws attention away from family conflict or tension contributes to her hopelessness and lack of participation in treatment. After Enmeshment blurs family boundaries with overinvolvment and hyper-responsiveness discussion with her family about how her de- Rigidity and lack of conflict resolution impede pressive symptoms are preventing her recov- parent-child communication ery, Cassandra is started on escitalopram, 10 Somatic complaints avoid emotional mg/d. CBT helps her manage her depressive expression that increases family symptoms, prevent further somatization, Source: Reference 11 and correct misperceptions about her body Clinical Point function and disabilities. For conversion disorder patients, physical disorders,7 or sexual abuse8 produce the Cassandra’s physical therapy can be combined with incentives tied negative emotions caused by the primary debility may have to improvements in functioning. Cassandra conflict. Cassandra yearned for a closer been her way to has overwhelming anxiety while attempt- relationship with her mother, yet she re- foster dependency on ing physical therapy, which interferes with mained enmeshed with poor intrapsy- her father and protect her participation in the therapy. Lorazepam, chic boundaries with her father. The fact him from perceived 0.5 mg/d, is prescribed for her intense anxi- that he assisted his 17-year-old daughter ety and panic attacks, which led her to avoid with toileting raised the possibility of persecution physical therapy. sexual abuse. Sexual abuse could have led Staff at the rehabilitation hospital calls CPS to her depression and physical decline. because Cassandra’s father interferes with her Cassandra’s physical debility also may care and treatment plan. CPS continues to have been her way to foster dependency monitor Cassandra’s progress through outpa- on her father and protect him from per- tient care. An individualized education plan ceived persecution. and psychoeducational testing help determine Conversion disorder may have been a a school placement to meet Cassandra’s educa- result of Cassandra’s defense mechanisms tional needs. against admitting abuse and protect- CPS directs Cassandra to stay with her ing against abandonment. Establishing mother for alternating weeks. While at her a therapeutic alliance with Cassandra is mother’s, Cassandra is more interested in tak- essential to allow a graceful exit from the ing care of herself. She helps with getting her- conversion disorder symptoms and her self into bed and to the toilet. Upon returning father’s hold on her thinking about her to her father’s home, these gains are lost. illness. However, this alliance may seem to threaten the child’s special connection with the parent. A therapeutic alliance The author’s observations was elusive in Cassandra’s case and likely Psychodynamic and unconscious motiva- nearly impossible. tors for conversion disorder operate on Both parents underwent court-ordered a deeper, hidden level. The underlying psychological testing as part of the CPS primary conflict in pseudoseizures—a evaluation. Testing on Cassandra’s father more common conversion disorder—has indicated a rigid personality structure with been described as an inability to express long-standing and mistrust of au- negative emotions such as anger. Social thority. Because Cassandra endorsed his Current Psychiatry problems, conflict with parents, learning delusional system completely, it is likely Vol. 12, No. 6 43 Cases That Test Your Skills

haviors as a way to cope with stress and Related Resource gain attention to her needs. • Seltzer WJ. Conversion disorder in childhood and adoles- Cassandra’s negative affect, sensi- cence: a familial/cultural approach. Family Systems Medicine. 1985;3(3):261-280. tivity to change, and lack of resiliency Drug Brand Names were further risk factors for developing Escitalopram • Lexapro a somatoform illness.10 She resisted and Lorazepam • Ativan would not follow through with physical Disclosure therapy. Krisnakumar10 also reported that Dr. Leipsic reports no financial relationship with any company an inability to persist in completing tasks whose products are mentioned in this article or with manufac- turers of competing products. is a risk factor for somatoform disorder. Family dynamics of problematic parental interactions also played a role in her so- Clinical Point matoform disorder (Table 3, page 43).11 that her father inculcated her into believing Children who live his beliefs and transmitted his with a mother with to her by their close proximity and time OUTCOME Foster care, improvement a chronic illness are together. Based upon this delusional belief Cassandra receives weekly CBT and biweekly at risk of developing system, Cassandra gave up trying to move medication monitoring and demonstrates psychosomatic her legs and her muscles atrophied. Her a moderate improvement in mood with legs were so weak that she stopped trying less negativity and irritability. Her anxiety disorders to walk or move, illustrating the power of symptoms gradually respond to treatment. the mind-body connection to produce func- However, her emotional gains are not matched tional and physiological changes. with improvement in her physical functioning Children who live with a mother with or participation in physical therapy. Cassandra chronic illness are at risk of developing does not recover her muscular strength or psychosomatic disorders.9 Cassandra’s control and shows little improvement in her mother had fibromyalgia and chronic physical capacity and independence. pain with symptoms of headache, weak- After 3 months of treatment, Cassandra ness, and muscle pain and frequent does not make sufficient progress or actively medical office visits and tests without participate in treatment. Because her father definitive results or symptom relief. continues to interfere with the treatment plan Although Cassandra did not live with and does not receive treatment himself, CPS her mother, Cassandra’s somatization obtains a court order to prevent her father symptoms may be a result of modeling from directing her medical care and telling her or observational learning within her fam- treating physicians which tests to order. ily.9 Cassandra may have unconsciously Because these interventions do not im- adopted her mother’s symptoms and be- prove her treatment response, Cassandra is

Bottom Line Patients with conversion disorder present with functional impairment and physical symptoms without clear physiological causes. Parents have a strong influence on the presentation and course of conversion disorder in children and adolescents. Parents’ mental and physical illnesses are independent risk factors for childhood somatoform disorders. Evaluation of parents’ psychological and psychiatric state is Current Psychiatry 44 June 2013 essential to determine intervention. removed from her parents’ care and placed Philadelphia, PA: Lippincott Williams & Wilkins; 2000: 1243-1264. in a therapeutic foster care home, thereby 4. Meadow R. Munchausen syndrome by proxy. The improving her independence and chances hinterland of child abuse. Lancet. 1977;2(8033):343-345. 5. Campo JV, Fritsch SL. Somatization in children and for recovery. After 3 months in foster care, adolescents. J Am Acad Child Adolesc Psychiatry. 1994; she more actively participates in her physical 33(9):1223-1235. 6. Campo JV, Fritz G. A management model for pediatric rehabilitation. Water therapy, with the buoy- somatization. Psychosomatics. 2001;42(6):467-476. ancy and support in water, helps her regain 7. Silver LB. Conversion disorder with pseudoseizures in muscle strength and control of her lower adolescence: a stress reaction to unrecognized and untreated learning disabilities. J Am Accad Child Psychiatry. 1982; extremities. 21(5):508-512. 8. Alper K, Devinsky O, Perrine K, et al. Nonepileptic seizures References and childhood sexual and physical abuse. . 1993; 43(10):1950-1953. 1. Wyllie E, Glazer JP, Benbadis S, et al. Psychiatric features of children and adolescents with pseudoseizures. Arch Pediatr 9. Jamison RN, Walker LS. Illness behavior in children of Adolesc Med. 1999;153(3):244-248. chronic pain patients. Int J Psychiatry Med. 1992;22(4): 329-342. 2. Salmon P, Al-Marzooqi SM, Baker G, et al. Childhood family dysfunction and associated abuse in patients with 10. Krisnakumar P, Sumesh P, Mathews L. Tempermental nonepileptic seizures: towards a casual model. Psychosom traits associated with conversion disorder. Indian Pediatr. Med. 2003;65(4):695-700. 2006;43(10):895-899. 3. Manschreck T. Delusional disorder and shared psychotic 11. Minuchin S, Rosman BL, Baker L. Psychosomatic families: disorder. In: Sadock BJ, Sadock VA, eds. Kaplan & in context. Cambridge, MA: Harvard Sadock’s comprehensive textbook of psychiatry. 7th ed. University Press; 1978.

Commentary continued from page 35 and participate in a thoughtful, balanced, References 1. Carvalho A. Ideological cultures and media discourses on and logical process that keeps the patient’s scientific knowledge: re-reading news on climate change. Public Underst Sci. 2007;16(2):223-243. interests closely in mind. In Horgan’s case, 2. Centers for Medicare & Medicaid Services (CMS), he might have acknowledged that his HHS. Medicare, Medicaid, Children’s Health Insurance Programs; transparency reports and reporting of physician friend’s son’s antidepressant discontinua- ownership or investment interests. Final rule. Fed Regist. tion carried a risk of a negative outcome. 2013;78(27):9457-9528. 3. Pew Research Center’s Project for Excellence in Journalism. That is, he could have mentioned the ben- Ethics codes. http://www.journalism.org/resources/ ethics_codes. Accessed November 21, 2012. efit side of the risk-benefit calculation. 4. Smith MJ, Ellenberg SS, Bell LM, et al. Media coverage of Journalists should follow guidelines the measles-mumps-rubella vaccine and controversy and its relationship to MMR immunization rates in the to prevent scaring readers into jumping United States. Pediatrics. 2008;121(4):e836-e843. to unilateral conclusions, stopping their 5. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder, third needed medications and relapsing, or edition. http://psychiatryonline.org/content.aspx?bookid =28§ionid=1667485. Published October 2010. Accessed worse. There’s precedent for such guide- November 21, 2012. lines. In 2001, several organizations col- 6. Glazer WM. Rebuttal: questioning the validity of ‘anatomy of an epidemic’ (part 1). Behav Healthc. 2011; laborated to release “Reporting on Suicide: 31(7):42, 44-45. Recommendations for the Media.”8 A 7. Horgan J. Are psychiatric medications making us sicker? The Chronicle of Higher Education. September 12, recent study found that these guidelines 2011. http://chronicle.com/article/Are-Psychiatric- Medications/128976. Accessed November 21, 2012. impacted journalists’ behavior.9 Similar 8. Centers for Disease Control and Prevention, National guidelines should be developed for jour- Institute of , Office of the Surgeon General, and Mental Health Services nalists who report on scientific studies re- Administration, American Foundation for Suicide Prevention, American Association of Suicidology, lated to psychiatric treatments. I welcome Annenberg Public Policy Center. Reporting on suicide: hearing case examples in which patients recommendations for the media. http://www.sprc.org/ sites/sprc.org/files/library/sreporting.pdf. Accessed decided inappropriately to discontinue March 21, 2013. medications in response to reading news 9. Tatum PT, Canetto SS, Slater MD. Suicide coverage in U.S. newspapers following the publication of the media articles. guidelines. Suicide Life Threat Behav. 2010;40(5):524-534. Current Psychiatry Vol. 12, No. 6 45