Jefferson Journal of Psychiatry Volume 16 Issue 1 Article 3 January 2001 Conversion Disorder in a Depressed Patient: The Analysis of Paralysis Michael A. Chen Ph.D. University of Michigan Medical School, Ann Arbor, MI David S. Im M.D. Department of Psychiatry, University of Michigan Medical Center, Ann Arbor, MI Follow this and additional works at: https://jdc.jefferson.edu/jeffjpsychiatry Part of the Psychiatry Commons Let us know how access to this document benefits ouy Recommended Citation Chen, Michael A. Ph.D. and Im, David S. M.D. (2001) "Conversion Disorder in a Depressed Patient: The Analysis of Paralysis," Jefferson Journal of Psychiatry: Vol. 16 : Iss. 1 , Article 3. DOI: https://doi.org/10.29046/JJP.016.1.002 Available at: https://jdc.jefferson.edu/jeffjpsychiatry/vol16/iss1/3 This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Jefferson Journal of Psychiatry by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: [email protected]. Conversion Disorder in a Depressed Patient: The Analysis of Paralysis 2 Michael A. Chen, Ph.D. I and David S. 1m, M.D. Abstract Pat ients presenting with neurologic andpseudoneurologic symptoms present both a diagnostic and treatment challenge. This case report describes the ER course ofa man who presented wi th aphonia and paralysis, his medical clearance, transfer to the psychiatric ER and subsequent recovery. Th e history qfconversion disorder and its characteristics are briefiy reviewed, and the etiology qfthi s patient 's symptoms and a discussion qfeffectioe treatment pla ns are discussed. Although the conce pt of conversion symptoms dates at least to th e ancient Greeks and was discussed by Freud and Breu er in Studies on Hy steria ( I) in the la te 1890's, it has been an in cr easingly infrequent (although not rare) diagnosis. In contrast to most other DSM diagnoses, unconscious processes or conflicts are implicated in the development of conversion disorder. Conversion di sorder generally involves a symbolic relationship between an underlying psychological conflict and disturbed physical functioning. "Classic" symptoms include paralysis, aphonia , sei­ zures, malcoordination, dyskinesia, blindness , anesthesia, a nd parasthesias. The disorder has been most com monly described in rural women of lower socio -economic status. The following case des cribes a well- educated man wh o was brou gh t to the Emergency Department after becoming acutely unresponsive (with paralysis and aphonia), and highlights his subse q ue nt course in th e emergency setting . CASE REPORT Mr. B was a 47-year-old man who was brought to the Medical ER unrespon sive to verbal com ma nds (but responsive to ammonia) , with paralysis a nd apho nia. According to on e ofMr. B's cowo rk ers, earl ie r that day Mr. B had been fired from his job, and following an argum ent with his bos s, Mr. B became verbally non com muni­ cative and began to hyp erventilate. Shortly thereafter he collapsed, and an ambu­ lance was calle d. Upon arrival to the Medical ER he remained unresponsive, th ough on rare occasions his eye s would op en to voice. During these times he would intermittently become tearful wh en asked about the ea rl ie r eve nts of th at day. I Fourth Year Medi cal Student, Univer sity of Michigan Medi cal School, An n Arbor, MI 48 109 2 Psychiatric Resid en t, Department of Psychiatry, Univ ersity of Michigan Medical Center, Ann Arbor, MI 48109 9 10 J EFFERSON J O URJ"AL OF PSYCHIATRY Physical exa mination (including a detailed neurologic exam) was reportedly unre­ markabl e. Becau se sta ff could not rul e out toxic ingesti on , a nasogastric lavage was performed with ac tivate d cha rcoa l ad ministration. O xygen saturation by pulse oxime t ry was 98%, and blood and urine toxicology screens were negative. An elec t rocardiogra m was normal. After three hou rs in th e Med ical ER, it was felt by the ER staff th at no clear medi cal or neurological etiology cou ld account for Mr. B's clinica l pr esentation , and an urgent psychiatric referral was made. Upon arrival to th e Psychiatric Em ergen cy Room Mr. B was somewhat able to move his arms, but un abl e to sit up or speak. Over th e next few hou rs he displayed a slow, gra dua l improvem ent in his mobility and ability to vocal ize, ini tially voicing (with gre at difficulty) on e-word phrases such as "wife" and "da ug hter," and later indicating th at he did not want an y of his family to be contacted. Afte r thi s significant change in his st atus, a full neurologic examination was performed. This was entirely within normal limits (in particular, th ere was no evide nce of any se nsory/motor deficit s, abnormal muscle ton e, abnormal reflex responses, or other focal ab normal­ iti es). Mental st atus examination was notable onl y for mildly impaired at tcntion/ conce ntration (slow se ria l seve ns) and short-term memory (he rem em bered the th ird of three object s on delayed recall onl y after being pr ompted with th e first letter). Once he was finall y able to vocal ize, Mr. B provided inform ation regarding his past psychi atric history. He rep orted seeing a psychologist for a short time in high schoo l for "de pression," stating that this was not particul arly helpful. Four years pri or to this episode, whil e on a bu sin ess trip, he became angry and "tore up a hotel room" (e.g., throwing furniture and other obj ects). At th at time he was admitted to a psychi atric hospital overn ight, and was released on Xan ax and an antidepressant (he could not remember th e name). At th e time of our eva lua tion, Mr. B's wife was livin g at her mother's house. Mr. B eventually gave permission for staff to call his wifc. Discussion with his wife confirme d that she was staying with her mother, but th at she (according to his wife) was doing so becau se of Mr. B's violent behavior (smas hing and throwing household obj ects ) and verba l abuse . Three mon th s prior to our evaluation, Mr. B reported calling 911 "on himself" afte r he had th reaten ed to throw his wife down th e stairs. Mr. B also reported a vagu e hist ory of su icida l ideation in the past (no attempts), and minimized th e signifi cance of th ese th ough ts. H e cite d his relationship with his biological daughter as on e rea son he would not comm it suicide. How ever, he also admitted to recently telling his wife th at she "m ight as well keep th e insurance because I'd be better off dead." H e deni ed any homicidal ideation. Mr. B reported no significant past medical history, nor was he taking any medi cations at th e time of our evaluation. The patient's family history was significant for alcohol abuse in both par ents. He reported that his mother died from complications of alcoholic cirrhosis, and th at his father had struggled with depression as well as alcoholism . He reported no history of ph ysical or sexual abuse as a child. Mr. B was a college graduate, and had obtained a Mast er's degr ee in physics as well as a partial compute r scien ce degree. H e had worked in th e field of compute r COi\rvERSION DISORDER CASE REPORT 11 science for twenty years. At th e time of his pr esentation, he was involved in the sale of compute r software. He had been working 60 hours a week , a nd was aware of declining work performance over th e last six months. The patient reported living at home with his wife, her dau ghters from a previous marriage, and his daughter. He e mphasized that he had a pa rt icul arly good rela­ tionship with his biological daughter, and that he was ge tt ing along well with his former wife (who had also remarried) and her husband. Mr. B reported that for th e past two yea rs he had ex pe rie nce d worsening depressive symptoms, including decr eas ed sleep, impaired conce ntration, low energy, diminished appetite, and feelings of hopelessness and worthlessn ess. These symp­ toms had occurred in th e conte xt of a number of psychosocial st ressors . First , as noted pr eviously, Mr. B had been expe rienc ing seve re work stress and had not ed a recent decline in his work performance culm ina ting in his termination on th e day of our evalua tion. Second, Mr. B reported that he and his wife were involv ed in a custody battle over his wife's childre n from a pr evious marriage.