Cases That Test Your Skills A teen who is wasting away John Leipsic, MD How would you Cassandra, age 17, presents with weakness 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 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 Somatization disorder muscle biopsy was considered, but not ordered Conversion disorder because Cassandra and her father resisted. Hypochondriasis During this hospitalization, she was diag- Body dysmorphic disorder 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 anxiety disorder 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 occupational therapy 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 paralysis, 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, Delusional disorder. 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 antidepressant 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 psychosis or ment in the symptoms and perpetuating prodromal to schizophrenia.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