Conversion disorder

Michael B. Russo, MD*

Franklin R. Brooks, PhD^

Jason Fontenot, MD^^

Bruce M. Dopler, MD (sec) Edward T. Neely, MD (sec)

Alan W. Halliday, MD (sec)

We describe a patient originally diagnosed with clinically definite multiple sclerosis whose actual diagnosis of conversion disorder was revealed when his examination was found to be fictitious, his radiological, electrophysiological, and biochemical tests were determined to be normal, and his symptoms were reversed through the use of sodium pentothal and hypnosis.

Background

The co-morbidity of psychiatric illness in patients with multiple sclerosis (MS) is well established. Patients with MS may develop memory loss, mania, psychoses, or depression. Several cases have been described of conversion disorder compounding the disability in patients with MS. 2 One patient described as having a conversion disorder and possible multiple sclerosis was later determined to have only factitious disorder.3 No case has been described of conversion disorder presenting as multiple sclerosis.

Case

A 40-year-old man with a referral diagnosis of clinically definite multiple sclerosis was sent for evaluation to our neurology service as part of the process of verifying the diagnosis and establishing the level of disability before his retirement from the U.S. Army. He had been in good health and active until age 36, when he presented to the troop medical clinic with complaints of left upper-extremity paresthesias. The patient soon thereafter complained of episodes of diffuse tingling sensations in all extremities and was told that he could possibly have multiple sclerosis. He was referred to a neurologist, who reported a normal exam and normal brain and cervical magnetic resonance imaging (MRI) results. The patient developed complaints of fatigability, heat intolerance, numbness, chronic tremor in the right arm, and weakness in the right leg. A second neurological examination documented what were thought to be several beats of ankle clonus. He was again evaluated with brain MRI, and the results were normal. Cerebrospinal fluid was sent for oligoclonal banding, which was negative. During this second year, the patient was evaluated by a psychiatrist, who suggested that he had a conversion disorder and a dependent personality disorder.

During the third year of his illness, the patient became dependent on a wheelchair and developed bilateral thigh atrophy, but he remained mentally sharp and energetic. A neurological diagnosis of clinically definite MS was made.

When we evaluated the patient 4 years after symptoms began, multiple inconsistencies in the history and examination were found. The absence of visual, ocular, and bulbar complaints was disturbing considering the extent of the symptoms. In the examination, the tremor was flailing and irregular in both frequency and occurrence. The clonus and hyperreflexia were intermittent, unsustained, and without spastic muscle tone. Furthermore, the complaint of severe lower-body weakness was accompaniedby an erect and well-balanced sitting posture. The la belle indifference over the loss of much of his body function was inconsistent with the usual affects of patients with progressing neurological disease.

MRI of his brain and entire spine was performed for a third time, and again the results were normal. Cerebrospinal fluid was reevaluated for oligoclonal bands, myelin basic protein, and kappa and lambda protein chains, and all were found to be within normal ranges. Brainstem and somatosensory-evoked responses were also normal. We suspected that there was no physiological component to his MS presentation, and suggested that through the use of sodium pentothal hypnosis some of the symptoms might be reversed.4 We focused on relieving the weakness in his legs and the arm tremor.

The tremor, clonus, weakness, and hyperreflexia were reversed with suggestion, and the patient walked unassisted. The patient was later told that his symptoms were not caused by physiological multiple sclerosis and that the reversals achieved under hypnosis could be sustained with psychotherapy.

Discussion

The psychiatric differential diagnosis includes somatization disorder, factitious disorder, malingering, and conversion disorder. Somatization was ruled out because the patient's symptoms began well after age 30 years, the maximum age permissible for the onset of symptoms in that diagnosis, according to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders.5 In factitious disorder, a patient consciously develops symptoms for which he or she then repeatedly seeks medical care. This patient's symptoms appeared to develop unconsciously, as shown by the development of thigh atrophy. Muscle tone cannot be consciously inhibited to the stage of atrophy. Furthermore, the patient's concern for care was less than might be expected considering the rate and extent of functional deterioration. Malingering is also a conscious process and develops from a desire for secondary gain. This patient undoubtedly knew that medical disability would boost his retirement income, but he had no guarantee of being granted benefits. At the same time, his quality of life deteriorated significantly compared with his previous functional level. It is possible that this patient's fear of leaving the military outweighed his concern for his own health. Conversion disorder was suggested early on, but the possibility of neurological disease dominated the thinking at that time.

This patient eventually demonstrated all of the features required for the diagnosis of conversion disorder. Doubt regarding the organic cause of the symptoms is a required feature of conversion disorder and has been exhaustively described. The symptoms of conversion cannot be under voluntary control, and the development of disuse atrophy in the patient's thighs would be consistent with an unconscious process and expected in a long-standing conversion.6

The essential feature of conversion is an association with an identifiable psychological stress. In this case, the stress necessary to precipitate the conversion was being passed over for further promotion and the realization that retirement was imminent. The conflict arose when the patient saw no life beyond the military, and the conflict resolution was to become as physically dependent as he had been psychologically.

The military, for many members, especially those at the top of the pyramid, is more than a job; it is an extended family, a way of life, and usually the only life the member has known. The patient in question was quite well educated, had a high average intelligence quotient, and had risen to a high military rank. Throughout his career, he was effective in a position that had no civilian counterpart. The internal conflict associated with impending forced retirement in a senior noncommissioned officer with a large young family cannot be underestimated. We suggest that this patient unconsciously had found a way to relieve the trauma of separation.

The symptom course may represent a series of related individual conversions constituting a progressing conversion syndrome, or it might demonstrate that conversion disorder need not present in its entirety as a sudden event. In an educated patient, it is conceivable that conversion could take on the features of a well-known and complex neurological disease. We recommended withdrawal of the medical therapies on which this patient had developed dependence and referral for psychotherapy.

This case highlights the difficulty of discerning subtle neurological disease with psychiatric overlay from a purely psychiatric disorder. It demonstrates the development of conversion disorder in an educated, successful, and respected citizen and shows how psychiatric illness can closely mimic organic disease.

References

1. Caplan LR, Nadelson T. Multiple sclerosis and hysteria: lessons learned from their association. JAMA 1980; 243: 2418-21.

2. Nicolson R, Feinstein A. Conversion, dissociation, and multiple sclerosis. J Nerv Ment Dis 1994; 182: 668-9.

3. Berry JF, Hillis RE, Hitzman SE. Factitious triplegia: case report. Arch Phys Med Rehabil 1994; 75: 1161-4.

4. Russo MB, Brooks FR, Fontenot J, Dopler BM, Neely EW, Halliday AW: Sodium pentothal hypnosis: a procedure for evaluating medical patients with suspected psychiatric co-morbidity. Milit Med 1997; 162: 215-8.

5. Diagnostic and Statistical Manual of Mental Disorders, Ed 4. Washington, DC, American Psychiatric Association, 1994.

6. Kaplan HI, Sadock BJ, eds: Comprehensive Textbook of Psychiatry, Ed 4, pp 932-3. Baltimore, MD, Williams & Wilkins, 1985.

*Walter Reed Army Institute of Research, Division of Neuropsychiatry, Washington, DC 20307-5100.

^Psychology Service, ^^Anesthesia Service, and Neurology Service, Brooke Army Medical Center, San Antonio, TX 78234.

This manuscript was received for review in July 1997. The revised manuscript was accepted for publication in February 1998.

Copyright Association of Military Surgeons of the U.S. Oct 1998
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