Conversion disorder presenting as hemiplegia and hemianesthesia with loss of neurologic reflexes: a case report.

Abstract: Conversion disorders can present with a variety of sensorimotor signs and symptoms. We present the case of a young woman who presented with sudden onset hemiplegia and hemianesthesia including unilateral loss of deep tendon reflexes, Babinski reflex, and loss of rectal tone with bladder incontinence. The loss of rectal tone, loss of deep tendon reflexes, and a flaccid Babinski reflex are unusual signs in conversion disorders. A thorough medical workup including x-rays, CT scans, and magnetic resonance imaging revealed no organic causes for the neurologic deficits. Before the onset of symptoms, the patient was emotionally upset during an argument, which may have provided the psychologic stressor necessary for a conversion disorder. The young woman gradually regained full neurologic function over the next 14 hours. Conversion disorders should be considered when the neurologic findings do not correspond to known anatomic or physiologic pathways, although a thorough medical investigation must be performed to search for organic causes.

Key Words: conversion disorder, hemiplegia, hemianesthesia, reflexes, rectal tone

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Conversion disorders are typically first seen by emergency physicians and primary care providers. They can present with a wide variety of sensorimotor signs and symptoms that cannot be explained by anatomic or physiologic pathways. (1,2) A thorough medical examination must be performed to rule out organic causes for the symptoms. (1-3) The physical examination also helps to differentiate between a variety of psychiatric conditions, including conversion disorders, that can present with neurologic symptoms. The onset of symptoms in conversion disorders are typically preceded by a psychological stressor or conflict, (2) and most will resolve spontaneously within a few days. (1) The purpose of this case report is to present an unusual patient presentation in which the patient developed hemiplegia and hemianesthesia with loss of deep tendon reflexes and the Babinski reflex on the affected side, and had loss of rectal tone, which is under autonomic nervous system control.

Case Report

A 22-year-old female with no significant medical history was brought in by EMS with the sudden onset of hemiplegia with complete loss of motor function and sensation on the right side of the body from the neck down. Before onset, the patient had consumed several alcoholic drinks and had been arguing with her boyfriend throughout the night. While walking back to her hotel, the patient became unsteady on her feet, and she started to fall to the ground. The patient was caught by her boyfriend as she was falling, but she hit the back of her head on the ground. There was no loss of consciousness or obvious injury sustained after the fall, and the patient was able to walk back to her hotel without further difficulty. Approximately 30 minutes after the fall, the patient was sitting down, again arguing with her boyfriend, when she realized that she could not stand up and could not move the right side of her body.

At arrival of the paramedics, the patient was supine on the bed, alert and oriented to person, place, and time. Her Glasgow Coma Scale was 15. The patient was calm initially, but had brief periods of hysterical behavior. Initial vitals revealed a blood pressure of 118/60, pulse of 98, respiratory rate of 16, fingerstick glucose 118 mg/dL, and pO2 100 on room air. The physical examination revealed no obvious signs of trauma. The patient had complete loss of voluntary motor control on the right side of her body. She had no neurologic deficits above the neck, or on the left side of the body. The remainder of the physical examination was unremarkable. A C-collar was applied and the patient was secured to a long spine board without change in neurologic examination and was transported emergently to the Level 1 Trauma Center Charity Hospital in New Orleans.

The physical examination at arrival in the emergency department was unchanged from the initial paramedic assessment. Further neurologic examination revealed a complete loss of sensation and motor function on the right side of her body starting at the midsagittal line, from the base of the neck down, including the arm and leg. Sensory loss included pain, proprioception, and cutaneous light touch sensation. Occasional involuntary muscle fasciculations were noted in the right hand. The patient had no deep tendon reflexes in the upper or lower extremities, had a flaccid Babinski reflex, and was incontinent of bladder. Rectal examination revealed no sphincter tone. Complete blood count, basic metabolic panel, and urinalysis were all normal. Urine toxicology screen was positive for ethanol, and her blood alcohol level was 98 mg/dL. Chest x-ray was clear with no findings. X-rays of the cervical, thoracic and lumbar spine showed no evidence of acute fracture or sub-luxation. CT scans with and without contrast of the head and spine were also negative for any injuries, bleeding, or impingement on the spinal cord. A magnetic resonance angiogram of the carotids and vertebral arteries were all normal. Magnetic resonance imaging scans of the head and spine were also normal.

A few hours after the onset of symptoms, the patient regained some motor function and sensation in the arm and leg. Over the next 10 hours, she continued to recover more motor and sensory function. The patient was discharged 14 hours after admission with full neurologic recovery.

Discussion

Conversion disorders can present with a variety of neurologic symptoms that typically do not conform to any known anatomic or physiologic pathways, and are typically preceded by a psychological stressor or conflict for the patient..(2) A classic example is a stocking-and-glove loss of sensation of an extremity, or even hemianesthesia of the body starting at the midline. (1) Loss of sensation is not confined to a particular dermatome or nerve innervation. Other symptoms include paralysis, blindness, deafness, seizures, ataxia, and other motor symptoms. Visceral symptoms such as psychogenic vomiting, diarrhea, and urinary retention can also occur. In this patient, there was no anatomic explanation for the unilateral loss of pain, proprioception, and light touch, as well as loss of voluntary and involuntary motor function.

Before the diagnosis of a conversion disorder can be made, a thorough medical examination must rule out other organic causes for the neurologic symptoms. (1-3) In this case there was minor trauma preceding the onset of symptoms, which presents medicolegal considerations. A thorough trauma workup with x-rays, CT scans, and MRIs are necessary to look for injuries that may be causing the symptoms. (4) A couple of simple bedside tests can help the clinician in the diagnosis. Raising the patient's paralyzed hand above their face and dropping it to see if the patient protects themselves may help determine if the patient has paralysis in the arm. The Hoover test can also be performed on the legs to determine if the patient is truly trying to lift the affected leg. If the patient exerts downward force with the unaffected leg while attempting to lift the affected leg, this indicates the patient is genuinely attempting to raise the leg.

According to the DSM-IV-TR, the diagnostic criteria are as follows: 1) One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurologic or other general medical condition. 2) Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors. 3) The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering). 4) The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience. 5) The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. 6) The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder. (2)

One of the great difficulties in diagnosing conversion disorder is ruling out other diagnoses. After anatomic and physiologic causes have been ruled out, the physician must still differentiate between malingering, factitious disorder, somatization disorder, and conversion disorder. Malingering and factitious disorder both involve a conscious, voluntary control of the symptoms. Malingerers have a secondary gain as their motive, which may include such goals as money, drugs or medications, escape from police, etc. Factitious disorder patients typically enjoy playing the "sick role" and their motives are not typically as transparent as the malingerers. Somatization disorder patients can also present with sensorimotor symptoms, but the complaints tend to include pain and sexual dysfunction which are not commonly seen in conversion disorders, and the symptoms involve multiple organ systems. (1) Conversion disorder is an unconscious, involuntary production of symptoms with no secondary gain as a goal.

This patient had a loss of involuntary reflexes on the affected side including deep tendon reflexes and the Babinski reflex, and had muscle fasciculations in the right arm. In addition, the patient had no rectal tone, which is under control of the autonomic nervous system. The lack of reflexes and loss of rectal tone helps rule out malingering and factitious disorders, as these symptoms cannot be consciously faked. The loss of neurologic reflexes, muscle fasciculations, and loss of sphincter tone are unusual signs in this disorder, (1,2) but have been described by other authors. In a small prospective study of 14 patients with "hysterical paralysis," over 50% had weak or absent voluntary control of the anal sphincter muscle. (5)

Patients may present with "la belle indifference" or lack of concern about their symptoms or their implications. This is a very subjective measurement however, and is not diagnostic of this condition. Its presence or absence does not rule in or rule out a conversion disorder. (1) Patients can also be very dramatic, as in histrionic behavior. (6)

Conversion disorder is more commonly seen in women than men, anywhere from a 2:1 to 10:1 ratio. It is more common in rural areas, as well as in individuals of lower socioeconomic status and individuals with a poor understanding of medical and psychological concepts. It usually presents between the ages of 10 and 35; however, in children under the age of 10, the symptoms are usually limited to gait disturbances or seizures. (2) For many years, it was believed that this disorder presented with left-sided symptoms more frequently than right-sided symptoms. However, a systematic review of 121 studies failed to find any significant differences in the prevalence of left- or right-sided symptoms. (7)

Most conversion disorders usually resolve spontaneously within a few days of the onset of symptoms, and over 90% are resolved within a month. (1) The longer the symptoms persist however, the worse the prognosis. (1,2,6) Recurrence is common, occurring in up to one-quarter of individuals within 1 year, with a single recurrence predicting future episodes. (2) Good prognostic indicators include acute onset, presence of clearly identifiable stress at the time of onset, a short interval between onset and the institution of treatment, and above-average intelligence. (1,2,6) Symptoms of aphonia and blindness are associated with a good prognosis. (6) Poor prognostic indicators include long duration of symptoms, (1,2,6) delay in initiating treatment, (1) and tremors and seizures. (2) Treatment options for the patient include supportive psychotherapy, behavior modification, physical therapy, hypnosis, and medications such as anxiolytics. (1,6)

References

1. Sadock J, Sadock V. Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th Edition. Lippincott Williams & Wilkins, pp 647-651.

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Edition. Text Revision. Washington, DC, American Psychiatric Association, 2000, pp 492-498.

3. Laraki M, Orliaguet GA, Flandin C, et al. Hysterical paraplegia as a cause of transient paraplegia after epidural anesthesia. Anesth Analg 1996;83:876-877.

4. Haghighi SS, Meyer S. Psychogenic paraplegia in a patient with normal electrophysiologic findings. Spinal Cord 2001;39:664-667.

5. Yugue I, Shiba K, Ueta T, et al. A new clinical evaluation for hysterical paralysis. Spine 2004;29:1910-1913.

6. Heruti RJ, Levy A, Adunski A, et al. Conversion motor paralysis disorder: overview and rehabilitation model. Spinal Cord 2002;40:327-334.

7. Stone J, Sharpe M, Carson A, et al. Are functional motor and sensory symptoms really more frequent on the left? A systematic review. J Neurol Neurosurg Psychiatry 2002;73:578-581.

Eric Hill, BA, NREMT-P and Micelle Haydel, MD

From the Section of Emergency Medicine, Department of Medicine, Louisiana State University School of Medicine, New Orleans, LA.

Reprint requests to Eric Hill, BA, NREMT-P, 801 Henry Clay Avenue, #106, New Orleans, LA 70118. Email: [e-mail]

Accepted October 10, 2005.

RELATED ARTICLE: Key Points

* Conversion disorders present with sudden onset motor and/or sensory dysfunction in an individual that does not correspond with anatomic or physiologic pathways.

* Loss of neurologic reflexes and loss of rectal tone are unusual findings in conversion disorders.

* Before a diagnosis of conversion disorder can be made, a thorough medical workup must be done to search for organic causes for the signs and symptoms.