admit for conversion?

[heyjack70]

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for instance, pseudoseizures multiple times daily, preventing patient from going to work, using wheelchair due to falls. Mild to moderate underlying GAD, no obvious acute stressors, but who knows they might not be totally honest.

Do you admit to inpatient psych for acute/intense treatment?

 

[whopper]

Inpatient is one of the only appropriate places for an amytal/benzo interview.

I figure if the person's got conversion disorder, aside from that zonked interview, psychotherapy should be the next step.

I'd do a battery of psychological testing including malingering testing, and an MMPI. Again, inpatient is not a bad idea.

 

[OldPsychDoc]

In my experience, they end up getting admitted anyway, since their families want to make sure we find what was missed at Outside Hospital. 🙄

 

[nitemagi]

The treatment should depend on the form of the conversion disorder, but it's rare that ideal tx will happen on an inpt psych unit. Usually neuro or medicine is better to assure it's really conversion, with psych consulting. If it's pseudoseizures, 24-hour video EEG monitoring should be the first step to make sure it's conversion. I don't think an inpt psych ward is appropriate for that. Neuro is obviously ideal, followed by outpt therapy.

For conversion d/o paralysis or weakness (motor specific), an amytal interview can be useful, which requires slow IV push, but this is also not usually possible on a psych unit, and more of a diagnostic procedure than treatment per se. Keep in mind there's case reports of patients suiciding after symptom removal via amytal.

Hypnosis is the old school treatment for symptom removal, and may help in revealing if someone is suggestible, which conversion patients usually are. Again, somewhat more diagnostic, though can be a part of longitudinal treatment.

Quality psychotherapy for sx removal isn't usually available on an inpt basis, and I don't know of any literature on using something like CBT, though theoretically it could work since they're very suggestible and laying out a stepwise course of recovery would likely lead to just such a recovery. Psychoanalysis was designed to be THE psychotherapy for treatment of conversion d/o (named hysteria at the time), but we all know the financial limitations.

And of course make sure to keep in mind factitious and malingering in the ddx.

Seems for the most part the only reason to admit a pt to the psych unit is to give respite to the family, rather than for a hope of recovery. Especially since family dynamics may play into it, admitting with hope of remission will likely lead to relapse after being released. Longer term therapy with family education is essential.

I treated a pt. with severe conversion d/o throughout my residency. I saw him first as an intern, when he was having drop attacks. Everyone thought it was seizures or narcolepsy. I hypnotized him and he could have temporary reversal of symptoms. I picked him up as an outpt case 2 years later and he had been chased with meds (interestingly had conversion sx's of psychosis as well, and had been dx'd as schizophrenia many years earlier). By the time I inherited him as an outpt he was mute, nearly completely immobile with "freezing" episodes throughout the day. Epilepsy and narcolepsy had been ruled out. I stopped changing his meds and saw him once weekly for psychotherapy for 2 years, using a combined approach of hypnosis, psychodynamic, with psychoeducation for the family. He had nearly complete symptom resolution of the motor symptoms within 9 months, and complete resolution of his pseudohallucinations within 15 months.

 

[whopper]

Another advantage of inpatient is that you could likely consult with the non-psychiatric doctors better.

In outpatient, several doctors will not be willing to discuss a case with you over the phone because doctors can't bill for it through insurance.

Several tests done to rule out a non-psychiatric problem are nowhere near 100% accurate, and often times non-psychiatric doctors are too willing to say the problem is psychiatric simply because they want to drop the patient to someone else.

While in residency, every so often, I'd get a patient who was medically cleared when in fact it was blatantly obvious the problem was not strictly non-psychiatric-medical. E.g. person with hyperammonemia and asterexis being diagnosed with schizophrenia at age 50 despite no prior history of psychosis, a long history of alcohol dependence, and the liver labs are all out of whack.

But while the above is black and white, often times conversion DO could present in a grey area where both the psychiatrist and non-psychiatric doctor are still unsure whose domain the patient should be in. In such cases, teamwork and doctor-to-doctor talks are important. Don't expect to find cooperative doctors. Several docs I know don't give a damn when it requires them to truly engage themselves into a patient's situation.

I got a patient now with some type of serious adrenal problem and is on corticosteroids despite having bipolar disorder. To this day, after more than 5 phone calls, and persistent requests from the patient and I to talk to the other doctor, nope, she will not talk to me. The patient doesn't know what the name of her disorder is, the other doctor only tells her it's an "adrenal disorder."

 

[cleareyedguy]

A few reasons for inpatient in this case: safety from the falls; to give the family a break; and, most importantly, to try to induct them into become a psychiatric patient rather than a neuro one. Overall, though, I'd probably try to do the induction as an outpatient.

 

[nitemagi]

There's a pro/con to admitting vs. not. Admitting to psych may acclimate the family to the psychiatric system, but it also biases consultants that the condition is more definitively psychiatric and I believe makes them less likely to look thoroughly for a medical cause.

The "prevention" of falls I'd take with a grain of salt. The nature of Astasia-Abasia is the conversion pt. seems like they're going to fall and hurt themselves, yet never seem to really get injured. Other people get concerned at the risks and intervene with things like wheelchairs, or someone with them at all times.

 

[Sneezing]

I would not admit to psychiatry and this is assuming the diagnosis is a concrete conversion disorder.

Enough psychotherapy in the hospital is not going to happen to make a difference. People don't stay on inpatient units for months anymore. Secondarily, if safety were an issue regarding falls, an inpatient psych unit isn't appropriate but a nursing home is. A big question we have to ask ourselve prior to admitting is not just patient severity, but will they benefit from hospitalization. If we can't justify that hospitalization would benefit, then document as such and recommend what will benefit the patient.

 

[heyjack70]

I would not admit to psychiatry and this is assuming the diagnosis is a concrete conversion disorder.

Enough psychotherapy in the hospital is not going to happen to make a difference. People don't stay on inpatient units for months anymore. Secondarily, if safety were an issue regarding falls, an inpatient psych unit isn't appropriate but a nursing home is. A big question we have to ask ourselve prior to admitting is not just patient severity, but will they benefit from hospitalization. If we can't justify that hospitalization would benefit, then document as such and recommend what will benefit the patient.

I think this is reasonable. The one benefit of inpatient psych is it will remove the patient from their stressors and could potentially jump start treatment.

That being said, it seems like there is not premier treatment for conversion disorder.

 

[Mattchiavelli]

for instance, pseudoseizures multiple times daily, preventing patient from going to work, using wheelchair due to falls. Mild to moderate underlying GAD, no obvious acute stressors, but who knows they might not be totally honest.

Do you admit to inpatient psych for acute/intense treatment?

is it "preventing patient from going to work [and preventing her from] using wheelchair" or is it "preventing patient from going to work [and now she has decided she will be] using [a] wheelchair"? commas R confus. Anyway someone even with PNES can injure themselves, if you can't come up with any prior workup don't admit to psych. pseudoseizures are rule out not rule in and you at least should admit for obvs I would say so they can be on fall/seizure precautions, basic head imaging if it's never been done (even if it were not PNES and was malingering they could end up hurting themselves if a staged fit got out of control).

 

[nitemagi]

is it "preventing patient from going to work [and preventing her from] using wheelchair" or is it "preventing patient from going to work [and now she has decided she will be] using [a] wheelchair"? commas R confus. Anyway someone even with PNES can injure themselves, if you can't come up with any prior workup don't admit to psych. pseudoseizures are rule out not rule in and you at least should admit for obvs I would say so they can be on fall/seizure precautions, basic head imaging if it's never been done (even if it were not PNES and was malingering they could end up hurting themselves if a staged fit got out of control).

I agree that this should be a diagnosis of exclusion. But assuming epileptiform seizures have been excluded, and the definitive d/o PNES has been established, anyone care to explain how admitting to a psychiatric unit reduces the risk of harm? Put them on a 1:1? This may only add to the problem (PNES don't likely have their pseudoseizures when NOT being observed). Give the AED's? I would hypothesize that in some circumstances admitting could iatrogenically worsen the condition.

 

[whopper]

Enough psychotherapy in the hospital is not going to happen to make a difference

Agree unless there is a highly structured plan such as a preplanned amytal interview or the conversion disorder was somehow determined to be dangerous. Most docs I know if they saw an conversion DO patient would simply discharge immediately.