Question about Conversion Disorder

[Messerschmitts]

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I was in dermatology clinic when a patient started (apparently) seizing, and had to be transferred to the ER. The patient said, "it's my conversion disorder". My derm attending was fascinated and asked me whether it is still conversion disorder if the patient has insight and knows it's conversion disorder. Embarassingly, I had no idea. What are your thoughts? My original impression was that part of the treatment of conversion disorder was to (very gently) introduce the idea to the patient that his/her symptoms may have a psychiatric component or cause, and that once the patient realises he/she no longer requires the symptoms as a crutch, the symptoms resolve.

 

[loveoforganic]

>premed<

That particularly case sounds like malingering. I have the same feeling you do about your actual question though, although I'd think the symptom resolution would probably take time.

 

[Doc Samson]

Folks with psychogenic non-epileptic seizures (PNES - the artist formerly known as pseudoseizures) under the current DSM schema do have conversion disorder. Just knowing you have PNES is not typically enough to have the symptoms resolve (that's where the psychotherapy comes in). Having a patient who'll tell you they have PNES is nice because it stops them from getting intubated and loaded with Cerebyx.

 

[erg923]

When patients attempt to use clinical terminology, they terms often do not mean the same thing to them as it does to us. Just like if a patient says they are depressed, you don't just say "oh ok" and give them a diagnosis of MDD. You would probably say something like... "we,ll what does depression feel like for you, tell me more about that.

And yes, if you apply occam's razor to this one... it is most likely that he has conscious control over his "seizing." However, i suppose i can buy that he doesn't...id have to know alot more of his hx.

 

[Doc Samson]

Conscious = malingering vs. factitious

Unconscious = conversion

I'm not sure why folks are so keen to drop this one in the conscious/malingering category. I see folks that know they have PNES but continue to suffer from PNES every week.

It would be an interesting case report though: "Pseudopseudoseizures: A case of malingered conversion disorder"

 

[OldPsychDoc]

...
And yes, if you apply occam's razor to this one... it is most likely that he has conscious control over his "seizing." However, i suppose i can buy that he doesn't...id have to know alot more of his hx.

There's a difference between being conscious of his PNES and having conscious control of them. One could easily imagine a patient who is becoming aware that his spells are triggered by stress and anxiety, but not yet having mastered the coping skills to avoid this well-learned automatic response to the stress.

 

[erg923]

I agree. However, without knowing the guys history or that he even really has a true conversion disorder, i think the most parsimonous explanation is malingering or factitious.

 

[Doc Samson]

If we're being parsimonious about things, then I'd say that PNES are MUCH more common than malingered PNES. I spend an awful lot of time on the epilepsy monitoring unit dealing with a whole bunch of PNES patients and I have yet to see malingered PNES. If the guy had a nonepileptiform seizure and said "I need to be admitted to the hospital" I'd agree that malingering and factitious were high on the differential. When the patient says "I have conversion disorder" after their episode the malingering/factitious options significantly decrease in likelihood.

 

[whopper]

If the guy is actually saying it's conversion DO, makes you wonder......

For argument's sake let's assume he is a malingerer. Why would a malingerer say he's having conversion disorder? That's an admission that the problem is psychogenic.

I'm not sure why folks are so keen to drop this one in the conscious/malingering category.

I think because it neatly gives someone a nice, clean, and crisp explanation. Kinda like those psychiatrists who'll treat a borderline with a mood stabilizer while diagnosing them as bipolar when in fact they do not have bipolar. The psychiatrist understands how to better treat bipolar than borderline so this creates a bias to dx with bipolar instead of borderline. If PNES truly is not deliberately done, now that's a mystery. WTF is causing it? It can be uncomfortable territory for a psychiatrist.
(That at least is my opinion).

A neurologist told me this. Whether or not it's malingering/factitious disorder, do not accuse the patient of such unless you have very strong evidence. Even when there's strong evidence be careful not to be accusatory. There's several notables in the field that theorize that it could be a form of conversion disorder. If that's the case, then to blame them for deliberately faking the PNES simply based on suspicion, or even some evidence that do not meet strong standards can cause serious harm between your relationship with the patient, and could fuel mistrust between that patient and those in the medical field.

Now that said, there could be several reasons to believe this guy is a malingerer, but we aren't there and don't know much more about this---so I suggest we not judge what we aren't supposed to judge on a professional level.

On a side note--the more I've learned about tools to assess malingering in forensics fellowship, the less and less frustrated I am with malingerers. In residency, I think part of my frustration with malingering was seeing so many people where everyone on the team believed the person was malingering and little was done to confront the issue. Now, having done several tests for malingering on people, I feel I'm in a position where I don't have to feel frustrated because I know what to do, but heck, I don't know of any standardized tests to test for malingered or factitious PNES.

 

[loveoforganic]

There's a difference between being conscious of his PNES and having conscious control of them. One could easily imagine a patient who is becoming aware that his spells are triggered by stress and anxiety, but not yet having mastered the coping skills to avoid this well-learned automatic response to the stress.

For things like this where stress/anxiety is the trigger, is it the biological response to stress/anxiety that cause the symptoms or psychogenic? Or is it too difficult to determine that?

 

[OldPsychDoc]

For things like this where stress/anxiety is the trigger, is it the biological response to stress/anxiety that cause the symptoms or psychogenic? Or is it too difficult to determine that?

Explain how the two are different things, and I will venture a guess as to which one it is.

 

[loveoforganic]

Maybe this hypothetical is nonsensical, but here goes. Patient is in a coma. If injected with the chemicals associated with stress (whatever hormones, etc. I'm not a bio major and MCAT is in the past 😛), would you expect the patient to seize? Or is the conscious experience of being stressed a necessary component?

 

[erg923]

On a side note--the more I've learned about tools to assess malingering in forensics fellowship, the less and less frustrated I am with malingerers. In residency, I think part of my frustration with malingering was seeing so many people where everyone on the team believed the person was malingering and little was done to confront the issue. Now, having done several tests for malingering on people, I feel I'm in a position where I don't have to feel frustrated because I know what to do, but heck, I don't know of any standardized tests to test for malingered or factitious PNES.

There's actually alot of research on PNES profiles with the MMPI/MMPI-2. Carl Dodrill did a lot of work on this, and later Dona Crager and others have adapted his work to the MMPI-2. I think the PAI is promising as well.

With the MMPI profiles, usually about 70% of PNES will produce a psychogenic profile, while about 30% of genuine epilepsy will do so. In the case of the latter patients, I'm not sure that they actually represents a false positive, as I think this profile really reflects more of a tendency towards somatization. No personality profile is likely to discriminate well enough between these groups to use for diagnostic purposes, but they remain useful adjuncts to combine with other available data. It is also probable that if one wanted to use these measures for diagnostic discrimination, it would be more useful to combine them with relevant demographic factors (e.g., patients with PNES are more likely to report that they have fibromyalgia and chronic pain, are more likely to be female, to have experienced abuse, etc) and other test scores.

Use of the Personality Assessment Inventory as an efficacious​

and cost-effective diagnostic tool for nonepileptic seizures​

Mark T. Wagner​

a,*, Joy H. Wymer a, Kris B. Topping b, Paul B. Pritchard b


a Division of Neuropsychology, Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, USA

b Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, USA
Received 14 March 2005; revised 23 May 2005; accepted 25 May 2005
Available online 25 July 2005
Abstract
Video electroencephalographic monitoring (VEEG) is considered the &#8216;&#8216;gold standard'' for making the differential diagnosis between epileptic seizures (ES) and nonepileptic seizures (NES), but is a costly, time-consuming procedure and not readily available in all communities. Of the various diagnostic techniques and measures that have been used, the Personality Assessment Inventory (PAI) has shown promise as an effective psychological screening tool to aid in the differential diagnosis of ES/NES. Using VEEG results as the outcome measure, this study examined the diagnostic effectiveness of the PAI in a group of adults with treatment-refractory seizures. Results indicated that, on psychological screening, patients with NES endorse significantly greater functional consequences of their seizure-like episodes than participants with ES. A &#8216;&#8216;NES Indicator'' score, calculated from the PAI Somatization subscales, provided a sensitivity of 84% and specificity of 73% for the diagnosis of NES versus ES. The PAI appears to be a useful screening tool prior to hospital admission for for VEEG.​

 

[Regnvejr]

There's a difference between being conscious of his PNES and having conscious control of them. One could easily imagine a patient who is becoming aware that his spells are triggered by stress and anxiety, but not yet having mastered the coping skills to avoid this well-learned automatic response to the stress.

And the anxiety escalates when they're told that they have pseudoseizures, and that this means that they are malingering. Then they start feeling guilty and anxious about it, and of course, then it gets much worse. #*&#^$#^$*& *****s who tell patients that.

I simply tell them that non-epileptic seizures are seizure symptoms originating from outside the brain itself, but that adrenalin certainly can trigger them. Then we talk about relaxation training to calm down adrenal responses etc, and give them a dose of vistaril, and suddenly it is no longer a shameful malingering, but rather "hyperactive glands," and the shame and anxiety drops down. Almost a cure, or at least a reduction in symptoms, and I look good 😀

I swear, over half of psychiatry is about shutting down adrenaline.

 

[Regnvejr]

I feel one problem is our desire to label and make insurance companies happy. We can start fighting patients and accusing them of all sorts of things instead of merely take the Rogerian look that they are where they are in their lives, and if we can help them get more control over their own head and their own life, then they get better.

The approach of "How can I help you get more control over your own life" is a lot more collaborative with the patient, and you work toward a common goal. If the patient lies, then they are representing what they want to be the reality, and I can work with that. Once you're not trying to fit the patient into a diagnosis, but rather helping them break out of a diagnosis, everything gets a lot easier. I don't care if they malinger. I can talk to them about how the traditional model describes malingering, and that per the book, that would be one of the things considered as diagnosis, and hence, that would cause negative situations for the patient, so "how can we avoid that negative outcome." Works fine so far, but does require a little bit of insight.

If they malinger, then we talk about the habit of exaggeration and its consequences. If non-epileptic seizures, then we discuss stress and how it can stress the brain and make people reach. And so on. The diagnosis stops being the goal once residency is done, fortunately.

 

[nancysinatra]

Conscious = malingering vs. factitious

Unconscious = conversion

I'm not sure why folks are so keen to drop this one in the conscious/malingering category. I see folks that know they have PNES but continue to suffer from PNES every week.

It would be an interesting case report though: "Pseudopseudoseizures: A case of malingered conversion disorder"

Somatoform disorders and malingering are very interesting in a logical sense. For example, can a person have a factitious factitious disorder? Can a person say "I really want to have a factitious disorder?" and then go to psychiatric hospitals seeking help for that factitious disorder, which they actually only appear to have because they have set up clues that they have it? For example, they have hidden medical supplies in their purse so it will LOOK like they are infecting their own wounds or whatever (and maybe sometimes they go as far as actually trying to do things like that for the sake of effect), but the help they are actually seeking is FOR the psychiatric problem OF factitious disorder, so it's really a secondary illness, so to speak, without them doing any true downstream physical harm to themselves? Hmmm...

A question I used to wonder when I was a naive innocent medical student was whether people ever seek help for their problem with malingering. By this I mean actively book an appointment in which they could ask for assistance for this particular problem. I was so eager to understand! Now as a resident I know the answer.

 

[masterofmonkeys]

my standard approach for dealing with conversion is to remind the patient that I am in fact a physician and that there is a real problem with them. I'll point out that the problem is in their brain, it's just not a neurologic one. And then when introducing the idea that therapy and/or confrontation of underlying stressors is the right course of action, will point out that psychotherapy isn't any different from physical therapy. Real musculoskeletal issues can be treated with physical therapy and this is in fact a biologic treatment. Same goes for psychotherapy.

But what the heck do I know, I'm just an intern.

 

[strangeglove]

Conscious = malingering vs. factitious

Unconscious = conversion

I'm not sure why folks are so keen to drop this one in the conscious/malingering category. I see folks that know they have PNES but continue to suffer from PNES every week.

It would be an interesting case report though: "Pseudopseudoseizures: A case of malingered conversion disorder"

My understanding of the whole conscious vs. unconscious distinction in the determination of malingering is that it relates to an awareness of the secondary gain that the symptom causes. A patient being aware that they have pseudoseizures (i.e. knowing that the seizures are psychogenic and not caused by epilepsy) is not malingering unless they are aware of the ways in which this symptom achieves some interpersonal goal (e.g. getting SSI, avoiding an abusive relationship).

 

[strangeglove]

my standard approach for dealing with conversion is to remind the patient that I am in fact a physician and that there is a real problem with them. I'll point out that the problem is in their brain, it's just not a neurologic one. And then when introducing the idea that therapy and/or confrontation of underlying stressors is the right course of action, will point out that psychotherapy isn't any different from physical therapy. Real musculoskeletal issues can be treated with physical therapy and this is in fact a biologic treatment. Same goes for psychotherapy.

But what the heck do I know, I'm just an intern.

My approach involves saying something like this: "As a doctor, your physical health is of utmost concern to me. I'm very concerned about these symptoms you've been having, and I'm going to work very closely with your primary care doctor in order to try to understand how they might be related to a medical cause. However, the fact that you are here suggests that this relationship has not been so clear. That must be frustrating [Pause...patient starts crying]. I would like to help you deal with some of these feelings."

There is no need to "diagnose" the problem for the patient right there and then. They pretty much know that they are in your consultation room because someone else thought that their symptoms were psychogenic (its a different matter on the C-L service).

 

[Messerschmitts]

Oh wow...I just started this thread because I wanted to know if you can have conversion disorder if you know you have conversion disorder. I guess the answer is yes?

 

[Doc Samson]

Oh wow...I just started this thread because I wanted to know if you can have conversion disorder if you know you have conversion disorder. I guess the answer is yes?

Yes.

 

[Doc Samson]

My understanding of the whole conscious vs. unconscious distinction in the determination of malingering is that it relates to an awareness of the secondary gain that the symptom causes. A patient being aware that they have pseudoseizures (i.e. knowing that the seizures are psychogenic and not caused by epilepsy) is not malingering unless they are aware of the ways in which this symptom achieves some interpersonal goal (e.g. getting SSI, avoiding an abusive relationship).

Malingering:

"I want to be admitted to the hospital because it's cold outside. I'm going to go to the ED, lay down on the floor, and shake like I'm having a seizure. Then they'll admit me."

Factitious:
"I want to be admitted to the hospital because I like being a patient and having tests done. I'm going to go to the ED, lay down on the floor, and shake like I'm having a seizure. Then they'll admit me."

Conversion:

"It's cold outside. I can't afford my heating bill... who's going to take care of me... my parents never did... my life is so out of control... aaaaahhhhhh" <falls to floor in not deliberately produced PNES>

 

[billypilgrim37]

Malingering:

"I want to be admitted to the hospital because it's cold outside. I'm going to go to the ED, lay down on the floor, and shake like I'm having a seizure. Then they'll admit me."

Factitious:
"I want to be admitted to the hospital because I like being a patient and having tests done. I'm going to go to the ED, lay down on the floor, and shake like I'm having a seizure. Then they'll admit me."

Conversion:

"It's cold outside. I can't afford my heating bill... who's going to take care of me... my parents never did... my life is so out of control... aaaaahhhhhh" <falls to floor in not deliberately produced PNES>

That single post should get its own sticky!

 

[OldPsychDoc]

Malingering:

"I want to be admitted to the hospital because it's cold outside. I'm going to go to the ED, lay down on the floor, and shake like I'm having a seizure. Then they'll admit me."

Factitious:
"I want to be admitted to the hospital because I like being a patient and having tests done. I'm going to go to the ED, lay down on the floor, and shake like I'm having a seizure. Then they'll admit me."

Conversion:

"It's cold outside. I can't afford my heating bill... who's going to take care of me... my parents never did... my life is so out of control... aaaaahhhhhh" <falls to floor in not deliberately produced PNES>

Soo...this reminds me...you folks in DC and Philly getting more admissions because of the storm, or are they staying home 'cuz they can't get to the ED?

 

[whopper]

Use of the Personality Assessment Inventory as an efficacious

and cost-effective diagnostic tool for nonepileptic seizures

Wow. Thanks for the info Erg923. Another reason why we psychiatrists need to be working with our psychology and neurology colleagues on good terms.