|Year : 2017 | Volume
| Issue : 5 | Page : 218-221
Conversion disorder in a neurological emergency department: Restrospective series
Alejandro Cardozo1, Maria-Alejandra Rubiano2, Giovanny Garces3, Jaime-Andres Giraldo3, Jose Bareño4
1 Emergency Medicine Physician, Emergency Department, Instituto Neurologico de Colombia, Colombia
2 General physician, Emergency Department Instituto Neurologico de Colombia, Colombia
3 Emergency Medicine Resident, Universidad CES, Colombia
4 Research and Teaching, Instituto Neurologico de Colombia, Colombia
|Date of Submission||20-Mar-2017|
|Date of Decision||01-May-2017|
|Date of Acceptance||10-Jun-2017|
|Date of Web Publication||7-Dec-2017|
Emergency Medicine Physician, Emergency Department, Instituto Neurologico de Colombia
Source of Support: None, Conflict of Interest: None
Objective: To observe the conversion disorder in a neurological emergency department. Methods: It is common that the initial approach to this patients include the use of various diagnostic exams. In this series we reviewed 94 patients that arrived a neurological emergency room in a 3 year period. Results: 72 patients were females (76%), and the initial presumptive diagnosis were: neurovascular syndrome in 36 patients (38.3%), convulsive disorder in 20 patients (21.28%), and conversive disorder in 8 patients (8.51%). 82 patients had motor symptoms and 61 sensitive symptoms. 88 patients (93%) required neuroimaging studies, 77 (81%) patients underwent through basic biochemical panels. Other tests performed were: electroencephalogram in 12 patients (12.77%), electromyography in 11 patients (11.7%), lumbar punction in 8 patients (8.04%) and regarding the medical consult in the care of these patients 11 were evaluated by 1 specialists, 35 (37.2%) by 2 different specialties, 42 (44.63%) patients required evaluation by 3, and 6 patients (6.38%) required evaluation by 4 different specialties. Conclusions: Based on this data, we conclude that conversion disorders require a lot of resources in the emergency room and that the similarities with neurological diseases demands a complete workup including expensive diagnostic tools. However, this patients can be discharged safely without requiring hospitalization.
Keywords: Conversion disorder, Neurological symptoms, Clinical
|How to cite this article:|
Cardozo A, Rubiano MA, Garces G, Giraldo JA, Bareño J. Conversion disorder in a neurological emergency department: Restrospective series. J Acute Dis 2017;6:218-21
|How to cite this URL:|
Cardozo A, Rubiano MA, Garces G, Giraldo JA, Bareño J. Conversion disorder in a neurological emergency department: Restrospective series. J Acute Dis [serial online] 2017 [cited 2020 Dec 4];6:218-21. Available from: http://www.jadweb.org/text.asp?2017/6/5/218/219617
| 1. Introducion|| |
Conversion disorders (functional neurological symptom disorder) is a heterogenous group characterized by the simulation of symptoms and/or neurological diseases. Given its clinical presentation, the initial approach is mainly directed towards discarding the syndrome or disorder that the patients is simulating. Attention is focused on searching clinical and paraclinical etiology of symptoms, consuming expensive health care resources and time.
Usually, neurological symptoms demand for the use of imaging, specialized neurological diagnosis exams and an interdisciplinary approach that causes delays and higher workload given the time patients must spend in the emergency rooms and lack of efective treatment while the initial workup is performed.
Given that literature relevant for this disorders in the Emergency Room setting is scarce, we describe the clinical presentation and use of diagnostic resources in patients with conversion disorer in a neurological emergency department.
| 2. Material and Methods|| |
The Instituto Neurologico de Colombia is a reference treatment center for neurologic and neurosurgical conditions. It is a small institution in Medellin, Colombia, that receives approximately 4 000 patients visits in the emergency department. This institution offers different specialties as emergency medicine, neurology, neurosurgery, neurooncology, child neurology, neurointerventional procedures, demyelinating diseases, abnormal movement disorders, cephalea, psichiatry, and neurological and neurosurgical intensive care units. Our emergency department is composed by general physician, and specialized physicians in emergency medicine, neurology and neurosurgery, The other specialties are available upon request or consultation. Patients that arrive spontaneously to the emergency room are initially assessed by general physicians who classify the patients and assign a specialty as their primary care provider. Patients referred from other institutions are directly evaluated by a pre assigned specialty. During night time, patients are usually evaluated by general physicians.
Given our observation that patients with conversion disorders require a significant time and use of resources in the emergency room, a retrospective analysis was performed reviewing electronic medical records of patients with a final diagnosis of somatic symptom disorder (DSM IV) or conversion disorder (DSM V). Patients included in this retrospective series where those who received medical attention in our emergency department between September 2013 and November 2016. The following inclusion criteria were used: chief complaint of neurological symptoms or related contidions suggesting an underlying neurological disorder, abscence of previously diagnosed conversion disorder or somatic symptom disorder, and patients in which neurological disorders were excluded after a through clinical, paraclinical and specialized assessment. All patients included were discharged from the emergency department and had as final diagnosis in their medical records somatization disorder (ICD 10: F450), undifferentiated somatoform disorder (F451), Other somatoform disorders (F458), somatoform disorder, unspecified (F459) and those in which the specialist evaluation suggested conversion disorder or functional neurological symptoms.
Patients with history of previously diagnosed psychiatric disorders as well as those diagnosed outside the emergency room (hospitalization or outpatient setting) were excluded from this study. The statistical analysis was performed using Excel. This is a retrospective, descriptive study.
| 3. Results|| |
From September 2013 to November 2016, 266 patients were identified. After excluding patients using the previously described criteria, 94 patients diagnosed with somatization disorder and/ or patients that met the DSM V criteria for conversion disorders (functional neurological symptoms) were included. The hospital stay length was less than 24 hours for all patients. The variables considered in our study were: sex, age, presumptive initial diagnosis, diagnostic exams performed and number of different medical specialties involved in the patient care. The final diagnosis was confirmed by either psychiatry or by one of the specialists of the emergency room as well as the abscense of alternative diagnosis 3 months after de initial emergency room visit. The follow up was performed reviewing outpatient medical records, health insurance medical records and follow up telephone calls to patients.
In the demographic data 72 (76.6%) of the patients were females while 22 (23.4%) were male patients. 23 (24.4%) patients belonged to the group of patients between 13 and 25 years of age, 52 patients (55.32%) belonged to those between 26 and 50 years of age and finally 19 (20.21%) patients comprised those 51 years of age and older.
The initial presumptive diagnosis (simulated disorders) were: neurovascular syndromes in 38.3% of the patients (stroke in 34 patients, Transient ischemic attack in 2 patients), seizure disorder in 21.28% of patients (first seizure episode or single seizure in 16 patients, epilepsy in 2 patients, and status epilepticus in 2 patients), conversion disorder in 8.51% of patients, myelopathy in 7.44% (3 patients simulated cord compression) and less frequently cephalea, syncope, polyneuropathy, quadriparesia, and optic neuritis [Table 1]. Sixty-one (64.89%) of patients experienced sensitive symptoms while as 82 (87.23%) experienced motor symptoms.
Regarding diagnostic exams performed, 77 patients (82%) underwent basic biochemical panels (Complete Blood Count, electrolytes, Blood urea nitrogen (BUN), creatinine, pregnancy assay). 52 patients (55.3%) required magnetic resonance imaging (MRI), 25 patients (26%) computed tomography (CT), 11 patients (11.7%) underwent both MRI and CT scans and 6 patients (6.3%) no imaging. Other diagnostic studies performed included: 12 patients (12.77%) were assessed through electroencephalogram, 11(11.7%) had electromyography, 8 required lumbar punction, 4 (4.2%) underwent video monitoring, 2 (2.12%) patients had neck vessels ultrasound, and 1 (1.06%) patient required evoked potentials.
Finally, in relation with the different specialties involved in the evaluation and care of these patients: 11 patients (11.7%) were evaluated only by one physician, 35 patients (37.1%) required evaluation from physicians of 2 different specialties, and 48 patients (51%) required evaluation from physicians of 3 or more medical specialties [Table 2].
|Table 2: Number of medical specialties involved in the evaluation and care of patients with final diagnosis of conversion disorder.|
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| 4. Discussion|| |
Recently classified as part of the group of somatization disorders in the DSM V, conversion disorders or functional neurological symptoms,, may present with a frequency close to 30% in outpatient specialized neurology clinics,,,. Other authors have reported a frequency close to 22% in general clinics and others have stated that up to 9% of these patients require inpatient hospital admission adding up to 10% of the total health care system total costs,,.
Conversion disorders and somatic symptom disorders are entities that occur when patients present with the loss of sensitive or motor functions despite the incompatibility between the symptoms and the existence of a true neurological or medical condition discarded through a complete medical and diagnostic assessment. This patients experience these type of symptoms due to changes in the function and not in the structure of their nervous system,, in specific clinical context, up to 10-20% of these patients may present with psychogenic seizures, 5% with psychogenic movement disorders, 30% with psychogenic syncope or pseudostroke,,. Symptoms described include: weakness, gait disorders, tremor, dizziness, speech and deglution disorders, and visual, auditory and sensitive abnormalities. 60% of these patients are females between 20 and 30 years of age, with a 1.8:1 female to male ratio. However this disorders have been also reported in all age groups including children of early ages,,,,.
In general, 50% of these patients present with sudden onset symptoms specially those that describe experiencing weakness or movement disorders. These patients tend to present very symptomatic infront of health care providers, and usually the physical exam findings are not congruent with the symptomatic description provided by patients. The sudden onset of symptoms, emotional event related to the onset of symptoms, paroxismal and migratory fashion of the symptoms experienced may be elements of the history in favor of a conversion disorder. Most importantly, symptoms should not be related with neuroanatomical abnormalities and some patients may improve with distractions. However, no indicators may absolutely be used to define a conversion,.
Commonly, this type of patients may have associated disorders like depression, anxiety or even post traumatic stress disorder before the conversion episodes. Many undergo through emotional triggers or other psychiatric comorbidities as a consequence to the disability that they experience given that thorugh time, symptoms may evolve in severity and migrate,.
If this disorder is considered as the principal diagnosis, the treatment include explaining the diagnosis to the patient as well as treating other possible psychiatric comorbidities. Ideally this patients should be evaluated by neurologists and psychiatrists,,,.
It is important to understand that conversion disorder is a condition with a slow recovery which may be frustrating. It has been described that patients with symptoms lasting less than 2 weeks and children usually recover faster than other patients. Only 50% of the patients report feeling better after 8 months as compared to 72% of patients that report a significant improvement after 1 year when assessed by an multispecialty group of care,,.
Limited literature describing the clinical presentation of adult patients in the Emergency Room is available. However, it is clear that conversion disorder should be considered among highly symptomatic patients with an abrupt onset of symptoms. In case of convulsive syndromes, it it suggested to include a videomonitoring study given the low sensitivity of an electroencephalogram during the asymptomatic period. In case of pseudo stroke or spinal cord related symptoms, MRI could be the test of choice,.
It is important to know that physicians may have a high capacity to initially approach this patients. However, it is necessary to avoid a “snow ball” syndrome in which the patient consumes and consumes clinical and paraclinical resources without a real need. Even if a correct diagnosis is made, patients may show no improvement through time. If symptoms are correctly categorized, less than 1% of the patients will experience changes in their diagnosis through time,. It is possible that as a neurological disorder, the diagnositc error rate could be close to 4%, misdiagnosing epilepsy, movement disorders and multiple sclerosis.
Different to other studies, in this registre, we found a higher rate of neurovascular syndromes as the simulated condition. We think that this is given that in the Instituto, hyperacute changes in function are approach initially ruling out vascular conditions and this explains that one third of our patients to have as a presumptive diagnosis a neurovascular syndrome. However, similar to other reports, the use of clinical and paraclinical (including human resources) resources is very high. This confirms that even in emergency rooms this conditions have a high impact and represent a heavy working load to the emergency and health care systems. Patients included in this series were discharged from the emergency department and none experienced complications or alternative diagnosis that could suggest a bad or erroneous primary evaluation in the emergency department. It is very important for primary care providers to be aware of these conditions and consider them as diagnosis early in their patients evaluations. This could avoid an overload to the health care system by reducing the use of unnecessary diagnostic tools and represent an impact in the care of this patients by performing early interventions reducing chronic symptoms that this patients may experience.
Conflict of interest statement
The authors report no conflict of interest.
| References|| |
American Psychiatric Association. The diagnostic ans statistical manual of mental disorders
. 5th ed. Virginia: American Psychiatric Association; 2013.
Dimsdale JE, Creed F, Escobar J, Sharpe M, Wulsin L, Barsky A, Lee S, Irwin MR, Levenson J. Somatic symptom disorder: an important change in DSM. JPsychosom Res
Dimsdale JE, Levenson J. What's next for somatic symptom disorder? Am J Psychiatry
Carson A, Ringbauer B, Stone J, Sharpe M. Do medically unexplained symptoms matter? A prospective cohort study of 300 new referrals to neurology outpatient clinics. J Neurol Neurosurg Psychiatry
Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet
Fink P, Sorensen L, Engberg M, Holm M, Munk-J0rgensen L. Somatization in primary care: prevalence, health care utilization, and general practitioner recognition. Psychosomatics
de Waal MW, Arnold IA, Eekhof JA, van Hemert AM. Somatoform disorders in general practice: prevalence, functional impairment and comorbidity with anxiety and depressive disorders. Br J Psychiatry
Evens A, Vendetta L, Krebs K, Herath P. Medically unexplained neurologic symptoms: a primer for physicians who make the initial encounter. Am J Med
Lempert T, Dieterich M, Huppert D, Brandt T. Psychogenic disorders in neurology: frequency and clinical spectrum. Acta Neurol Scand
Neimark G, Caroff SN, Stinnett JL. Medically unexplained physical symptoms. Psychiatr Ann
De Gusmâo CM, Guerriero RM, Bernson-Leung ME, Pier D, Ibeziako PI, Bujoreanu S, et al. Functional neurological symptom disorders in a pediatric emergency room: diagnostic accuracy, features, and outcome. Pediatr Neurol
Anderson KE. Evaluation and diagnosis of psychogenic disorders in neurological patients. Semin Neurol
Benbadis SR, Chichkova R. Psychogenic pseudosyncope: An underestimated and provable diagnosis. Epilepsy Behav
2006 Aug; 9
Behrouz R, Benbadis SR. Psychogenic pseudostroke. J Stroke Cerebrovasc Dis
Carota A, Calabrese P. Hysteria around the world. Front Neurol Neurosci
Siket MS, Merchant RC. Psychogenic seizures: A review and description of pitfalls in their acute diagnosis and management in the emergency department. Emerg Med Clin North Am
Stone J, Carson A. Functional neurologic symptoms: assessment and management. Neurol Clin
Carson A, Stone J, Hibberd C, Murray G, Duncan R, Coleman R, et al. Disability, distress and unemployment in neurology outpatients with symptoms ‘unexplained by organic disease’. J Neurol Neurosurg Psychiatry
Olde Hartman TC, Blankenstein AH, Molenaar AO, Bentz van den Berg D, Van der Horst HE, Arnold IA, et al. NHG guideline on medically unexplained symptoms (MUS). Huisarts Wet
Dimsdale JE, Levenson J. Diagnosis of somatic symptom disorder requires clinical judgment. J Psychosom Res
Cottencin O. Conversion disorders: psychiatric and psychotherapeutic aspects. Neurophysiol Clin
Carson AJ, Best S, Postma K, Stone J, Warlow C, Sharpe M. The outcome of neurology outpatients with medically unexplained symptoms: a prospective cohort study. J Neurol Neurosurg Psychiatry
Demartini B, Batla A, Petrochilos P, Fisher L, Edwards MJ, Joyce E. Multidisciplinary treatment for functional neurological symptoms: a prospective study. J Neurol
Gelauff J, Stone J, Edwards M, Carson A. The prognosis of functional (psychogenic) motor symptoms: a systematic review. J Neurol Neurosurg Psychiatry
Stone J, Carson A, Duncan R, Coleman R, Roberts R, Warlow C, et al. Symptoms ‘unexplained by organic disease’ in 1144 new neurology out-patients: how often does the diagnosis change at follow-up? Brain
Stone J, Smyth R, Carson A, Lewis S, Prescott R, Warlow C, et al. Systematic review of misdiagnosis of conversion symptoms and “hysteria”. BMJ
[Table 1], [Table 2]