A question for doctors - med students

[tb-av]

I was just informed of someone close to me that has symptoms that the doctors can't seem to pinpoint.

Lifestyle - Average person but works 7 days a week and has what I would say is moderately high family stress.

Out of the blue the following occurs....

while sitting and usually when tired....

Slumps in chair, arms go limp, legs go limp, speech goes, vision goes blurry. Duration 30 minutes and once in hospital 3 hours until speech restored. Placed in sleep deprivation at hospital to bring it on which did not work but he did go into one of these states while there.

Has headache afterwards.

The best they have come up with is some form of migraine. Anti-seizure meds not working.

No recent trauma.

Any of you doctors ever hear of anything like this? Oh, they say it's not a stroke either. When in the state, the best he can do is lightly squeeze someone's hand when questioned. Mid 40's

His wife is a nurse so relaying a potential medial term should not be an issue. I personally no nothing about medicine.

Thanks

TB

[Sensei]

I was just informed of someone close to me that has symptoms that the doctors can't seem to pinpoint.

Lifestyle - Average person but works 7 days a week and has what I would say is moderately high family stress.

Out of the blue the following occurs....

while sitting and usually when tired....

Slumps in chair, arms go limp, legs go limp, speech goes, vision goes blurry. Duration 30 minutes and once in hospital 3 hours until speech restored. Placed in sleep deprivation at hospital to bring it on which did not work but he did go into one of these states while there.

Has headache afterwards.

The best they have come up with is some form of migraine. Anti-seizure meds not working.

No recent trauma.

Any of you doctors ever hear of anything like this? Oh, they say it's not a stroke either. When in the state, the best he can do is lightly squeeze someone's hand when questioned. Mid 40's

His wife is a nurse so relaying a potential medial term should not be an issue. I personally no nothing about medicine.

Thanks

TB

Conversion disorder

[Shoulderthinggoesup]

They are either missing TIAs or +1 for conversion disorder.

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[Barfly76]

Conversion >> Migraine > TIA or Seizure.

[Hmac]

Conversion disorder

Good possibility. If he responds to commands at all, certainly less likely to be a seizure disorder.

CT/MRI head was negative, I assume. What did the carotid ultrasound or angiography show? Cardiac ultrasound or other investigation for embolic phenomena? (TIA ruled out?) TIA is usually going to be unilateral, but some of those symptoms might show up if it's transient ischemia of the spinal cord. I guess a Holter monitor would be something to consider.

[tb-av]

Thanks guys, I'll have to look some of these terms up. I just looked up "conversion disorder"... I spoke to my neighbor yesterday. He too is a doctor. He paused for a second and said "I don;t want to sound like I'm insulting anyone but what you describe, because it's global is often a mental disorder often referred to in general as hysteria. He went on to describe in more detail.

When I was told of when the symptoms occurred especially the one in the hospital when his wife showed up. I thought he might be having some sort of mental collapse. He, they, have been under a lot of stress and I have also learned that just about the time this started happening another level of general family stress was introduced. I can't go into details.

It sounds like everyone is on the same wavelength.

@hmac I'm getting info second hand but the general story is that nothing looks wrong. I'm only aware of a 36 hour sleep deprivation test and the hospitals here are pretty good. He might have been in MCV in Richmond but all the ones here seem to be pretty good. I'll pass along your questions and see if those areas were explored. He certainly fits the profile of someone that could just be shutting down from stress. Both past heavy stress and more recent ongoing and additional.

[Shoulderthinggoesup]

An important thing to remember is that conversion disorder, while a mental illness, is NOT someone faking it. They are genuinely experiencing these symptoms.

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[jknopp44]

Good possibility. If he responds to commands at all, certainly less likely to be a seizure disorder.

CT/MRI head was negative, I assume. What did the carotid ultrasound or angiography show? Cardiac ultrasound or other investigation for embolic phenomena? (TIA ruled out?) TIA is usually going to be unilateral, but some of those symptoms might show up if it's transient ischemia of the spinal cord. I guess a Holter monitor would be something to consider.

This..... we see this quite often in the ER... Conversion disorder is a definite consideration

[tb-av]

An important thing to remember is that conversion disorder, while a mental illness, is NOT someone faking it. They are genuinely experiencing these symptoms.

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Right, I understand... I've run it by my contact whom I am getting the info from. He was not exactly receptive to it until I went deeper in explaining things. Then he wanted to know how you cure it.... which I have no idea, but at least he accepted it as something real. He's going to pass it on and I'm going to follow up. I have actually heard of it but didn't know it had a name and I certainly didn't realize it was as common as it apparently is.

I asked him if it had happens when this person was at work... Nope.... only happens when he's home with all of them and he's tired. He went through the MCV epilepsy clinic ( MCV/VCU ).. so I expect they monitored all the standard stuff.
The only thing I was not told before was that he fell off a ladder a while back.... the details on this are sketchy but no indication of him getting hurt and it was not one of those episodes.


One thing my neighbor told me that can be a test for CD and I'd like to see if you guys agree, because I could have his wife try it. He said if you hold someone's arm above their head then let it go they will just drop it right on their head or face but the CD people tend to sort of be able to brush off to the side of their face... sort of consistent with being able to lightly squeeze their hand on command..... and again.. I know this is not faking it even if they are able to have some form of normal response. Have any of you ever seen this as any sort of additional diagnostic?

[Sensei]

One thing my neighbor told me that can be a test for CD and I'd like to see if you guys agree, because I could have his wife try it. He said if you hold someone's arm above their head then let it go they will just drop it right on their head or face but the CD people tend to sort of be able to brush off to the side of their face... sort of consistent with being able to lightly squeeze their hand on command..... and again.. I know this is not faking it even if they are able to have some form of normal response. Have any of you ever seen this as any sort of additional diagnostic?

The "arm drop test" is a maneuver commonly performed during many types of factitious disorder. It is not diagnostic and probably has a rather poor specificity, but we still do it (along with a deep sternal rub).

The real way to establish the diagnosis of conversion disorder is to "rule out" other more serious causes such as TIA/CVA, seizure, brain mass, MS, cardiac syncope, etc. What you have left is a diagnosis of exclusion based on neurologic symptoms that do not correspond to known anatomy or pathophysiology and an expensive negative work-up.

Keep in mind that about 50% of people thought to have a conversion disorder prior to the diagnostic testing end up having an actual disease. I've been humbled by strange presentations of strokes, seizures, MS, etc. That is why conditions such as conversion disorder, pseudoseizures, fibromyalgia, complex migraines, and irritable bowel are all diagnosed after evaluating for serious pathology.