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Stroke

Conversion disorder or stroke?

04/16/2007

Question:

Apologizes for reiterating questions already asked; we’re looking for more answers. Also sorry for writing too much, thought it would be better w/ a broader picture.

2 ½ months ago mom had severe r-sided weakness and fell to floor at work. 911 was called and arrived immediately. B/c her face was drooping and drooled, speech completely slurred, couldn’t move at all, and BP was dangerously high – firemen said stroke and rushed her to hospital. She stayed overnight w/ several tests (CAT scan, MRI of neck and head, MRA, EKG, etc ?). Everything showed clear…although she still had symptoms – along w/ r-sided weakness in leg, arm, shoulder, and hand, also had comprehension problems and couldn’t understand commands. Mixed up words and it took awhile to formulate sentences.

Started intensive Speech, PT, and OT (recomm. by Dr. in hospital). All therapists agreed she displayed symptoms of stoke patient. Hand specialist performed pressure test showing she had less than 50% strength in r-hand. Wasn’t able to go back to work since therapy was all she could do in one day, was extremely weak and grew tired very easily, and used mostly fine motor skills at work.

Second week we visited an Internal Dr. someone recommended. Mom didn’t have reg. treating physician – since only 55 ys, in good health, doesn’t smoke/drink, and takes vitamins and eats only healthy food daily. Only medical history was what we gave him (never had major health prob.s except for a few visual disturbances w/ jagged prism of colors some months prior to event, and old injuries caused by car accidents; and only family history is her dad had several strokes and seizures in the recent past...although he has also always been healthy).

So during visit, Dr. became very skeptical of situation b/c of tests run in the hospital. Wanted to write off her condition as being a “conversion disorder.” We didn’t know anything about it, so went w/ it. Also said didn’t want to write it in chart b/c he was still going to treat it as a stroke. Since BP was still extremely high and her blood work came back, went ahead and prescribed: an aspirin a day, blood pressure, heart, cholesterol, and anti-depressant medications. Also scheduled more tests.

Next week: more therapy, took meds, did some research on CD, and went back to Dr. Until now seen him about 4 times and every visit he gets more condescending and even down-right rude at times. He dismissed everything we told him including visual prob.s and therapists’ reports. Says just about everything except calling her a liar to her face….when we asked about his diagnosis. She works extremely hard in therapy and isn’t someone you can just look at and tell has had a stroke, so at times people are questionable. He wants to see surveillance video from work and even claims being fatigued has nothing to do w/ stroke and that she should be fine by now.

Mom is very strong, independent, happy, educated person and feels he’s claiming all symptoms are basically “in her head”. She doesn’t get stressed easily and b/c we are spiritual we hand over our problems to God instead of becoming overly worried about them….so she’s not the type to do something like this just for attention and never has been.

Then visited neurologist who ordered EEG w/ another MRI. Was polite and wanted to wait for new results before making any conclusions. First test not back, but we do have the MRI report. I’ve tried to read as much as possible but feel like I’m going in circles. Her Dr. is not an end-all bad guy and at times can be charming, but is just stubborn and big-headed sometimes and doesn’t want to back down. If possible don’t want to change Dr.s this late, but will if all it means is better bed-side manners. Have another follow-up w/ him next week and was just wondering if you could help us interpret results or if you have any comments.

MRI findings: along with technical terms stating that she does have “significant bilateral foraminal stenosis” and bone spurs, concerning her brain it states that “there does appear to be some slight periventricular white matter changes in the deep white matter of the left frontal region.”

Does this mean that she had a stoke, and if not…was it definitely a conversion disorder? What do we do next? Thanks for your time and consideration.

Answer:

Despite the extensive information provided, I cannot tell you if your mother's event represents a conversion disorder or a stroke.  The recent MRI and EEG results will be very helpful, but may still leave a lingering doubt.  If the report is as you have written, it is not clear if they saw something in the left hemisphere that they feel is consistent with a new ischemic lesion (stroke) or not.  It will probably be necessary for your neurologist to review the films him/herself to determine whether this lesion is related to the symptoms.  The findings are in a location where they could potentially be related to the symptoms.

In either case, the symptoms are real--your mother is not normal, with right sided weakness.  The problem lies in that the expected test results were not seen (an obvious stroke on the MRI).  This is a difficult circumstance in medicine--physicians are troubled when they can't clearly explain the symptoms.

A conversion disorder is defined by somatic symptoms without a clear cause, and thus is a consideration for your mother.  Part of the definition is that the patient is not willingly "faking" the symptoms--they consider the symptoms quite real and are not actively trying to have or portray the symptoms.  Typically, the physical symptoms are indicative of a psychological conflict or stress that the person cannot deal with cognitively, and the body's way of dealing with the stress is to manifest physical symptoms.  These conversion disorder symptoms typically get better if the conflict/stress is identified and the patient is able to confront and deal with the stressor.  Often this is not obvious, and so conversion disorders are hard to treat.  The lack of voluntary control of symptoms separates conversion disorder from malingering, in which symptoms are voluntarily portrayed for a secondary gain (a classic example of malingering is a student portraying illness to get out of taking an exam they didn't study for).

Let's presume for a minute that it is indeed a conversion disorder.  As to how individual physicians deal with a potential conversion disorder, there is certainly a variety of responses.  Some become frustrated with the patient and family.  Some are quite uncomfortable being in a position where they can't explain the symptoms with a biological problem.  Some physicians and some allied health personnel are not aware of (or have never seen) a conversion disorder, and thus might inappropriately insist that a biological cause exists.  A frank discussion of the symptoms with the physician, and trying to come to an understanding of the future care plan may be helpful.

I hope this helps. 

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Response by:

Brett   Kissela, MD Brett Kissela, MD
Assistant Professor of Neurology
Director, Neurology Residency Program
College of Medicine
University of Cincinnati