Because of the unusual manifestations of the child's muscle weakness involving only the lower extremity, with no cranial nerve involvement, no relationship to activity, worsening of weakness on school days, and improvement during holidays and weekends, in addition to a recent history of school difficulty, a diagnosis of conversion disorder was entertained.
A simple test strongly supported that diagnosis; 1 mL of intravenous normal saline was administered to the child after it was explained to her that this could cure her illness. Shortly after the injection, the child stood up alone and walked unassisted back and forth in the hallway. Psychiatric consultation identified school as a major stressor in the patient's life. The presence of type 1 diabetes, with its daily testing and insulin injections, was identified as a vulnerability that might have triggered the conversion reaction.
Physical therapy was initiated and the parents advised about the nature of the problem. Strategies were offered to alleviate the stressors in the child's life. The family also was advised to shift attention from the child's symptoms and to focus on recovery. The girl responded well to treatment, and follow-up showed better coping abilities and amelioration of her muscle weakness.
The Condition
Conversion disorder should be suspected when a patient's symptoms do not fit into the framework of known medical illnesses or when appropriate evaluation reveals no organic disease or plausible pathophysiologic explanation. Conversion disorders in children do not indicate a major psychiatric disorder but represent the child's subconscious plea for help in situations in which he or she cannot cope. These situations can arise from a variety of stressors, such as struggles in school, family disharmony, and sexual and physical abuse. Symptoms are referable to the CNS in 65% of children who have conversion disorders. The most usual presentations are episodic loss of awareness, such as pseudoseizures and syncope; motor dysfunction, including gait disturbances and paresis; sensory abnormalities, primarily pain and numbness; and disorders of the special senses.
Diagnosis
Once the diagnosis of conversion disorder is suspected in a child who has persistent and debilitating symptoms, a sensible evaluation plan should be created. In severe cases, hospitalization may be warranted. During the evaluation, focused investigation and testing should be pursued to be reasonably certain that there is no medically treatable cause. Psychiatric evaluation instituted simultaneously should concentrate on five main areas: 1) the levels of stress or anxiety in the child and family, 2) any special predisposing vulnerabilities in the child that might lower the threshold for coping with stress and anxiety (eg, learning disabilities, peer pressures, problems of body image, chronic illness, and family disharmony or conflict), 3) a possible temporal relationship between a specific stress and the onset of symptoms, 4) role models from whom the symptoms might have been learned, and 5) evidence of primary or secondary gain from the symptom.
Differential Diagnosis
The differential diagnosis of a child presenting with intermittent muscle weakness includes familial periodic paralysis (hypokalemic or normokalemic); metabolic myopathies, including myophosphorylase deficiency and mitochondrial deficiency; limb-girdle muscular dystrophy; myasthenia gravis; and endocrinopathies such as thyroid disorders and adrenal disorders. Delineation of the clinical pattern and laboratory testing should allow the clinician to determine if any of these disorders is present. If no other disorder fits and if significant stress is evident, a psychosomatic cause should be considered.
Treatment
Once the evaluation has been completed, a treatment plan is presented to the parents and the child. The first step is to explain that the symptom is real but that no organic disease has been demonstrated. Anxiety or stress has led to the symptom, and this element must be understood and relieved for the child to get better. The treatment must be tailored to the problem, with set goals and the provision of positive feedback as goals are achieved. In addition to measures aimed at understanding and relieving stress, treatment for a patient complaining of weakness might involve "graded" physical therapy.
Removing the secondary gain achieved by the symptom is essential for recovery and to eliminate perpetuation of the symptom. Examples of secondary gain include missed school days and increased parental attention because of the symptom. It is essential that the treatment provide "escape with honor" and that the regimen give some control to the child. After discharge, continued psychotherapy should be aimed at allowing the child to give up the sick role and cope with future stress and anxiety more productively.
Prognosis
Except for children who have pseudoseizures, most children who have a conversion disorder have no underlying major mood disorder or psychiatric illness. Major mood disorders have been identified in 32% of children who have pseudoseizures. A history of sexual abuse is common in patients who have conversion disorders.
Because children are still in the formative stages of personality development, the adult diagnosis "hysterical personality," now called "histrionic personality disorder," is questionable when applied to children who have conversion disorder. Histrionic personality disorder comprises a constellation of traits, including dependency, immaturity, egocentricity, attention-seeking behavior, and manipulation. With timely intervention, the child who has a conversion disorder will develop better coping abilities and give up the sick role, thus aborting perpetuation of the symptom and progression to an adult histrionic personality disorder.
Further Observations
This patient had a chronic illness and had become aware of its power to influence the adults in her world. Another example of this effect is that pseudoseizures are common in children who have true epilepsy.
Clinical testing should be judicious because the tests themselves promote anxiety and confirm and reinforce the power and seriousness of the symptom. The child herself is deceived about the source of her symptoms, and families of children who have conversion disorders tend to have conversion symptoms, reinforcing the impressionable child's symptomatology. The clinician must be firm in the diagnosis of conversion and resist his or her own anxiety, which tends to produce the need to do more testing. The simple test employing intravenous saline was an effective diagnostic tool in this case, but it is important that clinicians undertake such procedures with sensitivity to avoid their being perceived by the patient as a trick, potentially undermining trust.
The use of physical therapy was a face-saving treatment for the patient and more likely to be acceptable to patient and parents than a purely psychiatric approach, which can be counterproductive if instituted at the wrong time. Similarly, early hospitalization can raise the stakes ominously. Sometimes, psychotherapy will be acceptable if the reason given for recommending such treatment is "to help you cope with the stress of being ill for so long."
Lessons for the Clinician
Conversion disorder represents a child's expression of a difficult or stressful situation through a physical symptom. The pediatrician, being familiar with the child and parents, should be able to gain the trust of the child and identify stressors and difficulties in the child's life. Psychiatric referral and sometimes hospitalization are crucial for the recovery of children whose symptoms are prolonged and unresponsive to counseling by the pediatrician.