3.07.2007

Can't Escape the Psych

'I don't know. I can't localize his lesion; he's had three episodes of left-sided weakness, he says it came on suddenly followed by headache, and he had pins and needles on both sides. So, if we were to go with one lesion, motor only, let's say, that could be his right internal capsule...but to have three episodes that resolve completely and last for days?'

Dr. S strokes his beard, says a non-commital 'yes', which means, 'I'm thinking of how to tell you what I think', and says, 'I don't think he's had a stroke. At this point, I'm hesitant to call it conversion disorder...there's always a kernel of truth to these. And, just because this isn't, quote-unquote, real, doesn't mean he can't have a real stroke'.

'What about the one-sided migraines that affect 0.00005% of the population?'

'Well, it doesn't fit the onset...and before you really go and lay your nickel down and say, 'I think it's migraine', we would need to rule everything else out...'

Conversion. As in conversion from the brain to the body, crossing the border, if there is one. Conversion disorder occurs most in young women with other psychiatric diagnoses. As in, 27-yo female w/hx of OCD presents with acute onset of bilateral pins and needles in hands along with right-handed weakness, worse in her fingers than wrist. Oh, BTW, she just had a huge fight with her boyfriend and he's moving out. There's no explanation for her neurological complaint. None. You can't put it anywhere in the CNS. So the patient 'converts' their emotional stress into a syndrome that fits their own idea of illness, and makes it real. The opposite of self-help.

Or, factitious disorder. The patient fakes it, but in order to take on the role of the patient, be cared about, get tests, perhaps in an attempt to compensate for some loneliness curled around their heart. We look at their hearts, often, with sound waves, with dye. We don't see the loneliness.

At extremes, people may contaminate their own surgical wounds, give themselves thyroid hormone. An historical precursor was named after a German baron, Munchausen, who told amazing tall tales upon returning from a war with the Turks.

That's him. But the idea that these patients are making up their lesions is somewhat more sinister than his tall tales of riding on a cannonball, or pulling himself out of quicksand by his beard. I've blogged about one before, the patient below who would put her head in the pillow to drop her O2 saturation. Perhaps not faking, but on a spectrum from the professional patient to Munchausen's.

Or, most distasteful, described in my lifetime, Munchausen's by proxy, in which a parent, usually a mother, makes their child sick deliberately in order to receive care for themselves. Perhaps I won't say any more about that.

These people are included with malingering in some articles, people who are faking pain, for example, in order to obtain narcotics. But I don't see them in the same spectrum. Imagine being so lonely that the attention of a stress test relieves some need; that the clustering of your family in a tiny room, with the gentle beeps of IV monitors to guide you, starts to feel more familiar and comfortable than home, or what passes for it. That seems worse than wanting narcs bad enough to complain about abdominal pain, a lot.

My world tilts a bit more towards the bizarre; or, more likely, I see a bit more of what's real. I still can't let go if the idea that he has the migraines that cause paralysis, and that's he's in that 0.00005%.

2 comments:

Anonymous said...

is the guy taking a lipophilic statin? may well be adverse effects of that class of drugs.

A, a fourth-year medical student said...

It could be, we didn't check his medication list. I've found even with the reminders that we should always consider iatrogenic causes, we still tend to put them at the bottom of the differential.