Psychosomatics 46:187-188, April 2005
© 2005 The Academy of Psychosomatic Medicine
Spinal Cord Astrocytoma Mistaken for Conversion Disorder
Pascal Cathebras, and
Martial Koenig, Saint-Etienne, France
TO THE EDITOR: The risk of overlooking organic pathology is inherent in making a diagnosis of "hysterical" conversion. In older studies, this risk has been considered high, up to 30%,1,2 while more recent studies have found it extremely low.3,4 We report the case of a young woman whose symptoms that were initially attributed to conversion disorder were finally explained by a spinal cord tumor.
Case Report
Ms. A, an 18-year-old woman, was admitted twice to our internal medicine ward. The first admission was requested by a surgeon who had removed her appendix a week before. She kept vomiting despite the absence of surgical complication. She also complained of hiccups. Her clinical examination was normal. A brain computerized tomography scan ruled out the major causes of acute intracranial hypertension. A symptomatic treatment had some efficacy within a few days. A conflict between Ms. A and her parents was thought to have contributed to this delayed recovery.
She was admitted 4 months later for a gait disorder. A neurological examination was inconclusive because her response was considered unreliable. However, her vibratory sense seemed altered on the left hemibody, and her ankle relexes were symmetrically decreased. For that reason, an electromyographic and nerve conduction study was carried out and proved to be normal. Ms. A displayed histrionic behavior, and again, conflict with her parents was apparent. Because of these features and of the previous episode of "abnormal" illness behavior, a diagnostic of "hysterical" conversion disorder was made. When she was seen as an outpatient 1 month later, she was much better, her gait disturbance seemed to improve, and thus, a neurological examination was not performed. We gave her general practitioner the advice to avoid new investigations. However, 9 months later, her neurological state was alarming, and a diagnosis of infiltrating astrocytoma of the cervical spinal cord was made. She improved after palliative surgery (laminectomy) but remains to date disabled with ataxia and spasticity.
Discussion
Vomiting is a classical symptom of somatization disorder, and conversion symptoms may involve the autonomic system. In the case of our patient, vomiting and hiccups were likely related to the recent coelioscopic surgery but might have been exaggerated by familial conflict and favored by the astrocytoma (located in the upper spinal cord, thus not far from the bulbar centers involved in vomiting). Later, the abnormalities of the neurological examination may have been overlooked or misinterpreted. Somesthesic evoked potentials, or spinal cord magnetic resonance imaging, might have allowed an earlier diagnosis of the tumor.
There are anecdotal reports of brainstem or medullary tumors masquerading as conversion disorder.5,6 Neurological pathology and conversion disorder may indeed coexist.7 With a patient suspected of conversion disorder, the physician faces a dilemma: on one hand, avoidance of inappropriate investigations is considered important in the management of the somatizing patient8; on the other hand, the risk of missing organic disease is real, the positive evidence for a psychological cause for the symptom is often weak, and a diagnosis of "hysteria" is mainly a matter of faith. Therefore, a diagnosis of conversion disorder must remain a provisional hypothesis that has to be periodically reevaluated. We believe that our patient did not have conversion symptoms, but atypical early symptoms of a rare tumor, nonspecific psychological distress, and "abnormal illness behavior" erroneously labeled as "hysterical."
REFERENCES
- Slater E: Diagnosis of hysteria. BMJ 1965; 5447:1395–1399
- Lazare A: Conversion symptoms. N Engl J Med 1980; 305:745–748
- Binzer M, Kullgren G: Motor conversion disorder: a prospective 2- to 5-year follow-up study. Psychosomatics 1998; 39:519–527[Abstract/Free Full Text]
- Crimlisk HL, Bhatia K, David A, Marsden CD, Ron MA: Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms. BMJ 1998; 316:582–586[Abstract/Free Full Text]
- Burch EA, Hutchinson CF, Still CN: Hysterical symptoms masking brain stem glioma. J Clin Psychiatry 1978; 39:75–78[Medline]
- Jones JB, Barklage NE: Conversion disorder: camouflage for brain lesions in two cases. Arch Intern Med 1990; 150:1343–1345[Abstract/Free Full Text]
- Marsden CD: Hysteria: a neurologist view. Psychol Med 1986; 16:277–288[Medline]
- Mayou R, Bass C, Sharpe M (eds): Treatment of Functional Somatic Symptoms. Oxford, Oxford University Press, 1995
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