RevBrasAnestesiol.2017;67(6):644---646
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologiawww.sba.com.br
CLINICAL
INFORMATION
When
a
patient
falls
(asleep)
and
can’t
get
up:
conversion
disorder
---
paraplegia
following
general
anesthesia
夽
Chawla
LaToya
Mason
BaylorCollegeofMedicine,DepartmentofAnesthesiology,Houston,USA
Received4September2014;accepted28October2014 Availableonline9June2015
KEYWORDS
Generalanesthesia; Paraplegia;
Psychiatry;
Conversiondisorder
Abstract
Backgroundandobjectives: Thiscasereportdescribestherareoccurrenceofparaplegiacaused byconversiondisorderinawomanwhoreceivedgeneralanesthesiaforbreastsurgery.
Casereport: A46-year-oldhealthywoman receivedgeneralanesthesiaforexcisionofaleft breastfibroepitheliallesion.Inthepost-anesthesiacareunit,shereportedbilaterallossofboth sensationandmotorfunctionbelowtheknees.Physicalsignsandsymptomsdidnotcorrelate withanyanatomicalorneurologicalpatterns;imagingrevealednoabnormalities.Psychiatric consultationwasperformedwhereinfamilialstressorcircumstanceswereidentified,leadingto diagnosisandmanagementofconversiondisorder.
Conclusion:Conversion disorder is characterized by alteration of physical function due to expressionofanunderlyingpsychologicalailment.Itsdiagnosisrequiresthoroughevaluation includingappropriateworkuptoexcludeorganiccauses.Themeshingtogetherof anesthesiol-ogyandpsychiatry---asdemonstratedbythiscasereport---offersanopportunitytohighlight importantinformationpertainingtothedefinition,diagnosis,andmanagementofconversion disorderasitmaybeencounteredinthepostanesthesiarecoveryperiod.
©2015SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
PALAVRAS-CHAVE
Anestesiageral; Paraplegia; Psiquiatria;
Transtornoconversivo
Quandoumpacientecai(nosono)enãoconsegueacordar:transtornoconversivo ---paraplegiaapósanestesiageral
Resumo
Justificativaeobjetivos: Descreverararaocorrênciadeparaplegiacausadapordistúrbio con-versivoemumamulherquerecebeuanestesiageralparaacirurgiademama.
夽
Institution:DepartmentofAnesthesiology,BaylorCollegeofMedicine,Houston,TX,USA.
E-mail:[email protected]
http://dx.doi.org/10.1016/j.bjane.2014.10.002
Conversiondisorderaftergeneralanesthesia 645
Relatodecaso: Mulhersaudávelde46anosrecebeuanestesiageralparaexcisãodeumalesão fibroepitelialnamama esquerda.Nasala derecuperac¸ãopós-anestésica,apacienterelatou perdabilateraldesensibilidadeemotricidadeabaixodosjoelhos.Ossinaisfísicosesintomas nãocorrelacionavamcomnenhumapadrãoanatômicoouneurológico;examedeimagemnão revelouanormalidades.Umaconsultapsiquiátricafoifeitaeconstatoucircunstânciasfamiliares estressantes,oquelevouaodiagnósticoetratamentodetranstornoconversivo.
Conclusão:Otranstorno conversivoé caracterizadoporalterac¸ãodafunc¸ãofísica devidoà expressãodeumadoenc¸apsicológicasubjacente.Seudiagnósticorequerumaavaliac¸ão min-uciosa, incluindo tratamento adequado para excluir causas orgânicas. O entrosamento de anestesiologia e psiquiatria, como demonstrado nesterelato de caso,ofereceuma oportu-nidadeparadestacarasinformac¸õesimportantesrelativasàdefinic¸ão,diagnósticoemanejo dotranstornoconversivo,poisessetranstornopodeserencontradonoperíododerecuperac¸ão pós-anestésica.
©2015SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigo OpenAccess sobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Conversiondisorder, previouslyknownashysteriaandnow oftenreferredtoasfunctionalneurologicalsymptom disor-der,isrepresentativeofanunconscious,involuntaryprocess in which psychosocial needs, conflicts, or stressors are expressedassomaticsymptomsforwhichthereisno con-forminganatomic or physiologic explanation.1 Among the general United States population, its incidence has been reportedtobebetween11and300per100,000peopleor 0.01---0.5%andappearstoaffect femalesmorethanmales ataratioof2:1.1---3Greaterprevalencehasbeenreportedin otherpopulations:5---14%amonggeneralhospitalpatients, 1---3%amongoutpatientreferralstopsychiatrists,and5---25% amongpsychiatricoutpatients.4Theprevalenceof conver-sion disorder in the perioperative setting --- specifically after administration of general anesthesia --- is unknown. The meshing together of anesthesiology and psychiatry ---as demonstrated by this case --- offers an opportunity to highlightimportantinformationpertainingtothedefinition, diagnosis,andmanagementofconversiondisorderasitmay beencounteredinthepostanesthesiarecoveryperiod.
Case
report
A 46-year-old 74kg woman presented to an ambulatory surgery unit for excision of a left breast fibroepithelial lesion.Hermedicalhistoryincludedlaparoscopic cholecys-tectomyandrightbreastsurgery;bothprocedureshadbeen performedundergeneralanesthesiawithoutadverseevent. After performing preanesthetic assessment and acquiring informedconsent,midazolam(2mg)wasadministeredfor anxiolysis.Intheoperatingsuite,anuneventfulanesthetic inductionensuedwithfentanyl(100mcg),lidocaine(70mg), and propofol (150mg). General anesthesia via a laryn-geal mask airway(LMA) wasmaintainedusing sevoflurane in a 50/50 air/oxygen mixture for the uneventful 46-minprocedure.Otherintravenousmedicationsadministered
intraoperativelywerecefazolin(1000mg), acetaminophen (1000mg),andondansetron(4mg).Attheprocedure’send, theLMAwasremovedandthepatientwastransferredtothe postanesthesiacareunit.Approximatelyhalfanhourlater, shereportedabsenceofmotorcontrolandsensation affect-ingbothlowerextremitiesbelowtheknees.Vitalsignshad remainedwithinnormallimits.Neurosurgeryandneurology teams were immediately consulted for further evaluation whichincludedneurologicalphysicalexamination andstat
computedtomography(CT)ofthe headastherewas con-cernthatthepatientexperiencedacerebrovascularinsult thatwouldrequireemergenttherapy.Uponconfirmationof negativeCT imaging and in the absenceof any apparent organic explanation for the patient’s neurological symp-toms, psychiatricconsultation wasobtained. Interview of thepatientrevealedthepresenceofsignificantfamilialand socialstressorsinherlife(includingrecentconflictwithher spouse),leading toa presumptivediagnosis of conversion disorder.Subsequentmanagementincludedpsychotherapy, physicaltherapy,andeducationregardingcopingstrategies. Thepatientwasdischargedhomethreedayslateratwhich timesherequiredawalkerforambulationassistance.The patientwas lost to follow-up until she presented several monthslaterforanunrelatedfamilymedicinevisit.Atthat time,shedemonstratednoneurologicaldeficitsorphysical limitations.
Discussion
646 C.L.Mason
symptomsordeficits,pseudoseizures, ormixed presenta-tion.Thedisorderisusuallytriggeredbyarecentsignificant stressor emotional trauma.Other risk factorsfor conver-siondisorderinclude ahistoryof physical orsexual abuse andneglectinchildhood,personalor familialhistory ofa mentalhealthcondition,orhistoryofaneurologicaldisease thatcausessimilarsymptoms.4
Onmanylevels,conversiondisorderimplicatestherole of the unconscious in the pathophysiology of a particu-lar condition. Its diagnosis is often challenging to make and mandates definitive determination that symptoms or deficitsarenotbeingintentionallyproduced.Thiskey fac-tordifferentiatesconversion disorder frommalingeringor otherfactitiousdisorders.Whenconsideringthediagnosisof conversiondisorder,itisessentialtocarefullyeliminateany possibleanatomic,physiologic, or pathologicexplanations for the symptomatology. Conversion disorders may mimic a variety of neurological and musculoskeletal conditions includingbutnotlimitedtocerebrovascularaccident,spinal cordinjury, myasthenia gravis,Guillian---Barre’ syndrome, Parkinson’sdisease,epilepsy,ormultiplesclerosis.
In the literature, few reports describe the occurrence ofconversiondisorderinassociationwithanesthetic tech-niques.Threereportsdescribeitsdevelopmentinpediatric patientsaftergeneralanesthesia.3,5,6Han etal.7describe thepostoperativedevelopmentofconversionlocked-in syn-drome in a woman who received general anesthesia for implantationofaspinalcordstimulator.Atleastthreeother isolated cases report the occurrence of conversion disor-der after neuraxial techniques (2 spinals,1 epidural).8---10 Thepatientdiscussed inthis reportexperiencedprofound neurological and motor deficits during recovery from an uneventfulgeneralanesthetictechniqueandoperative pro-cedure that could not be explained by any abnormalities foundonphysicalexaminationandworkup.
Effectivemanagementofconversiondisorderrequiresa multidisciplinary approach. Timely referral to psychiatric servicesis an essential component aswell as psychother-apy, physical therapy, and addressing the related stress. It is paramount that care providers be cognizant of the patient’s current life events, past stress responses, and present support systems. Pharmacological therapy is not amainstayof treatment regimens and,in fact,shouldbe
avoided whenever possible due to concern for develop-mentofsubstancedependency.2Appropriatepharmacologic agents maybeconsidered inselectpatients withextreme anxiety.Thereissomedatathatsuggestsanimpactfulrole for theutilization of transcranialmagnetic stimulation in themanagementofthisdisorder.11Aboveall,management ofconversiondisordershouldcompriseofhonestdisclosure, reassurance of recovery,andreinforcement ofalternative copingstrategies.3
Conflicts
of
interest
Theauthordeclaresnoconflictsofinterest.
References
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dis-orderinanelderlyman.AnnLong-TermCareClinCareAging. 2012;20:30---5.
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4.FeinsteinA.Conversiondisorder:advancesinour understand-ing.CMAJ.2011;183:915.
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6.ReillyMJ,MilmoeG,PenaM.Threeextraordinarycomplications of adenotonsillectomy. Int J Pediatr Otorhinolaryngol. 2006;70:941---6.
7.HanD,ConnellyNR,WeintraubA,etal.Conversionlocked-in syndromeafterimplantationofaspinalcordstimulator.Anesth Analg.2007;104:163---5.
8.Yokoyama K, Okutsu Y, Fujita H. A case of monoplegia from conversion disorder after spinal anesthesia. Masui. 2002;51:1363---7.
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