Abstract
Hysterical paralysis, a type of conversion disorder, presents with the loss of motor or sensory function. Although this disorder is nonorganic, it resembles the symptoms of a structural disease of the nervous system. It is generally associated with a traumatic or social event. The patients often require excessive testing and comprehensive assessment in exposing this psychogenic ailment. We reported the most dramatic type of conversion disorder, hysterical paralysis, in which full recovery was obtained with early recognition and rehabilitation approach including faradic stimulation.
Introduction
Hysterical paralysis, a type of conversion disorder, is a nonorganic loss of sensory or motor function that may be precipitated by a traumatic or social event. It is not fully explained by a medical condition because of the expression of an underlying psychological basis. Seizures, paralysis, and anesthesia are most common features in hysterical conditions [1, 2]. The prevalence of conversion disorder is reported 5 and 22 per 100,000 persons in the general population [3]. Although no definite epidemiological research has been undertaken in our country, observations suggest that this percentage may be higher [4]. It is more common in females, with reports varying from 2: 1 to 15: 1 [5]. An estimated incidence of pediatric psychogenic movement disorder was reported as approximately 2% [6]. An accurate diagnosis is imperative but not easy. Frequently, a complete medical assessment and laboratory, electrodiagnostic and imaging studies are essential to establish the correct diagnosis and avoid unnecessary treatments with potentially significant side effects. After the diagnosis is confirmed, an interdisciplinary team approach including psychiatric, psychological, and rehabilitative components should be introduced as early as possible [1, 2]. There is no proven effective treatment method for conversion disorder. For this reason the prognosis of this condition appears unfavorable. However, early diagnosis and an acceptable explanation would be valuable in clinical practice [7]. Rapid recovery should be expected, but can take up to six months [1]. Hafeiz and Khalil et al. [5, 8] found faradic stimulation to be as effective as other treatment modalities in treating conversion paralysis. Sethi et al. [9] presented faradic stimulation treatment in an 11-year-old girl with prolonged hysterical aphonia. They reported that painless application and quick results were possible.
Light of this information, the aim of the presented case is to indicate the significance of the faradic current which can be easily and safely applied in the diagnosis and treatment of the hysterical paralysis in children.
Case
A 10-year-old girl was admitted to our clinic one week after the complete loss of motor function in both lower extremities, with impaired coordination and balance. She was hospitalized in our clinic with these complaints. Her medical history revealed that she had been hospitalized for appendectomy one month before. She had no history of prenatal, natal or postnatal disorders or of use of any medication or herbal or illicit drugs. Her family history was unremarkable. Clinically, her body temperature was 36.4
Discussion
Hysterical paralysis, a type of conversion reaction, resembles the symptoms of a structural disease of the nervous system [2]. Many clinicians are cautious in diagnosing this disorder for fear of missing and organic cause for the patient’s symptoms [1]. The difficult nature of the diagnosis of motor conversion was also appreciated by Atan et al. [10]. Their conclusion was that in cases in which symptoms are difficult to explain neuroanatomically or are functionally inconsistent, hysteria should enter into the differential diagnosis. In the physical examination, the preservation of normal muscle tone, normal reflexes, and flexor plantar reflexes, despite apparent muscle weakness, was of the greatest value in establishing an accurate diagnosis. The autonomic system is usually unaffected, with full sphincter control and normal bowel movement. Typically with such features, the diagnosis can be made confidently and any residual doubt can be removed with laboratory tests, imaging (X-ray, MRI) and electrophysiologic studies [1, 2]. In our case, all of these tests were performed, and there was no evidence in favor of organic causes.
Patients must be screened when there is an apparent discrepancy between objective findings and clinical presentation. It is important to consider the possibility of disability due to psychological mechanisms, at the earliest contact. It should be remembered that these patients are not malingering; their conditions are due to their unconscious reactions while coping with some stressful or traumatic situation [1]. In the past, patients were referred to psychiatric departments, but this tendency has changed. Treatment is recommended to be directed toward the symptoms in the rehabilitation clinics according to their physical symptoms [2]. Dvonch et al. [11] have reported five children and adolescents who displayed a conversion reaction and demonstrated that physical therapy helps to resolve symptoms. Also, they recommend psychotherapy only for patients with persistent maladaptive behavior.
Rehabilitation interventions may include faradic stimulation, balance-coordination training, strengthening, and walking/gait training exercises [2, 5, 8]. Faradic stimulation is a low-frequency alternative current and causes incomplete tetany in skeletal muscle with sufficient current severity. With this feature, it can be used as placebo in the treatment of hysterical paralysis. The most important effect of faradic stimulation is saving or forming central muscle and movement pattern [10]. In clinical practise, pain and discomfort sensation of faradic current application may cause hesitation in the usage of this therapy modality. On the other hand, Dubowitz and Sethi et al. [12] demonstrated that faradic stimulation can be safely applied in children.
In our case, we performed faradization and a response was obtained relatively quickly. A review of published treatment regimens shows a wide variation in lengths of stay. Recovery can generally be expected within a few weeks, although previously published case reports have suggested that time to recovery is dependent upon the length of duration of symptoms [11]. Our case supports these findings, with a short duration of symptoms (one week) and relatively quick recovery (length of stay, 14 days).
In conclusion, hysterical paralysis is a conversion disorder that can present a diagnostic challenge. With this case presentation of hysterical paralysis, we wish to emphasize the challenges related to the diagnosis and the confusing clinical picture of these patients in order to raise physician awareness, reduce neglect and assist in the proper diagnosis and treatment of this phenomenon. Additionally, it is showed that the administration of the faradic stimulation resulted in a dramatic response to a rehabilitation approach facilitated by a psychosocial support and proper diagnosis and pharmacologic management of the underlying psychiatric pathology.
Conflict of interest
None to report.