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Conversion disorder presenting in a patient with an implantable morphine pump and an epidural abscess resulting in paraplegia
226
Conversion Disorder Presenting in a Patient With an Implantable Morphine Pump and an Epidural Abscess Resulting in Paraplegia Michael G. Shell, DO, H. Lee Mitchell, MD, Michael W. Lees, MD, Andrew P. Belin, PhD ABSTRACT. Shell MG, Mitchell HL, Loes MW, Belan AP. Conversion disorder presenting in a patient with an implantable morphine pump and an epidural abscessresulting in paraplegia. Arch Phys Med Rehabil 1997;78:226-9. Conversion disorders are symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or medical condition. The psychological symptoms associatedwith the medical condition must be preceded by conflict or other stressors.We present an individual who developed conversion disorder and paraplegia secondary to a sterile epidural abscess near the tip of her surgically implanted, epidural morphine infusion pump. She manifested at varying times both transient bilateral blindness and pseudoseizuresconsistent with a diagnosis of conversion disorder. Neurological evaluation for seizure activity and meningitis were negative. The etiology of the sterile epidural abscessremained unknown. The essential features of conversion disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, are discussed. Treatment of patients diagnosed with conversion disorder remains primarily supportive, with the focus on consistency and behavioral management. Extreme caution is suggested in regards to further investigations. 0 1997 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
ONVERSION DISORDER, presenting in a medically soC phisticated individual with both physical and psychological symptoms, is extremely difficult to evaluate and treat. The complexity of the patient’s presentation may delay appropriate treatment unless careful differentiation is made early. Even more of a problem is that inappropriate treatment may be instituted on the basis of symptoms, especially when specialists are not consulted and old records are unavailable for review. The essential features of conversion disorder are symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or medical condition as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.’ The psychological symptoms associatedwith the medical condition must be preceded by conflict or other stressors. Conversion disorder differs from factitious disorder or malingering, in that the symptoms are not intentionally produced. Pain complaints may be associatedwith conversion disorder, From the Department of Anesthesiology (Drs. Shell, Lees, and B&n) and the Department of Psychiatry (Dr. Mitchell), University of Arizona School of Medicine, Maricopa Medical Center, Phoenix. Submitted for publication July 7, 1995. Accepted in revised form July 5, 1996. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or won any oreanization with which the authors are associated. _Reprint &est to Michael G. Shell, DO, Arizona Pain Institute, Department of Anesthesiology, Mticopa Medical Center, 2601 East Roosevelt, Phoenix, AZ 85008. 0 1997 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/97/7802-3585$3.00/O
Arch
Phys
Med Rehabil
Vol78,
February
1997
but conversion disorder is not limited only to pain complaints.1*2 The essentialfeature of pain disorder necessitatesthat pain is the dominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.’ Pain is not intentionally produced as required by DSM-IV criteria for the diagnosis of factitious disorder or ma1ingering.i We present the case of a medically sophisticated individual who developed paraplegia secondary to a sterile epidural abscessnear the tip of her epidural morphine infusion pump. In addition to her multiple somatic and psychological complaints, she manifested at varying times both transient bilateral blindness and behavior best characterized as pseudoseizure, consistent with a diagnosis of conversion disorder. CASE REPORT A 39-year-old, right-hand-dominant woman psychotherapist presented to our pain institute in early October 1994 to refill her implanted morphine pump. She reported a history of multiple thoracic compression fractures, secondary to multiple myeloma, and numerous lumbar spine surgeries for intervertebral disc disease.The surgeries had left her with arachnoiditis and persistent left leg pain. She complained of constant lower back pain with mildly radiating pain to the lateral right leg. A morphine pump had been epidurally implanted in May 1993 because of intractable back pain and an inability to tolerate oral morphine. The pump provided only mild relief of her back and leg pain despite an epidural infusion of morphine up to 4mg per day. Her medical history was significant for adult-onset diabetes mellitus, multiple myeloma, ulcerative colitis, hypertension, and polycystic ovarian disease. She also reported multiple motor vehicle accidents. None of these entities could be documented, although 1 month earlier she had been admitted to our medical center, where studies were negative for multiple myeloma and diabetes. She related multiple prior surgeries: seven laparotomies, two laminectomies, a hysterectomy, oophorectomy, and a repair of a strangulated inguinal hernia. She listed multiple allergies to many opioids of various chemical classes and to several other medications. The patient went to the pain clinic to refill her morphine pump about 3 weeks before the precipitous admission to the hospital for spinal cord compression. Physical examination revealed an antalgic gait, no lower extremity motor deficits, normal reflexes, and mild sensory loss in the right L5-Sl dermatome. She had a long midline scar over the lumbar region and multiple abdomen scars. Her pump was not empty and was not filled at that time. The patient was asked to return after her medical records were evaluated. The patient presented to the emergency department approximately 2 weeks later, complaining of a 3- to 4-day history of right flank pain and bladder discomfort, right lower extremity pain, and inability to ambulate. She had previously been placed on an antibiotic for a bladder infection. She refused oral opiates. She was initially observed by staff to be writhing on the floor in pain. The episode was called a seizure at the time, but later review of the incident revealed some inconsistencies with that
CONVERSION
DISORDER
EPIDURAL
label, one of which was that the seizure appeared too coordinated. Later, she was observed walking without difficulty outside of the emergency department and was standing unaided to smoke a cigarette. The physical examinations revealed right flank tenderness, no sensation throughout the right lower extremity and the left foot, absent right knee and ankle reflexes, normal left knee and ankle reflexes, and the patient’s report of inability to move her right lower extremity. Both urinalysis and renal ultrasound were negative. Dorsal and lumbosacral spine radiographs were reported by the radiologist as normal; however, when the lateral radiographs were personally reviewed with the radiologist, rnnor superior endplate abnormalities were noted at T6, 7, and 8, consistent with a hyperflexion injury and minor thoracic compression fractures. The patient was sent home with instructions to follow up with her primary care physician. The patient returned to the emergency department 2 days later complaining of circumferential numbness of both lower extremities and numbness across the lower back and right anterior abdominal area to the umbilicus. She denied incontinence. Physical examination revealed normal reflexes in the lower and upper extremities. She denied sensation to pinprick in the lower extremities, yet she exhibited brisk withdrawal and denied sensation to cold and light touch in the lower extremities. Strength was judged to be l/5 in the left lower extremity and O/5 in the right lower extremity to command. When she was confronted by emergency department personnel about her inconsistent history, her behavior in and near the emergency department, the absence of objective physical examination findings, and the normal dorsal and lumbosacral radiographs, she became verbally abusive and left the emergency department. She presented to the emergency department a few days later with additional complaints. She complained of ascending numbness on the right up to under the right breast crease. She also complained of inability to move the lower extremities. Her physical examination remained consistent with normal reflexes, neutral Babinski reflexes, normal rectal tone, and inconsistent sensory examination in the lower extremities. She either refused or was unable to move the lower extremities on command, but was observed to have spontaneous movement during transfers from the wheelchair to the stretcher and while lying down. The patient was discharged home after arrangements were made for additional neurology evaluation in the outpatient clinic. Approximately 5 days later, she presented to the emergency department with continued complaints of ascending numbness and an inability to move her lower extremities. Physical examination revealed a discrete sensory level differential at T6 on the right and at T12 on the left. Her knee and ankle reflexes were slightly hyperreflexic, Babinski reflex was present bilaterally, and a crossed adductor response was elicited. She was admitted for a thoracic myelogram to evaluate for spinal pathology as the etiology of her neurological findings. When requested to sign the consent for the thoracic myelogram and for a release of medical records from local hospitals, the patient suddenly developed bilateral blindness followed by seizure activity. The seizure resolved after a few minutes with no tongue biting, convulsant activity, or incontinence observed. The seizure activity was described as periods of verbal and physical nonresponsiveness. Her physical examination revealed breath holding, normal upper extremity tone, with controlled fall of her outstretched arms to the side of the bed away from her face. Cranial computed tomography (CT), electroencephalogram, and cerebrospinal fluid (CSF) analysis were negative. It was concluded by the neurologist that she did not have a seizure disorder or spinal meningitis. The blindness did not resolve
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until nearly 24 hours later. During the period of blindness, she avoided eye contact and demonstrated absolutely no concern regarding her blindness. Normal sight returned and she reported that she experienced a dissociative state as if parts of her body did not belong to her. Although some of the symptoms were considered genuine, others appeared to have suspicious components. In addition to the symptoms described, she continued active fabrication of her medical history, including descriptions of previous hospital stays at multiple hospitals; however, she refused to sign medical release forms for those records to be obtained. She complained about poor pain control and was hostile to staff even when given intravenous opioids. Instead, she requested refill of her implanted morphine pump as the only method of pain control. Beyond the positive physical symptoms, psychiatric evaluation was suggestive of the presence of factitious disorder and of conversion disorder. She eventually agreed to sign the consent form for the thoracic myelogram. It was performed immediately and demonstrated complete obstruction of the cephalad flow of contrast medium at the level of the Tll-12 interspace. Postmyelogram thoracolumbar CT confirmed complete obstruction of contrast flow at the inferior end plate of Tll with lower thoracic cord displacement to the left. The tip of the morphine pump catheter could be seen in the midst of amorphous epidural material at the site of the blockage on the right. The patient proceeded to surgery after another confrontation regarding consent to operate and to remove the morphine pump and catheter. She consented to surgery for removal of the abscess, but adamantly refused removal of her morphine pump and catheter. She indicated that her refusal was based on her reports that it had cost her approximately $30,000, which she had obtained by the sale of her home and her belongings. The patient proceeded to surgery where a TlO to T12 spinal cord decompression with laminectomy and removal of sterile abscess at the morphine pump catheter tip were performed. The morphine pump was reluctantly left in place. Necrotic tissue from the epidural site was reported by pathology as insufficient for diagnosis. Infectious disease consultation was obtained and empirical antibiotic treatment initiated. Infectious disease evaluation included blood cultures, urine for mycobacteria and fungi, CSF for fungal serology, skin test for purified protein derivative, candida, and coccidioidin, rapid plasma reagin, and chest x-ray. All cultures, skin tests, and chest X-ray were negative. It was concluded that she had developed a sterile, epidural abscess at the catheter tip. Infectious disease consultation was specifically asked as to the necessity of removing the pump. They did not recommend immediate pump removal. The patient’s postoperative course was uneventful, with some neurologic return to her lower extremities. She was discharged to a rehabilitation hospital for spinal cord injury rehabilitation of her paraplegia.
DISCUSSION This case illustrates the complexity of a patient presenting with combined physical and psychological problems. Inconsistencies in her history and physical examination were ubiquitous. The patient was medically and psychiatrically sophisticated and demanding of hospital staff. She was uncooperative and verbally abusive. Yet, an underlying problem of functional and lifethreatening significance was evolving. Perhaps its identification and treatment would have occurred earlier, and been easier, if consistent information and previous medical records could have been obtained. On the patient’s first outpatient visit, it was readily clear to the medical staff in the pain clinic that this patient had significant psychiatric comorbidities. That impression was so evident that
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Phys Med
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1997
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CONVERSION
Table
1: Diagnostic
Criteria
for 300.11
Conversion
DISORDER
EPIDURAL
Disorder
A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors. C. The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering). D. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience. E. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder. Specify With With With With Reprinted
with
type of symptom or deficit: Motor Symptom or Deficit Sensory Symptom or Deficit Seizures or Convulsions Mixed Presentation
permission.’
the anesthesiology resident physician insisted on labeling her a Munchausen syndrome. Both the attending physician, pain fellow, and the neuropsychologist believed that this diagnosis could only be tentative until further data were known. The diagnostic dilemma centered on the new way that the DSM-IV was approaching factitious diseaseand associatedpain disorders with a psychiatric disease. It was only after her admission that the extent of her psychopathology and the severity of her evolving medical condition became clearer. The myelogram showed arachnoiditis, as well as the epidural abscessthat necessitated the surgery. The radiographs suggested that she had a previous compression injury to the thoracic spine. The events that occurred in the hospital, particularly the bilateral transient total blindness and the pseudoseizure, were indicative of conversion reactions. She exhibited these reactions accompanied by a belle indifference, whereby she was noted to not express the usual and emotional response to her condition, as would be expected in a healthy person experiencing a sudden, new, and life-jarring event. The crux here was whether she was intentionally producing her symptoms or whether they represented a major psychopathology complete with somatic, delusional, and dissociative states. The intentional production of her symptoms could not be confirmed, even during her period of blindness, when she was carefully observed under hospital confinement and examined on multiple occasions.Hence, conversion disorder in a patient with a known chronic, nonmalignant pain syndrome was thought to be the best unifying diagnosis. According to the DSM-IV, the essential feature of conversion disorder is the presence of symptoms or deficits affecting voluntary motor or sensory function that suggests a neurological or other general medical condition (criterion A).’ Psychological factors are judged to be associated with the symptoms or deficits. This judgment is based on the observation that the initiation or exacerbation of the symptoms or deficits are preceded by conflicts or other stressors(criterion B).’ The symptoms are not intentionally produced or feigned, as in factitious disorder or malingering (criterion C) (table I).’ It should be noted that belle indifference, described as a Arch
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1997
ABSCESS
PARAPLEGIA,
Shell
relative lack of concern regarding the implication of the symptoms, is not unique to the diagnosis of conversion disorder. It may manifest as part of repressivedefense mechanisms (denial) or occur in either delusional or demented states. It may occur in individuals with known neurological conditions. Usually, however, the symptoms of conversion disorder do not conform to known neurological pathways and objective signs (ie, reflexes are not affected). The reported symptoms tend to be bizarre, but may be culturally appropriate in certain age groups and in certain religious and cultural experiences. The more medically sophisticated the individual, the more plausible are the symptoms.’ Conversion symptoms in adults are reported to affect women to a greater extent than men with reporting ratios varying from 2: 1 to 10: 1. The prevalence rate reportedly varies from 11 per 100,000 to 300 per 100,000. The time course of conversion symptoms is usually 2 weeks or less, with recurrence common in the first year.’ The differential diagnosis must include neurological or other general medical conditions that must be actively sought and excluded. Additional psychological disorders that must be carefully considered include pain disorder, sexual dysfunction, somatization disorder, and dissociative disorders. These must be evaluated within the context of the presenting physical and psychological symptoms and classified according to DSM-IV criteria (Table l).’ Munchausen syndrome is not recognized as a distinct disorder by DSM-IV but included under factitious disorder.’ Watson and Tilleskjor: in their review of the interrelationships of conversion reactions, psychogenic pain, and dissociative disorder symptoms, concluded that psychogenic pain and conversion symptoms were positiveIy correlated but were inversely related to dissociative symptoms. The new DSM-IV criteria clearly state that the essential feature of pain disorder is pain that is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention. In our case presentation, there is the clear association of pain as the predominant focus of the patient seeking refill of her morphine pump. In addition, the focus on pain continued throughout her multiple emergency department visits and her postoperative course. The conversion symptoms were manifested during her hospitalization, evidently precipitated by the stressof the hospitalization, the request to remove her morphine pump, and the necessity of signing procedural and operative consents. Speed3 conducted the largest series of behaviorally treated patients with conversion disorder. Intervention included physical therapy, occupational therapy, recreational therapy, and psychological counseling. He concluded that behavioral treatment of conversion disorder provides an effective, clinically useful model and that there is a positive correlation between length of conversion symptoms and the time required to eradicate them. A conversion disorder treatment protocol is presented.3 The presentation of factitious disorders, presenting as acute emergencies, has been thoroughly reviewed.4 In our case, the diagnosis of factitious disorder, although strongly suggested, could not be fully confirmed by supporting medical records or local relatives. It was also not confirmed by careful nursing and physician observation during her hospitalization. The patient reported that the implantable morphine infusion pump was epidurally implanted in May 1993 because of intractable back pain and an inability to tolerate oral morphine. Since she refused to sign for a release of medical records, it is unclear as to the exact reason the morphine pump was implanted. The evaluation for multiple myeloma was negative and the mild, thoracic compression fractures noted on radiographs were not
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DISORDER
EPIDURAL
ABSCESS
PARAPLEGIA,
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Shell
a morphine infusion
evaluation and treatment of physical disease must be conducted in a reasonable manner to rule out life-threatening events. The
The safety and efficacy of implanted infusion systems for long-term subarachnoid delivery of opioid drugs in the management of malignant and nonmalignant pain is well documented.5*7 In our case, the etiology of the sterile epidural abscess is unclear. It may have resulted from the local toxicity of the infusion agent (morphine) or foreign body reaction.* The current recommendation in the United States is for the catheter to be intrathe-
treatment of associated conversion disorder remains supportive
of sufficient severity to warrant implanting
pump for pain control.
tally placed. Subarachnoid delivery of opioid drugs provides several advantages
over epidural
administration.
These include
the use of greater drug potency allowing for a smaller volume of drug in the pump and extended pump refill times. The selection of patients for implantation of opioid drug infusion is vitally
important
for a successful outcome.
In patients
with nonmalignant pain, infusional therapy is utilized as a last resort, and the patients are rigorously screenedby psychometric testing and psychological evaluation prior to an opioid infusion trial.’ The psychologic report should state unequivocally the absence of a nonfunctional pain state.’ Following successful completion of selection criteria, a therapeutic trial to determine the response to intrathecally administered opioid drug (morphine) is conducted for 3 to 5 days. A favorable trial response is a 50% reduction in pain and/or 50% reduction in as-needed analgesic use per 24 hour.’ Implantation is conducted only after all trial selection criteria are achieved. Numerous authors have recently reviewed the interrelationship of pain and factitious, somatoform, and conversion disorders.““’ The treatment remains primarily supportive, with the focus on consistency and extreme caution in regards to further
investigations, particularly invasive procedures and surgery.i3 In conclusion, patients with psychiatric disorders can and will get life-threatening
physical illnesses. A high index of suspicion
is necessary to adequately diagnosis physical illness complicated by medical sophistication, inconsistent history and physical examination, and complicated psychiatric overlays. The
and behaviorally
oriented. References
1. American Psychiatric Association. Somatoform Disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington [DC]: American Psychiatric Association, 1994. 2. Watson CG, Tilleskjor C. Interrelationships of conversion, psychogenic pain, and dissociative disorder symptoms. J Consult Cl& Psvchol 1983:51:758-g. 3. Speed J. Behavioral management of conversion disorder: retrospective study. Arch Phys Med Rehabil 1996;17:147-54. 4. Banejee A. Factitious disorders presenting as acute emergencies. Postgrad Med J 1994;70:68-73. 5. Hassenbusch SJ, Stanton-Hicks M, Covington EC, Walsh JG, Guthrey DS. Long-term intraspinal infusions of opioids in the treatment of neuropathic pain. J Pain Symptom Manage 1995; 10:52743.
Onofrio BM, Yaksh TL. Long-term pain relief produced by intratbecal morphine infusion in 53 patients. J Neurosurg 1990;72:200-9. 7. Kanoff RB. Intraspinal delivery of opiates by an implantable, programmable pump in patients with chronic, intractable pain on nonmalignant origin. J Am Osteopath Assoc 1994;94:487-93. 8. North RB, Cutchis PN, Epstein JA, Long DM. Spinal cord compression complicating subarachnoid infusion of morphine: case report and laboratory experience. Neurosurgery 1991;29:778-84. 9. Krames ES. Intrathecal infusional tberaoies for intractable pain: patient management guidelines. J Pain Symptom Manage 1993;8: 6.
36-46.
10. Bacon NMK, Bacon SF, Atkinson JH, Slater MA, Patterson TL, Grant I, et al. Somatization symptoms in chronic low back pain patients. Psychosom Med 1994;56:118-27. 11. Joukamaa M. Depression and back pain. Acta Psychiatr Stand 1994; Suppl 377:83-6. 12. Smith RG. The epidemiology and treatment of depression when it coexists with somatiofonn disorders, somatization, or pain. Gen Hosp Psychiatry 1992; 14:265-72. 13. Bass C, Benjamin S. The management of chronic somatization. Br J Psychiatry 1993; 162:472-80.
Arch
Phys Med
Rehabil
Vol 78, February
1997
Conversion Disorder Presenting in a Patient With an Implantable Morphine Pump and an Epidural Abscess Resulting in Paraplegia Michael G. Shell, DO, H. Lee Mitchell, MD, Michael W. Lees, MD, Andrew P. Belin, PhD ABSTRACT. Shell MG, Mitchell HL, Loes MW, Belan AP. Conversion disorder presenting in a patient with an implantable morphine pump and an epidural abscessresulting in paraplegia. Arch Phys Med Rehabil 1997;78:226-9. Conversion disorders are symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or medical condition. The psychological symptoms associatedwith the medical condition must be preceded by conflict or other stressors.We present an individual who developed conversion disorder and paraplegia secondary to a sterile epidural abscess near the tip of her surgically implanted, epidural morphine infusion pump. She manifested at varying times both transient bilateral blindness and pseudoseizuresconsistent with a diagnosis of conversion disorder. Neurological evaluation for seizure activity and meningitis were negative. The etiology of the sterile epidural abscessremained unknown. The essential features of conversion disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, are discussed. Treatment of patients diagnosed with conversion disorder remains primarily supportive, with the focus on consistency and behavioral management. Extreme caution is suggested in regards to further investigations. 0 1997 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
ONVERSION DISORDER, presenting in a medically soC phisticated individual with both physical and psychological symptoms, is extremely difficult to evaluate and treat. The complexity of the patient’s presentation may delay appropriate treatment unless careful differentiation is made early. Even more of a problem is that inappropriate treatment may be instituted on the basis of symptoms, especially when specialists are not consulted and old records are unavailable for review. The essential features of conversion disorder are symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or medical condition as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.’ The psychological symptoms associatedwith the medical condition must be preceded by conflict or other stressors. Conversion disorder differs from factitious disorder or malingering, in that the symptoms are not intentionally produced. Pain complaints may be associatedwith conversion disorder, From the Department of Anesthesiology (Drs. Shell, Lees, and B&n) and the Department of Psychiatry (Dr. Mitchell), University of Arizona School of Medicine, Maricopa Medical Center, Phoenix. Submitted for publication July 7, 1995. Accepted in revised form July 5, 1996. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or won any oreanization with which the authors are associated. _Reprint &est to Michael G. Shell, DO, Arizona Pain Institute, Department of Anesthesiology, Mticopa Medical Center, 2601 East Roosevelt, Phoenix, AZ 85008. 0 1997 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/97/7802-3585$3.00/O
Arch
Phys
Med Rehabil
Vol78,
February
1997
but conversion disorder is not limited only to pain complaints.1*2 The essentialfeature of pain disorder necessitatesthat pain is the dominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.’ Pain is not intentionally produced as required by DSM-IV criteria for the diagnosis of factitious disorder or ma1ingering.i We present the case of a medically sophisticated individual who developed paraplegia secondary to a sterile epidural abscessnear the tip of her epidural morphine infusion pump. In addition to her multiple somatic and psychological complaints, she manifested at varying times both transient bilateral blindness and behavior best characterized as pseudoseizure, consistent with a diagnosis of conversion disorder. CASE REPORT A 39-year-old, right-hand-dominant woman psychotherapist presented to our pain institute in early October 1994 to refill her implanted morphine pump. She reported a history of multiple thoracic compression fractures, secondary to multiple myeloma, and numerous lumbar spine surgeries for intervertebral disc disease.The surgeries had left her with arachnoiditis and persistent left leg pain. She complained of constant lower back pain with mildly radiating pain to the lateral right leg. A morphine pump had been epidurally implanted in May 1993 because of intractable back pain and an inability to tolerate oral morphine. The pump provided only mild relief of her back and leg pain despite an epidural infusion of morphine up to 4mg per day. Her medical history was significant for adult-onset diabetes mellitus, multiple myeloma, ulcerative colitis, hypertension, and polycystic ovarian disease. She also reported multiple motor vehicle accidents. None of these entities could be documented, although 1 month earlier she had been admitted to our medical center, where studies were negative for multiple myeloma and diabetes. She related multiple prior surgeries: seven laparotomies, two laminectomies, a hysterectomy, oophorectomy, and a repair of a strangulated inguinal hernia. She listed multiple allergies to many opioids of various chemical classes and to several other medications. The patient went to the pain clinic to refill her morphine pump about 3 weeks before the precipitous admission to the hospital for spinal cord compression. Physical examination revealed an antalgic gait, no lower extremity motor deficits, normal reflexes, and mild sensory loss in the right L5-Sl dermatome. She had a long midline scar over the lumbar region and multiple abdomen scars. Her pump was not empty and was not filled at that time. The patient was asked to return after her medical records were evaluated. The patient presented to the emergency department approximately 2 weeks later, complaining of a 3- to 4-day history of right flank pain and bladder discomfort, right lower extremity pain, and inability to ambulate. She had previously been placed on an antibiotic for a bladder infection. She refused oral opiates. She was initially observed by staff to be writhing on the floor in pain. The episode was called a seizure at the time, but later review of the incident revealed some inconsistencies with that
CONVERSION
DISORDER
EPIDURAL
label, one of which was that the seizure appeared too coordinated. Later, she was observed walking without difficulty outside of the emergency department and was standing unaided to smoke a cigarette. The physical examinations revealed right flank tenderness, no sensation throughout the right lower extremity and the left foot, absent right knee and ankle reflexes, normal left knee and ankle reflexes, and the patient’s report of inability to move her right lower extremity. Both urinalysis and renal ultrasound were negative. Dorsal and lumbosacral spine radiographs were reported by the radiologist as normal; however, when the lateral radiographs were personally reviewed with the radiologist, rnnor superior endplate abnormalities were noted at T6, 7, and 8, consistent with a hyperflexion injury and minor thoracic compression fractures. The patient was sent home with instructions to follow up with her primary care physician. The patient returned to the emergency department 2 days later complaining of circumferential numbness of both lower extremities and numbness across the lower back and right anterior abdominal area to the umbilicus. She denied incontinence. Physical examination revealed normal reflexes in the lower and upper extremities. She denied sensation to pinprick in the lower extremities, yet she exhibited brisk withdrawal and denied sensation to cold and light touch in the lower extremities. Strength was judged to be l/5 in the left lower extremity and O/5 in the right lower extremity to command. When she was confronted by emergency department personnel about her inconsistent history, her behavior in and near the emergency department, the absence of objective physical examination findings, and the normal dorsal and lumbosacral radiographs, she became verbally abusive and left the emergency department. She presented to the emergency department a few days later with additional complaints. She complained of ascending numbness on the right up to under the right breast crease. She also complained of inability to move the lower extremities. Her physical examination remained consistent with normal reflexes, neutral Babinski reflexes, normal rectal tone, and inconsistent sensory examination in the lower extremities. She either refused or was unable to move the lower extremities on command, but was observed to have spontaneous movement during transfers from the wheelchair to the stretcher and while lying down. The patient was discharged home after arrangements were made for additional neurology evaluation in the outpatient clinic. Approximately 5 days later, she presented to the emergency department with continued complaints of ascending numbness and an inability to move her lower extremities. Physical examination revealed a discrete sensory level differential at T6 on the right and at T12 on the left. Her knee and ankle reflexes were slightly hyperreflexic, Babinski reflex was present bilaterally, and a crossed adductor response was elicited. She was admitted for a thoracic myelogram to evaluate for spinal pathology as the etiology of her neurological findings. When requested to sign the consent for the thoracic myelogram and for a release of medical records from local hospitals, the patient suddenly developed bilateral blindness followed by seizure activity. The seizure resolved after a few minutes with no tongue biting, convulsant activity, or incontinence observed. The seizure activity was described as periods of verbal and physical nonresponsiveness. Her physical examination revealed breath holding, normal upper extremity tone, with controlled fall of her outstretched arms to the side of the bed away from her face. Cranial computed tomography (CT), electroencephalogram, and cerebrospinal fluid (CSF) analysis were negative. It was concluded by the neurologist that she did not have a seizure disorder or spinal meningitis. The blindness did not resolve
ABSCESS
PARAPLEGIA,
227
Shell
until nearly 24 hours later. During the period of blindness, she avoided eye contact and demonstrated absolutely no concern regarding her blindness. Normal sight returned and she reported that she experienced a dissociative state as if parts of her body did not belong to her. Although some of the symptoms were considered genuine, others appeared to have suspicious components. In addition to the symptoms described, she continued active fabrication of her medical history, including descriptions of previous hospital stays at multiple hospitals; however, she refused to sign medical release forms for those records to be obtained. She complained about poor pain control and was hostile to staff even when given intravenous opioids. Instead, she requested refill of her implanted morphine pump as the only method of pain control. Beyond the positive physical symptoms, psychiatric evaluation was suggestive of the presence of factitious disorder and of conversion disorder. She eventually agreed to sign the consent form for the thoracic myelogram. It was performed immediately and demonstrated complete obstruction of the cephalad flow of contrast medium at the level of the Tll-12 interspace. Postmyelogram thoracolumbar CT confirmed complete obstruction of contrast flow at the inferior end plate of Tll with lower thoracic cord displacement to the left. The tip of the morphine pump catheter could be seen in the midst of amorphous epidural material at the site of the blockage on the right. The patient proceeded to surgery after another confrontation regarding consent to operate and to remove the morphine pump and catheter. She consented to surgery for removal of the abscess, but adamantly refused removal of her morphine pump and catheter. She indicated that her refusal was based on her reports that it had cost her approximately $30,000, which she had obtained by the sale of her home and her belongings. The patient proceeded to surgery where a TlO to T12 spinal cord decompression with laminectomy and removal of sterile abscess at the morphine pump catheter tip were performed. The morphine pump was reluctantly left in place. Necrotic tissue from the epidural site was reported by pathology as insufficient for diagnosis. Infectious disease consultation was obtained and empirical antibiotic treatment initiated. Infectious disease evaluation included blood cultures, urine for mycobacteria and fungi, CSF for fungal serology, skin test for purified protein derivative, candida, and coccidioidin, rapid plasma reagin, and chest x-ray. All cultures, skin tests, and chest X-ray were negative. It was concluded that she had developed a sterile, epidural abscess at the catheter tip. Infectious disease consultation was specifically asked as to the necessity of removing the pump. They did not recommend immediate pump removal. The patient’s postoperative course was uneventful, with some neurologic return to her lower extremities. She was discharged to a rehabilitation hospital for spinal cord injury rehabilitation of her paraplegia.
DISCUSSION This case illustrates the complexity of a patient presenting with combined physical and psychological problems. Inconsistencies in her history and physical examination were ubiquitous. The patient was medically and psychiatrically sophisticated and demanding of hospital staff. She was uncooperative and verbally abusive. Yet, an underlying problem of functional and lifethreatening significance was evolving. Perhaps its identification and treatment would have occurred earlier, and been easier, if consistent information and previous medical records could have been obtained. On the patient’s first outpatient visit, it was readily clear to the medical staff in the pain clinic that this patient had significant psychiatric comorbidities. That impression was so evident that
Arch
Phys Med
Rehabil
Vol78,
February
1997
228
CONVERSION
Table
1: Diagnostic
Criteria
for 300.11
Conversion
DISORDER
EPIDURAL
Disorder
A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors. C. The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering). D. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience. E. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder. Specify With With With With Reprinted
with
type of symptom or deficit: Motor Symptom or Deficit Sensory Symptom or Deficit Seizures or Convulsions Mixed Presentation
permission.’
the anesthesiology resident physician insisted on labeling her a Munchausen syndrome. Both the attending physician, pain fellow, and the neuropsychologist believed that this diagnosis could only be tentative until further data were known. The diagnostic dilemma centered on the new way that the DSM-IV was approaching factitious diseaseand associatedpain disorders with a psychiatric disease. It was only after her admission that the extent of her psychopathology and the severity of her evolving medical condition became clearer. The myelogram showed arachnoiditis, as well as the epidural abscessthat necessitated the surgery. The radiographs suggested that she had a previous compression injury to the thoracic spine. The events that occurred in the hospital, particularly the bilateral transient total blindness and the pseudoseizure, were indicative of conversion reactions. She exhibited these reactions accompanied by a belle indifference, whereby she was noted to not express the usual and emotional response to her condition, as would be expected in a healthy person experiencing a sudden, new, and life-jarring event. The crux here was whether she was intentionally producing her symptoms or whether they represented a major psychopathology complete with somatic, delusional, and dissociative states. The intentional production of her symptoms could not be confirmed, even during her period of blindness, when she was carefully observed under hospital confinement and examined on multiple occasions.Hence, conversion disorder in a patient with a known chronic, nonmalignant pain syndrome was thought to be the best unifying diagnosis. According to the DSM-IV, the essential feature of conversion disorder is the presence of symptoms or deficits affecting voluntary motor or sensory function that suggests a neurological or other general medical condition (criterion A).’ Psychological factors are judged to be associated with the symptoms or deficits. This judgment is based on the observation that the initiation or exacerbation of the symptoms or deficits are preceded by conflicts or other stressors(criterion B).’ The symptoms are not intentionally produced or feigned, as in factitious disorder or malingering (criterion C) (table I).’ It should be noted that belle indifference, described as a Arch
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relative lack of concern regarding the implication of the symptoms, is not unique to the diagnosis of conversion disorder. It may manifest as part of repressivedefense mechanisms (denial) or occur in either delusional or demented states. It may occur in individuals with known neurological conditions. Usually, however, the symptoms of conversion disorder do not conform to known neurological pathways and objective signs (ie, reflexes are not affected). The reported symptoms tend to be bizarre, but may be culturally appropriate in certain age groups and in certain religious and cultural experiences. The more medically sophisticated the individual, the more plausible are the symptoms.’ Conversion symptoms in adults are reported to affect women to a greater extent than men with reporting ratios varying from 2: 1 to 10: 1. The prevalence rate reportedly varies from 11 per 100,000 to 300 per 100,000. The time course of conversion symptoms is usually 2 weeks or less, with recurrence common in the first year.’ The differential diagnosis must include neurological or other general medical conditions that must be actively sought and excluded. Additional psychological disorders that must be carefully considered include pain disorder, sexual dysfunction, somatization disorder, and dissociative disorders. These must be evaluated within the context of the presenting physical and psychological symptoms and classified according to DSM-IV criteria (Table l).’ Munchausen syndrome is not recognized as a distinct disorder by DSM-IV but included under factitious disorder.’ Watson and Tilleskjor: in their review of the interrelationships of conversion reactions, psychogenic pain, and dissociative disorder symptoms, concluded that psychogenic pain and conversion symptoms were positiveIy correlated but were inversely related to dissociative symptoms. The new DSM-IV criteria clearly state that the essential feature of pain disorder is pain that is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention. In our case presentation, there is the clear association of pain as the predominant focus of the patient seeking refill of her morphine pump. In addition, the focus on pain continued throughout her multiple emergency department visits and her postoperative course. The conversion symptoms were manifested during her hospitalization, evidently precipitated by the stressof the hospitalization, the request to remove her morphine pump, and the necessity of signing procedural and operative consents. Speed3 conducted the largest series of behaviorally treated patients with conversion disorder. Intervention included physical therapy, occupational therapy, recreational therapy, and psychological counseling. He concluded that behavioral treatment of conversion disorder provides an effective, clinically useful model and that there is a positive correlation between length of conversion symptoms and the time required to eradicate them. A conversion disorder treatment protocol is presented.3 The presentation of factitious disorders, presenting as acute emergencies, has been thoroughly reviewed.4 In our case, the diagnosis of factitious disorder, although strongly suggested, could not be fully confirmed by supporting medical records or local relatives. It was also not confirmed by careful nursing and physician observation during her hospitalization. The patient reported that the implantable morphine infusion pump was epidurally implanted in May 1993 because of intractable back pain and an inability to tolerate oral morphine. Since she refused to sign for a release of medical records, it is unclear as to the exact reason the morphine pump was implanted. The evaluation for multiple myeloma was negative and the mild, thoracic compression fractures noted on radiographs were not
CONVERSION
DISORDER
EPIDURAL
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a morphine infusion
evaluation and treatment of physical disease must be conducted in a reasonable manner to rule out life-threatening events. The
The safety and efficacy of implanted infusion systems for long-term subarachnoid delivery of opioid drugs in the management of malignant and nonmalignant pain is well documented.5*7 In our case, the etiology of the sterile epidural abscess is unclear. It may have resulted from the local toxicity of the infusion agent (morphine) or foreign body reaction.* The current recommendation in the United States is for the catheter to be intrathe-
treatment of associated conversion disorder remains supportive
of sufficient severity to warrant implanting
pump for pain control.
tally placed. Subarachnoid delivery of opioid drugs provides several advantages
over epidural
administration.
These include
the use of greater drug potency allowing for a smaller volume of drug in the pump and extended pump refill times. The selection of patients for implantation of opioid drug infusion is vitally
important
for a successful outcome.
In patients
with nonmalignant pain, infusional therapy is utilized as a last resort, and the patients are rigorously screenedby psychometric testing and psychological evaluation prior to an opioid infusion trial.’ The psychologic report should state unequivocally the absence of a nonfunctional pain state.’ Following successful completion of selection criteria, a therapeutic trial to determine the response to intrathecally administered opioid drug (morphine) is conducted for 3 to 5 days. A favorable trial response is a 50% reduction in pain and/or 50% reduction in as-needed analgesic use per 24 hour.’ Implantation is conducted only after all trial selection criteria are achieved. Numerous authors have recently reviewed the interrelationship of pain and factitious, somatoform, and conversion disorders.““’ The treatment remains primarily supportive, with the focus on consistency and extreme caution in regards to further
investigations, particularly invasive procedures and surgery.i3 In conclusion, patients with psychiatric disorders can and will get life-threatening
physical illnesses. A high index of suspicion
is necessary to adequately diagnosis physical illness complicated by medical sophistication, inconsistent history and physical examination, and complicated psychiatric overlays. The
and behaviorally
oriented. References
1. American Psychiatric Association. Somatoform Disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington [DC]: American Psychiatric Association, 1994. 2. Watson CG, Tilleskjor C. Interrelationships of conversion, psychogenic pain, and dissociative disorder symptoms. J Consult Cl& Psvchol 1983:51:758-g. 3. Speed J. Behavioral management of conversion disorder: retrospective study. Arch Phys Med Rehabil 1996;17:147-54. 4. Banejee A. Factitious disorders presenting as acute emergencies. Postgrad Med J 1994;70:68-73. 5. Hassenbusch SJ, Stanton-Hicks M, Covington EC, Walsh JG, Guthrey DS. Long-term intraspinal infusions of opioids in the treatment of neuropathic pain. J Pain Symptom Manage 1995; 10:52743.
Onofrio BM, Yaksh TL. Long-term pain relief produced by intratbecal morphine infusion in 53 patients. J Neurosurg 1990;72:200-9. 7. Kanoff RB. Intraspinal delivery of opiates by an implantable, programmable pump in patients with chronic, intractable pain on nonmalignant origin. J Am Osteopath Assoc 1994;94:487-93. 8. North RB, Cutchis PN, Epstein JA, Long DM. Spinal cord compression complicating subarachnoid infusion of morphine: case report and laboratory experience. Neurosurgery 1991;29:778-84. 9. Krames ES. Intrathecal infusional tberaoies for intractable pain: patient management guidelines. J Pain Symptom Manage 1993;8: 6.
36-46.
10. Bacon NMK, Bacon SF, Atkinson JH, Slater MA, Patterson TL, Grant I, et al. Somatization symptoms in chronic low back pain patients. Psychosom Med 1994;56:118-27. 11. Joukamaa M. Depression and back pain. Acta Psychiatr Stand 1994; Suppl 377:83-6. 12. Smith RG. The epidemiology and treatment of depression when it coexists with somatiofonn disorders, somatization, or pain. Gen Hosp Psychiatry 1992; 14:265-72. 13. Bass C, Benjamin S. The management of chronic somatization. Br J Psychiatry 1993; 162:472-80.
Arch
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1997