Do doctors torture patients with complex regional pain syndrome?
PART IV: Conversion Reactions in Children
Sabine Kost-Byerly MD, Associate Professor, Johns Hopkins Medical SchoolDirector of Pediatric Pain Management at Johns Hopkins
This video series presents an interesting topic although I approach it somewhat differently. The first time I heard of a conversion reaction was as a teenager when my brother’s best friend developed bilateral lower extremity paralysis. This was in Germany. He very much believed that he could not move. He was admitted to the hospital. There was no organic problem but even then I understood that he was experiencing intense emotional pain.
The girl you presented on the video seemed to have had a flare-up of CRPS in the lower half of her body after surgery- always a concern even with preoperative preventive measures.
The pain was likely overwhelming for her, physically and maybe even psychologically as the pain will reactivate all the memories surrounding previous CRPS events (the pain, the failed therapies, the time required to get better, the strain on the family, etc.)
There was only one way out: have a seizure-like unconscious event. This is not planned. She has no conscious intent. The physical pain is so extreme that it precipitates a conversion reaction- a protective reaction, in my view.
A conversion reaction is psychiatric in nature. An older diagnosis would have been hysteria. Interestingly, some of the patients that Freud described as being hysterics had underlying pain- which was described and acknowledged by Freud. One of them had severe neck cramps. Freud thought that it was the person’s psychological distress manifesting itself as a conversion reaction with physical symptoms. This is what psychiatrists still believe today. I wonder what an MRI would have been able to show and believe some of Freud’s famous patients likely had Chiari malformations and fibromyalgia.
I have seen a number of patients with CRPS who had conversion reactions. There was a girl with CRPS of the hand receiving treatment who developed rapid onset “paralysis” when she hit her affected hand into a door handle.
Interestingly, the paralysis was complete, motor and sensory. There was no more pain at all where before she had allodynia, hyperesthesia, etc.
I had another patient who developed a certain kind of “color blindness” (just seeing black and white) after being treated for CRPS at an earlier time. CRPS was in remission at the time. She developed flare-up in another extremity at a later time. At that time she still had color blindness but could still see black, white, and gold. Ophthalmological evaluations were completely normal.
One of my patients developed a long-lasting motor tic in one of her fingers after an otherwise successful treatment of CRPS of the same hand. A neurologist thought this was “functional” as it interfered with writing. I am sure “functional” in his mind implied something negative, as in it’s “just in your head”. I have also had patients who had flare-ups of CRPS in response to psychological distress. Last week one of my patients who was successfully treated within the last 6 months described how her hand became very symptomatic within 30 minutes when she lost her wallet on vacation in Spain. Symptoms gradually improved over 3 days. She came back just to see me and to discuss this event.
Question: How do you prevent recurrence? Findings and presentations reflecting these brain connections need to be addressed. Thus, treatment for physical findings needs to occur concurrently with treatment for emotional symptoms. The latter can be as simple as saying “the pain you experienced must have been so bad that your body just needed to find a way out, having a “seizure”, “passing out”, helped your body protect itself. Now let’s see what we can do that your body does not have to do the same again in the future. Let’s see what we can do for your pain.”
By the way, in the inpatient program we have here at Kennedy Krieger, we have treated kids with classic “conversion disorders”. I do not approach them any differently. They are just trying to cope. Medical training provides limited knowledge concerning brain area interactions and functional results in these unfortunate experiences. I try to approach my patients with humility and wonder concerning the myriad presentations of human suffering.
Sabine Kost-Byerly MD
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