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CONVERSION

OR NOT?
LISA M RUIZ, MD
CHILD & ADOLESCENT PSYCHIATRY PGY-5
AUGUST 18, 2014
CASE PRESENTATION
CC: Worsening HA
HPI:
15y/o WF h/o migraines presenting w/ intractable HA for past 7
days
Starting to vomit & have dizziness
Missing school
PCP gave Zofran & Benadryl w/o improvement
Mom concerned for appendicitis Hospital

HPI CONTINUED
OUTSIDE HOSPITAL
Admitted for dehydration
& migraines
CBC, CMP, lipase,
ESR, head CT all
unremarkable
Tx w/
Chlorpromazine,
Imitrex, Topamax,
Benadryl,
amitriptyline,
Phenergan, Toradol,
Ativan
No improvement
PCH
PRIMARY CHILDRENS
Admitted to PCH
Psychiatry
consulted: acute
on chronic HA w/
probable
psychiatric
component
Neurology
consulted
IV fluids to
maintain hydration

PSYCHIATRY ARRIVES
Extremely upset mother
Using vulgar words to express her frustration
Difficult to redirect
Hx gathered
Pt has HA since 6 months of age based on EEG
Typical migraine sx
Stressors present
New school 2/2 LD no peers, bullying, behind academ.
Frequent arguing btw mom & brother
Inappropriately touched by peer & lewd comments made



REVIEW OF PSYCHIATRIC
SYMPTOMS
Depression:
Endorses anhedonia, guilt
Sleep, energy & app but may be from HA
No current SI, h/o passive SI but no self harm
Anxiety:
Sensitive to criticism
Non-specific worries
Psychosis:
H/o seeing ghosts
MORE HISTORY
Psychiatric: no treatment
Though depakote, topomax & elavil for migraines
Medical: asthma, migraines
Developmental: delayed in talking only
Family: undx depression both parents, no txmt
Social:
Lives out of state w/ parents & 3 younger siblings
9
th
grade at new schl w/ LD (unclear of 504 or IEP)
Wants to be a teacher
LDS

MENTAL STATUS
EXAM
Vital Signs:
T 36.8-37.1, BP 97-104/56-64, HR 74-102, RR 16-20
MS:
Normal strength & tone, prefers not to move
Appearance:
Wearing casual clothes, appropriate hygiene
Attitude/Behavior:
Lying on bed playing w/ cell phone
Minimally interactive w/ mom present
Speech:
Slow rate, low volume (whisper)
MSE CONTINUED
Mood/Affect:
Depressed & congruent
Thought content:
Somatic; no SI/HI/AH/VH
Thought process:
Linear, concrete
Attention/Concentration:
WNL
Insight/Judgment:
Fair to good
WHAT NOW?
Labs/Imaging:
Outside WNL along w/ PCH labs
Differential:
Conversion, depression, anxiety, adjustment, PTSD
Diagnosis:
Psychol. factors affecting medical condition (migraines)
Txmt recs:
Can consider increasing Elavil (benefits vs. SE) or changing to SSRI
Relaxation techniques for now
Follow up with Neurology
Needs outpatient therapy to target stressors


WHY NOT
CONVERSION?
Review criteria for conversion
Look at criteria for Psychological factors affecting other
medical condition (migraines)

CONVERSION
DISORDER
1 sx of altered voluntary motor or sensory fxn
Clinical findings provide evidence of incompatibility between
the sx & recognized neuro or medical condition
Sx or deficit is not better explained by another medical or
mental disorder
Sx or deficit causes clinically significant distress or
impairment in social, occupation, or other important areas of
fxning or warrants medical evaluation
PSYCHOLOGICAL
FACTORS AFFECTING
OTHER MEDICAL
CONDITIONS
Part A
Medical sx/condition (other than mental health disorder) is
present


PSYCHOLOGICAL
FACTORS AFFECTING
OTHER MEDICAL
CONDITIONS
Part B
Psych or behavior factors adversely affect med condition in 1 of the
following ways:
Factors have influenced the course of the medical condition as
shown by close temporal association between the psychological
factors & the development or exacerbation of, or delayed recovery
from, the medical condition
Factors interfere w/ txmt of medical condition
Factors constitute addl well-established health risks for the patient
Factors influence the underlying pathophysiology, precipitating or
exacerbating symptoms or necessitating medical attention

PSYCHOLOGICAL
FACTORS AFFECTING
OTHER MEDICAL
CONDITIONS
Part C
The psychological and behavioral factors in Part B are not
better explained by another mental disorder
FOLLOW-UP
Neurology
No red flags on exam
Dx w/ Status migrainosus exacerbated by psychosocial stressors &
mothers confrontational behavior
Tx migraine & potential underlying psych d/o
Continue Elavil 50mg qHS w/ Ketorolac q 6hx3d
Start vistaril 50mg & promethazine 25mg; both q 6h
Supplemental IV fluids
Dark quiet room, minimal stimulation
Risk mgmt notified




LATER SAME DAY
Problems in PT
Began demonstrating significant left LE weakness
Dragging toe on treadmill
Numbness left LE
Neuro paged for re-evaluation
Exam reassuring
Educated mother that episode likely part of presentation of
lack of ability to function in her life & severe HA
NEXT 24 HOURS
HA worsening per patient
Vomiting overnight
Repeat Neuro exam
Sustained clonus left LE only
Numbness left LE below knee
Abnormal RAM left hand
Abnormal gait w/ dragging of left foot
Order for MRI brain & spine

1. Extensive dural venous
sinus thrombosis
involving virtually all of
the superior sagittal sinus,
left transverse & sigmoid
sinus; non-occulsive
2. Localized cortical venous
thrombosis adjacent to
clotted sagittal sinus
bilaterally near vertex
3. Ild venous ischemia right
parasagittal posterior
frontal cortex

MRI FINDINGS
EXTENSIVE DURAL VENOUS
SINUS THROMBOSIS SIDE VIEW 1
EXTENSIVE DURAL VENOUS SINUS
THROMBOSIS SIDE VIEW 2
EXTENSIVE DURAL VENOUS SINUS
THROMBOSIS SIDE VIEW 3
EXTENSIVE DURAL VENOUS
SINUS THROMBOSIS TOP VIEW
OMG!
Team disclosure:
CT from OSH showed
evidence of clot 6 days
prior
Actual disc recd, but
not over-read by
radiology
Impression was read
normal
Mother
upset/frustrated but
appreciates divulged
info
Txmt:
Anticoagulation initiated
Acetazolamide added
later
Mother has TBI from
MVA several years ago


TYING UP LOOSE
ENDS
Medical
Psychiatric
Establish care with a therapist
Follow up for medication management
Re-evaluate psychiatric medications
Purpose
Interactions
Transition back to normal functioning