Jedi mind tricks

If you work at The Children's Hospital in August or September, back-to-school season, you're almost guaranteed to come across conversion disorder. This is the subconscious “conversion” of psychological stress into physical symptoms and can often be metaphorical. Conversion disorder is a diagnosis of exclusion, which basically means that you have to assume the worst and order a bunch of expensive tests to rule out all the bad stuff. While needlessly spending lots of money is never a good thing, it starts to get serious when we talk about invasive procedures, such as lumbar puncture, that carry a real risk of complication.

The phrase of the week was "Jedi mind tricks." My attending is a Jedi Master.

One kid presented with altered sensation. With his eyes closed, he tells the doctor that he doesn't feel the light touch of a cotton swab. Next, still with his eyes closed, the instructions are, "Tell me if you don't feel anything." Sure enough, he said that he didn't feel anything each time he was touched by the cotton swab. Unprompted. He's a precocious little bugger but not good enough to outsmart the Jedi Master!

Another kid presented with seizure-like episodes that were suspicious for not being true seizures, so-called pseudopesizures. When she was told that she wouldn't be able to eat dinner until her seizures stopped, her seizures suddenly stopped. Go figure.

My attending emphasized that conversion disorder is a subconscious maladaptive response to stress, a distinction that merits consideration when discussing the diagnosis. Patients will understandably get upset if the doctor implies that they are faking it. My attending has a standard script to open this conversation:

"People do funny things when they are under a lot of stress. Some people bite their fingernails, some people pull at their hair, some people pick their nose, and some people do what you're doing. I believe you that you're not making this up. That's why it's so important to figure out exactly what's going on with you. What kind of stress do you have in your life?

He also says that neurology is a glass-half-full specialty when it comes to such patients. "Give them the benefit of the doubt. Leave it to the psychiatrists to figure out whether it's conversion or factitious."