Looking Beyond Symptoms
The next day, I had just finished reviewing the results when the nurse informed me that Jeremy Clark’s parents were waiting to talk to me.

After introductions, I told them: “Jeremy’s condition is stable, but he still isn’t speaking. Tell me a little bit about him.”

Mrs. Clark looked tense. “He’s always been healthy. He graduated cum laude and volunteered for this mission. He’s a very responsible young man.” She glanced at her husband, then at me. “Doctor, what’s wrong with our son?”

“The mris, lumbar puncture, and lab tests are normal.” I said. “That means there’s no tumor on his spinal cord or brain, no infection, and his liver, kidneys, and blood counts are fine. That’s all good news.” I paused. Our tests had ruled out physiological explanations for his problem, but there were other areas to explore. “Does Jeremy use drugs?” I asked.

“Never,” Mr. Clark said.

“What about mental health problems?”

They exchanged worried looks.

“Are you saying he’s faking it?”

“No. The symptoms he’s experiencing are real,” I said. “We’ll figure it out.”

“I hope so,” Mrs. Clark said.

After they left, I thought about Jeremy. Did he have something to gain by feigning his symptoms? I found his nurse.

“Does he move his legs when he isn’t aware we’re observing?” I asked.

“No,” she said. “We have to rotate him in the bed every few hours to prevent pressure sores.”

I nodded. Jeremy had no history of emotional problems, but I still wanted a psychiatric consult.

The staff psychiatrist, an old sage with decades of experience, listened to my account of the steps I’d taken to solve the puzzling case.

“I have a hunch,” he said. “Let’s go see the patient.”

After repeating the neurological exam, the psychiatrist pulled me aside and shot me a meaningful look. “Have you considered conversion disorder?” he asked.

“Considered what?”

He explained that conversion disorder is an unusual psychological malady with symptoms that resemble a neurological disorder or other medical condition. The onset is usually abrupt and typically begins with a mental conflict or emotional crisis, then “converts” to a physical problem that prevents the patient from engaging in the activity that was causing him stress.

The reported prevalence of conversion disorder varies widely from 11 to 500 cases per 100,000 people. More common in women, it can begin at any age but occurs primarily between 11 and 35. Symptoms may include blindness, double vision, paralysis, inability to speak, amnesia, unresponsiveness, and motor tics. Most cases of conversion disorder spontaneously remit within two weeks of hospitalization, but some patients who receive a diagnosis of conversion disorder are later found to be suffering from a physical illness.

Probing the Mind for Answers

On the fourth day of Jeremy’s hospitalization, I returned to his room, hoping to discover an underlying psychiatric issue. I gave him some Ativan, a mild sedative, then repeated the physical exam while tactfully presenting him the provisional diagnosis of conversion disorder. I reassured him that the tests had indicated his muscles and nerves were functioning normally and that his inability to move his legs was reversible. Finally, I told him his prognosis for recovery was excellent—that his symptoms might improve spontaneously or gradually.

I asked again if he’d been exposed to any chemicals, toxins, or illicit drugs. He made eye contact and slowly shook his head.

“No,” he said.

“Has anything been bothering you lately?” I asked.

“I couldn’t do it anymore,” he said, tearing up. “The mission. I hated being there and didn’t like approaching people about religion.”

“Why didn’t you come home?”

Jeremy’s brow furrowed. “I didn’t want to let my parents down. And I couldn’t break my promise to God.”

“Sounds like you were under a lot of stress,” I said. We continued to explore his concerns, and I reassured him that no one could force him to go back.

I explained the situation to his parents. Although initially reluctant to accept a psychiatric explanation for his physical symptoms, they agreed to involve themselves in his rehabilitation. After a few family therapy sessions, Jeremy realized they weren’t angry and opened up. By the end of the week, with his parents’ encouragement and some physical therapy, Jeremy was gingerly walking the halls with them. He was discharged from the hospital and scheduled for follow-up visits with a psychiatrist.

Ten days later, Jeremy had completely recovered from the paralysis.

Beverly Purdy is a psychiatrist at Valley Medical Center in San Jose, California. The cases described in Vital Signs are real, but names and certain details have been changed.