A Case Report on Dissociative Quadriplegia

INTRODUCTION: Conversion disorder has one or more symptoms that affect voluntary motor or sensory function suggesting a neurological or other medical condition, but they are inconsistent with known neurological or musculoskeletal pathologies. Individuals with conversion disorder do not intentionally produce or feign their symptoms. Instead, the symptoms are due to an unconscious expression of a psychological conflict or need. There might be associated primary and secondary gains which act as maintaining factors. The disorder is more common in adolescence than in childhood. CASE REPORT: A 17 years old male reported to the Emergency Department alleged history of fall from a 10 feet wall c/o neck pain, inability to move all 4 limbs, diminished sensation below the neck. Cervical immobilization was done and his vitals & routine blood investigations were found to be normal. No signs of any urinary retention or fecal incontinence. Routine neurological examination was performed which revealed hypotonia in all 4 limbs with flaccidity with a power of 0/5 and diminished sensation at the level of C3. Neuro imaging was done. MRI brain with cervical screening revealed no edema, cord compression. MRI CERVICAL SPINE – NORMAL. Stressor: He was convicted under POSCO act for 3 years, 2 days before the incident. Neurosurgeon ruled out the physical cause of the above presentation. Detailed history revealed he was being convicted for 3 years for a marrying a 17 years old girl with her consent under POSCO act 2 days prior to the incident. He was seen distressed after hearing the verdict, had sleep disturbances, remained aloof, not communicating with others. He attempted suicide by jumping from the wall. He had a history of occasional cannabis use for the past 2 years. Family history revealing possession attacks in his mother. He was raised by a single parent as his father left him and his mother when he was 5 years old. He had no episodes of similar illness in the past. His temperament revealed that he had difficulty in adjustment to the situations being impulsive and had self-injurious behavior. Mental status examination revealed that the patient was lying in supine position, not able to move his all 4 limbs with obvious psychomotor retardation decreased talks, sad mood. DISCUSSION: The clinical picture is indicative of Dissociative Motor Disorder F44.4 according to ICD 10. After taking a detailed history, it was clear that he was extremely distressed regarding his punishment under POSCO act as he willfully married a 17 years old girl with her consent which could not stand in the court of law. Patient was started on therapy sessions as well as low-dose diazepam. In the sessions, possible causes of these symptoms were discussed, his family members were also psycho-educated about the psychosomatic nature of the symptoms and advised to encourage him for a symptom-free lifestyle. They were also given an instruction not to pay attention to his complaints of physical nature. Psychotherapy sessions were started in which all her stressors were therapy discussed. CONCLUSION: Conversion disorder, somatoform disorder, and malingering always remain a diagnostic challenge for the clinicians. The prompt history taking, identification of stressors, use of appropriate and validated physical examination manoeuvres, and coordination of care and information exchange between all family members and medical team may facilitate the expeditious care of these patients in a cost-effective manner. Psychogenic symptoms should be treated using suggestions, patience, and reassurance. Early recognition of a conversion disorder will limit unnecessary tests and medications. The quality of doctor-patient relationship can influence outcome. The existing literature supports a multidisciplinary treatment approach, with specific interventions, such as cognitive behaviour therapy for cognitive restructuring and psychodynamic therapy for addressing symptom connections to trauma and dissociation.