Severe Microcytic Hypochromic Anemia Masquerading as Conversion Disorder: A Case Report

Abstract

Conversion disorder is a psychiatric illness in which an affected person experiences signs and symptoms of voluntary motor or sensory dysfunction in absence of any underlying neurological or medical condition. According to recent studies, fewer people initially labelled with a diagnosis of conversion have subsequently been found to have an organic disorder. We report a case of 13-year-old female, with a provisional diagnosis of conversion disorder later on, after detailed evaluation came out to be a case of severe anemia. Patient was transferred to the Psychiatry Department in view of the possibility of conversion symptoms. Detailed assessment of routine blood work (complete blood count with general blood picture) yielded severe microcytic hypochromic anemia (hemoglobin = 4.1 gm/dL). The patient was advised accordingly and an urgent blood transfusion was advised. It is mandatory that before labelling someone as having conversion disorder, rule out all essential and possible organic etiologies which can explain the clinical presentation, as it can be life-threatening.

Introduction

When symptoms impacting sensory or motor functions cannot be explained by a neurological disease or medical disorder, conversion disorder (DSM IV) comes into play to explain these varied symptoms based on psychological theories of mind.^1,2 The symptomatology of this disorder cannot be explained by investigations. Moreover, symptoms cannot be attributed to patients’ engagement in various traditional culturally accepted practices.^1,2 The lifetime prevalence of this has been estimated to be between 11 and 300 per 100,000 persons in community.^1,2

In recent studies it has been reported that the proportion of patients who were primarily diagnosed with conversion disorder who were later diagnosed with physical disorder has been decreasing. ³ However, there is paucity of literature regarding importance of excluding organicity and the significance of physical examination in conversion disorder. Also, it is understandably dangerous to make the diagnosis of conversion disorder in the absence of positive manifestations. Unfortunately, in certain cases, unreliable behavioral presentations in psychiatry do pose a diagnostic dilemma in front of clinicians.

With this background, we present a case of long-standing compensated anemia with clinical features suggestive of conversion disorder, with a strong emphasis on ruling out all possible differentials. Additionally, This case shows that a physical and systemic examination is still a valuable tool in addition to blood and other investigations in suspecting and excluding physical causes.

Case Presentation

A 13 year old female, who was a student of 8th standard belonging to low socioeconomic status presented to pediatrics OPD in a tertiary care hospital with history of episodes of unresponsiveness. The patient often experienced shortness of breath and chest pain during the episodes. These episodes lasted variably, sometimes for minutes and sometimes up to hours. These episodes were not associated with clenching of teeth, drooling of saliva, soiling of clothes, incontinence, tongue or cheek bite, abnormal neck deviation, never occurring in sleep, and no history of injury during the episodes. Additionally there was no history suggestive of any other conversion symptoms such as sudden loss of vision/deafness/speech, any altered gait disturbances or paralysis. However, after the episodes and in between, patient used to experience generalized weakness in whole body. Total duration of illness was 1.5 years in which the frequency of unresponsiveness increased subsequently over the past 2 months. Family members visited multiple faith healers and local practitioners without any significant improvement. There was no history of fever, head injury, substance use, chronic hospitalization, no history of any behavioral problems either present or past or any other inexplicable psychiatric symptoms.

Initially she was admitted in the pediatrics department and next day transferred to psychiatry department in view of the apparent mismatch between symptomatology and clinical presentation. We took a thorough history of the patient, in which unresponsive episodes were not associated with bleeding from any orifices, pica, generalized weakness/tiredness, any toxins/drug exposure. There was no history of hot/cold intolerance, headache/bruising, abnormal/irregular menstrual cycles. Physical examination revealed pallor, not associated with any nail changes, icterus, or tachycardia. Further, systemic examination didn’t yielded any clue to arrive at any diagnosis. Vitals were within normal limits. On mental state examination, her mood/affect was euthymic and she was concerned with a recently happened examination in her school in which she was unable to perform well than what was expected of her. From around one and a half year, mode of study was primarily online in lieu of COVID-19 and no significant scholastic backwardness was observed, she was able to resume her studies in a fine manner. Cognition was intact. Other than that, there was no significant findings in MSE (mental state examination) and also, no significant stressors could be elicited even on repeated MSEs. Even her parents denied any significant stressors in the life of patient.

There was no family history suggestive of consanguinity or any history suggestive of psychiatric illness. Family environment was cordial, and her premorbid temperament was adjustable. She was good at academics. Routine investigations were sent to rule out possible organic causes of her clinical presentation as we were unable to find any possibility of conversion in this patient and the results were surprising. In complete hemogram with GBP, hemoglobin came out to be 4.1 gm/dL along with increased reticulocyte count (2.5%). GBP revealed microcytic hypochromic anemia, and rest investigations including liver function, renal function, chest X-ray (to exclude lung pathology), and CECT Head (to exclude neurological cause) came back within normal limits. After this we were clear in our thoughts what was happening with the patient and we were able to identify the cause of her clinical presentation ie severe anemia cause—Iron deficiency (considering it to be the common cause of microcytic hypochromic anemia). Following this we again approached our pediatric colleagues and transferred back this patient for proper assessment of the cause of severe anemia (iron deficiency or other causes) and management including the need for blood transfusion. Later, follow-up was lost in successive visits, but patient was contacted via telemedicine mode, and mother reported improvement in patient’s symptoms following treatment (iron supplementation and 3 units of blood transfusion).

Discussion

In most recent studies lower incidence is reported for the patients initially diagnosed with a conversion disorder ⁴ who were later identified to be having a physical disorder, in most cases a neurological disorder (false positive). ⁵ As in our case we find a systemic cause in the form of severe anemia which can explain unresponsiveness episodes before labelling it as conversion disorder. It is also very important to diagnose correctly as it has huge implications for the management of such patients. There are numerous examples of studies in which patients with a primary diagnosis of conversion disorder later come up with a diagnosis of physical disorder (false positives).^6–9 However substantial differences exist between these studies in terms of the duration of the illness, holistic clinical approach towards the case, and the frequency of repeated physical examination. Apart from this, research setting and the time of follow-up used in various studies also varied. Additionally, there are chances if a patients had previous history of psychiatric illness, there is an increased likelihood of them having their neurological symptoms misattributed to a psychiatric syndrome. It is major clinical concern; for instance, the reported occurrence of misdiagnosis in a systemic review consisting of 27 studies of conversion symptoms has been around 4%. ¹⁰ Another example of one of the important study ¹¹ revealed that among the patients who originally had neurologic symptoms at baseline (1144 out of 3781) but at 12-month follow-up, outcome data was obtained only on 1030 out of 1144 of these patients ie 90%. Same study (Scottish Neurological Symptoms Study) also reported 9 deaths. Similarly in our case it would have lethal consequences if she was misdiagnosed as conversion disorder.

Considering Iron Deficiency Anemia (IDA), there is evident relationship between psychiatric diagnosis and IDA among child and adolescent. To specify, there is concomitant risk of developing tic disorder and developmental disorders (Autism and ADHD). ¹² Another study also reported that IDA is associated with higher risk of depression, anxiety disorders, sleep disorders, and psychotic disorders. ¹³ Similar results were obtained in Shah et al. ¹⁴ Hence, follow up becomes equally important in lieu of risk of other psychiatric illness and clinician alertness to decrease the duration of untreated illness and thereby improving prognosis.

In Clinical settings, it might be difficult at times for clinicians to discern between “organic” and psychogenic illnesses because of apparent personality factors or obvious “bizarreness” of psychiatric presentation or maybe because of busy clinical settings. Nevertheless, it is prudent to keep in mind that overlooked diagnosis of an organic condition when the conversion was the real cause can have a negative impact on the patient, and vice versa is also true. Furthermore, a good clinical/general examination can give a clue to possible organic causes such as the presence of pallor in our case. Hence, it is necessary to do a thorough physical examination in cases presenting with psychological/pseudoneurological symptoms. Additionally, if conversion disorder is diagnosed more often, it is the need of the hour to conduct more research to prevent misdiagnosis in the best interest of patients.