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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 14  |  Issue : 2  |  Page : 140-143

A report of three cases of Nigerian children with conversion disorder


1 Department of Psychological Medicine, College of Medicine, University of Nigeria, Nsukka, Enugu State, Nigeria
2 Department of Pediatrics, College of Medicine, University of Nigeria, Nsukka, Enugu State, Nigeria
3 Department of Psychological Medicine, University of Nigeria Teaching Hospital, Ituku-Ozalla, Nigeria

Date of Web Publication21-Nov-2015

Correspondence Address:
Appolos Chidi Ndukuba
Department of Psychological Medicine, College of Medicine, University of Nigeria, Nsukka, Enugu State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2384-5589.170188

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  Abstract 

There is a scant report in the literature on conversion disorder in children. These investigators are not aware of any report of this condition among Nigerian children. This could be because this condition is easily missed thus, creating the impression that conversion disorder is rare. This paper presents three cases of Nigerian children who manifested with features consistent with conversion disorder. This communication aims to highlight the need to consider this condition in children, especially those with difficult to explain symptoms.

Keywords: Conversion disorder, Nigerian children, three cases


How to cite this article:
Ndukuba AC, Ibekwe RC, Odinka PC, Muomah RC. A report of three cases of Nigerian children with conversion disorder. Afr J Med Health Sci 2015;14:140-3

How to cite this URL:
Ndukuba AC, Ibekwe RC, Odinka PC, Muomah RC. A report of three cases of Nigerian children with conversion disorder. Afr J Med Health Sci [serial online] 2015 [cited 2021 Mar 8];14:140-3. Available from: http://www.ajmhs.org/text.asp?2015/14/2/140/170188


  Introduction Top


Conversion disorder is defined by Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition, Text Revision (DSM-IV-TR) [1] as a mental disorder whose central feature is the appearance of symptoms affecting the patient's senses or voluntary movements that suggest a neurological or general medical disease or condition. DSM-IV-TR specifies criteria for the diagnosis of conversion disorder to include having one or more symptoms or deficits affecting the senses or voluntary movement that suggest a neurological or general medical disorder, the onset or worsening of the symptoms being preceded by conflicts or stressors in the patient's life, the symptom not being faked or produced intentionally, the symptom cannot be fully explained as the result of a general medical disorder, substance intake or behavior related to the patient's culture, and the symptom is severe enough to interfere with the patient's schooling, employment, or social relationships, or is serious enough to require a medical evaluation. Four subtypes of conversion disorder are listed in DSM-IV-TR: Conversion disorder with motor symptom or deficit with sensory symptom or deficit with seizures or convulsions, and with a mixed presentation.

Conversion disorder could present a diagnostic challenge and as observed by Thomson and Sills [2] unnecessary and sometimes potentially harmful procedures may be performed or proposed in pursuit of the supposed organic cause. These children may also inadvertently be exposed to certain drugs with their attendant side effects. There is a need for early identification and treatment in order to reduce cost and suffering of the patient. This depends on a high index of suspicion by the attending physicians. In pediatric practice, however, children presenting with conversion disorder may not be easily identified and treated. The reason for this according to Ndukuba et al. [3] may be due to the low level of knowledge of conversion disorder among Nigerian Pediatricians.

There is scanty literature emanating from this country on this clinical condition in children. This may suggest that these conditions either do not exist in children or are not identified and subsequently referred for treatment. This article is a report of three Nigerian children that presented with features consistent with conversion disorders. Their parents consented to the report of these conditions. It hopes to enlighten clinicians about this condition in children and to raise the index of suspicion of the disorder when attending to children especially those with neurological conditions.


  Case Reports Top


Case 1

PO was a 6-year-old girl who achieved developmental milestones as at when due, and was immunized according to the immunization schedule for Nigerian children. She is the last of the parents' four children (three girls and one boy) and was in good state of physical health. Her academic performance has been impressive. Her parents, however, lived in different zones of the country. Her father lives in Port Harcourt in South-Southern Nigeria, while her mother lives in Enugu South-Eastern Nigeria with the children. Her mother was unemployed though she had a tertiary level of education. Her father visits the family regularly on weekends. During these visits, he takes them out shopping and sight-seeing. The general family environment when he visits, however, is characterized by frequent arguments and occasional physical fights between the parents, which PO often witnesses. During one of such visits, PO developed high-grade fever associated with nausea and vomiting. She cried excessively and became progressively weak, and this worsened on the 2 nd day when she developed severe throbbing headache and neck stiffness, and by the 3 rd day, she could not able to walk longer. She was admitted in a private hospital in Enugu owned by a consultant pediatrician, who made a diagnosis of acute bacterial meningitis. The diagnosis was confirmed by the results of laboratory investigations that included blood and cerebrospinal fluid cultures.

PO received parenteral antibiotics and responded well to the treatment. However, despite resolution of other symptoms and stabilization of vital signs, she was still unable to walk by the 2 nd week of admission. Her serial neurological examinations were normal, and she was able to move all limbs and even helped herself when no one was in the room. Her inability to walk generated significant concern with both parents and other relatives and on account of this, her father was unable to return to his station. Given the inconsistency between her symptom and examination findings she was referred for psychiatric evaluation. An assessment of conversion disorder was made. PO made rapid improvement following the application of behavioral techniques. She was discharged without any residual deficits. Her parents were given psychoeducation and encouraged to improve their intra-family relationships.

Case 2

MN is an 8-year-old boy who is the only child of highly educated and doting parents. Both parents had university education. He was a well-child. His milestones and growth were appropriate for age, and he was fully immunized. He liked his school and was performing well academically. One day he complained to his teacher that he could no longer see the chalkboard. His teacher changed his position in the class, but this did not resolve the problem. At about the same time, he also complained that he could not see at home. However, his parents and teachers were intrigued by the fact that in spite of his complaint, he could navigate through the house without bumping into objects and could follow his parents whenever they come to pick him from school without assistance. MN had his sight examined by an ophthalmologist, who did not find any organic explanation for "his condition" and therefore, referred him for psychiatric evaluation. On evaluation, it was observed that though MN could not read any of the things given to him, he could navigate himself in the doctor's office and even shook hands with the doctors without any difficulties. MN was given a pair of glasses that had no power, and was informed that his sight would correct the next day. He returned to the clinic 2 days later and was now able to read effortlessly. An assessment of conversion disorder was made, and MN has since been able to carry on with his activities unaided. A session with his parents revealed that they were about to adopt a girl at about the time MN's problem started. They were encouraged to discuss the issue of adoption with MN, and he has remained symptom-free on follow-up visits.

Case 3

UN is a 7-year-old boy and the third of the parents five children of his parents. The father is a politician and a businessman while the mother though well-educated with university education, is unemployed. The family environment is characterized by occasional disharmony that the children often witness. UN was well until 1-day when he developed fever, headache, and vomiting. His father gave him sulfadoxine/pyrimethamine (Fansidar) and paracetamol that were bought from a pharmacy shop. The fever and other symptoms subsided by the next day but UN started exhibiting unusual body movements. He could no longer stand erect and walked with a "staggering" gait, with the legs crossing themselves while walking. Despite the abnormal gait, UN did not fall and was apparently unconcerned about his problem. He was reviewed by a pediatric neurologist who noted the inconsistency between UN's normal neurological examination finding and his symptoms. Conversion disorder was suspected, and UN was referred for psychiatric evaluation. During the psychiatric review, he was observed to cling to the father, apparently unconcerned with the goings-on around him, playing with the father's phone without any observable difficulties. Both parents were extremely anxious about UN's problems especially as his elder sister had in the past experienced turning of neck and tongue protrusion following ingestion of medication to control vomiting when she had malaria, which UN witnessed. While being reviewed, UN made no efforts to move his limbs when he was asked to do so and slumps when efforts were made to keep him in standing position. He could, however, run to give the father his phone when it rang without any difficulties. An assessment of conversion disorder was made. The parents were given psychoeducation and were encouraged to avoid reinforcing the behavior. UN resumed school the next day and has remained stable.


  Discussion Top


Conversion disorder has been described in many cultures. However, in cultures where children with medical conditions are readily brought for consultation, a higher prevalence rate has been reported. For instance, Srinath et al. [4] reported a prevalence of 30.8% of South Indian inpatients and 14.8% of the outpatients. It is said to be more frequently seen in adolescents, and young adults compared to children, with the frequency decreasing considerably among children under five. However, Akdemir and Unal [5] described a case of an 8-year-old girl whose symptoms started at the age of three. All the children presented in this paper were below 8 years of age suggesting that the condition could be found in very young children in this culture.

Various clinical manifestations of the condition in children have been described in various case reports. [6],[7],[8],[9] The three cases exemplify manifestations of seemingly very serious organic illnesses which were not explicable medically. In the case of PO, the inability to walk simulated paralysis, while MN's case simulated blindness and UN's motor dysfunction. While some studies reported that pseudoseizure (nonepileptic seizure) as the commonest presentation, [10],[11] others reported paralysis [12] and disturbances of voluntary motor function. [13] The cases presented in this paper suggest that children in this culture could have varied manifestations of conversion disorder.

All the children were experiencing stressful living conditions at the time of the illness. In cases, 1 and 3 their stresses may be due to dysfunctional family setting. This is in agreement with Maloney [14] who reported that compared with controls; children with conversion disorder had a higher frequency of recent family stress, unresolved grief reactions, and family communication problems. In recent times, African cultures have undergone major changes that could have negative impacts on our families. For instance, the traditional extended family system is gradually disappearing, and many mothers are now working. These changes could pose some threats to the families, especially when there are few social structures in place to cope with the aftermath of these changes. This also highlights the importance of good history in cases of diagnostic difficulties, unraveling the presence of stressful family environment should increase the index of suspicion of conversion disorder in children.

Earlier reports had noted that pseudoseizures were more common in children with epilepsy or whose family members had epilepsy. [10] This is consistent with our findings, In one of the children his elder sister had a "similar" problem while in two children, their disorders developed in the context of valid physical illness. These physical illnesses, however, could not fully explain the symptoms expressed by the children, and this is consistent with the clinical features of this condition. Missing the diagnosis in these children could have exposed them to a longer hospital stay and invasive and expensive laboratory investigations. There is a need for thorough and continuous evaluation of children with physical illnesses, and in the presence of psychosocial stressors conversion disorder should be considered.

The three children reported in this study showed remarkable improvement following the application of some behavioral techniques. While the outcome is good if conversion disorder is identified early and treated, it could lead to a more lasting impairment especially when not treated early. There is, therefore, need to have a high index of suspicion of conversion disorder even among children with valid physical illnesses.


  Conclusion Top


Conversion disorder could be contributing to a proportion of children seeking care in our healthcare facilities, and childcare practitioners should have a high index of suspicion in order to identify such children early and if necessary refer them appropriately.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4 th Edition, Text Revised. Washington, DC: American Psychiatric Association; 2000.  Back to cited text no. 1
    
2.
Thomson AP, Sills JA. Diagnosis of functional illness presenting with gait disorder. Arch Dis Child 1988;63:148-53.  Back to cited text no. 2
    
3.
Ndukuba AC, Ibekwe RC, Odinka PC, Muomah RC, Nwoha SO, Eze C. Knowledge of conversion disorder in children by pediatricians in a developing country. Niger J Clin Pract 2015;18:534-7.  Back to cited text no. 3
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4.
Srinath S, Bharat S, Girimaji S, Seshadri S. Characteristics of a child inpatient population with hysteria in India. J Am Acad Child Adolesc Psychiatry 1993;32:822-5.  Back to cited text no. 4
    
5.
Akdemir D, Unal F. Early onset conversion disorder: A case report. Turk Psikiyatri Derg 2006;17:65-71.  Back to cited text no. 5
    
6.
Laria C, Perez ME, Perez E, Pinero DP, Ruiz-Moreno JM, Aliò JL. Conversion visual loss: A differential diagnosis in infant amblyopia. Eur J Ophthalmol 2009;19:1065-8.  Back to cited text no. 6
    
7.
Peer Mohamed BA, Patil SG. Psychogenic unilateral pseudoptosis. Pediatr Neurol 2009;41:364-6.  Back to cited text no. 7
    
8.
Coskun M, Zoroglu S. Long-lasting conversion disorder and hospitalization in a young girl: Importance of early recognition and intervention. Turk J Pediatr 2009;51:282-6.  Back to cited text no. 8
    
9.
Schiff A, Ravid S, Hafner H, Shahar E. Acute hemiplegia and hemianesthesia together with decreased tendon reflexes mimicking acute stroke representing a conversion disorder. Harefuah 2010;149:129-32.  Back to cited text no. 9
    
10.
Krishnakumar P, Sumesh P, Mathews L. Temperamental traits associated with conversion disorder. Indian Pediatr 2006;43:895-9.  Back to cited text no. 10
    
11.
Ghosh JK, Majumder P, Pant P, Dutta R, Bhatia BD. Clinical profile and outcome of conversion disorder in children in a tertiary hospital of north India. J Trop Pediatr 2007;53:213-4.  Back to cited text no. 11
[PUBMED]    
12.
Teo WY, Choong CT. Neurological presentations of conversion disorders in a group of Singapore children. Pediatr Int 2008;50:533-6.  Back to cited text no. 12
    
13.
Kozlowska K, Nunn KP, Rose D, Morris A, Ouvrier RA, Varghese J. Conversion disorder in Australian pediatric practice. J Am Acad Child Adolesc Psychiatry 2007;46:68-75.  Back to cited text no. 13
    
14.
Maloney MJ. Diagnosing hysterical conversion reactions in children. J Pediatr 1980;97:1016-20.  Back to cited text no. 14
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